Pelvic Floor Problems 101: prolapse, leaking and why more squeezing isn’t always the answer

Helen Ledwick went into pelvic floor problems with a familiar assumption: if something went wrong, a few squeezes would put it right. After developing a prolapse following her second birth, that explanation no longer made sense of her experience.

In Pelvic Floor Problems 101, she talks to her own women’s health physiotherapist, Manchester-based Katie Syrett, about what that simple picture leaves out. Their conversation covers supporting tissues, muscles that struggle to relax, fear of movement and the practical details of getting assessed.

The useful thread running through it is that pelvic floor problems need an explanation that fits the person’s symptoms. Strength may be part of the answer, but it is not the only thing Katie considers.

Prolapse involves more than muscle strength

Helen describes the pelvic floor as a hammock supporting the pelvic organs. Katie adds a detail that changes the picture: a hammock has both material and attachments. Alongside changes in muscle function, the tissues that provide support can stretch or be injured.

For Helen, this helps explain why strengthening her pelvic floor did not simply return everything to where it had been before childbirth. Katie separates improving support and symptoms from reversing every structural change. She also makes clear that a structural change does not automatically mean surgery is the next step.

That distinction matters when judging progress. In Katie’s account, a person may regain comfort and do more of the activities they want without being able to describe their anatomy as completely restored.

For current treatment context, the NHS prolapse guidance describes options including physiotherapy, pelvic floor muscle training, pessaries and, in some circumstances, surgery. The choice depends on the prolapse and how it affects the individual.

Leaking and prolapse do not always go together

Helen points out that she has a prolapse but does not experience the incontinence she hears other women describe. Katie explains that the two can overlap without being the same problem: some people have prolapse without noticeable symptoms, while others have continence problems without a prolapse.

Earlier in the conversation, Katie distinguishes leaking during a cough, sneeze or jump from a sudden need to reach the toilet. She also sees people with heaviness, discomfort and persistent pain. Her patients include women after childbirth, younger women who notice symptoms during exercise, and women experiencing changes around menopause.

The practical value of these examples is specificity. Telling a clinician that you leak when you jump describes something different from saying you cannot get to the toilet in time, or that you feel a vaginal heaviness. The episode gives those experiences separate space instead of putting them all under one label of a weak pelvic floor.

An overactive pelvic floor can be painful and ineffective

Katie’s explanation of persistent pain is one of the clearest reasons this is not simply an episode about doing more pelvic floor exercises. She describes seeing people whose pelvic floor muscles remain excessively active and have difficulty letting go.

She compares that sustained effort to keeping an arm muscle contracted: being tense continuously is not the same as being ready to work well when needed. In her explanation, fatigue and difficulty relaxing can sit alongside pain and leaking. She discusses birth trauma, recurrent urinary infections and anxiety as possible parts of the histories she encounters, rather than offering one explanation for every person’s pain.

This is also why Katie describes pain treatment as looking at symptoms and triggers more closely, instead of handing out a generic strengthening routine.

The Royal United Hospitals Bath information on pelvic floor relaxation supports the underlying distinction: a pelvic floor that is already tense can be difficult to contract effectively, and overactivity can be associated with bladder, bowel and sexual pain. The leaflet emphasises individual assessment. Symptoms alone do not tell you whether you need strengthening, relaxation work or another approach.

What does lifting advice mean when you have a baby?

Helen and Katie spend time on a very concrete problem: someone has been told to avoid heavy lifting, but still needs to carry a toddler, move a pram or lift a baby’s car seat.

“So there really is no point just saying don't lift because you're not really being realistic about what that woman's lifestyle is like.”

— Katie Syrett, women’s health physiotherapist

Katie describes women arriving frightened and unsure whether ordinary childcare tasks are now unsafe. Her response is to make the advice practical: discuss the task, consider breathing, and look at the work of the abdominal and gluteal muscles as well as the pelvic floor. Helen says that understanding the role of the surrounding muscles helped her feel able to move again.

This part of the episode is about individualised rehabilitation, not blanket permission to lift or run through symptoms. The NHS currently advises avoiding activities that put a lot of strain on the pelvic floor, including heavy lifting, for people with prolapse. A useful question for your own physiotherapist is therefore: how should I adapt the tasks I actually have to do? Katie’s car-seat example shows why a specific conversation is more useful than leaving someone to guess what heavy means.

What happens at a pelvic health physio appointment?

Katie describes an appointment that begins with questions about bladder and bowel function, daily symptoms and how they affect your life. Sexual symptoms may also come up. The questions help her understand the problem before deciding what to examine or work on.

She explains that an internal examination can help assess how the pelvic floor contracts and allow feedback while someone tries a contraction. Helen describes her own experience as less uncomfortable than a cervical screening appointment; that is her personal experience, not a promise about how an examination will feel for everyone.

Crucially, Katie says the examination is optional. Someone may want to return another day, or pain may make an internal assessment inappropriate at that stage. She describes postponing it for some patients rather than treating it as a requirement to receive help.

The University Hospitals Sussex appointment guide also explains that consent is needed, that treatment can continue if you decline an internal examination, and that a chaperone is available. Its description of the physio examination does not involve a vaginal speculum. Other kinds of pelvic examination, including assessment for prolapse by a doctor, can differ.

Menopause and the fear of becoming less active

Later, Katie describes seeing symptoms change around menopause, including in women who have not had children. Helen asks whether her emphasis on exercise means pelvic floor exercises alone. Katie’s answer is broader: she also discusses strength and resistance work.

Her concern is that leaking can lead someone to withdraw from activities they value. That echoes the earlier discussion of lifting and Helen’s account of feeling more hopeful after physiotherapy. For a listener, the question becomes how to get help with the symptom and discuss appropriate activity, rather than assuming that having a pelvic floor problem ends the possibility of exercise.

The question this episode helps you ask

By the end, the useful question is more detailed than “How many squeezes should I do?” It is: what is contributing to my symptoms, and what would help me do the things that matter to me?

That might mean discussing whether your muscles relax fully, what a sensation of heaviness could mean, how to manage lifting at home, or what an examination would involve before agreeing to it. These are all questions the conversation makes tangible.

Listen to the full episode below for Helen and Katie’s exchange, or explore our Why Mums Don’t Jump series guide. If you have a vaginal bulge or other prolapse symptoms, the NHS recommends seeing a GP.