Specialist article on the pelvic floor
Strengthening the pelvic floorThinking from the top down
For many people, pelvic floor training means: tense, hold, release. Here you will learn which muscles belong to the pelvic floor, how it forms a pressure chamber together with the diaphragm and breathing, why the right timing counts as much as strength, and how the FaceFormer pelvic floor exercise links the lips, breathing and pelvic floor in one sequence.
Does this sound familiar?
The pelvic floor makes itself felt when the pressure rises
What applies to you?
Tap whatever applies to you.
If several points apply, it is worth looking beyond the pelvis. The pelvic floor is the lower end of a pressure chamber whose upper end reaches up to the mouth. How well it holds therefore also depends on breathing, swallowing and head balance, and this interplay can be trained.
Two patterns of the pelvic floorThe connection to the mouthThe key points at a glance
- The pelvic floor is a plate of muscle made up of several layers. It supports the organs in the pelvis, keeps the bladder and bowel closed and stabilises the trunk, in women as in men.
- Together with the diaphragm, it forms the floor and lid of a pressure chamber. During calm breathing, both move together; under load, the pelvic floor has to hold against the pressure, and at the right moment.
- In our view, pelvic floor training also includes the upper part of the system, that is, breathing, swallowing and head balance. The FaceFormer pelvic floor exercise links the lips, breathing and pelvic floor in one sequence.
Video
Pelvic floor: what is often forgotten in training
Das Video lädt erst nach dem Klick. Dann werden Daten an YouTube (Google) übertragen.
Anatomy
Pelvic floor muscles: three layers, one floor
The pelvic floor closes off the trunk at the bottom. You cannot see it, you rarely feel it, and yet it works along with every breath.
The pelvic floor refers to the muscles and connective tissue plates that close off the bony pelvic ring at the bottom. They stretch between the pubic bone, the coccyx and the two sitting bones. On the outside lie the sphincter muscles of the urethra and anus, and deeper down the large levator ani, which fills the pelvis like a hammock. The urethra and rectum pass through this floor, and in women the vagina as well.
Supporting
The bladder, the bowel and, in women, the uterus rest on the pelvic floor. It absorbs their weight and every surge of pressure from above.
Closing
The sphincter muscles keep the urethra and rectum sealed and release them when you go to the toilet.
Stabilising
Together with the diaphragm and the deep abdominal and back muscles, it keeps the trunk stable, especially during rapid movements.
Breathing along
It moves with every breath, together with the diaphragm.
So the pelvic floor has to be able to do two things: support and close, but also let go when the bladder or bowel empties. Men have a pelvic floor too. It is shaped differently but fulfils the same tasks. Pelvic floor training is therefore not purely a women’s topic, even though much of the research has been done on women. In men, it often only comes into focus after prostate surgery.
Pelvic floor and diaphragm
A pressure chamber with a lid and a floor
Anyone who wants to understand the pelvic floor has to look upwards. Its most important partner sits one floor higher.
The abdominal cavity is enclosed by muscles all around. At the top lies the diaphragm, the most important breathing muscle, at the bottom the pelvic floor, and in between the abdominal and back muscles. This space can hardly be compressed. If it becomes narrower at one point, the pressure rises everywhere, and the other walls have to absorb it. When the diaphragm lowers as you breathe in, it pushes the organs downwards, and the pelvic floor takes up this pressure.
During calm breathing, the diaphragm and pelvic floor move together. A research group in Tyrol filmed this in eight healthy women using real-time MRI. When breathing in, both sank downwards; when breathing out, both rose again, also when coughing1.
The pelvic floor is not merely a passive follower. In measurements from Brisbane, it tensed even before the test subjects moved an arm, as part of anticipatory trunk stabilisation. Its breathing activity there occurred mainly during exhalation2.
Like a tube with two ends
If you squeeze a tube of toothpaste, the contents escape where the tube offers the least resistance. It is similar in the trunk. When the pressure rises during coughing, sneezing or lifting, it seeks out the most yielding point. If the pelvic floor does not hold against it in time, something gives way down below.
3D film
The pelvic floor exercise seen inside the body
In 46 seconds, the animation shows what happens in the trunk during the FaceFormer pelvic floor exercise. When breathing in, the diaphragm and pelvic floor move against each other.
Two patterns
Moving along and holding against
The pelvic floor has two ways of working. Which one is needed at any moment is decided by the pressure from above.
During calm breathing, the pelvic floor moves along with the diaphragm. This is its basic tension pattern, physiological and useful. When coughing, sneezing, laughing, lifting or jumping, however, the pressure in the abdomen shoots up in fractions of a second. Now a second pattern is needed, the pressure-adaptive protective function. The pelvic floor does not give way but tenses and keeps the closure sealed, ideally even before the pressure wave arrives.
Basic tension pattern
- Runs during calm breathing
- Diaphragm and pelvic floor move together
- When breathing in, the pelvic floor yields slightly
- Needs little strength
Protective pattern under pressure
- Runs when coughing, sneezing, laughing and lifting
- The pelvic floor holds against the pressure from above
- It tenses before the pressure arrives
- Needs above all the right timing
Both patterns are physiological. Whether you stay sealed in everyday life is decided mainly by the second.
less urine loss with a moderate cough was achieved on average by 27 older women with mild to moderate stress incontinence when they tensed the pelvic floor just before and during the cough, one week after instruction3
less was the figure with a deep cough. The improvement was not related to the measured muscle strength3
The researchers from Michigan called this technique “The Knack”. It shows what matters in the protective pattern: not only strength, but that the pelvic floor kicks in at the right moment. In our view, this timing is given too little attention in classic programmes, because they mainly activate the muscle at rest and in isolation.
Floor of the mouth, diaphragm, pelvic floor
Pelvic floor and breathing: the connection from above
The pressure chamber does not have just one lid. Above the diaphragm lie the larynx, throat and mouth, and pressure is regulated there too.
Coughing, sneezing and laughing begin at the top. The surge of pressure arises in the chest, larynx and mouth, and down below the pelvic floor has to respond immediately. The lips, tongue and floor of the mouth form the upper valve of the airways. When the lips are closed and the tongue rests against the palate in the tongue reference position, the mouth is sealed. The air takes the route through the nose, calmly and with a little resistance.
of continent women in a Berlin study co-contracted the pelvic floor when they strained against a closed mouth and closed glottis4
was the figure when they instead strained downwards as during a bowel movement. The bladder neck and pelvic floor sank markedly lower in the process4
Breathing
Nasal breathing is slower and more even than mouth breathing. The diaphragm works in calm strokes, and the pressure in the abdomen rises and falls gently. In our view, shallow, rapid chest breathing distributes the load less favourably.
Swallowing
You swallow many hundreds to a thousand times a day. Each time, the mouth closes, the tongue rests against the palate, and the floor of the mouth and the hyoid bone briefly tense. The pelvic floor exercise uses this moment as a pacemaker.
Head balance
When the head is balanced over the trunk, the rib cage and pelvis are stacked above one another, and the diaphragm and pelvic floor face each other. If the head moves forward, in our view the whole axis beneath it shifts.
You often read that the tongue and pelvic floor are connected by a continuous fascial line. This comes from the Anatomy Trains model by Thomas Myers. A review from Frankfurt evaluated 62 dissection studies on six of these lines. Several were well supported, but the deep line leading to the tongue was not among them5. A continuous fascial connection down to the pelvic floor therefore remains an assumption.
An explanation via control is more plausible.Breathing, swallowing, trunk tension and the pelvic floor are organised together by the nervous system. That is why the pelvic floor can also be addressed via the mouth.
The jaw and pelvic floor also appear to be connected in muscle tension. In our experience, people who clench or grind their teeth often also have a tense pelvic floor, and vice versa. In a randomised study from Kraków with 47 young women who had pain in the jaw joint, a single 15-minute soft tissue treatment at the jaw joint measurably lowered the resting activity of the pelvic floor11. This is a single session without a clinical endpoint and does not prove a cause.
Dr. Berndsen describes a longitudinal line of pull on the front of the trunk, via the straight muscles. He observes that tension in the mouth makes the pelvic floor tense involuntarily as well, and the Berlin measurement above fits with this. This route as a whole has not been studied, but that does not mean it does not exist. Whether it runs via the muscles or via the shared control is open.
Mouth and floor of the mouth
The lips, tongue and floor of the mouth tense when you close your mouth, press or swallow.
Hyoid bone
Below the hyoid bone, straight muscles run to the breastbone.
Rib cage
The straight abdominal muscle begins at the lower rib cage.
Pubic bone
It runs down to the pubic bone. Parts of the pelvic floor also originate there.
Pelvic floor
According to Dr. Berndsen’s observation, it tenses as well when the mouth closes above and builds up pressure.
Developmental history also connects the two ends. In the early embryo, the mouth and the pelvic outlet develop at the two sites where the outer and inner germ layers lie on top of each other without an intermediate layer, as the beginning and end of the same intestinal tube. The muscles themselves come from different primordia, so one cannot speak of the same tissue. In our view, however, both ends work according to the same principle, as closures that seal tightly at the right moment.
Head balance and posture
What acts on the pelvis from above
Skull, spine, pelvis and pelvic floor are stacked on top of one another. Whatever goes out of alignment at the top arrives at the bottom.
When the head is balanced over the body, the spine carries it with little muscular effort. If it moves forward, for example at a screen, the neck and back have to hold it. In our view, this changes the whole axis. The rib cage sinks, breathing becomes shallower, the pelvis tilts, and the pelvic floor works from a less favourable position. In this picture, a hollow back or rounded back are consequences rather than causes.
The head moves forward
At the screen, on the phone, during long periods of sitting. The neck and upper back take over holding work.
The rib cage sinks
The ribs have less room to move, and breathing becomes shallower and more often into the chest.
The diaphragm works less freely
Pressure in the abdomen rises and falls more irregularly, and the abdominal wall takes over more.
The pelvis tilts
With it, the position and baseline tension of the pelvic floor change.
The pelvic floor compensates
It works against a load it is not aligned for and, in our view, reacts too late to pressure peaks.
from the Australian longitudinal study on women’s health were surveyed about back pain, incontinence and breathing difficulties6
for frequent back pain was found in young women with frequent incontinence compared with women without. For frequent breathing difficulties, the value in middle age was 2.06
The authors explain this by the fact that the same trunk muscles have to secure posture, breathing and continence at the same time. A one-off survey does not prove a cause, but it fits the picture of a system in which a disorder rarely remains isolated.
Research
Classic pelvic floor training: what it can do and where it stops
Pelvic floor exercises are among the best-studied forms of training of all. That deserves recognition, and it is worth taking a close look at what they train.
Classic pelvic floor training goes back to the American gynaecologist Arnold Kegel, who in 1948 described a programme of repeated, targeted contraction of the perineal muscles7. To this day, people often speak of Kegel exercises.
with 1,817 women from 14 countries were evaluated by the Cochrane review on pelvic floor training for urinary incontinence8
of women with stress incontinence reported being free of symptoms at the end, with training compared with no treatment8
That is a clear result. However, the review also names limitations. The studies were small to medium-sized, mostly ran for less than twelve months, and the programmes differed greatly. It also remains unclear whether those practising actually activate the muscle correctly.
of 47 women, after brief verbal instruction, contracted in a way that strengthened the closure of the urethra without bearing down9
used a technique that could rather promote incontinence9
This is where our criticism comes in, and it is not directed against practising, but against the narrow focus. In our view, classic programmes presuppose an intact system, meaning free nasal breathing, a calmly working diaphragm and stable head balance. If this is missing, the muscle becomes stronger but does not necessarily engage in time at the decisive moment.
The question is not only how strong the pelvic floor is, but whether it holds at the right moment.Strength is a prerequisite. Continence in everyday life depends on timing and on the interplay with breathing, swallowing and head balance.
Training
Strengthening the pelvic floor with the FaceFormer: the pelvic floor exercise
Our approach starts at the top. First, the training organises the basic functions of breathing, swallowing and head balance, with lip closure, nasal breathing and the tongue reference position. Only once this is secure is the pelvic floor added. It is then specifically integrated into the protective pattern. It tenses during inhalation while the diaphragm descends, and so learns to hold against rising pressure instead of giving way.
The foundation is the basic exercise. The FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth. The tip of the tongue rests on the small ridge behind the upper front teeth, you breathe through your nose, and your head is upright.
You press the lip wedge together with your lips, bite briefly on your back teeth and swallow. The negative pressure draws the tongue up to the palate. In many people, the basic exercise is established after two to four weeks.
In the pelvic floor exercise, you sit on a stool without a backrest or stand, feet flat and about shoulder-width apart, neck lengthened. You slowly press the lip wedge for six seconds while breathing in through your nose in one continuous breath. At the same time, you tense your buttock muscles and draw the front pubic region slightly upwards.
Then you maintain the lip pressure and pelvic floor tension, briefly hold your breath and swallow once with a short bite. Finally, you slowly release your lips and pelvic floor and breathe out for six seconds.
- From day 1
Basic exercise
Three times a day with the FaceFormer ZERO, plus the pull exercise. The free app guides you and counts along.
- After 2 to 4 weeks
The basic exercise is established
Lip closure, tongue reference position, nasal breathing and swallowing come together reliably. At night you wear the ZERO.
- From week 6
Pelvic floor exercise
In addition to the basic training, 5 repetitions three times a day.
- Week 7
Building up
8 repetitions three times a day.
- From week 8
Full programme
10 repetitions three times a day. If you train with a practice, they can adapt the plan to you.
The pelvic floor exercise is module 10 of the FaceFormer exercises. You can find the animation, training plan and help if it is still difficult on the pelvic floor exercise page. If you are having physiotherapeutic pelvic floor therapy, the training can be combined with it. If you experience pain, pause the training.
Body awareness
Feeling your pelvic floor and using it in everyday life
You are about to sneeze. What does your pelvic floor do?
Tense before the pressure
Before coughing, sneezing or lifting, briefly draw the pelvic floor upwards. With a little practice, this becomes a habit.
Lips closed, nose open
Your lips rest lightly together, the tip of your tongue in its place on the palate. This way you breathe calmly through your nose, and the diaphragm works evenly.
Head balance when sitting
Set up your screen and chair so that your head is balanced over your body. Sit on your sitting bones, not slumped on your sacrum.
Practise letting go too
A constantly tense pelvic floor can also cause problems. Every contraction should be followed by conscious release.
Do not stop prescribed treatment on your own
If you use a pessary, medication or physiotherapy on medical advice, discuss any changes with your practice. The training can be combined with these.
Pelvic floor weakness and incontinence
When you should have your pelvic floor examined
Pelvic floor weakness is common, but it is not something you have to resign yourself to.
It occurs particularly often after childbirth. According to a Cochrane review, around a third of women have urinary incontinence afterwards, and up to a tenth faecal incontinence. Continent pregnant women who trained specifically early in pregnancy probably reported incontinence less often in late pregnancy10. However, not every cause lies in the muscles.
Urine loss over weeks
After childbirth or surgery, the urine loss persists or increases.
Pressure downwards
A feeling of a foreign body or of prolapse in the vagina or at the perineum, especially in the evening.
Stool or wind
You cannot reliably hold stool or wind.
Pain
Pain in the pelvis, when urinating, during bowel movements or during sexual intercourse.
Sudden urge to urinate
A strong urge that often takes you by surprise, with or without urine loss.
Blood or burning
Blood in the urine or burning when urinating.
If you have pelvic floor problems after childbirth, after pelvic surgery, for example on the prostate or uterus, or with such symptoms, have this assessed by a doctor or physiotherapist. A targeted examination shows whether muscles, connective tissue, nerves or the bladder itself are involved. Training the basic functions can be combined with such treatment.
Questions
Frequently asked
What is the pelvic floor and which muscles belong to it?
The pelvic floor is the plate of muscle and connective tissue that closes off the pelvis at the bottom. On the outside lie the sphincter muscles of the urethra and anus, and deeper down the large levator ani. It supports the organs, keeps the bladder and bowel sealed, stabilises the trunk and moves with breathing.
How are the pelvic floor, diaphragm and breathing connected?
The diaphragm and the pelvic floor are the lid and the floor of the same pressure chamber. During calm breathing they move together, downwards when you breathe in and upwards when you breathe out. If the pressure rises suddenly, for example when coughing, the pelvic floor has to hold against it. How well this works depends, in our view, also on how calmly and by which route you breathe.
Are the jaw and pelvic floor connected?
In our view, yes, above all via the shared control of breathing, swallowing, trunk tension and pelvic floor. In our experience, people who clench or grind their teeth often also have a tense pelvic floor. In a small study, a single treatment at the jaw joint lowered the resting activity of the pelvic floor. A continuous fascial line from the tongue to the pelvic floor, on the other hand, has not been demonstrated.
Why do you tense when breathing in during the FaceFormer pelvic floor exercise?
During calm breathing, the pelvic floor yields slightly when you breathe in. When coughing, laughing or lifting, it needs the opposite: it should hold while the pressure from above rises. In the exercise, the diaphragm lowers as you breathe in, and the pelvic floor deliberately pulls upwards against it. In this way the protective pattern is practised, not just the resting pattern.
Why does pelvic floor training not help everyone?
Pelvic floor training is well researched and helps many women with stress incontinence. However, not everyone activates the muscle correctly; in one measurement, only around half managed it after brief instruction. In our view, there is also the fact that isolated exercises hardly include control from above, that is, breathing, swallowing and head balance.
What is bad for the pelvic floor?
Above all, frequent strong pressure from above without counter-tension is a strain, for example straining hard on the toilet, persistent coughing or heavy lifting without tensing the pelvic floor beforehand. In our view, shallow mouth breathing and a head balance that has drifted forwards also play a role, because they change the distribution of pressure in the trunk. A constantly tense pelvic floor can also cause complaints.
Is pelvic floor training also something for men?
Yes. Men have a pelvic floor with the same tasks, that is, supporting, closing and stabilising. It is important for continence and also plays a role in sexual function. After prostate surgery, pelvic floor training should be accompanied by medical and physiotherapy support. The FaceFormer pelvic floor exercise is structured the same way for women and men.
When can I start pelvic floor training after giving birth?
After giving birth, the tissue first needs time. When you start which training is best discussed with your midwife, your gynaecology practice or your physiotherapist, especially after a perineal tear or a caesarean section. As in the plan, the FaceFormer pelvic floor exercise is only added once the basic exercise is firmly established.
How do I feel my pelvic floor?
Sit upright on a stool and imagine you want to hold back wind. The slight pull inwards and upwards is the pelvic floor. Your abdomen and thighs stay relaxed, and you keep breathing calmly. If you find it difficult, first pay attention to the buttock muscles and the lifting at the front during the exercise. The sensation becomes clearer with every session.
Which FaceFormer do I use for the pelvic floor exercise?
The FaceFormer ZERO is recommended. It is exactly the same size and shape as the ONE, only made of softer material.
More articles from the knowledge section
Where to go next
Sources
- Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A (2011). Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing: a dynamic MRI investigation in healthy females. International Urogynecology Journal 22(1):61-68. PMID 20809211. Source
- Hodges PW, Sapsford R, Pengel LH (2007). Postural and respiratory functions of the pelvic floor muscles. Neurourology and Urodynamics 26(3):362-371. PMID 17304528. Source
- Miller JM, Ashton-Miller JA, DeLancey JO (1998). A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. Journal of the American Geriatrics Society 46(7):870-874. PMID 9670874. Source
- Baessler K, Metz M, Junginger B (2017). Valsalva versus straining: There is a distinct difference in resulting bladder neck and puborectalis muscle position. Neurourology and Urodynamics 36(7):1860-1866. PMID 28139845. Source
- Wilke J, Krause F, Vogt L, Banzer W (2016). What Is Evidence-Based About Myofascial Chains: A Systematic Review. Archives of Physical Medicine and Rehabilitation 97(3):454-461. PMID 26281953. Source
- Smith MD, Russell A, Hodges PW (2006). Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Australian Journal of Physiotherapy 52(1):11-16. PMID 16515418. Source
- Kegel AH (1948). Progressive resistance exercise in the functional restoration of the perineal muscles. American Journal of Obstetrics and Gynecology 56(2):238-248. PMID 18877152. Source
- Dumoulin C, Cacciari LP, Hay-Smith EJC (2018). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 10:CD005654. PMID 30288727. Source
- Bump RC, Hurt WG, Fantl JA, Wyman JF (1991). Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. American Journal of Obstetrics and Gynecology 165(2):322-327. PMID 1872333. Source
- Woodley SJ, Lawrenson P, Boyle R, Cody JD, Mørkved S, Kernohan A, Hay-Smith EJC (2020). Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews 5:CD007471. PMID 32378735. Source
- Sulowska-Daszyk I, Gamrot S, Handzlik-Waszkiewicz P (2024). A Single Session of Temporomandibular Joint Soft Tissue Therapy and Its Effect on Pelvic Floor Muscles Activity in Women: A Randomized Controlled Trial. Journal of Clinical Medicine 13(23):7037. PMID 39685496. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
