In this guide we explain how to complete exercises to help with pelvic floor muscle relaxation and pain relief.

Suffering from chronic pelvic pain can cause your pelvic floor muscles to spasm. The muscles can become tight and uncomfortable and worsen your symptoms. A tight pelvic floor can even become an issue in itself. When the muscles spasm they stop functioning correctly, the symptoms of this can be similar to that of a weak pelvic floor. You may be unable to control your bladder and bowels. If you misunderstand this to be a result of a weak pelvic floor you can cause further pain by attempting traditional Kegel exercises. Therefore it is essential that a correct diagnosis of your pelvic floor condition is obtained before proceeding.

The following exercises can be supported by a Women's Health Physiotherapist to advise on how to make them most effective for you. They will also ensure you are disciplined and committed to the exercises, as consistency is the quickest way to lasting relief from your pain.

Educate Yourself

If the cause of your pelvic pain has been diagnosed, you will benefit from understanding why you are suffering and the musculoskeletal changes that are causing your symptoms. It helps to visualise why you are feeling the pain and how you can relax your muscles to overcome it. Even if you do not know what is causing your pelvic pain, you will still benefit from understanding about the structures of the pelvic floor and the pelvic organs. This can give you an insight into where your pain is felt, and again, how to get relief.

Diaphragmatic Breathing Technique

Diaphragmatic breathing is often used in yoga as it is the most efficient way to breathe and can provide relaxation and relief from stress. When you breathe incorrectly, your upper chest muscles are used to help your lungs as opposed to your diaphragm; this increases pressure on your pelvic floor. By sitting up straight and practising deep breathing, your diaphragm will work properly. It will strengthen and stimulate your abdominal and pelvic floor muscles to contract and relax in a way that will help to ease pelvic pain.

  1. Sit up straight - Consider using a support cushion to make sure that your lower back is in the right place and you’re not slouching.
  2. Breathe in through your nose - Place one hand on your abdomen, just below your rib cage. Breathe in slowly and deeply, focusing on drawing air into your belly and feeling your breathe with your hand. You will feel your diaphragm move up and your stomach move out. Your chest should remain still.
  3. Breathe out through pursed lips - Tense your stomach muscles and gently breathe out by letting your rib cage fall back into place. Again, your chest should remain still.
  4. Repeat - Try doing this for 5-10 minutes, 3-4 times throughout the day. At first it may be tiring to breathe this way, but it will quickly become easy and automatic with practice. To benefit even more, you can slowly increase the amount of time you are breathing this way, and even increase the effort by lying on your back and placing a book on your abdomen to try and move as you breathe.

Another way to focus on using your diaphragm is to breathe in deeply through your nose, then breathe out slowly through your mouth while making an ‘S’ sound like a snake. You may feel silly, but this will strengthen your diaphragm.

Its not just your pelvic floor muscles that will benefit from diaphragmatic breathing. It will also slow your breathing, decrease your blood pressure, reduce your stress levels and improve the circulation of oxygen in your body.

Progressive Muscle Relaxation

If you have been suffering from a tight pelvic floor for a long time, your body will have learned how to be tense and may be unable to relax without conscious effort. Progressive muscle relaxation is a technique used to retrain the pelvic floor into relaxing. It can also be used as a technique for mindfulness and to reduce stress, as it can be used for all the muscles in the body.

For this technique to be successful you need to give yourself head space to concentrate on yourself and put any current concerns to one side.

  1. Find somewhere quiet - Find a location which is quiet and not too bright. Lie on top of your bed or reclined on your sofa. Open a window or turn on a fan to get a breeze, and close your eyes.
  2. Take off shoes and glasses etc. - Get comfortable and remove any obvious weight from your body, such as blankets or glasses.
  3. Breathe deeply - Take a few deep breaths and imagine that any tension you have is flowing out of your body with each exhalation.
  4. Tense a muscle group for 7-10 seconds - Start at your feet and envision the muscle group in your feet tensing. Hold it for 7-10 seconds.
  5. Relax the muscles for 15-20 seconds - Quickly release the muscles and allow the relaxation to continue for at least 15 seconds. You may feel the surrounding muscles also benefit from this relaxation. The muscles may tingle, feel warm and heavy as they relax. This is a good sign that you are relaxing effectively.
  6. Move onto the next muscle group - As you work around your body, concentrating on one muscle group at a time, ensure the rest of the body remains as relaxed as possible. You may need to raise your arms and legs, lift your head and shrug your shoulders to tense these groups. Don't forget the muscles in the face as well, squeeze your eyes and press your lips and jaw together. Avoid working too hard on any muscle groups that are injured.
  7. Concentrate - If you find your mind wandering, gently guide yourself back to the sensation of your muscles. Let yourself go and do not worry about if the practice was a 'success'. It will become easier each time you try.
  8. Repeat - As with most techniques and exercises, progressive muscle relaxation must be repeated in order for it to become easier to achieve. Practice for 20 minutes each day. It may help to find a regular time to do this such as before going to sleep when you are in bed. The technique will take less and less time to achieve relaxation, but to begin with you may need to dedicate 30 minutes or more.

If you are struggling to relax into this technique it may be that you are trying to hard. It may seem odd, but if you are consciously trying to relax you may actually be making your body more tense.

Down Training or 'Reverse Kegels'

A reverse Kegel is exactly what it sounds like – the aim is to relax the pelvic floor muscles rather than tense them. The following exercise will help to relieve tension and improve flexibility by lengthening the pelvic floor muscles. When practiced alongside traditional Kegel (pelvic floor) exercises, you can balance your pelvic floor and get the most out of it.

What you are looking for is the same feeling as when you start to go to the toilet; the pelvic floor muscles ‘drop’ and relax to let urine come out. If you struggle to find your pelvic floor muscles, read our guide before proceeding with the exercise.

  1. Breathe deeply - Start by deeply breathing, while focusing on how the muscles around your anus, vagina and urethra feel as you breathe in and out. Breathe throughout the exercise to ensure you are not unconsciously tensing.
  2. Lie down - Lie down on your back with a pillow under your knees, or on your side with a pillow between your thighs.
  3. Relax your pelvic floor - Try to gently relax your pelvic muscles, allowing them to move downwards without straining. Think about how they feel when you go to the toilet (it is a good idea to go before you do this to avoid accidents). Hold this for 5 seconds. It may help to try relaxing your abdominal muscles first, by placing your hand on your navel and allowing your belly to relax and bulge forwards.
  4. Release and repeat - Repeat 10 times per set of reverse Kegels, at 2-3 points throughout the day.
  5. Make it harder - If you have been practising reverse Kegels for a while, try holding and releasing the pelvic floor for longer periods. Make sure that you continue to breathe throughout and are not rushing to finish.

Reverse Kegel exercises shouldn’t feel uncomfortable; if you feel like you’re not managing to release your muscles then resist the urge to bear down as this will cause strain. Don’t put too much pressure on yourself; now that you know how to do reverse Kegels you can keep trying every few days.



Pelvic Drops

Pelvic floor drops are another exercise that will train you in pelvic floor muscle relaxation. They are used by Physiotherapists to help clients get into the most relaxed position possible for their pelvic floor and provide relief. Your pelvic floor muscles are constantly contracted to keep you continent and avoid those little accidents. You need to learn how to release the muscles to relieve pelvic pain that is caused by the tension. It helps to visualise the movement of the pelvic floor as your relax.

  1. Lie on your back
  2. Pull your legs up - So that your knees are bent above you.
  3. Slowly and gently, drop your knees outwards to the sides - While keeping your feet together. As you do so, feel your muscles release all the way from the front to the back passage at the base of your spine. Don't push your knees down if it is uncomfortable for them to fall.
  4. Hold - For 30-90 seconds.
  5. Pull your legs back together
  6. Repeat - Repeat this for 5 minutes. This stretch will become easier and quicker over time. Don't rush and let your legs fall as this can strain your hips. Be gentle and move your legs slowly, concentrating on any areas that are more tender rather than skipping quickly over them as your knees fall.

Pelvic Floor Muscle Stimulators

Pelvic floor muscle stimulators, also known as electronic pelvic floor exercise toners, can aid the treatment of your pelvic pain. These devices can be purchased privately for home use, or loaned from a Women's Health Physiotherapist. The electrical devices stimulate the muscles for you, enhancing their strength and, as a result, your control over them.

Traditional pelvic floor exercises can overstimulate an already stressed, in-pain pelvic floor. This is where a quality pelvic floor electrical stimulator can really help. Pelvic floor toners are commonly used when you need a quick resolution to a weak pelvic floor, such as is the case if you suffer from urinary incontinence or an early stage pelvic organ prolapse. The programmes are set to avoid over-exercising the muscles. Some devices even have programmes specifically for releasing tight pelvic floors and relieving pelvic pain. Pain relief programmes help to relax the muscle and relieve the spasm, which in turn then starts the circulation again. Allowing blood to flow through the muscles bringing oxygen to help them function correctly.

Pelvic floor muscle stimulators often use a vaginal or anal probe, to deliver neuromuscular electrical stimulation (NMES) directly to the pelvic floor muscles. Some can also be used with skin electrodes to stimulate either the tibial nerve or sacral nerve, which runs to the pelvic floor muscles. Read our guide on electronic pelvic toners to learn more.

Biofeedback Machines

Biofeedback machines are often used to demonstrate whether you are exercising your pelvic floor correctly. Squeezing against a vaginal probe measures the strength of your pelvic floor. This can be used to monitor your progress in strengthening the muscles.

As with the muscle stimulators, biofeedback machines can be purchased privately for home use, or loaned from your Physiotherapist.

There are other biofeedback techniques used by Physiotherapists to complement the use of a biofeedback machine. These include practising to defecate with a water filled balloon, and techniques to avoid or cope with pain triggers. Speak to your Physiotherapist for more information.

Sitz Bath with Epsom Salts (Magnesium Sulfate)

Magnesium is essential for many of the bodies processes, it helps:

  • relieve pain
  • relax muscle spasms and tension
  • ease the symptoms of premenstrual syndrome
  • treat constipation more effectively than laxatives - by softening stool and relaxing your gut
  • the production of the happy-hormone, serotonin
  • hormone production responsible for calming the brain and inducing relaxation - aiding a good nights sleep
  • prevent seizures
  • treat asthma
  • enhance the action of analgesics used in surgery
  • relieve rheumatism

Most of us are currently deficient in magnesium as we do not get the recommended daily allowance from our diet. Certain health conditions can lead us to becoming further deficient, notably bowel problems such as Crohn's disease which prevents the absorption of magnesium as food passes through our intestines.

Epsom salts are a pure mineral compound of magnesium and salt. Food grade salts can be taken orally, or absorbed through the skin when dissolved within warm water. Dissolving the salts in water is preferable when bowel problems are present, as taking the salts as a supplement would have limited benefit. You can add Epsom salts to a bath, or into a sitz bath which sits in the toilet bowl for easy use.

  1. Fill the sitz bath - With water at 50-55°C.
  2. Add 1/2 cup (125ml) of Epsom salts - If you are using a full bath instead of a sitz bath, dissolve 2 cups (550ml) of Epsom salts into the water.
  3. Ensure the salts are completely dissolved
  4. Soothe yourself - For at least 12 minutes for optimum absorption.

Perineal Massage

Massaging the perineum can help relax the pelvic floor by increasing blood flow to the area, helping to loosen the tissue. This can be especially helpful before or after sex when penetration or orgasms can cause painful spasms or tightening. Some women massage their perineum during pregnancy to relieve tension in the area.

  1. Wash your hands - You can use your fingers, or a vaginal dilator and lubricant if you prefer.
  2. Lie comfortably - With your knees bent and feet flat.
  3. Apply pressure to the perineum - The area between the vagina and anus, for 30-90 seconds.
  4. Repeat - If necessary, wait a minute or two before applying pressure again.

Therapeutic Pelvic Wands

If you have tight muscles in your back you may get a massage. Your muscles will be manipulated with pressure applied to stretch out the tense and tight areas. However, tense areas in the pelvic floor are harder to get to. If you are working with a Women's Health Physiotherapist to manage your symptoms, they may massage your pelvic floor gently with their fingers or with a therapeutic pelvic wand. These pelvic wands are designed to be inserted into the vagina to put gentle pressure on painful tight areas.

Pelvic wands can be purchased for home use. Your Physiotherapist can advise on the best way for you to use your pelvic wand most effectively, as it varies depending on the location of your pelvic pain. However, the wand can be manipulated without much instruction to massage the pelvic floor muscles and relieve discomfort. The most important thing to understand is that you must be gentle with yourself and stop if anything is too uncomfortable or painful.

  1. Make yourself comfortable - You may find the most comfortable position to use the wand will be lying with your back propped on several pillows and with your knees bent. In this position your muscles are relaxed as gravity is not working against them.
  2. Lubricate the wand - Ensure you use a generous amount of lubricant. If you are particularly sensitive, you may want to use specific unscented sensitive lubricant to avoid any irritation.
  3. Breathe - Take some deep breaths and relax.
  4. Insert the pelvic wand - Insert the wand a few centimetres into your vagina. No more than you would insert a finger.
  5. Moving the wand - There are several techniques you can do to relax the pelvic floor.
    1. Apply pressure in certain areas - If you picture the vaginal opening as the centre of the clock, put pressure at 3 and 9 o'clock, towards each hip. Removing the wand fully before moving to the other side of the vagina. With a sweeping motion, move the wand against the muscles on each side. Unless discussed otherwise with your Physiotherapist, avoid applying pressure towards your front or back (12 or 6 o'clock). This is where the delicate urethra and rectum are. The back and front of the pelvic floor muscles will benefit from the release of tension elsewhere on the pelvic floor, and therefore do not need to be targeted specifically.
    2. Releasing trigger points - There may be specific spots within the muscle that are particularly tight or sensitive. These may be areas of scar tissue from undergoing a pelvic surgery, or may be a 'trigger point' in the muscle which is most tense. A motion of gentle strokes on these areas can provide relief by lengthening the muscle to remove trigger points of extreme tenderness. Holding the wand with pressure on a single point for 30-90 seconds can also stretch the muscle.
    3. Training your muscles to relax - As you place the wand on sensitive areas, contract your pelvic floor as if you are trying to stop wind from escaping. This will contract the pelvic floor causing it to rise. Let the wand be moved up with the contraction, and apply gentle pressure as you relax your pelvic floor again. This will train your muscles to know the sensation for relaxing the muscles fully. Try contracting and relaxing your pelvic floor without applying pressure to the pelvic wand. You should see the handle move as your muscles contract (move up) and relax (move down). Repeat this several times.
  6. Stop if you feel any discomfort - If you feel any discomfort or experience any bleeding during or after your use of the pelvic wand, speak to your doctor. Your Physiotherapist can help you improve your technique to avoid discomfort.
  7. Keep the wand clean - Ensure that you keep your pelvic wand clean and safe between uses. A small amount of warm water and soap will be enough.

Although using a pelvic wand may seem daunting, they are designed to curve to the shape of the body. They are slim, smooth and can be placed in cold or warm water to change their temperature for added relief. Many pelvic wands are so slim that they are indistinguishable from your fingers. Most importantly, using a pelvic wand for 5 minutes daily for 6 weeks has been shown to provide considerable relief from prolonged pelvic pain. If you are anxious, try using your thumb to apply pressure in the same way as described above, and see the relief that you can get.

Sources

Bhatia, T. (2015). Highly Acclaimed Doctor Suggests Magnesium Supplements and Epsom Salt Baths to Help Alleviate Common Women’s Health Conditions. [online] Epsom Salt Council, 2015 [viewed 02/07/18]. Available from: https://www.epsomsaltcouncil.org/health/highly-acclaimed-doctor-suggests-magnesium-supplements-and-epsom-salt-baths-to-help-alleviate-common-womens-health-conditions/

Berghmans, B. (2018). International Urogynecology Journal. Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource. [online] 29(5), p631-638. [viewed 02/07/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5913379/

Chiarioni, G. Nardo, A. Vantini, I. Romito, A. Whitehead, W. E. (2010) Gastroenterology. Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome. [online] 138(4), p1321-1329. [viewed 02/07/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847007/

Cronkleton, E. (2018). What Is a Reverse Kegel, and Why Should I Do One? [online] Healthline, 2019. [viewed 02/07/18]. Available from: https://www.healthline.com/health/fitness-exercise/reverse-kegel

DiNicolantonio, J. J. O’Keefe, J. H. Wilson, W. (2018). Open Heart. Subclinical magnesium deficiency: a principal driver of cardiovascular disease and a public health crisis. [online] 5(1), e000668. [viewed 02/07/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786912/

Do, S. H. (2013). Korean Journal of Anesthesiology. Magnesium: a versatile drug for anesthesiologists. [online] 65(1), p4-8. [viewed 02/07/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726845/

Epsom Salt Council. (2015). Health uses of Epsom salt. [online] Epsom Salt Council, 2015 [viewed 02/07/18]. Available from: https://www.epsomsaltcouncil.org/uses-benefits/health/

Goldfried, M. R. Davison, G. C. (1972). Clinical Behavior Therapy, Expanded. Relaxation Training. USA: Wiley & Sons, p81-111.

Morrison, P. (2013). Using the TheraWand to Treat Pelvic Floor Muscle Dysfunction. [online] StressNoMore, 2018. [viewed 29/06/18]. Available from: /downloads/instructions/10113-IFUS.pdf

NAFC (2017). Pelvic Floor Stimulation. [online] National Association for Continence, 2017. [viewed 02/07/18]. Available from: https://www.nafc.org/pelvic-floor-stimulation/

Ribeiro, A. M. Ferreira, C. H. J. Mateus-Vasconcelos, E. C. L. Moroni, R. M. Brito, L. M. O. Brito, L. G. O. (2014). Case Reports in Obstetrics and Gynaecology. Physical Therapy in the Management of Pelvic Floor Muscles Hypertonia in a Woman with Hereditary Spastic Paraplegia. [online] 306028. [viewed 02/07/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4247965/

Stein, A. (2013). Internal Pelvic Floor Self-Massage Guide. [online] Beyond Basics Physical Therapy, 2013. [viewed 02/07/18]. Available from: https://beyondbasicspt.files.wordpress.com/2013/11/internal-pelvic-floor-self-massage-guide.pdf

The Cleveland Clinic Foundation (2005). Diaphragmatic Breathing. [online] University of Georgia, Department of Psychology, 2005. [viewed 02/07/18]. Available from: http://www.psychology.uga.edu/sites/default/files/CVs/Clinic_Diaphragmatic_Breathing.pdf

The International Pelvic Pain Society. (2014). Chronic Pelvic Pain. [online] The International Pelvic Pain Society, 2014.

Waring, R. H. (2015). Report on Absorption of magnesium sulfate (Epsom salts) across the skin. [online] Epsom Salt Council, 2015 [viewed 02/07/18]. Available from: https://www.epsomsaltcouncil.org/wp-content/uploads/2015/10/report_on_absorption_of_magnesium_sulfate.pdf