Pelvic Floor Exercises for Women: A Physiotherapist’s Guide

Pelvic floor exercises are often reduced to one simple instruction:

“Do your squeezes.”

But strengthening your pelvic floor is about much more than learning how to contract the muscles while lying down.

Your pelvic floor has to work when you stand, walk, lift, cough, sneeze, run, jump and exercise. So if your goal is to get back to real life without leaking, heaviness or worrying about your pelvic floor, your exercises eventually need to prepare you for those demands too.

I’m Gemma West, a specialist pelvic health physiotherapist and founder of The West 6™.

I developed The West 6 after experiencing pelvic floor symptoms myself, as well as treating hundreds of women with pelvic floor dysfunction.

My background was originally in musculoskeletal and sports rehabilitation, and that shaped a simple principle behind the programme:

Rehabilitation should progress towards the activity you want your body to be able to do.

The pelvic floor should be no different.

What is the pelvic floor?

The pelvic floor is a group of muscles and connective tissues forming the base of your pelvis.

These muscles have several important jobs. They help support your pelvic organs, contribute to bladder and bowel control, play a role in sexual function and respond to changes in pressure within your abdomen.

They also need to work during everyday movement and exercise.

When you cough, sneeze, lift something heavy, run or jump, the demands placed on your pelvic floor change.

That’s why pelvic floor rehabilitation shouldn’t only be about whether you can perform a contraction in isolation.

Ultimately, it’s about whether your pelvic floor has the strength, endurance, coordination and capacity to cope with what you need it to do.

What are pelvic floor exercises?

Pelvic floor muscle exercises — sometimes called pelvic floor muscle training or Kegel exercises — involve deliberately contracting and relaxing the pelvic floor muscles.

A basic pelvic floor contraction involves gently closing around the openings of the pelvic floor and lifting the muscles upwards.

Imagine trying to stop yourself passing wind while also stopping the flow of urine. You should feel an internal squeeze and lift.

You shouldn’t regularly practise by actually stopping your urine mid-flow.

Just as importantly, after every contraction you need to fully relax the pelvic floor again.

How do I know if I’m doing pelvic floor exercises correctly?

A good pelvic floor contraction should feel like an internal squeeze and lift.

Ideally, you should be able to contract your pelvic floor without excessively squeezing your buttocks, gripping your thighs or holding your breath.

Keep breathing normally.

Then allow the muscles to completely relax before your next contraction.

And remember:

Quality matters.

Ten contractions aren’t particularly useful if the last five have become tiny, poorly controlled squeezes because your muscles have fatigued.

One of the principles I use in The West 6 is:

Can your 10th contraction be as strong and controlled as your first?

If not, that gives us useful information about your current endurance and capacity.

How often should women do pelvic floor exercises?

For women with stress or mixed urinary incontinence, NICE recommends supervised pelvic floor muscle training for at least three months as first-line treatment. NICE guidance recommends a programme comprising at least eight contractions performed three times per day.

But the words “at least” are important.

Three months isn’t a deadline by which your pelvic floor should be completely rehabilitated.

In my clinical experience, it can take considerably longer — particularly if your goal isn’t simply to perform a good pelvic floor contraction, but to return confidently to higher-demand activities such as lifting, running and jumping.

Like strengthening other muscles in the body, pelvic floor rehabilitation requires repetition, consistency, appropriate progression and time.

What are long and short pelvic floor exercises?

Your pelvic floor needs to be able to do different jobs.

Long holds help develop endurance — the ability to maintain a contraction over time.

You might gradually work towards holding a good-quality pelvic floor contraction for up to around 10 seconds, followed by a full relaxation.

Quick contractions train your pelvic floor to contract rapidly.

That matters because life isn’t predictable. A cough or sneeze can happen suddenly and your pelvic floor needs to respond quickly to that sudden change in pressure.

Both endurance and faster contractions therefore have a role in pelvic floor rehabilitation.

Why aren’t basic Kegels always enough?

Imagine rehabilitating a knee injury.

You wouldn’t expect someone to perform exercises lying on a treatment couch for several months and then immediately return to running, jumping or lifting heavy weights.

You would progressively increase the demands placed on the muscles.

Why should the pelvic floor be any different?

Your pelvic floor may need to cope with relatively low demands while you’re lying down, but considerably greater demands during standing, lifting, running and jumping.

So being able to perform pelvic floor exercises lying down doesn’t necessarily mean your pelvic floor is ready for everything you want it to do.

This is one of the fundamental ideas behind The West 6:

Life doesn’t happen lying down.

Should pelvic floor exercises get harder?

Yes — when appropriate for you, pelvic floor muscle training should progress as your strength, control and confidence improve.

And progression doesn’t simply mean squeezing harder.

It can mean changing the position you’re exercising in and gradually increasing the functional demands placed on your pelvic floor.

This is the principle behind The West 6™, which progresses through six levels:

Level 1: Lying → Level 2: Sitting → Level 3: Standing → Level 4: Movement → Level 5: Load → Level 6: Impact

Rather than jumping from basic pelvic floor exercises straight back to your most demanding activity, you progressively build towards it.

Why does position matter?

Performing a pelvic floor contraction lying down may initially be easier for some women.

But you don’t spend your life lying down.

Your pelvic floor needs to work when you’re upright too.

So rehabilitation might begin with lying, before progressing into sitting and standing and eventually incorporating movement.

The aim isn’t simply to become excellent at doing pelvic floor exercises.

The aim is to develop a pelvic floor capable of supporting your life.

Pelvic floor exercises during movement

Once you have established a good contraction and appropriate baseline strength and endurance, pelvic floor rehabilitation can become increasingly functional.

That might mean incorporating movements that begin to resemble the demands of everyday life.

This is particularly important if your symptoms occur when you’re moving rather than when you’re lying still.

If you experience symptoms walking quickly, climbing stairs, exercising or doing housework, for example, your rehabilitation eventually needs to prepare your pelvic floor for those demands.

Pelvic floor exercises with load

Women manage load every single day.

And load doesn’t just mean a barbell.

It might be lifting your baby or toddler, carrying shopping, gardening, moving something around the house, lifting weights at the gym or managing the physical demands of your job.

Avoiding load forever isn’t realistic for most women.

Where appropriate, rehabilitation can instead progressively develop the strength and capacity needed to manage it.

What about running and jumping?

This one is particularly personal to me.

Leaking when I ran after having my first baby is one of the reasons The West 6 exists.

I could contract my pelvic floor. I could do traditional pelvic floor exercises.

But my pelvic floor wasn’t yet capable of managing the demands of running.

With my background in musculoskeletal and sports rehabilitation, it didn’t make sense to me that pelvic floor rehabilitation should stop with basic exercises and then somehow expect the muscles to cope with impact.

So I applied the same principle I would use when rehabilitating any other part of the body:

Build the foundations, then progressively increase the demand.

It took me around 10 months of rehabilitation, but I was eventually able to return to running and skipping without leaking.

That experience changed the way I approached pelvic floor rehabilitation and ultimately led to the development of The West 6.

I’ve since helped hundreds of women rehabilitate their pelvic floors and work towards the activities that matter to them.

If your leakage happens when you run or jump, your pelvic floor rehabilitation needs to prepare it for those activities.

That’s why Impact is Level 6 of The West 6 — not Level 1.

We build towards it.

Can pelvic floor exercises help bladder leakage?

Yes.

Pelvic floor muscle training is recommended as a first-line conservative treatment for women with stress or mixed urinary incontinence.

One useful way to understand some stress urinary leakage is to think about capacity versus demand.

Activities such as coughing and sneezing create a sudden increase in intra-abdominal pressure and place a rapid demand on the continence system, including the pelvic floor.

Running and jumping repeatedly challenge it too.

If the pelvic floor and wider continence system cannot currently meet the demands being placed upon them, leakage can occur.

So rehabilitation isn’t simply about learning to squeeze.

It’s about progressively developing the strength, endurance, coordination and capacity needed for the demands of your life.

As pelvic floor function and capacity improve, leakage can improve too.

That’s why The West 6 progresses beyond lying-down exercises into standing, movement, load and impact.

Can pelvic floor exercises help prolapse?

Yes — pelvic floor muscle training can help some women with symptoms of pelvic organ prolapse.

One of the important roles of the pelvic floor is contributing to the support of the pelvic organs. When pelvic floor muscle strength or function is reduced, the muscular contribution to that support may also be reduced.

Prolapse symptoms such as heaviness, dragging and pressure can become more noticeable with increased physical demands — for example, being upright for longer, lifting or higher-impact activities.

That’s why rehabilitation needs to consider what happens beyond lying down.

Rather than simply avoiding those demands, The West 6 progressively builds through:

Lying → Sitting → Standing → Movement → Load → Impact

The aim is to progressively develop the strength and capacity required for real life, where appropriate.

Pelvic floor muscle training is recommended as a conservative management option for some women with symptomatic pelvic organ prolapse.

Read The West 6 Success Stories →

Prolapse isn’t simply a question of having a “weak pelvic floor”, however, and symptoms and management vary between women.

If you have a new vaginal bulge, significant or worsening symptoms, pain, difficulty emptying your bladder or bowel, or you’re unsure what’s causing your symptoms, seek an individual pelvic health assessment.

What if pelvic floor exercises make my symptoms worse?

Stop and seek individual advice.

Not every pelvic floor problem requires more strengthening.

Pelvic floor muscles can also be overactive, painful or have difficulty relaxing.

Symptoms such as pelvic pain, pain during sex, difficulty emptying your bladder or bowel, or symptoms that consistently worsen with strengthening warrant individual assessment rather than simply doing more contractions.

This is one reason why generic advice to “just do your Kegels” isn’t appropriate for everyone.

How long do pelvic floor exercises take to work?

This is one of the questions I’m asked most often.

And the answer is:

It depends where you’re starting and where you’re trying to get to.

Guidelines recommending at least three months of pelvic floor muscle training shouldn’t be interpreted as meaning every woman should have completed her rehabilitation within three months.

My own rehabilitation took around 10 months before I was able to return to running and skipping without leaking after having my second baby.

My previous retrospective analysis of patients who followed The West 6 pathway also suggested that women who had experienced their symptoms for longer tended to have longer rehabilitation journeys.

For someone with longstanding symptoms, rehabilitation can sometimes take a year or two — or longer.

That doesn’t mean doing the same set of pelvic floor squeezes for two years.

Your rehabilitation should progress as you progress.

You might begin by establishing a good contraction and building endurance, before progressing into sitting, standing, movement, load and eventually impact where appropriate.

And progress shouldn’t only be measured by the number of exercises you’ve completed.

Ask instead:

• Am I leaking less?
• Has my heaviness improved?
• Can I lift my child with fewer symptoms?
• Can I walk further?
• Can I exercise with more confidence?
• Am I getting closer to the activity I want to return to?

Those changes matter.

Where should I start?

At the beginning.

Even if your symptoms only happen when you’re running, lifting, coughing or sneezing, don’t rush straight to exercises at that level.

First, establish your foundations.

• Can you perform a good-quality pelvic floor contraction?
• Can you fully relax afterwards?
• What’s your endurance like?
• Can you repeat your contractions while maintaining their quality?
• Is your 10th contraction as good as your first?

Establishing a good baseline before increasing the demands gives you something solid to build upon.

That’s why everyone following The West 6 starts with Level 1: Lying.

The 60-second symptom checker does something slightly different.

It helps identify the level of demand at which your symptoms occur — your rehabilitation destination.

You then start at Level 1 and progressively work towards the level your pelvic floor needs.

If your symptoms happen with lifting, for example, you may need to progress towards Level 5: Load.

Coughing and sneezing create high, sudden demands and are classified as Level 6: Impact within The West 6 model.

That means many women experiencing common symptoms such as leaking when coughing or sneezing may ultimately need to progress through the full six-level programme.

But you don’t start at Level 6 just because that’s where your symptoms happen.

Your symptoms help identify the destination.
Your baseline determines where you begin.

And with The West 6, you begin by getting the foundations right.

Ready to start?

The West 6™ is a progressive six-level pelvic floor exercise programme designed to help you build from foundational pelvic floor exercises towards the demands of real life.

Start with Level 1 for £19.99, including pelvic floor education, technique guidance, guided self-checks, symptom measurement and your first structured level of exercises.

Work at your own pace.

Progress when you’re ready.

And build towards what you want your pelvic floor to be able to do.

Start where you are. Build what you need. Progress towards what you want to do.

Start Level 1 — £19.99 →