Pelvic floor disorder (PFD) affects roughly a quarter of all U.S. women, yet the overwhelming silence that accompanies living with it is deafening.

PFD is any condition that affects your ability to contract or relax your pelvic floor muscles, which can contribute to urinary incontinence, constipation, pain during intercourse, sexual dysfunction and even lower-back pain. Yes, it can be embarrassing, and some women feel the need to avoid certain impact exercises such as jumping rope, standing for long periods or even lifting a child.

Pelvic floor issues can present at any point in your life, but Alicia Jeffrey-Thomas, DPT, PT, PRPC, pelvic floor physical therapy manager at Greater Boston Urology in Dedham, Massachusetts, outlines a few common causes:

Pregnancy and childbirth. Unsurprisingly, the weight of a growing baby places extra pressure on your pelvic floor and organs. Childbirth and labor (even in the case of a cesarean section) can injure the muscles and nerves of the pelvic floor.

Menopause. Hormonal changes associated with menopause can cause atrophy (aka, shrinkage or weakening) of the vulva and vagina, as well as in the ligaments and muscles that support your pelvic organs.

Heavy lifting or high-impact athletics. There are several PFDs that can come as a result of these activities. One is length vs. tension: If your muscles are constantly clenched, they aren’t able to respond dynamically, resulting in a limited range of motion. “The pelvic floor needs to be able to absorb the force of the activity,” Jeffrey-Thomas explains. “It’s kind of like dropping an egg on a trampoline: The surface cushions the fall so the egg doesn’t break.” On the flip side, she says, if your pelvic floor muscles are clenched, it’s like dropping an egg on the ground: There is no cushioning response from the surface and the egg will crack.

Another issue is timing, e.g., coordinating when the pelvic floor needs to contract during activity. For instance, in the cognitive stage of motor learning, you may begin by training the pelvic floor to respond to impact by actively contracting it during an activity. Gradually, this may become more of a habit because the pelvic floor muscles have voluntary and involuntary components.

Trauma/Injury. From a fall on your tailbone to sexual assault to birthing a child — any kind of trauma or injury may cause hypertonic pelvic floor dysfunction — a constant spasm in which the muscles do not relax appropriately. In some cases, this may last for years.

It’s important to note, however, that it is not normal to experience pain with sex, when having a pelvic exam or by using tampons. “There are a lot of things that can potentially be causing this, but if your doctor can’t find anything wrong, it could be PFD,” Jeffrey-Thomas says. “If the muscles don’t relax appropriately, that tension can cause pain when provoked.”

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PFD and Athletes

Like any muscular system, your pelvic floor works in synergy with its surrounding muscle groups to manage intra-abdominal pressure. And in concert with your diaphragm and abdominal muscles, the pelvic floor provides core stability and support.

“If one part isn’t working correctly, it can throw off the whole system and result in back pain, leakage during workouts and diastasis recti (doming in the abdominals),” Jeffrey-Thomas says. “Your pelvic floor is also closely related to your hips because of shared attachments, and many times I’ve been able to solve someone’s ‘hip pain’ through pelvic floor therapy. This doesn’t necessarily indicate a weakness of the muscles. It could also mean there’s an imbalance where one area is tighter than another and needs to relax to restore balance.”

Many high-level athletes are particularly susceptible to a hypertonic pelvic floor disorder because frequent exercise can lead to the continual firing of core muscles without sufficient rest. “When that happens, you’re unable to fully relax your pelvic floor,” explains Heather Dunfee, DPT, PT, PCES, a Herman and Wallace Pelvic Floor Level 1 and Level 2 therapist. “Tightness contributes to pelvic floor weakness and leaking, because if the pelvic floor is unable to relax, it will have difficulty absorbing impact as well as difficulty having a full, strong contraction. Pelvic floor hypertonicity also contributes to poor coordination of the pelvic floor muscles, which are supposed to ‘react’ when we need them to.”

Heavy lifting can contribute to PFD because straining and constantly bearing down under load can stress the pelvic floor tissues and ligaments. However, with appropriate core activation and breathing mechanics (for example, not holding your breath with exercise can decrease downward pressure), heavy lifting can be safe.

On the other hand, many athletes have some level of hypertonicity in their pelvic floor. “Typically, this is because there is weakness or instability in the core, glutes or other hip-girdle muscles,” Dunfee says. “The pelvic floor is a stabilizer, and because it sits right at the base of your body, between your two moving legs, it can easily get ‘overworked’ if the other muscles aren’t strong or stable enough.” This can contribute to tightness and weakness (leaking) of the pelvic floor.

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Pelvic Floor Physical Therapy

Here’s the bad news: You probably can’t “Kegel” your way out of a PFD. “In many cases, Kegels can actually make symptoms worse,” Jeffrey-Thomas says. “People perceive their pelvic floor as being weak when really it’s stuck in a partially contracted position.”

Here, pelvic floor physical therapy may help. Yes, just as you’d see a physical therapist for a knee injury, you also can see a specialist for your pelvic region to identify and rehabilitate musculoskeletal and nervous system dysfunction.

“We have additional training to assess the pelvic floor muscles via either vaginal or rectal examination,” adds Jeffrey-Thomas, explaining that a trip to a pelvic floor physical therapist is different from having a gynecologic pelvic exam because there’s no speculum involved. “If you have any urinary incontinence, overactive bladder symptoms, pelvic pain, pain with intercourse, constipation, fecal incontinence or back/hip pain, ask to see a pelvic floor physical therapist.”

“Some incontinence and prolapse conditions can be treated with pelvic floor physical therapy, while others require office procedures or surgery,” adds Karyn Eilber, M.D., board-certified urologist with subspecialty board certification in female pelvic medicine and reconstructive surgery, and an associate professor of urology and obstetrics and gynecology at Cedars-Sinai Medical Center.

Expect to fill out pretty detailed paperwork about your health history and to have a conversation with your therapist to review your symptoms. You’ll also have an orthopedic screening to assess your strength and flexibility as it relates to your spine and hips, an internal pelvic floor assessment and a treatment plan.

Whether you have minor symptoms or major issues, know this: You don’t have to live with PFD for the rest of your life. Help is out there — all you have to do is find it.

To find a pelvic floor physical therapist near you, go to pelvicrehab.com or aptapelvichealth.org.

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Signs of Pelvic Floor Disorders

Pelvic floor issues present differently for every woman but may include the following:

• Leakage when you exercise, cough, sneeze or laugh
• A strong urge to urinate
• Urinating more often than normal
• Hesitancy/difficulty starting the flow of urine
• Fecal incontinence/irregularity/constipation
• Hemorrhoids
• Pain with intercourse
• Pelvic/abdominal pain
• Lower-back pain
• Pressure in the vagina
• Vaginal bulging (prolapse)

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5 Exercises to Ease PFD Symptoms

While there is no one-size-fits-all prescription to help with pelvic floor dysfunction, regular practice of these five moves from Heather Dunfee may help ease your symptoms.

1. Diaphragmatic Breathing with Pelvic Floor Relaxation

Purpose: relaxation

Being able to “breathe down” into the pelvic floor in order to relax it is imperative. Get into a position of pelvic outlet (e.g., one that stretches the muscles of the pelvic floor and the surrounding muscles that attach to the pelvis) such as Child’s Pose. When you inhale, your diaphragm descends and so does your pelvic floor, which mirrors the action of the diaphragm. Imagine expanding 360 degrees around — rib cage laterally, belly anteriorly, lower back posteriorly — as your pelvic floor descends. Think about breathing into your lower back instead of just your belly: Inhale, relax and expand; exhale, let everything recoil naturally.

Action: Perform this technique for one minute or more every day.

2. Deep Core Activation

Purpose: strengthening and coordination

Lie face up on the floor with your knees bent. Perform that big 360-degree inhale expansion (see No. 1). As you exhale, squeeze and lift your pelvic floor and gently draw in your lower abdomen, as if sucking a smoothie up with a straw through your vagina. Activate your core from the bottom up, allowing all the pressure to come out your mouth as you exhale, and completely relax your pelvic floor between contractions.

Action: Do one set of eight to 12 reps, and try it in multiple positions: sitting, on hands and knees, and standing. Once you’re comfortable, apply this strategy to certain exercises. When lifting, exhale and activate during the hardest part of the movement. When jumping, exhale and activate upon landing.

3. Deep Squat

Purpose: strengthening

Stand with your feet just wider than hip-distance apart. Inhale as you squat down until your hips are below your knees. Now exhale, activate (see No. 2) and stand, squeezing your glutes as you rise.

Action: Complete two to three sets of eight to 12 reps.

4. Foot-Elevated Glute Bridge with Ball Squeeze

Purpose: strengthening

The glutes and inner thighs attach in close proximity to the pelvic floor muscles, so strengthening them can help fortify your pelvic floor. Lie on your back with your feet elevated on a couch or bed, knees bent. Place a ball or small throw pillow between your knees. Inhale deeply (No. 1), then exhale and activate (No. 2), and squeeze the ball with your knees as you contract your glutes to lift your hips. Inhale, lower down and completely relax.

Action: Complete two to three sets of eight to 12 reps.

5. Single-Leg Hip Opener

Purpose: strengthening and relaxation

Single-leg stability and hip rotation is crucial for optimal pelvic floor function because hip rotators are actually pelvic floor muscles, too. Stand on one leg, lift the other knee up in front of you to hip height, then open your leg to the side. Pause, bring it back to center and repeat.

Action: Start with 10 reps on each leg without losing your balance and work your way up to 20.