What’s Up Down There? Understanding and Caring for Your Pelvic Floor

Hey Scarleteen readers! I’m Caitlyn, a pelvic health physical therapist and lover of all things pelvic anatomy. When I tell someone that I help people with problems related to the abdomen, pelvis, and pelvic floor, I often get a curious look.

What is the pelvic floor, after all? How do we care for it and the tissue around it? Here’s a thorough walkthrough of the anatomy of your pelvic floor and perineum⁠ (perineum: The general region of the body between the anus and the testes or the anus and the vaginal opening. Some people call the perineum the “tain’t.”) and how you can keep tabs on this area.

What is the pelvic floor, and why should I care?

Your pelvic floor is a collectionexternal link, opens in a new tab of muscles, nerves, blood vessels, and connective tissue. It’s located at the bottom⁠ (bottom: Either a colloquial term for buttocks or even the whole genital area, or someone who wants to consensually relinquish control or active leadership during sex to a partner and follow their lead.) of the pelvis, where it connects your pubic bones (in the front), your tailbone, and your sitting bones.

As a pelvic floor PT, I spend a lot of time thinking specifically about the muscles and nerves of the pelvic floor. PTs divide the muscles and nerves into 3 layers and 5 key functions.

The three layers:

1. The outermost, with four muscles: The Superficial Perineal Pouch
2. The middle, with four muscles: The Urogenital Diaphragm
3. The deepest, with two muscles: The Pelvic Diaphragm

The 5 primary functions of the pelvic floor—the “Five Ss”:

1. Sphincter: Opening and closing the urethra⁠ (urethra: The urinary tract, where people pee from. On a penis, the opening to the urethra is at the head of the penis; on a vulva, the opening is above the vaginal opening and below the external clitoris.) and rectum⁠ (rectum: The internal passage between the anus and the colon; stores solid waste until it leaves the body through a bowel movement.) (the openings you pee and poop from)
2. Support: Supporting the pelvic organs (like the bladder and rectum) from below
3. Stability: Connecting the two sides of the pelvis and supporting the joints
4. Sexual and reproductive anatomy functions: Allowing the vagina⁠ (vagina: The internal passage leading from the opening of the vulva to the cervix of the uterus.) to stretch, the clitoris⁠ (clitoris: A sexual organ both external and internal on the vulva and inside the pelvis of those often assigned female at birth that is similar to the penis, but serves no other known purpose besides providing sexual pleasure.) to swell, and the penis⁠ (penis: One of the two external reproductive organs of people often assigned male at birth.) to stay erect during arousal⁠ (arousal: A state of sexual excitement and interest that sends messages to the brain which create physical changes and sensations, such as increased blood pressure, erection, lubrication, loosening of the vaginal or anal muscles, and increased physical sensitivity.) and sexual⁠ (sexual: About or relating in some way to sex or sexuality.) activity. These are the muscles that are often engaged during orgasm⁠ (orgasm: An event typically in response to physical or intellectual sexual stimulation, controlled by the involuntary nervous system. ) and also allow for childbirth.
5. Sump pump: Pumping contaminants out⁠ (out: Short for ‘out of the closet’. When someone’s LGBTQ+ identity is known to other people.) of the pelvis (in a fluid called lymph) to keep it healthy and free of infection⁠ (infection: When harmful microbes, or germs, or harmful levels of microbes/germs, enter the body and multiply, causing illness. The common cold, flu viruses, sexually transmitted infections, chickenpox, impetigo, rabies and diphtheria are some kinds of infections.)

To achieve all these functions, the muscles of the pelvic floor must be able to contract and relax in a coordinated fashion. Some tasks require them to contract strongly and hold; others require a series of small, quick contractions. The ability to relax fully between contractions is just as important as the contractions themselves.

That’s a lot of work for just a few small muscles! As you might imagine, these muscles don’t always work in perfect harmony. Injuries, medical conditions, surgeries, and more can disrupt the balance between these muscles and cause a variety of pelvic floor issues. Check out my “Pelvis Problems” series here at Scarleteen to learn more about many of these issues.

Now that you understand the basic anatomy and function of the pelvic floor muscles, let’s discuss what covers them on the outside.

Keeping Tabs on Your Pelvic Parts

Everyone has pelvic floor muscles, and everyone has skin covering the muscles to create the perineum. The perineum is the name for the diamond-shaped area between the pubic bones, sitting bones, and tailbone in people of all sexes and genders. It includes the muscles of the pelvic floor, and the layers of skin and cushioning fatty tissue that cover the area — including the external genitals.

Regardless of your pelvic anatomy, it’s important to care for this area throughout your life. You are your own best health advocate: the better you understand what’s normal for you, the better you’ll be able to explain to a healthcare provider⁠ (healthcare provider: A qualified person to provide sound physical and/or mental healthcare, such as a doctor, nurse, clinician, counselor, medical assistant, midwife or other healthcare professional.) when something isn’t right.

Remember: genitals come in all shapes, sizes, and colorsexternal link, opens in a new tab – the only “right” appearance is your baseline appearance!

Once you’ve started puberty⁠ (puberty: The process of physical and sexual changes from childhood to adulthood, initiated by hormone signals from the brain to the gonads. ) , it’s important to begin regular self-examsexternal link, opens in a new tab of your genitals: this will help you better understand your baseline and watch for any important changes over time.  Once a month, stand undressed in front of a mirror so you can check the area. 

If you have a penis and testicles (whether you call them by those names or not)

It helps to self-check after a warm shower, when the scrotum (the sack that holds the testicles) is fully relaxed.

Here are some simple stepsexternal link, opens in a new tab for a self-exam:

• Wash your hands before you begin. Start by looking for any signs of swelling in the penis or testicles. Lift your penis out of the way to check the skin of your scrotum, both front and back.
• Hold one testicle with your thumb on top⁠ (top: In sexuality, this is someone who wants to take the/a lead during sex with a partner or partners, or to consensually take the role of being in charge of sexual actions.) and index and middle fingers underneath. Gently roll it between your fingers, feeling for any new lumps, bumps, or changes in size or texture.
• Repeat with the other testicle. You can also check the shaft⁠ (shaft: On the penis, the portion of the penis extending from below the head to the base of the penis, where it is attached to the body. On the vulva, an internal portion of the clitoris behind and beneath the clitoral glans.) of the penis with the same technique. Wash your hands after finishing the exam.
• By doing this self-exam regularly, you’ll learn your baseline so you can easily recognize if something’s out of the ordinary.

If you have a vulva⁠ (vulva: The name for the external genitals of people assigned female at birth. The vulva includes the mons, external clitoris, inner and outer labia, fourchette and perineum.) (whether you call it a vulva or not)

For folks with vulvas, visually examining your genitals can be a bit trickier, but it’s still equally important. Your self-exam can also be done monthly. If you menstruate, try to perform it at roughly the same time in your monthly cycle.

Here’s how to check your bitsexternal link, opens in a new tab:

• Wash your hands before beginning. Ditch your underwear and sit comfortably with your knees bent and slightly separated. Alternatively, you can stand with one foot propped on a chair or the edge of the bathtub.
• Hold a hand mirror in your non-dominant hand so you can see your vulva. Examine the outer labia⁠ (labia: On the vulva, both inner (labia minora) and outer (labia majora) sets of skin with sensory nerve endings which surround the vaginal opening.) (lips) of the vulva for any new color changes, spots, sores, or lumps. Check the skin just in front of and behind the labia as well.
• Use your dominant hand to gently separate the outer labia so you can see the inner labia. Inspect as above. Gently pull back the skin at the top of the labia to check your clitoris.
• If you can’t easily see your vaginal opening⁠ (vaginal opening: The external opening to the vagina.) , gently separate the inner labia and inspect the skin around the opening, examining as described above.
• Use gentle pressure through your finger pads to feel for any lumps or bumps that you can’t see – press along the labia and the vaginal opening. Note if you feel any new discomfort where you are pressing.
• When you’re finished, wash your hands again. As for folks with penises, consistent performance of this self-exam will help you establish your baseline.

Following Up on Funky Findings

If you find something new or unusual during a genital self-exam, or if you’re having problems with peeing, pooping, or any genital sexual activity, call a healthcare provider to get it double-checked.

Your provider may be able to assess the issue with a visual inspectionexternal link, opens in a new tab and/or a gentle hands-on exam. They may recommend testing (like taking a urine sample or ordering a blood test) to help rule in/out certain conditions that could be causing your symptoms. Depending on your symptoms and anatomyexternal link, opens in a new tab, they may recommend an internal vaginal and/or rectal exam to better assess the area of concern.

As a pelvic PT, I’m constantly hearing from people who thought longtime symptoms of a problem were “just normal.” Adolescents and young people in particular tend to have less knowledge of the issues that can affect the pelvic floorexternal link, opens in a new tab, often due to a lack of education and/or cultural taboos about discussing these subjects. If you’re leaking a little pee during exercise, having pain with sexual activity, or struggling to control sudden urges to poop, don’t wait: these are all things that can be helped! Reach out to your primary care provider, or find a pelvic PT near youexternal link, opens in a new tab.

Remember: you are a partner⁠ (partner: In a sexual context, a person with whom someone is having some kind of sex. The term “partner” can be used for all kinds of relationships, not just serious ones. “Partner” can also mean the person someone is with in a romantic or familial partnership.) in your healthcare – you always have the right to ask questions about any test, exam, or treatment that your providers recommend, and you have the ultimate say on which procedures are performed. Check out this article on all things pelvic exams (link to new article on exams) to learn more!