Overactive pelvic floor: can women store their anxiety 'down there?'

Philippa Batley, 30, spent years as a figure skater and model maintaining her core strength, exercising regularly, and being mindful of her posture.

That’s a good thing, right?

It meant her pelvic floor, the funnel-shaped muscle that supports the bladder, reproductive organs, and bowel in men and women, was constantly taut.

Throw in the pain of endometriosis, a disease that often comes with excruciating periods among a host of other symptoms, add some surgery to treat the disease, plus the anxiety of life, and Batley’s body was riddled with pain. This included pain in her pelvic region that switched between dull and sharp stabs as well as pain. Urinary incontinence was also an issue, says Batley, who lives in Whangārei.

“When I was about 24, I was talking to my mum in the kitchen, so calm no issues and I wet my pants and I just started crying. How did this happen? I didn’t feel any urge to go to the bathroom....”

Four months ago, she started seeing pelvic health physiotherapist Nicol Ranger, who found Batley’s pelvic floor was overactive, a byproduct of continuous pain.

“....people associate [urinary incontinence] with a weak pelvic floor and in my case, it’s the opposite.”

And that’s the intricate and complicated existence of the pelvic floor muscle. In recent decades, pelvic health physiotherapists, the main port of call for anything pelvic floor, have worked to destigmatise pelvic floor weakness, which tends to plague women following childbirth and around menopause.

However, having an overactive pelvic floor has flown under the radar with young women in their late teens, 20s, and 30s making up a large number of patients seeking treatment, according to four New Zealand pelvic health physiotherapists and a urologist. Yet, not every clinician is seeing this pattern, including New Zealand’s leading pelvic health physiotherapist Dr Melissa Davidson, citing a lack of quality research linking pain to an overactive or hypertonic pelvic floor.

It also presents something of a Goldilocks dilemma for the one in three women who will experience some sort of pelvic floor dysfunction: How to keep the muscle not too tense, not too weak, but just right to avoid some joy sucking symptoms like urinary or fecal incontinence, pain during sex, difficulty using tampons, and lower back pain. While research is limited, one study indicated that 16 percent of men can experience pelvic floor dysfunction.

About half the patients who come to Liz Child’s pelvic health physiotherapy clinic in Wellington each week have some level of overactivity in their pelvic floor, she says. For Ranger, who is treating Batley, about 30 percent of her patients have an overactive pelvic floor.

“I think in the media generally it is all about pelvic floor strengthening, and I think we are having a little bit of an epidemic of tight pelvic floor at the moment,” says Ranger.

Numerous studies found a high prevalence of overactive pelvic floor muscles in those with other gynecological issues, such as lower urinary tract symptoms and endometriosis. Negative sexual experiences can also trigger overactivity. However, assessment methods were inconsistent and led to unreliable results, according to a 2023 systematic review of 151 studies on the subject.

One of the reasons is the difficulty in accessing the intimate muscle, says one of the review's co-authors, Associate Professor David Cowley, a pelvic health physiotherapist at the University of Queensland. The gold standard for assessing the pelvic floor is an internal exam performed by the pelvic health physiotherapist using their fingers.

“We're not denying that there is this phenomenon. We're just saying that the way we're doing it, both clinically and in research, the methods we have to assess it aren't stringent enough and aren't reliable enough and often aren't validated...”

Davidson, a leading pelvic health physiotherapist internationally and in New Zealand, is concerned that some clinicians are too focused on overactivity rather than the issue behind it. Fears that the muscle could be overworked might also steer women away from pelvic floor exercises, a treatment for pelvic floor weakness that has quality evidence behind it, she says.

“I don't think we should be assuming those muscles are tight. We need to look at the whole person. We need to look at them mentally, physically, the whole person."

Davidson gave the example of a patient who had pain during sex that linked back to overly religious beliefs about intimacy; therefore, the treatment was largely counselling. Another teenage patient came to her because inserting a tampon was unbearably painful. A clinician had previously told the patient her pelvic floor was too tight, but what Davidson discovered was a small, highly sensitive area at the vagina entry.

“...by changing the angle of her insertion point, she's able to use the tampons successfully.”

Like other pelvic health physiotherapists, Ingrid Vollweiler sometimes enlists the support of a psychologist for patients who have an overactive pelvic floor, which makes up 50 percent of her patient load.

​“If you’ve got stress or anxiety, it’s really normal to have tightness there,” she says, adding that “no one is just their vagina and you can’t separate the body from the brain...”

Overactive pelvic floor patients are typically taught “down-training”, says Vollweiler. This includes breathing techniques that engage the diaphragm, mindfulness to cope with stress, and hip and back mobility work through massage and stretching. Physiotherapists may also prescribe dilators, which are insertable tools that slowly stretch the muscle. There is also a device called a pelvic wand for self-massage and gentle stretching.

Urologist Dr Eva Fong occasionally uses Botox when other methods, such as breathing and stretching, have failed.

“Botox only lasts for three months, so if [patients] don’t follow it with sustained physio, it’s not going to be a long-term solution, so [Botox] can be a sort of circuit breaker.”

Because overactivity in the pelvic floor is underresearched, patients should feel empowered to push for other options if a specific treatment isn’t working within a reasonable timeframe, even if that means going to another pelvic health physiotherapist, says Cowley, from the University of Queensland. That advice can be applied to any medical field, he added.

Batley, who started treatment for an overactive pelvic floor four months ago, has seen her pain dialed back. The key has been diaphragmatic breathing, stretches for the hips and lower back, as well as abdominal massage from Ranger, the pelvic health physical therapist. When Batley feels up to it during an appointment, Ranger does an internal massage and stretches too. Batley also sees a psychologist to help manage her pain.

When Batley first visited Ranger, she could hardly walk and arrived with three hot water bottles and a heat pack to manage the pain.

“... I went to see her last week and I didn’t have one with me.”