Pelvic Floor Dysfunction: The Overlooked Cause of Pelvic Pain
If you’ve ever been told your exam, labs, or imaging are “normal” — but your body is very much not — pelvic floor dysfunction might be the missing piece.
Pelvic floor dysfunction is one of the most common, underdiagnosed causes of pelvic pain, painful sex, bladder issues, and bowel problems. It doesn’t show up on ultrasounds. It doesn’t get fixed with antibiotics. And it’s often misunderstood as weakness, anxiety, or something you’re supposed to “push through.”
It’s none of those things.
What Is Pelvic Floor Dysfunction, Really?
Your pelvic floor is a group of muscles that sit like a supportive hammock at the base of your pelvis. They help control urination and bowel movements, support pelvic organs, and play a huge role in sexual function.
Pelvic floor dysfunction happens when these muscles don’t work the way they’re supposed to — not because they’re broken, but because they’re misfiring, overworking, underworking, or stuck in a pattern that no longer serves you.
And no, it’s not just about being “weak.”
The Forgotten Muscle Group
When we think about musculoskeletal problems, we usually picture things like shin splints, pulled hamstrings, rotator cuff injuries, ligament sprains, or low-back strain. We understand that muscles, joints, and connective tissue can become tight, irritated, injured, or dysfunctional — especially when they’re overused, guarded, or compensating for something else.
The pelvic floor is no different. In fact, it’s one of the most complex and constantly working muscle systems in the body.
It often gets forgotten because it does much of its work subconsciously, without us ever having to think about it. It responds to posture, breathing, stress, pain, trauma, surgery, and movement. It adapts — sometimes too well. And like any other musculoskeletal system, it can develop dysfunction when it’s asked to do too much, protect too hard, or work through pain for too long.
The difference is that we’re far less practiced at recognizing pelvic floor issues — even though they behave just like muscle problems everywhere else.
The Different Ways Pelvic Floor Dysfunction Can Show Up
Pelvic floor dysfunction isn’t one thing. It’s a spectrum.
Some people have muscles that are:
Overactive (too tight, guarded, unable to relax)
Underactive (not providing enough support)
Uncoordinated (contracting when they should relax, or vice versa)
Many people have a combination — and that’s where things get confusing.
What Causes Pelvic Floor Dysfunction?
Pelvic floor dysfunction doesn’t have a single cause. Instead, it usually develops when the pelvic floor muscles are exposed to stress, injury, pain, or prolonged compensation — much like any other muscle group.
For some people, the muscles become overactive or tight. This can happen in response to:
Chronic or past pelvic pain
Trauma (medical, sexual, or otherwise)
Repeated painful experiences
Stress or anxiety
Anticipation of pain, leading to unconscious guarding
In other cases, the pelvic floor becomes weakened or less supportive over time. Contributing factors can include:
Pregnancy and childbirth
Prolonged pushing or delivery-related injury
Pelvic or abdominal surgery
Aging and hormonal changes
Many people experience a combination of these factors — tight muscles in some areas, weakness or poor coordination in others. This overlap is one reason pelvic floor dysfunction can be so hard to recognize and so easy to misdiagnose.
Common Symptoms (That Are Often Misattributed)
The symptoms of pelvic floor dysfunction often depend on what’s going wrong with the muscles — whether they’re too tight, too weak, poorly coordinated, or stuck in a protective pattern. It’s also not uncommon to have more than one type of dysfunction happening at the same time.
Pelvic floor dysfunction can cause:
Pain with penetration, tampons, or pelvic exams
Chronic pelvic pain with no clear diagnosis
Urinary urgency, frequency, or leaking — even without infection
Constipation or difficulty emptying the bowels
Pain after sex (not just during)
A feeling of pressure, tightness, or heaviness in the pelvis
Hip, tailbone, or low back pain that never quite resolves
If you’ve tried treatment after treatment and nothing seems to fully help, this is a big clue.
How Is Pelvic Floor Dysfunction Actually Diagnosed?
Diagnosing pelvic floor dysfunction relies far more on a good history and physical exam than on a single test.
Often, the way someone describes their symptoms alone — pain with penetration, difficulty relaxing, bladder or bowel symptoms that don’t follow typical patterns — raises strong suspicion for pelvic floor involvement.
Many patients still undergo additional testing to rule out other causes, such as pelvic pathology or structural conditions. This is appropriate and often helpful. But ruling other things out doesn’t rule pelvic floor dysfunction in.
To truly evaluate pelvic floor dysfunction, a specialized pelvic exam is needed — one that assesses the pelvic floor muscles themselves, including tone, tenderness, coordination, and ability to contract and relax.
Any women’s health care provider can technically perform this type of exam, but not all are specifically trained to do so. Providers who tend to be more attuned to recognizing pelvic floor dysfunction include gynecologists, OB-GYNs, minimally invasive gynecologic surgeons (who see many patients with pelvic pain and endometriosis), urogynecologists, and pelvic floor physical therapists.
That said, if any provider suspects pelvic floor dysfunction — or if you bring it up — it’s always reasonable to request referral to someone who can evaluate this more thoroughly or to pelvic floor physical therapy directly.
Why Tests Are Often “Normal”
This is one of the most frustrating parts.
Pelvic floor dysfunction doesn’t usually show up on:
Ultrasound
MRI
CT scans
Bloodwork
Standard pelvic exams
That doesn’t mean nothing is wrong. It means the issue lives in muscle behavior, tone, coordination, and the nervous system — things imaging doesn’t capture.
The Nervous System Piece (The Part That Gets Missed)
Pelvic floor dysfunction is often tied to:
Other causes of pelvic pain (endometriosis, adenomyosis, etc.)
Past pain
Trauma (medical, sexual, or otherwise)
Chronic stress or anxiety
Anticipation of pain
When the body expects pain, muscles brace. Over time, that bracing becomes automatic — even when the original trigger is gone.
This isn’t “in your head.”
It’s your nervous system doing its job a little too well.
What About Vaginismus?
Vaginismus is best understood as one presentation of pelvic floor dysfunction, not a separate failure or psychological flaw.
It involves involuntary tightening of the pelvic floor muscles that makes penetration painful or impossible. Many people with vaginismus also have:
Pelvic floor overactivity
Fear-pain cycles
Prior painful experiences
Overlapping conditions like vulvodynia
Treatment isn’t about “forcing relaxation.” It’s about retraining the muscles and nervous system safely and gradually — which is exactly where pelvic floor physical therapy shines.
What Is the Treatment for Pelvic Floor Dysfunction?
Treatment focuses on restoring normal muscle function, reducing pain, and retraining the nervous system — not just strengthening muscles indiscriminately.
For most people, treatment includes a combination of:
Targeted relaxation and retraining exercises
Addressing breathing, posture, and movement patterns
Pain modulation strategies when needed
The approach is individualized. What helps one person may worsen symptoms in another — which is why guidance matters.
Why Pelvic Floor Physical Therapy Is the Cornerstone of Treatment
Pelvic floor physical therapy isn’t an add-on. It is the treatment.
Seeing a specialized pelvic floor physical therapist is essential. Pelvic floor therapy is highly individualized, and what helps one person may worsen symptoms in another.
Online guides or generic “do-it-yourself” pelvic floor programs are often less effective — and in some cases may even make symptoms worse — because they aren’t tailored to your specific muscle patterns, symptoms, or underlying causes.
A trained pelvic floor physical therapist can:
Assess muscle tone and coordination (including internally, when appropriate)
Help relax overactive muscles
Retrain coordination and timing
Address posture, breathing, and movement patterns
Help you effectively and safely use additional tools, such as dilators or pelvic floor wands, when appropriate
Guide safe, effective at-home tools when needed
This work is precise, individualized, and often life-changing.
Why Pelvic Floor Physical Therapy Is the Cornerstone of Treatment
Pelvic floor physical therapy isn’t an add-on. It is the treatment.
Seeing a specialized pelvic floor physical therapist is essential. Pelvic floor therapy is highly individualized, and what helps one person may worsen symptoms in another.
Online guides or generic “do-it-yourself” pelvic floor programs are often less effective — and in some cases may even make symptoms worse — because they aren’t tailored to your specific muscle patterns, symptoms, or underlying causes.
A trained pelvic floor physical therapist can:
Assess muscle tone and coordination (including internally, when appropriate)
Help relax overactive muscles
Retrain coordination and timing
Address posture, breathing, and movement patterns
Help you effectively and safely use additional tools, such as dilators or pelvic floor wands, when appropriate
Guide safe, effective at-home tools when needed
This work is precise, individualized, and often life-changing.
Is It Going to Hurt?
Sometimes, yes — especially at first if pain has been present for a long time.
But pain during therapy isn’t a sign of failure. It’s often confirmation that the right system is being addressed. With time, consistency, and good communication, therapy should become more tolerable and eventually relieving.
If pain is too intense, adjustments can — and should — be made.
For a deeper dive into what pelvic floor physical therapy involves — and ways to make it more effective and comfortable — we break this down further in our dedicated pelvic floor physical therapy article.
Other Treatments That Can Help (Alongside Physical Therapy)
While pelvic floor dysfunction can’t be fully addressed without appropriate physical therapy, additional treatments can be helpful when used in conjunction, especially in more severe cases.
Some of these include:
Pelvic floor injections
In certain situations, specialized providers can inject medications directly into the pelvic floor muscles to help reduce pain and muscle tension.
Nerve-calming medications
Medications such as gabapentin, pregabalin (Lyrica), amitriptyline (Elavil), or duloxetine (Cymbalta) may be used for pain modulation.
Addressing stress and mental health
If stress or anxiety is contributing to symptoms, therapy or medication (such as SSRIs) may be part of the overall treatment plan.
Localized or topical treatments
Depending on the symptoms, local treatments such as topical lidocaine, compounded topical medications, or vaginal suppositories may help calm irritated nerves.
Local muscle relaxants
Treatments such as vaginal diazepam (vaginal Valium) or other localized muscle relaxants like baclofen may be used in select cases.
All of these treatments are generally short-term supports. They don’t address the underlying cause of pelvic floor dysfunction on their own, so they aren’t usually long-term solutions. However, in more severe cases, they can be used strategically to make physical therapy more tolerable and help it work more effectively.
The Bottom Line
Pelvic floor dysfunction explains symptoms that don’t make sense on paper — but make perfect sense in the body.
If you’ve been dismissed, told to relax, or made to feel like you’re overreacting, you’re not alone. And you’re not imagining things.
There is a name for what you’re experiencing. And there is a path forward.
Tell us how you really feel
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