Is A Tight Pelvic Floor A Strong Pelvic Floor?

Key Messages

  • Pelvic floor muscle overactivity has a multifactorial aetiology and pathophysiology.
  • It can contribute to many pelvic floor disorders such as sexual pain, pelvic pain and bladder / bowel dysfunction.
  • An individualised treatment approach targeting the cause of the muscle overactivity is recommended.
“Isn’t it good for my pelvic floor to be tight? Isn’t a tight pelvic floor a strong pelvic floor?” These are two questions we are often asked, and the answer to both is NO! More and more commonly we are diagnosing pelvic floor muscle overactivity as a contributing factor to bladder and bowel dysfunction, pelvic pain and dyspareunia. Shan and Leonie attended a workshop at the International Continence Society 2018 conference run by prominent researchers in this field. The workshop explored the latest in pelvic floor muscle overactivity, and how it is best managed.

What Is An Overactive Pelvic Floor?

The International Urogynecological Association (IUGA) and International Continence Society (ICS) released a joint terminology report in 2018 to ensure that we are all speaking the same language when referring to pelvic floor dysfunction. 
They define an overactive pelvic floor as: “Pelvic floor muscles which do not relax, or may even contract when relaxation is functionally needed, for example, during micturition or defecation”1.  
Other associated pelvic floor dysfunctions include: 
  • Hypertonicity: “A general increase in muscle tone that can be associated with either elevated contractile activity and/ or passive stiffness in the muscle”1.
  • Pelvic floor muscle spasm: “The presence of contracted, painful muscles on palpation and elevated resting pressures by vaginal manometry. This persistent contraction of striated muscle cannot be released voluntarily. If the contraction is painful, this is usually described as a cramp”1.

What Causes An Overactive Pelvic Floor?

An overactive pelvic floor can be caused by a wide variety of reasons, including: 
  • Neurologic conditions
  • Problems with motor control
  • Protective physiological reflexes
  • Visceral or autonomic connections
  • Emotions or fear / anticipation of pain
It is then likely perpetuated by learned and anticipatory behaviours, and central nervous system changes in response to longstanding pain and dysfunction.  Interestingly, the pelvic floor musculature is indirectly innervated by the limbic system, and therefore highly reactive to emotional state and emotional stimuli.  

For example, the pelvic floor muscles have been found to involuntarily, and often unconsciously, contract in response to potential physical or emotional pain. One study found pelvic floor activity to be enhanced whilst watching films about sexual violence, and also during anxiety provoking films without sexual content2

Symptoms Of An Overactive Pelvic Floor

Patients with an overactive pelvic floor will commonly present with one or more of the following symptoms: 
  • Pelvic pain: vulval, penile, testicular, perineal, rectal, or suprapubic pain. We often see this muscle presentation in endometriosis, painful bladder syndrome and chronic pelvic pain. 
  • Dyspareunia: in particular entry dyspareunia or inability to achieve penetration. There is strong evidence that most women with vulvodynia present with increased resting and contractile tone in their pelvic floor muscles.  
  • Voiding dysfunction / bladder symptoms: reduced stream, incomplete emptying, urethral irritation.
  • Obstructed defecation: urge to empty but unable, incomplete bowel emptying, straining.
However, we also often see patients with symptoms similar to a weak pelvic floor, such as stress or urgency urinary incontinence.  Particularly in younger, nulliparous females, urinary symptoms can often be present with an overactive pelvic floor rather than a weak one. 

How To Diagnose An Overactive Pelvic Floor?

There is no gold standard for assessing pelvic floor muscle tone, and there is no normative data available.  The most commonly used assessment tool is palpation via internal examination, with the therapist grading resting muscle tone using a standardised scale, such as Reissings’s scale. This scale has good inter-rater reliability, and proven sensitivity to change.
Real time ultrasound (transabdominal or transperineal) must be used with caution as on an ultrasound, an overactive pelvic floor and a weak pelvic floor can look very similar.  However, an experienced clinician will be able to detect the movement patterns associated with an overactive pelvic floor, and will be able to confirm this with an internal examination. 

How To Treat An Overactive Pelvic Floor?

To effectively treat an overactive pelvic floor and its associated symptoms, the cause of the dysfunction must be identified. This can include alteration in resting pelvic floor muscle tone, muscle spasm, poor motor control, relays from emotional and visceral pathways, or changes in central or peripheral processing. 
Common treatment techniques pelvic floor physiotherapists use include:
  • Education: explaining the concept of an overactive pelvic floor and how it is contributing to the clinical presentation.  A detailed understanding makes a huge difference in a patient’s ability to normalise their pelvic floor muscle function, as often they have had the perception that their muscles are ‘weak’ or that it is good to hold their muscles tight. We see this presentation frequently in gymnasts, dancers and those doing lots of “core” exercises. 
  • Pelvic floor muscle ‘downtraining’: teaching the patient how to consciously contract and then RELAX their pelvic floor muscles, using education and varying forms of biofeedback such as tactile via internal examination, real-time 2D transperineal ultrasound, EMG, or a mirror. 
  • Internal pelvic floor muscle release: in the presence of muscle spasm, gentle internal vaginal or rectal stretching and muscle release will help the muscles to contract and relax normally. 
  • Vaginal trainers: to retrain the learned behaviour of pre-emptive muscle spasm prior to penetration. 
  • Referral to psychology / sexual counselling: to address fear and anxiety surrounding pain.

Getting Results

With a correct diagnosis and individualised treatment approach, pelvic floor muscle overactivity responds very well to therapy, and symptomatic improvement can often be quite rapid. 
Before recommending pelvic floor ‘strengthening’ exercises to your patients, always ensure they have had an internal examination to properly assess their muscle dysfunction, as pelvic floor strengthening exercises for an overactive pelvic floor will only make things worse. 
To learn more about an overactive pelvic floor, you might be interested in this case study 


1Rogers, R., Pauls, R., Thaka, R., Morin, M., Kuhn, A., Petri, E., Fatton, B., Whitmore, K., Kingsberg, S., & Lee, J. (2018). An international Urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction. International Urogynecology Journal, 29, 647–666.
2van der Velde, J., Everaerd, W. (2001). The relationship between involuntary pelvic floor muscle activity, muscle awareness and experienced threat in women with and without vaginismus. Behav Res Ther, 39, 395-408. 


May 2019