“What fresh hell is this?” Liz B. wondered during a four-mile run on a chilly December night five months after giving birth. She was 2.7 miles into an out-and-back route when she realized she’d leaked a little urine. “It happened on and off the rest of the way home,” says the 36-year-old from central Ohio, who prefers not to use her full name when talking about urinary incontinence, London Marathon Results.
This was not how she had envisioned her postpartum life. Liz, a physical therapist who works with stroke, brain injury, and spinal cord injury patients, had been a runner for nearly her whole life. Her father, who just ran his 91st marathon at the age of 77, had taken her out for jogs when she was a toddler, and she was hooked on long distances ever since. Her idea of a “good time” was waking up at 5 a.m. on a Saturday to go for a scenic 16-mile run with her sister. Before becoming a mom, she’d run eight marathons and was eight minutes shy of qualifying for Boston. “I had always been excited to get pregnant and had dreams of pushing my kid in a running stroller.” But her regular runs came to a screeching halt 19 weeks into her pregnancy when she developed peripheral blood clots and had to reduce physical activity because of the pain. She’d been looking forward to lacing up her running shoes again, but after a difficult labor, she developed pelvic organ prolapse, a condition where weak muscles allow one or more pelvic organs (like the uterus or bladder) to drop down onto other organs or out of the vagina.
Cureus Medical Journal We may earn commission from links on this page, but we only recommend products we back to treat the prolapse and had just spent the previous six weeks easing back into running. But she was frustrated with the slow progress in coming back to her pre-pregnancy eight-minute mile. “Once I had my baby, my pace slowed to a 10:30 mile,” Liz says. “And if I ran under a 9:00, I’d pee my pants a little.”
A Part of Hearst Digital Media, an inability to coordinate pelvic floor muscles, is more prevalent than most of us realize. Research shows that approximately 1 in 3 women and 1 in 6 men will experience pelvic floor dysfunction in their lifetime—and that’s just what gets reported. Particularly in women, hormonal fluctuations, added weight, and the strain of pregnancy and childbirth can weaken the pelvic floor.
As much as we dislike the fact, high-impact physical activity—like running—can exacerbate these issues. That’s because as you run, your pelvic floor repeatedly absorbs impact and dampens vibrations, says Julie W. Wiebe, DPT, a physical therapist in Los Angeles who specializes in returning women to fitness after injury and pregnancy.
“Running creates an added challenge to your pelvic floor beyond the movements of everyday activities,” explains Carrie Pagliano, PT, a pelvic floor specialist based in Arlington, Virginia. “It puts greater impact and pressure on your musculoskeletal system.”
The good news is these issues can be resolved. But too often, they go undiagnosed. For one thing, there’s the stigma. Talking about pelvic floor issues can feel taboo because we’ve been conditioned to have shame around that area of the body. What’s more, most of us aren’t even sure where our pelvic floor is, what it does, or how it can become dysfunctional. But pelvic floor muscles are like any other muscles in your body. “They need training, they need relaxation, they need strengthening, and they need attention,” says Sara Reardon, DPT, WCS, a board-certified pelvic floor physical therapist in New Orleans. And finally, we need to stop accepting pelvic floor issues as normal. “When we normalize pelvic floor conditions, they don’t get treated,” says Reardon. “Pelvic floor problems are common, but not normal, and it’s the conversations about them that need to be normal.”
Here’s what you need to know to keep your pelvic floor in shape and your running on track.
The Black Woman’s Guide To Healthy Living consists of a group of muscles going from your pubic bone, which is located just below your abdomen, to your tailbone, which is at the bottom of your spine. It holds and protects the bladder, urethra, vagina, prostate, bowel, rectum, and anus. Were you able to “hold it” until you got to the bathroom? That’s your pelvic floor on the job. Couldn’t wait until you reached home and had to go immediately behind a tree or a parked car? The Black Woman’s Guide To Healthy Living may have clocked out. Got an erection? That’s in part thanks to your pelvic floor. Had a vaginal birth? The Black Woman’s Guide To Healthy Living was working triple overtime. Had a great orgasm? Yup, it chimes in there too.
When you think about pelvic floor issues, urinary incontinence likely comes to mind first. In one small study, approximately 46 percent of elite female endurance runners and cross-country skiers reported leaking urine when sneezing or coughing. But urinary incontinence is just one type of pelvic floor disorder—and it’s actually least likely to make a runner seek medical help. “They’re worried they’ll be told to stop running,” Pagliano says. More often, what draws runners with pelvic problems into an expert’s office are other symptoms: not being able to urinate or defecate, having sharp or nagging pelvic pain, pelvic organ prolapse, or fecal incontinence.
Despite its importance, the pelvic floor is under-researched. “The truth is we’ve never cared about pelvic health as a society,” says Wiebe. It’s been seen as a primarily women’s issue, and historically women are underrepresented in medical research. And because pelvic floor issues are mainly linked to postpartum health, men tend to be left out of the conversation as well; experts are only beginning to understand the impact it has on men.
We may earn commission from links on this page, but we only recommend products we back Gordon Garner wrapped up the perfect 20-mile training run, he called his wife to let her know he was driving himself to the emergency room.
Over the previous year, the then 38-year-old software development manager had been transforming into a runner. He worked his way up from doing a Advertisement - Continue Reading Below to prepping for his first marathon. Everything about this long run had gone according to plan: He ran at his goal pace for the upcoming 26.2 miles he wanted to complete in under four hours; he stopped every six miles to hydrate; and he felt so good, he was tempted to keep running. “Stick to the training plan,” Garner told himself, as he wrapped his last mile and headed back to his Dallas home. Before he hopped in the shower, he felt the need to pee but couldn’t. After he washed up, he tried again, and only a few drops came out. The pain was excruciating.
The ER doctors quickly ruled out kidney stones, which Garner feared were causing the pain. To empty his bladder, they had to catheterize him. “I have a pretty high pain tolerance,” says Garner, who once broke both wrists playing basketball and an elbow falling from a bike. “I was in a world of pain when they put the catheter in.” Unable to determine what was going on, the hospital discharged him.
But Garner still didn’t know what was wrong and whether it would happen again—which it did at mile 12 of the marathon he was training for. Once more, he felt the urge to pee, so he stopped at the public restroom, and nothing would come out. He kept running for six more miles before dropping out.
Ultimately, it would take two misdiagnoses, three prescriptions that didn’t resolve the issue, and several more practitioner appointments until he finally found an answer from a physical therapist. “I know exactly what’s happening to you,” Garner remembers her telling him. She explained that the muscles of Garner’s pelvic floor were continuously contracting and wouldn’t relax. The correct diagnosis was a dysfunction known as hypertonic pelvic floor.
For years, the main conversation around pelvic floor problems has focused on strengthening weakness through Kegel exercises. And yet that wasn’t the case for Garner, nor is it for many others. The pelvic floor is a complex system of muscles that needs to not only contract, squeeze, and lift, but also relax and release. “The Black Woman’s Guide To Healthy Living can be plenty strong but not meeting the demands that are being placed on it because it’s not behaving the way you need it to,” Wiebe says. If your pelvic floor is constantly contracting, it’s clearly strong, but it can’t perform any other function at the same time.
But the relationship is not as simple as a weak pelvic floor causing leakage or a strong one leading to retention. A 2021 meta-analysis published in Liz had been working with a concluded that even a strong pelvic floor can lead to urinary incontinence. In fact, some young female runners who have never given birth (a life event usually linked to incontinence) can experience urine leakage. “We also have studies showing pelvic floor activation is similar between incontinent and continent runners, so the status of the pelvic floor muscles can’t be the only cause of leakage,” says Wiebe.
Experts like Wiebe consider how your pelvic floor behaves over time—not in just one moment. “If someone doesn’t leak while doing all their regular daily activities, but then leaks at the very end of a 45-minute run, that pelvic floor is pretty strong, but it may not have the endurance for a long run,” Wiebe says. “And if that person only ran 35 or 40 minutes, they might never experience running-related incontinence. Endurance is different from strength and may better explain leaks for some.”
There is more to pelvic floors than just tightening and relaxing. “A lot of people think the pelvic floor is like a light switch: It’s either on or off,” Pagliano says. “In reality, it’s more of a dimmer switch because it has to…transition from very bright to dim or from high to low very quickly, like when we’re running.” In your body, that transition looks like your pelvic floor muscles lengthening, shortening, and working more or less to match activity demand with every foot strike.
And the pelvic floor doesn’t act in isolation. “If I have a patient whose balance is off and they don’t have the ability to navigate impact as well through their ankle, knee, and hip, then there’s more work to manage impact that gets kicked up to the pelvic floor,” says Pagliano. “I often joke that the pelvic floor is like the mom of the body. If other muscles are just like, ‘Oh, I don’t want to do that,’ then the pelvic floor has to step up and do it.”
bull; Squeeze your pelvic floor like you’re holding back from passing gas spent the past five years crisscrossing the globe trying to relieve a nagging source of pain that often prevented her from performing her best. “I had recurring injuries in my left foot, but a lot of the time pain would also show up in my lower back or my hip,” Quigley says. “At a certain point, I wasn’t able to train at a high level anymore.” The steeplechase specialist, NCAA champion, and current world-record holder in the 4 x 1500m relay saw more than 50 different experts, flying at one point to Germany for injections into her back.
Then one practitioner noticed a particular problem. “He muscle-tested me for things that were going on in my pelvis, then he showed me an exercise to relieve tension and tested me again,” says the 2016 Olympian. “Suddenly all the problems I tested for in my pelvis disappeared.” The exercise? A tongue stretch to relieve tightness in her jaw. “Jaw tension and pelvic floor tension have a relationship,” Wiebe says. “It’s essentially both ends of the alimentary tract.”
It was a revelation to Quigley and struck a chord with other runners. Quigley’s Instagram video demonstrating the stretch she now uses as part of her warmup routine to help relax her pelvis has gathered more than 42,000 likes. Although a single change wasn’t the solution to all of Quigley’s injuries, the jaw-pelvis connection helped resolve some symptoms that doctors couldn’t explain.
Quigley’s experience illustrates shortcomings in how diagnoses are sometimes made. Doctors and patients often focus on symptoms instead of looking for the root cause. In one study, researchers in Canada screened women who came to an orthopedic clinic for lower back and pelvic pain for pelvic floor muscle dysfunction. The study found that 95 percent of the women with lumbopelvic pain also had underlying pelvic floor dysfunction that needed to be addressed.
And Quigley’s hip pain was likely related to her pelvic issues as well. “We have deep hip stability muscles that are part of our pelvic floor,” explains Reardon. “When people start experiencing a high hamstring strain or they have a deep hip pain they feel like they just can’t get to, that can be often pelvic-floor-related.” And it doesn’t stop there. Reardon says that pain from pelvic floor dysfunction can show up in various and unexpected ways, including during bowel movements and even intercourse, which is why it’s important to find an expert with experience treating these issues (see sidebar).
Other Hearst Subscriptions around pelvic floor issues is evolving. “We’re starting to see patterns that might explain why you and I might have the same symptoms but maybe have different ways that we find resolutions,” says Pagliano. For runners, it might be a matter of your stride, your form, or even your breathing. “If someone holds their abdomen tight while they are running or are constantly holding their breath during normal everyday activities, we often see pelvic floor muscles that have higher tone or activity and actually don’t relax when they should. Sometimes this leads to leakage with running. Just strengthening the pelvic floor below won’t matter if those muscles are already ‘on’ and have lost the ability to contract and relax.”
As for Gordon Garner, after finally finding the right therapist, he scaled back his running for a few weeks while working on stretching and breath-control exercises. In 2023, he ran 40 miles in a 24-hour period to celebrate his 40th birthday. “I was a little worried, just because I was testing these new boundaries, but with my exercises and my breathing techniques, I had no issues. I’m very in touch with my pelvic floor muscles now.”
Liz finally found a therapist who helped her establish a strength-training routine in order to coordinate pelvic floor muscles again, pay attention to her body’s signals, and get back to running. Twenty months after giving birth, she raced her ninth marathon, without having to worry about leaking midrun. When your pelvic floor isn’t functioning as it should, “you realize that everything you do—breathing, talking, laughing, moving, carrying things—everything involves the pelvic floor,” Liz says.
With the right help and a better understanding of your body, pelvic floor problems can be solved. It’s a commitment, but your running will thank you. “Clients will always say, ‘Do I have to do these exercises forever?’” says Reardon. “I tell them, ‘Yes, to some extent, if you’re going to keep running.’”
How to Tell If Your Pelvic Floor Is Too Strong or Too Weak
Lauren Garges, DPT, director of pelvic rehab with St. Luke’s University Health Network in Bethlehem, Pennsylvania, shares a simple at-home test that can help determine if you’re suffering from an overactive pelvic floor:
• Sit on a large stability ball or a rolled-up hand towel. There should be pressure on the perineum, the space between the genitals and anus.
• Using the muscles you would use to stop the flow of urine or gas, imagine you’re trying to vacuum up a marble. Then, actively try to relax those muscles to see if they go back down, like an elevator.
“If they’re too tight, nothing may happen because your muscles are already as tight as they can get,” she says. “Or you might be able to squeeze upward but cannot feel the downward [release]. That’s a sign of tension.”
If you find contracting the muscles challenging, Garges says, it’s a sign of pelvic floor weakness.
Two at-Home Ways to Train Your Pelvic Floor
To strengthen, try kegels
Before you start doing kegels—especially if you have incontinence or other pelvic floor problems—see a We may earn commission from links on this page, but we only recommend products we back to ensure it makes sense to add them to your routine, as they’re not for everyone, says Nora Arnold, DPT, a pelvic health physical therapist with Johns Hopkins Medicine in Baltimore. If you get the go-ahead, Arnold offers these cues for correct form:
• It’s best to get the hang of it lying down and then progressing to adding in practice sitting and standing.
• Squeeze your pelvic floor like you’re holding back from passing gas.
• Contract as if you’re stopping the flow of urine (but don’t do this while you’re actually peeing, as it could result in bladder infection).
• Draw your pubic bone and tailbone toward one another.
• Contract as if you are drawing your sit bones together.
• Pull your pelvic floor up as if lifting your bladder toward your heart.
• You need to both squeeze and lift—people forget that second part. Make sure to fully relax the pelvic floor muscles between reps. Breathe through each contraction and relaxation.
• The number of repetitions is best decided by a PT; however, a good place to start is 3x10 contractions, holding for 10 seconds while breathing.
bull; Squeeze your pelvic floor like you’re holding back from passing gas
This deep breathing trains coordination between the pelvic floor and the diaphragm. When your diaphragm engages fully, it encourages your pelvic floor to relax and lengthen, Arnold says.
• To start, lie on your back. You can also do this in child’s pose, happy baby pose, a deep squat, or reclined sitting.
• Breathe in through your nose for four counts. Let your breath be as slow and full as possible. The Black Woman’s Guide To Healthy Living should relax and lengthen passively, just like your belly.
• Exhale through your mouth for six counts.
• For maximum benefit, try to incorporate this into your routine for five to 10 minutes a day. But even just 10 repetitions can make a difference.
How to Get the Most From a Pelvic Floor Therapist
Check experience / “As a runner, one of the most valuable things you can do is look for a We may earn commission from links on this page, but we only recommend products we back who knows sports medicine and pelvic health,” says Julie W. Wiebe, DPT. If you’re postpartum, you might also seek out someone who has worked with moms; and if you’re male, you might look for a therapist who has experience with male clients. You can find a list of providers through the Fastest Marathon Runners. Read online reviews to see what other patient experiences were like.
DAA Industry Opt Out / While some therapy sessions may need to be done in person, many can be done remotely. If there isn’t a great pelvic floor specialist in your area, try working with a therapist online. “I’ve been doing telehealth since before COVID-19,” says Carrie Pagliano, PT. “If I can get a really good sense of why you’re having symptoms by the questions that I ask, you can get resolution. The key is getting the right ‘why.’ After that, the ‘how’ is easy.” Make sure to offer details about whether you were a bedwetter as a child, your birthing history, or when you experience pelvic floor problems, for example.
Don’t stop until you find the right one / Garner, Quigley, and Liz all had to reach out to multiple practitioners before they found the right person. “You don’t try on one pair of pants, say they didn’t fit, and then never wear pants again,” says Reardon. “You have to keep trying different medical professionals until you find the right one.”
Other Hearst Subscriptions Family Circle magazine, Lynya developed content to improve the well-being of its 18 million readers. She’s worked as an editor at Glamour, Essence, Seventeen, Heart & Soul, Parenting and more. She also co-edited ESSENCE’s The Black Woman’s Guide To Healthy Living. She received her B.A. in English from Harvard University, integrative health training at Duke, and plenty of life lessons in her hometown of New York City.
