Kegels and Painful Sex: When Strengthening Is the Wrong Fix

Do Kegels help with painful sex? Sometimes. Often they do not. Kegels train your pelvic floor muscles to squeeze harder and longer. Some pain during sex comes from pelvic floor muscles that are already too tense, or that will not relax when they need to. Squeezing more does not fix a muscle that cannot let go. Find out which problem you have first. A pelvic floor physiotherapist can check.

"Do your Kegels" is the advice almost every woman hears, for almost everything below the belly button. For leaking when you laugh or sneeze, it is good advice. For pain during sex, it can be the wrong advice. Here is why, and what tends to help instead.

What do Kegel exercises do?

Your pelvic floor is a group of muscles at the base of your pelvis. They support the organs in your pelvis, like your bladder, bowel and vagina, and they are the muscles you use to stop the flow of pee. A Kegel is a simple exercise for them: you tighten and lift the pelvic floor, hold it, then let go. Cleveland Clinic suggests starting with three seconds of squeezing and three seconds of relaxing, ten times, twice a day (Cleveland Clinic).

For bladder leaks, the evidence is strong. A 2018 Cochrane review pooled 31 trials with 1,817 women. Among women with stress urinary incontinence, a type of bladder leak, 56% of those who did pelvic floor muscle training reported being cured at the end of treatment, compared with 6% of women who had no treatment or an inactive control treatment (Cochrane, 2018). In that review, women with bladder leaks who did the training also had better sexual outcomes than those who did not.

So Kegels help with bladder leaks, a problem linked to weak or relaxed pelvic floor muscles.

Why can a tight pelvic floor make sex hurt?

Pain during sex is common. ACOG, the American College of Obstetricians and Gynecologists, says nearly 3 out of 4 women have pain during intercourse at some time in their lives (ACOG). The causes vary: dryness, infection, skin conditions, hormonal change, endometriosis and more. One cause that often gets missed is the pelvic floor itself.

A review in the journal Mayo Clinic Proceedings describes a group of problems it calls nonrelaxing pelvic floor dysfunction. It separates them from problems caused by relaxed muscles, such as prolapse and urinary leaks. In nonrelaxing pelvic floor dysfunction, the muscles do not relax and coordinate the way they should. Women with it can have pain and problems with sex, peeing and bowel movements, because all three need the pelvic floor to relax at the right moment (Faubion et al., 2012).

Vaginismus is one example of muscles that tighten when they should relax. The muscles around the vaginal opening tighten on their own when something tries to go in: a penis, a finger, a toy, a tampon, or a speculum at a smear test. You cannot control it. Cleveland Clinic explains the main theory: fear of painful sex makes the muscles tighten automatically, the tightening causes pain, and the pain feeds more fear (Cleveland Clinic). ACOG makes a related point. When you cannot relax, arousal is difficult, and pain may result.

Cleveland Clinic also warns that Kegels are not for everyone. Doing too many, or doing them when you do not need to, can make the pelvic floor muscles too tense or tight (Cleveland Clinic). If your muscles may already be tight, get checked before you add more squeezing.

Can your pelvic floor be tight and weak at the same time?

Yes, and this is why "my muscles feel weak, so I need Kegels" can mislead you.

A 2005 study compared 29 women who had pain at the vaginal entrance (a condition then called vulvar vestibulitis) with 29 women who had no pain during sex. Physiotherapists examined every woman without knowing which group she was in. The women with pain had more tension in the vaginal muscles, less muscle strength, and a tighter vaginal opening than the women without pain (Reissing et al., 2005).

The researchers suggested the tension was a reaction to pain: the muscles guard the area, the way you might tense your shoulders before an injection. They wrote that treatment needs to address this protective guarding.

In that study, the women with entry pain had more muscle tension and less muscle strength at the same time. The two physiotherapists examining each woman reached almost perfect agreement on what they found. So a feeling of weakness does not tell you whether your muscles need more strength or need to learn to let go. A trained physiotherapist can check.

Signs your pelvic floor may be too loose or too tense

These lists come from medical descriptions of each problem. Use them to start a conversation with a doctor or physiotherapist. They cannot diagnose you, and you can have signs from both lists.

What does a pelvic floor physiotherapist do for painful sex?

A pelvic floor physiotherapist is a physiotherapist trained to assess and treat these muscles. They ask about your symptoms, check how the muscles tighten and relax, and build a plan around what they find. For vaginismus, Cleveland Clinic says a specialist can teach you exercises to help relax your pelvic muscles and decrease pain (Cleveland Clinic).

The strongest trial in our research is for provoked vestibulodynia, which is pain at the entrance of the vagina when pressure is applied or penetration is attempted. In a trial of 212 women, a 10 week physiotherapy programme beat a numbing ointment (lidocaine) for pain during sex, and the difference held six months later. Asked how they felt, 79% of the physiotherapy group said they were much or very much improved, compared with 39% of the lidocaine group (Morin et al., 2021).

Morin et al., 2021, American Journal of Obstetrics and Gynecology. One condition only: pain at the vaginal entrance.

Look at what that programme included:

The programme went far beyond Kegels. The NHS describes treatment for vaginismus in a similar way: relaxation and breathing exercises, squeezing and releasing exercises to gain control of the muscles, and vaginal trainers in gradual sizes, first under the guidance of a specialised therapist and then practised at home (NHS). The squeezing is there to learn control, and it goes together with learning to release.

The trial result applies to provoked vestibulodynia, and other kinds of pain may need different care. Long-lasting vulvar pain may need several treatments together, such as vulvar care, medication, physiotherapy and sexual counselling (ACOG).

What can you do before your appointment?

How do you find pelvic floor help in Malaysia?

Start with a GP or an O&G (obstetrics and gynaecology) doctor. Tell them sex hurts and say you want to rule out a pelvic floor muscle problem. Ask if they can refer you to a physiotherapist who treats the pelvic floor. When you search on your own, try "pelvic floor physiotherapy" or "women's health physiotherapy" with your city name.

A few things help the first visit go well:

What to tell your partner

Pain during sex can feel like a relationship problem, and it can turn into one when nobody talks about it. Your partner may think you do not want them. You may feel guilty for avoiding sex.

Say the plain version: "My muscles tighten and it hurts. It is a body reaction that a physiotherapist can treat, and it has nothing to do with how much I want you." The NHS notes that vaginismus does not necessarily affect your ability to get aroused and enjoy other kinds of sexual contact, and that you can choose to involve your partner in treatment (NHS).

While you get help, you can still be close. Touch, kissing and sex without penetration are all still sex. If you want ideas for bringing something new into it together, start with how to bring up sex toys with your partner.

When to see a doctor

See a doctor if pain during sex is frequent or severe, or if you notice a lump, a sore or other changes on the skin of the vulva, itching, burning or unusual discharge (ACOG). If you want the bigger picture of what can cause pain, low desire or trouble reaching orgasm, read our guide: sex hurts, desire is gone, or you can't orgasm? Start here.

Kegels and painful sex: common questions