The Hidden Work of the Pelvic Floor: My Journey With Chronic Postpartum Pain

I’d just settled into one of those airport gate workstations—high stools, built-in electrical outlets, perfect for killing time before boarding—and was waiting for the departure announcement when a sharp, gathering ache bloomed at the top of my buttocks. It was May, and this was the final leg of my two-week book tour, the last flight I’d take before heading home. For two weeks straight, I’d barely left my seat: between promotional posts, podcast recordings, last-minute writing, and the nervous, endless scrolling that comes with launching a new book, I’d been glued to a chair almost nonstop. Still, I’d moved fine between planes, hotels, and bookstores up to that point. I’d even made a point of walking to and from each venue from my hotel, leaning into a silly, Walt Whitman-esque fantasy of being one with the city on tour.

But now, at the very end of the trip, my body was blaring alarm bells. The pain felt identical to the time I flipped off an inner tube jump and landed straight on my tailbone on packed snow—except there’d been no accident this time. It had come out of nowhere. Now, not only did sitting hurt, but I still had two hours of mandatory sitting ahead of me, and the ache only grew sharper by the minute.

I spent the entire flight hunched forward in my seat, shifting all my weight onto one leg, rocking gently back and forth just enough to dull the pain without looking like I was having some kind of bizarre religious episode. By the time I stood up to deplane, I was barely holding back a cry. Sitting had been bad enough, but standing sent a jolting, searing pain straight through my coccyx, like a guitar string plucked so hard it hummed.

At that point, I was four months postpartum, after delivering my first baby. All things considered, my recovery had been surprisingly smooth. I’d lifted heavy weights for more than a decade, and I kept up the practice until two weeks before giving birth, so my pelvic muscles were strong as steel. I’d only been back to lifting for a couple of months—deadlifts, squats, bench press, overhead presses, the occasional row or lat pull-down—and everything had gone perfectly fine up to that point.

At first, I told myself the pain would fade as quickly and mysteriously as it had arrived. I knew that just as the body loosens and expands to prepare for childbirth, it slowly tightens back up over the months after birth. I wondered if my recent weeks of near-constant sitting had compacted my body too much, like the cursed pitching arm in Rookie of the Year. I dug up stretches online to pull my bones back into alignment: ankle crossed over knee, pulling the knee to the chest; sitting upright with legs splayed at right angles to the floor; forcing my knees into an overzealous lotus position. It helped a little, but the pain lingered, and eventually got so bad that I’d cry out any time I tried to sit for longer than 10 minutes. That was a major problem—sitting is my livelihood. As a writer, I can’t write or read if I can’t stay still. After weeks of lying around the house avoiding pain, I finally booked an appointment with a physical therapist, who heard my symptoms and referred me straight to a pelvic floor specialist.

Growing up, pelvic floors were never a part of the body I heard anyone talk about. It wasn’t until I started dealing with my own issues that I learned every human has one—old people, kids, men, women, all of us. Most people’s only familiarity with pelvic floor health goes as far as Kegels: that semi-mysterious squeezing exercise women are told to do to be better at sex, and incorrectly told to practice to push a baby out during labor. But Kegels only scratch the surface of what the pelvic floor actually does.

Countless people can’t even intentionally engage their pelvic floor at all, even people who are otherwise totally healthy. That often means they can’t engage it properly when lifting something, shifting weight, laughing, or for birthing people, when pushing a baby out during delivery. These are core bodily functions, so pelvic floor issues can lead to a whole host of unexpected problems.

Let me break it down simply. Picture looking down into your pelvis like it’s a big open bowl with no bottom. The pelvic floor is a network of muscles that stretches across the base of that bowl, connecting the different parts of your pelvis, your spine, and your legs to one another. You might remember from high school biology that the diaphragm—the muscle that controls breathing—relaxes when your lungs are empty, and contracts when you breathe in. The pelvic floor works like a trampoline, and it’s meant to move in sync with the diaphragm: when you inhale, it relaxes to make space for your organs to shift down as your lungs fill. When you exhale, it contracts back up. It also includes muscles that control bowel movements, and for men, muscles that help maintain an erection.

That’s how a healthy pelvic floor works, anyway. When we’re stressed, overloaded, traumatized, burnt out, or even just forced to confront constant bad news, violence, and chaos in the world around us, that stress can turn into pelvic dysfunction—no matter who you are. As wellness influencers and brands have realized pelvic floor problems are a largely untapped marketing opportunity, they’ve flooded the space with supposed quick fixes, treatments, and miracle products. And now, after going through this myself, I understand better than anyone the desperate urge to chug straight from the social media infomercial hose, too desperate for relief to worry about the junk that comes with it.

My soft-spoken specialist, in a white coat, asked me to squeeze and relax my pelvic floor while she assessed it. She confirmed it was strong and responsive, then said she needed to do an internal exam. After what felt like an eternity waiting, she finally spoke: “I don’t actually feel like your tailbone is out of position.” I nodded, already braced for the familiar feeling of having chronic pelvic pain brushed off as a perfunctory afterthought. I sat there, internally burning with impatience, as she kept assessing, and then she asked a question that stopped me cold: “Do you hold your breath a lot?”

That question caught me completely off guard. My whole life, I’ve unconsciously held my breath and struggled to breathe steadily, a habit I picked up growing up in an endlessly tense household. “Yes,” I said.

“I can feel it,” she said. “You never fully relax your pelvic floor. Even when you think you’re relaxed, you’re still holding 20, 30 percent tension there.” That level of constant tension felt familiar—it was the same subtle grip I used for “polite fart prevention” in public, the same way I’d learned to subtly suck my stomach in after a high school friend slapped my soft belly repeatedly in the hallway between classes. She walked me through all the small issues that had stacked up to create my big pain: my body was still holding the shifted posture I had during pregnancy; I had weak lower abs that were still separated after birth, and my front pelvic joint was still loosened from pregnancy, which had given me terrible pain in my third trimester and needed more core work to heal.

“Like dead bugs?” I asked.

“No,” she said, shaking her head like the idea was mildly repulsive. “No. Planks.”

She had me lie on my stomach and prodded my sacrum, the triangular bone at the base of my spine. She noted it was misaligned—tilted outward on my left side, inward on my right, a side effect of playing sports as a kid: as a left-handed person, I’d always stabilized on my right side to throw or kick with my left. She set the heels of her hands at the top of my left butt cheek, leaned steadily into my hip, and I felt a gentle pop. When I sat back up, she told me that in addition to doing planks, I needed to build the habit of releasing all that constant pelvic floor tension every time I sat down. I was frustrated that there wasn’t one single easy fix for my pain, but I was fascinated to see how my pelvic dysfunction was the intersection of so many different threads of my life: childhood family trauma, youth sports, pregnancy, a writing career that keeps me sitting all day, the constant unrelenting stress of modern life, all twisting together to pull on my tailbone like a fussy toddler. My body had tolerated one stress after another, until the final straw of a book tour broke through.

The Long Neglect of a Misunderstood Body Part

John De Lancey, director of pelvic floor research at the University of Michigan Medical School, is sharp-dressed in a black polo buttoned all the way up, with neatly combed hair. Behind him hangs an anatomical cross-section illustration: it was made in the 19th century, when a pregnant woman’s cadaver was sliced in half, and an artist pressed glass to the cut side to draw what he saw. De Lancey says it’s one of the most accurate pelvic illustrations ever made, but in the last 50 years, no one but him has ever asked to see it.

There’s hardly a body part that’s harder to render in 2D. Most pelvic diagrams make it nearly impossible to tell what cross-section you’re even looking at: which way the spine is pointing, whether you’re looking at the front or the back. Every time I look at a pelvic illustration, I just want to hold a 3D model I can turn over and open up. And the more detailed the drawings get, the worse it is. It doesn’t help that, according to De Lancey, most pelvic diagrams online are just wrong.

In fact, he says “virtually all the drawings are wrong” because they just copy each other and replicate the same old mistakes. Most of the correct ones date back to the early 20th century, when artists drew pelvic floors from real dissections. Because of where it sits, deep inside the body, De Lancey says it’s the one area even medical providers treating living patients will never, can never, actually see.

Even as anatomical renderings got more accurate, the pelvic floor and its functions remained a total mystery. And it was largely a mystery by neglect: when researchers studied cadaver pelvic anatomy, they rarely noted whether the person had ever given birth. Kristi Kliebert, a board member of the Academy of Pelvic Health, calls it a historically “mystical area.” For a long time, we just assumed that after giving birth, everything down there just stretched out and gave out, like old chewing gum. Postpartum people accepted as a given that their pelvic floor was ruined, that they’d always leak a little pee when they laughed or exerted themselves.

But the medical world was missing a huge piece of the well-being puzzle for so many people: one study estimates that more than 25 percent of reproductive-age women globally have some form of pelvic floor dysfunction, including chronic pain, painful sex, incontinence, organ prolapse, and a host of other poorly understood conditions. And like so much research about body parts we’re too embarrassed to talk about, that number only counts the cases people have actually reported.

There are three big reasons pelvic floor health will never be good party conversation: sex, pee, and poop. The pelvic floor surrounds all the openings for elimination and reproduction, no matter how those are used, so talking about it feels inherently uncomfortable for most people.

It wasn’t until the late 1970s that doctors and researchers started studying it more closely, and discovered that the thin sheets of muscle that make up the pelvic floor can be conditioned, strengthened, and rehabilitated just like any other muscle in the body. In 1977, the American Physical Therapy Association founded the Academy of Pelvic Health Physical Therapy. According to De Lancey, the combination of MRI technology and studies with healthy volunteer women in the 1990s and 2000s changed everything. Suddenly, researchers could study pelvic floors they confirmed were healthy, which opened up a whole new world of understanding.

“Healthy” pelvic floor function, first and foremost, means you don’t accidentally urinate or defecate, none of your pelvic organs have prolapsed (sagged out of their normal position, which can happen when too much strain hits a weak pelvic floor), the muscles are strong enough to maintain tension when challenged, and they work in coordinated unison. Weakness and poor coordination lead to incontinence, and no one wants to deal with accidental leakage when they get older and move around. As awareness of pelvic floor health grew in the 2000s, that issue drove a lot of research. Even so, the shame around pelvic issues, and the fact that prolapse and incontinence disproportionately affect women, meant for a long time we just accepted that postpartum women would leak a little when they laughed for the rest of their lives—until wellness brands like Goop picked up the cause, likely seeing a new profit opportunity.

Good pelvic floor function turns out to be pretty random, even for very fit people. Even elite athletes don’t automatically have well-functioning pelvic floors. You’d be shocked to learn how many of our top athletes, out there competing on courts, fields, and lifting platforms, leak a little pee when they pull off their hardest moves. I’m not kidding. Studies of athletes from Olympic trampolinists to triathletes to indoor football players to basketball players find they’re just as likely, sometimes more likely, to experience urinary incontinence (or “stress incontinence,” when the pelvic floor gives way under strain and leaks a little pee) as the general population.

One specific thing researchers have learned from more study is that the levator ani— the sheets of muscle that run from the front of the pelvis and attach to the very tip of the coccyx, or tailbone—get especially strained during childbirth, and can tear or even rupture. I grew up hearing over and over that the tailbone was a useless vestigial body part, a leftover from our evolutionary past. It doesn’t feel very vestigial to me now, when it holds the whole cradle of our pelvic structure together.

My Journey to Healing

Over the next few weeks, I became hyper-aware of how my pelvis was positioned in my body. I realized I’d been walking in a weird, twisted shape: my upper body hunched forward, my hips pushed all the way back. I tried to correct my posture into something more normal. I stopped the random online stretches and stuck to my planks, even though I’ve always hated planks. I tried to remember to release my constant pelvic floor tension when I sat down, though I forgot more often than not.

I realized that when I held my son to rock him to sleep, I was arching my lower back forward, bending my spine into a question mark to give him a steeper incline to rest on, which put tons of extra strain on my pelvic floor. I tried shifting my posture the other way. I also noticed that when I got to the bottom of a heavy squat, I wasn’t engaging my front core, so my butt would drift out behind me. I started making a conscious effort to keep my butt aligned under my hips.

At my next PT appointment, she asked how my pain was. “Better,” I said. It came on slower and hurt less, though shifting from sitting to standing still gave me a sharp jolt of pain. I proudly told her I’d been doing my planks like she said, I could hold one for a full minute now.

She shrugged indifferently. “Sure,” she said, clicking over to her notes. She had me lie back on the table and probed my sacrum again, then said it was less stiff but still misaligned. She tried pressing gently to get another pop like the first time, but nothing happened. She moved her hands up to my shoulder blades, pressing to the left of my spine. “You’re tense,” she said thoughtfully.

“Does that have to do with my sacrum?” I asked.

“Maybe,” she said. I’d looked up the sacrum between appointments: it’s the large triangular bone at the base of the spine, where the two sides of the pelvis meet, where your upper body connects to your lower. Its name comes from the Latin for “sacred,” or maybe it’s just a mistranslation of “strong bone.” If you’ve heard of the SI joint, that’s where the sacrum meets the ilium, the pelvic bone on either side. Important nerves run through that joint, so if my sacrum issues got worse, I could end up with sciatica or even incontinence.

As I waited for her advice, I noticed that across from a corkboard covered in glowing thank-you notes from past clients, she had a chakra poster hanging high on the wall above the exam table. My pelvic floor is tied to the sacral chakra, associated with the color orange, the element of water, emotions, desires, relationships, and creativity, ruled by Parvati, the goddess of fidelity, fertility, and power. It was an unexpected thing to see in a clinical exam room, but it sort of made sense.

She suggested I add bench presses and overhead presses to my routine. Then she demonstrated another exercise: extending her arms fully out to her sides, thumbs pointing up, then bringing them together over her head. That was the last thing I expected to be prescribed for my pelvic pain.

Pelvic dysfunction affects people of all ages, genders, and backgrounds. (For anyone taking notes: the muscle group that enables erections, for both penises and clitorises, is called the ischiocavernosus.) Just like a sudden scare—someone jumping out from behind a wall—triggers physical responses like a racing heart and shallow breathing, acute or chronic trauma can make people unconsciously hold constant tension in their pelvic muscles. When that tension becomes a habit, they often can’t fully relax their pelvic floor without conscious, sometimes sustained effort. Ironically, this constant tension can cause the same symptoms as a weak pelvic floor—like incontinence and organ prolapse—just like holding a full beer stein out in front of you with all your strength for too long will eventually make you drop and shatter it.

A Quick Self-Check for Your Pelvic Floor

Now might be a good time for you to check in on your own pelvic floor.

1. Sit on the edge of your chair, or even better the edge of a table, so the area between your legs is fully in contact with the surface. (If you’re in a public place or office, just try to be a little subtle about it.)

2. Now imagine you’re trying to lift that area up off the surface by contracting your pelvic floor, and hold it there.

3. Now relax, take a deep breath, and breathe all the way down into your abdomen, all the way down to the part that’s touching the chair or table, which will create gentle downward pressure.

If you can do all that on command, and hold the contraction and relaxation for at least a few seconds, your pelvic floor function is probably pretty good. If you can’t feel anything happening at all, or there’s constant tension you can’t release, or you can’t contract it when you try, you and your