Pelvic Floor Muscle Training: It's Not Always About Strength

When most people think about pelvic floor exercises, they think about Kegels – squeeze, relax and repeat. Many people with pelvic floor issues assume they have a weak pelvic floor that needs strengthening. But for many people the problem is the opposite – pelvic floor muscles that are in excessive tension and unable to fully relax. A lot of different words are used to describe this kind of pelvic floor including tight, tense, high-tone, hypertonic, non-relaxing, and overactive. For this kind of pelvic floor, the treatment is not more squeezing or strengthening, but down-training.

A pelvic floor in excessive tension does not equal a strong pelvic floor. In fact, a shortened and tense muscle cannot generate a full contraction, which means symptoms commonly associated with a "weak" pelvic floor, such as urgency or leakage, may actually be caused by excessive tension rather than weakness. This is why speaking to a pelvic floor physiotherapist for any pelvic floor symptoms is so important.

An excessively tense pelvic floor may be associated with a range of symptoms and conditions including:

• Chronic pelvic pain

• Pain during sex (dyspareunia) or inability to tolerate penetration (vaginismus)

• Painful periods

• Urinary urgency, frequency, or difficulty fully emptying the bladder

• Constipation or pain with bowel movements

• Pelvic heaviness or pressure

• Endometriosis and other chronic pelvic conditions, where ongoing pain and protective muscle guarding add to pelvic floor tension over time.

What is downtraining?

Downtraining is a structured physiotherapy approach to reducing excessive tension in the pelvic floor muscles, including restoring the muscle's ability to fully lengthen and relax, and retraining the nervous system's connection with the pelvic floor.

A 2022 systematic review found that pelvic floor physiotherapy, including downtraining approaches, was effective in reducing symptoms associated with excessive pelvic floor tension across a range of conditions including chronic pelvic pain, dyspareunia, and vaginismus. Downtraining approaches including manual therapy and relaxation training showed to be particularly beneficial.

What does a downtraining program look like?

A downtraining program is highly individualised but typically includes a combination of the following:

• Breathing and nervous system regulation: Diaphragmatic breathing is a key component of downtraining. During inhalation, the diaphragm descends and the pelvic floor naturally lengthens and releases. Relearning slow, full diaphragmatic breathing helps restore this movement pattern and sends signals of safety to the nervous system, reducing protective muscle tension over time. This is particularly important because pelvic floor tension is often linked to a heightened stress or threat response in the nervous system.

• Stretching and lengthening exercises: Stretches targeting the pelvic floor and surrounding muscles, including the hip flexors and external rotators, inner thighs, and lower back help reduce tension in the broader pelvic region and create more space for the pelvic floor to release. Common positions used may include child's pose, happy baby, a deep squat, and the butterfly stretch.

• Muscle awareness and discrimination training: Many people with excessively tense pelvic floor muscles have difficulty sensing what the muscles are doing. At rest, they may not know whether the pelvic floor is contracted or relaxed. Downtraining includes body awareness exercises to help identify what full relaxation feels like, and to distinguish between contraction, partial release, and complete relaxation.

• Manual therapy: Manual therapy, including internal and external soft tissue release, the use of vaginal dilators, trigger point therapy, and myofascial release, can directly address areas of tightness and help the muscles lengthen and relax. A pelvic floor physiotherapist may provide treatment with these techniques, and/or teach how these can be done independently at home.

• An exercise program: Consistent practice is essential. A pelvic floor physiotherapist will prescribe a personalised home program of breathing exercises, stretches, and relaxation positions that can be performed regularly, building independence and supporting long-term change to the pelvic floor muscles.

  
  

Improvement in the pelvic floor muscles from downtraining is typically gradual. A program of eight to ten physiotherapy sessions at weekly intervals, alongside home exercises, is often prescribed.

The bottom line

Not all pelvic floor issues are caused by weakness, and not all pelvic floor treatment should focus on strength. For people with an excessively tense pelvic floor, downtraining is a targeted, evidence-based approach that can make a significant difference to pain, bladder and bowel function, and sexual health. A pelvic floor physiotherapist can assess what your pelvic floor is actually doing and design a program that is right for you.

References

1. Pedraza R, Nieto J, Ibarra S, Haas EM. Pelvic muscle rehabilitation: a standardised protocol for pelvic floor dysfunction. Advances in Urology. 2014. https://pmc.ncbi.nlm.nih.gov/articles/PMC4071781/ 

2. Voorham-van der Zalm PJ, et al. Pelvic floor physical therapy for pelvic floor hypertonicity: a systematic review of treatment efficacy. Sexual Medicine Reviews. 2022;10(2):209-221. https://academic.oup.com/smr/article/10/2/209/6880344

3. Meister MR, et al. A treatment algorithm for high-tone pelvic floor dysfunction. PubMed. 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC10953682/

4. Chalmers KJ, et al. Pain science education concepts for pelvic pain: an e-Delphi of expert clinicians. Frontiers in Pain Research. 2025. https://doi.org/10.3389/fpain.2025.1498996 

5. Mardon AK, Chalmers KJ, et al. "I wish I knew then what I know now" - pain science education concepts important for female persistent pelvic pain: a reflexive thematic analysis. Pain. 2024;165(9):1990–2001. https://doi.org/10.1097/j.pain.0000000000003205