The Pelvic Floor: The Most Overlooked Variable in Intimate Difficulty
There is a group of muscles that governs a substantial portion of sexual function in both men and women, that almost nobody can locate, and that is treatable by a specific kind of physical therapist that most people do not know exists.
If you are experiencing pain during intimacy, difficulty with arousal or erection, problems with ejaculatory control, or a persistent sense that something physical is not working the way it used to — there is a meaningful chance that the pelvic floor is involved, and a meaningful chance that nobody has mentioned it to you.
This is one of the largest gaps between what is treatable and what is being treated in the entire landscape of intimate difficulty. I want to close a bit of it.
What the Pelvic Floor Actually Is
The pelvic floor is a group of muscles forming a hammock across the base of the pelvis. It supports the bladder, bowel, and reproductive organs. It governs continence. And it is directly involved in sexual function — arousal, erection, orgasm, and ejaculatory control all depend on its coordination.
Like any muscle group, it can be too weak, too tight, or poorly coordinated. All three produce problems, and — importantly — they produce different problems requiring different treatment.
This is the reason generic advice to "do Kegels" is frequently unhelpful and occasionally harmful. A pelvic floor that is already hypertonic — chronically gripped and unable to release — does not need strengthening. It needs to learn to let go. Prescribing strengthening exercises to someone with an overly tight pelvic floor can make their symptoms worse.
Which is why this requires assessment rather than guessing.
What the Research Shows for Women
A 2025 review in Clinical Obstetrics and Gynecology by Prendergast and colleagues examined pelvic floor physical therapy and female sexual dysfunction, noting that the pelvic floor's involvement in sexual function means impairment can produce pelvic pain, bladder and bowel dysfunction, incontinence, prolapse, and sexual dysfunction. The paper specifically provides screening tools for OBGYNs to use in practice — which tells you something about how frequently this is not being screened for.
A 2025 systematic review and meta-analysis published in Sexual Medicine by García-Laria and colleagues at the University of Vigo evaluated the effect of pelvic floor muscle training on sexual function in postmenopausal women — a population where genitourinary symptoms and resulting sexual difficulties are extremely common and where the standard treatments offered are typically hormone therapy or lubricants. The researchers note that pelvic floor muscle training has demonstrated beneficial effects on sexual function in other groups of women and set out to establish whether it does so here as well.
A review summarizing a workshop at the 2024 International Urogynecology Association meeting concluded plainly that management of pelvic floor disorders can have a positive impact on sexual function — and specified that for patients with female sexual interest and arousal disorder and orgasmic disorder, pelvic floor physical therapy is among the appropriate treatment options alongside medical management and sex therapy.
For pain during intercourse specifically, pelvic floor physical therapy is frequently the single most effective intervention available. Pain during intimacy is not something to accept as normal, and it is not primarily psychological.
What the Research Shows for Men
This is the part that is genuinely under-known, so I want to spend a moment on it.
A narrative review published in the International Journal of Impotence Research in February 2025 — reviewing twenty-six articles on pelvic physical therapy for male sexual dysfunction — opened with a statement worth quoting in substance: pelvic physical therapy is an evidence-based, first-line treatment for many pelvic floor disorders and sexual dysfunction, and studies have shown that pelvic physical therapy programs can improve both pelvic floor dysfunction and sexual function.
The review found that pelvic physical therapy approaches — exercise, electrotherapy, manual techniques, lifestyle changes, behavioral strategies, and pain management — should be suggested for potential benefit in improving erectile function, premature ejaculation, and sexual dysfunction associated with chronic pelvic pain. The authors noted that more research is needed on hypoactive desire and delayed ejaculation specifically.
A clinical summary of that review from a pelvic health practice highlights two specific findings: one randomized trial found a 47% cure rate for erectile dysfunction after a four-month intervention combining pelvic floor muscle training, biofeedback, and home exercises. Another found increased intravaginal ejaculation latency time in men with premature ejaculation — meaning genuinely improved control.
A 47% cure rate for ED from physical therapy is a remarkable number for an intervention that almost no man experiencing ED has been offered.
Why Nobody Told You
The gap here has a documented cause.
The American Physical Therapy Association's pelvic health section states directly that pelvic floor dysfunction in men is common but often overlooked and undertreated despite strong evidence supporting physical therapy intervention. And they report a workforce statistic that explains a great deal: 95% of pelvic health clinicians feel underprepared to treat male pelvic health conditions, with access particularly limited in rural and underserved areas.
Ninety-five percent. Among the specialists.
The situation for men is that a treatable condition is being missed because the referral pathway barely exists and the practitioners who do exist frequently do not feel equipped. The clinical summary I cited above notes the common pattern: men cycle through rounds of antibiotics for what is presumed to be prostatitis, and frequently find their way to the correct treatment only through their own research.
For women the pathway is somewhat better established, but still: the 2025 Clinical Obstetrics paper found it necessary to provide OBGYNs with screening tools and with language for addressing patient fears around sexual dysfunction. That is not a sign of a well-functioning referral system either.
Signs It Might Be Worth Investigating
For anyone: pain during or after intimacy. Chronic pelvic, low back, hip, or tailbone pain. Urinary urgency, frequency, or leaking. A sensation of pressure or heaviness in the pelvis. Constipation or straining.
For women: pain with penetration, particularly at entry. Difficulty with tampon insertion or gynecological exams. Reduced genital sensation. Difficulty reaching orgasm. Postpartum changes that have not resolved. Symptoms following pelvic surgery.
For men: erectile difficulty, particularly the kind that feels mechanical rather than desire-related. Difficulty with ejaculatory control. Pain with ejaculation. Chronic pelvic pain syndrome or a prostatitis diagnosis that antibiotics did not resolve. Post-prostatectomy changes.
For either: a history of trauma, which as I have written about elsewhere frequently produces genuine musculoskeletal guarding in the pelvic floor that responds to physical treatment.
What to Actually Do
Find a pelvic floor physical therapist.
Not a general PT. Someone with specific pelvic health training. The APTA Academy of Pelvic Health maintains a practitioner directory, and Nashville has qualified practitioners.
Ask for a referral if you need one, and be persistent.
Many physicians do not think of this. Asking directly — "could this be pelvic floor related, and could I get a referral to pelvic floor PT?" — is frequently what initiates the pathway.
Do not start Kegels on your own.
Get assessed first. If the problem is a hypertonic pelvic floor, strengthening will make it worse.
For men specifically, be prepared to advocate.
Given the workforce gap, you may need to look harder and ask more insistently than feels comfortable. It is worth it.
Why I Write About This
My work is coaching — the relational, somatic, and psychological dimensions of intimate life. Pelvic floor dysfunction is not my lane and I do not treat it.
But I encounter it constantly, because a substantial number of people arrive at coaching having concluded that their intimate difficulty is psychological or relational when a meaningful component of it is muscular and treatable.
If something physical is not working, rule out the physical first. It is frequently faster, more effective, and considerably less complicated than everything else.
Book a free discovery call — and if what you need is a pelvic floor physical therapist rather than a coach, I will tell you so and point you toward one.
And for the somatic awareness work that complements physical treatment, Coelle offers guided experiences designed to rebuild genuine connection with your own body.
Scott Schwertly is a Nashville-based sex and intimacy coach, founder of Coelle, and co-host of Do You Feel That? with his wife Brittney. This post is educational and is not a substitute for medical care.
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