Personal trainers know their clients better than almost anyone else in those clients’ lives. You see them most weeks. You know their goals, their limits, what’s changed, what’s new, what’s bothering them. That kind of relationship, built over months and sometimes years, doesn’t happen in a 30-minute appointment with a physio.
Which is exactly why, as a Sports & Exercise Physiotherapist with a special interest in pelvic health, the trainers I work alongside are some of the most useful people in a client’s care team. You implement the recommendations, you monitor what’s working, and because of that trust you’re often the first person a client mentions a symptom to. You are in a unique position to notice when something isn’t quite right, and to refer on early.
The pelvic floor is one of those things worth knowing about. It’s quiet, it’s under-talked-about, and it’s the muscle most likely to push a woman out of the gym, usually without her ever telling you why. So this article isn’t about how to treat it. It’s about how to spot it, how to talk about it, and when to refer on.
What the pelvic floor actually does
The pelvic floor is a group of muscles. They attach from the pubic bone at the front to the tailbone at the back, with lateral attachments along the side walls of the pelvis.
Think of it as the floor of a working canister. The diaphragm sits at the top. The deep abdominals wrap around the front and sides. The spinal stabilisers run up the back. The pelvic floor closes the bottom. The four walls move together, so when one part fires, the others respond.
Inside that system, the pelvic floor itself does a few things. It supports the bladder, uterus, and bowel against gravity, and it controls when those organs empty and when they hold. It contributes to sexual function. And it works with the diaphragm and deep abs to manage every spike in pressure inside the abdomen: the cough, the sneeze, the heavy lift, the bottom of a squat, the moment a foot strikes the ground in a sprint.
Men have a pelvic floor too. Same group of muscles, same canister, just supporting a prostate and urethra instead of a uterus. The same training principles apply. The same dysfunctions show up. Post-prostate-surgery incontinence is one of the most common reasons men get referred to a pelvic health physio. Chronic pelvic pain, erectile dysfunction, urinary urgency, and constipation can all trace back to a pelvic floor that is either too weak or too tight. Active men in particular (cyclists, heavy lifters, anyone holding constant tension through the trunk) are over-represented in the overactive group. Men talk about this even less than women do. If a male client mentions any of those symptoms in passing, the same rules apply: notice, ask, refer.
Weak vs overactive: the half of the conversation no one is having
When pelvic floor health gets talked about in the gym, it is almost always about weakness. Kegels. Strengthen. Tighten and lift.
Weakness, clinically called a hypotonic or underactive pelvic floor, is real and common. The muscles can’t generate or sustain a strong contraction, so the rest of the system can’t manage spikes in abdominal pressure. It looks like leaking with a sneeze, a cough, or a box jump. A feeling of heaviness or a vaginal bulge by the end of the day. Trouble holding in wind. Quick fatigue when she tries to sustain a pelvic floor squeeze. She can switch the muscle on, but she can’t keep it on.
But there is another presentation that gets almost no public airtime: the overactive, or hypertonic, pelvic floor. These muscles stay switched on. They can contract, but they can’t fully release. The signs are different. Pelvic, vaginal, or perineal pain. Pain with intercourse, tampons, or a routine cervical screening test. Urinary urgency, frequency, or the feeling that the bladder isn’t fully emptying. Difficulty starting a urine stream. Constipation, or having to bear down hard to pass a bowel motion. Pain that gets worse, not better, when she trains.
The pelvic floor can also be both weak and overactive at the same time. Underactive in its ability to generate force, but unable to fully release the tension it is holding. Sending that pelvic floor into a Kegel program is the wrong intervention. This is why a clinical assessment matters more than a guess.
If your client has an overactive pelvic floor and you put her on a Kegel program or push her into more bracing under load, you can make things worse. The muscle doesn’t need more tone. It needs to learn how to release. You can’t tell the difference by looking, and neither can your client.
Stress incontinence: what it is, and what it isn’t
Stress incontinence is leaking with a sudden increase in pressure inside the abdomen. Coughing, sneezing, jumping, lifting, running. It is one of the most common reasons women drop out of fitness, and it is wildly under-reported because most clients will never bring it up.
The cause is usually one of three things, often in combination: a weak pelvic floor that can’t help close the urethra under pressure, a urethra that moves too much because its supporting tissues have given way (urethral hypermobility), or a urethra that doesn’t close properly even at rest (intrinsic sphincter deficiency). Strengthening helps the first. The other two usually need additional input from a pelvic health physio or a urogynaecologist. Which is another reason “just do more Kegels” is not a default safe answer.
It is not a normal consequence of having a baby. It is not something women should just deal with. And it is not something an aggressive core program will fix on its own. According to Continence Health Australia (formerly the Continence Foundation of Australia), 1 in 3 women who have ever had a baby will experience some form of incontinence, and almost 4 in 10 Australian women will experience incontinence at some point in their lives. Common is not the same as normal.
Active women are over-represented in the stats. Runners, weightlifters, CrossFit athletes, dancers. If a client mentions leaking, even once, the moment you acknowledge it and ask one or two more questions is the moment her trust in you grows. Most clients won’t bring it up a second time if it gets glossed over the first.
Pelvic organ prolapse: what trainers should know
Prolapse is when one of the pelvic organs (bladder, uterus, or rectum) drops down into the vagina, pushing the vaginal wall along with it. It is more common than most people realise. The organs are supported from above by fascia and ligaments, and from below by the pelvic floor.
Clients who do have symptoms describe it in their own words as heaviness, dragging, pressure, a sensation of something falling out. A sense that something is not right. Sometimes a visible bulge by the end of the day. It often gets worse with weight-bearing or high-impact load.
The thing to know about prolapse is what’s at stake if it gets ignored. Continuing to overload symptomatic tissue can make a prolapse worse, and once the fascia and ligaments are stretched, that change is irreversible. A pelvic health physio can’t unstretch the tissue, but with the right input they can significantly reduce symptoms and stop the prolapse progressing.
Prolapse is not a reason to stop training. But it is a reason to modify, and to refer.
When to pause and refer
If a client mentions any of the following, hold the program you have her on and refer her to a pelvic health physiotherapist before you progress:
- Any leakage of urine, wind, or faeces during exercise
- Pelvic, vaginal, or perineal pain
- A sensation of heaviness, dragging, or a visible bulge
- Pain or discomfort with intercourse
- Sudden onset of urgency or frequency
- A postnatal client returning to high-impact exercise without a pelvic health physiotherapy assessment
Let me highlight that last point. Every postnatal woman should be assessed by a pelvic health physiotherapist before she returns to running, jumping, or heavy load. A postnatal physiotherapy assessment is not the same as a six-week GP check. A pelvic health physio examines the pelvic floor directly, screens for prolapse, looks at abdominal separation, and watches how the whole system manages pressure under load. GPs are wonderful, but a routine postnatal GP visit doesn’t include that depth of examination. If a client is heading back to high-impact training, in my view a pelvic health physio assessment isn’t optional. It’s the minimum standard of care.
How you raise it matters. You don’t need to be clinical and you don’t need to make it awkward. Something like:
“What you’re describing is really common and there are people who specialise in fixing it. I’m going to keep working with you, but I want you to see a pelvic health physio alongside our sessions so we can do this properly.”
That’s it. You’re not stepping outside your scope by referring. You are operating well inside it.
What to expect at a pelvic health physio appointment
Most clients have never been to a pelvic health physio and they are nervous. The fear is the single biggest barrier to the referral converting. If you can demystify the appointment in thirty seconds, you remove most of it.
A first appointment is usually 45 to 60 minutes. The physio takes a full history covering bladder, bowel, sexual function, training load, birth history if relevant, and what makes symptoms better or worse. The assessment may include external observation of breath and bracing patterns, real-time ultrasound to view the pelvic floor activating and relaxing on screen, and an internal vaginal examination if the client consents. Real-time ultrasound is often a useful alternative for clients who aren’t comfortable with an internal exam, and a powerful teaching tool either way.
Consent is essential and ongoing. The client can request a chaperone, decline any part of the exam, or stop at any point. Nothing happens that the client hasn’t agreed to.
The physio’s job is to work out what the muscles are actually doing: strong or weak, coordinated or not, holding tone or able to release. Then they hand the client back to you with a clear picture of what her training can and can’t include.
One more thing every personal trainer reading this should hear directly from a pelvic health physio: I am not going to tell your client to stop training with you. That isn’t what we do. My job is to work out what’s going on, then work with you so she can keep training safely. That might mean modifying an exercise so the pelvic floor tolerates the load. It might mean teaching her how to activate, or how to release, the muscle. It might mean fitting her with a pessary (essentially a bra for a pelvic organ prolapse) so she can lift, run, or jump with proper support. There are usually far more options than people realise. We share the same goal as you do: keep her training, and keep progressing her.
Three strategies you can use tomorrow
You don’t need to be a pelvic health specialist to train these clients well. The same three strategies apply for women and men. Add them to your toolkit.
Cue the breath – exhale on exertion. The lift phase of a deadlift, the press of a squat, the punch of a burpee. Holding the breath ramps up intra-abdominal pressure and pushes everything down through the pelvic floor. A long, controlled exhale lets the floor lift up with the diaphragm instead.
Watch the base of support – a wide stance (wide squats, sumo deadlifts, plié work) opens the urogenital hiatus and increases load on the pelvic floor. A symptomatic client doesn’t need to avoid these forever, but narrowing the stance is the easiest first modification.
Think about gravity and position – standing impact loads the floor more than seated work. Seated loads more than supine. If symptoms flare under load, regress the position before you regress the weight. A glute bridge on the floor and a heavy back squat are not the same demand on the pelvic floor.
The order matters. First, understand what the pelvic floor is doing. Then make sure it can fully contract and fully release. Once those two pieces are in place, every exercise you prescribe in your sessions becomes more effective.
Personal trainers can make a real difference in pelvic health. You see your clients more than any clinician does. You have their trust. You see how they move week to week. That is real influence, and the women and men you train need you using it. Pelvic health is an area where we can change lives.
About the Author, Jade Basham
Jade Basham is an Australian APA Titled Sports & Exercise Physiotherapist with a special interest in pelvic health, and has over 13 years’ experience in the pelvic health space. She is the founder of Blossom Pelvic Health (blossompelvichealth.com.au), a physiotherapist led ecommerce brand offering evidence based education and pelvic health products for women and men. Jade works clinically alongside fitness professionals, postnatal clients, and active women and men to help them stay strong and keep training. You can find Blossom on Instagram @blossom.pelvic.health.
Disclaimer: This article is general education for fitness professionals. It is not a substitute for individualised clinical assessment by a pelvic health physiotherapist.
References
- Continence Health Australia (formerly the Continence Foundation of Australia). Statistics on incontinence.