“Can Stronger Pelvic Muscle Floor Improve Sexual Function?” (2010) by Lior Lowenstein, Ilan Gruenwald, Irena Gartman, and Voram Vardi

In 2010, Lior Lowenstein and colleagues published “Can Stronger Pelvic Muscle Floor Improve Sexual Function?” hereafter, “Stronger Pelvic Muscle Floor,” in the International Urogynecological Journal. They explain that they examined 176 women to assess whether their pelvic floor muscles, or PFMs, contribute to their sexual function, including their ability to feel sexual desire, become sexually aroused, and experience orgasm and pleasure. The PFMs are a group of muscles that stretch from the tailbone in the spine to the pelvic bone in the pelvis. They support the pelvic organs, which include the bladder, intestines, and the uterus in females. Prior to “Stronger Pelvic Muscle Floor,” researchers suspected a connection between the strength of PFMs and sexual function, but there was little scientific evidence to support it. Lowenstein and colleagues found that women with stronger PFMs had enhanced sexual function and concluded that the strength of women’s PFMs affects their sexual function. “Stronger Pelvic Muscle Floor” provided evidence for a direct relationship between PFM strength and sexual function, a finding that could help improve the quality of life and sexual health of females.  

1. Background and Context
2. Article Roadmap
3. Detailed Content
4. Impact

Background and Context

At the time of publication, all four authors of “Stronger Pelvic Muscle Floor” were associated with the Neuro-Urology Unit at the Rambam Health Care Campus in Haifa, Israel. Neuro-urology is a multidisciplinary field that encompasses neurological problems that occur in the lower urinary tract and sexual organs. Additionally, in 2010, Lowenstein was associated with the Department of Obstetrics and Gynecology at Rambam Medical Center. Gynecology is a medical specialty that focuses on the diseases and functions of the female reproductive system, and obstetrics is the field that focuses on pregnancy and childbirth. As of 2024, Lowenstein works as the Director of the Department of Obstetrics and Gynecology at the Galilee Medical Center in Nahariya, Israel, and continues to work in the field of urogynecology. As of 2024, Ilan Gruenwald is the Director of the Neuro-Urology unit at the Rambam Medical Center. Since beginning his career in medicine, the European Society for Sexual Medicine and the European Association of Urology presented Gruenwald with eight Awards of Excellence for his achievements in the field. Prior to and at the time of publication Irena Gartman and Yoram Vardi had been conducting research on sexual dysfunction and sexual function. 

In “Stronger Pelvic Muscle Floor,” Lowenstein and colleagues build on prior research suggesting that PFM strength may influence or improve sexual functioning. The research team based their study on the work of Arnold Henry Kegel, who was a physician in the 1900s from the US who worked in the fields of obstetrics and gynecology. He researched the pelvic floor and was one of the first to suggest performing pelvic floor exercises, or Kegel exercises, to strengthen those muscles, and prevent the likelihood of health problems such as pelvic organ prolapse. Pelvic organ prolapse is a condition where one or multiple pelvic organs slide out of place and cause a bulge called a prolapse. In 1952, Kegel was one of the first to publish an article explaining that pelvic floor exercises could also improve female sexual function. Lowenstein and colleagues further supported their work by examining studies later that examined a connection between PFMs and aspects of sexual functioning. For example, in 1979, a nurse-physician team, Benjamin Graber and Georgia Kline–Graber, published an article reporting that the pubococcygeus muscle, one of the pelvic floor muscles, was stronger in those that could achieve orgasm. Using those previous studies as a guide, Lowenstein and colleagues examined and evaluated women who were experiencing sexual dysfunction to determine whether the strength of their PFMs affected the strength of their sexual function. 

Article Roadmap

Lowenstein and colleagues organize “Stronger Pelvic Muscle Floor” into five sections. In the first section, titled “Introduction,” the authors explain the process leading up to an orgasm and how the PFMs contract during it. They also reference prior research suggesting that PFMs strength plays a role in improved sexual function. Then, in “Methods,” Lowenstein and colleagues explain that to conduct their research, one physician examined all of the women experiencing sexual dysfunction and measured both their PFM strength, PFM contraction duration, and had them self-evaluate their sexual function. In the third section, “Results,” the authors communicate that those with higher scores in the arousal and orgasmic domains also had stronger PFMs and that the PFM contraction durations were often linked to higher self-reported satisfaction for both orgasm and sexual arousal. Then, in the “Discussion,” they claim that their results are further supported by prior research showing that pelvic muscle strength or training can improve sexual function. In the final section, titled “Conclusion,” the authors reiterate that they found a correlation between the strength of PFMs and women’s sexual function. They also state that researchers need to conduct future studies to test whether PFM exercises improve sexual function.

Detailed Content 

In the “Introduction” of “Stronger Pelvic Muscle Floor,” Lowenstein and colleagues explain the mechanisms leading up to an orgasm as well as the research articles they built on to investigate how the strength of PFMs impacts sexual function. The authors explain that as stimulation occurs, blood flows to the genital organs. That causes the outer part of the female genitalia, and the vagina, which is the canal leading from the internal reproductive organs to the outside of the body, to swell. Lowenstein and colleagues explain that the swelling results in an increase in secretions during sexual arousal and when someone applies uninterrupted stimulation, arousal begins to build up and reach what the researchers call a maximum point. At that maximum point, the PFMs reach maximum tension, where they hold for a moment, and then they release. The researchers refer to that release as an orgasm, which is also when the pubococcygeus and iliococcygeus, another muscle that makes up the pelvic floor, contract. Thus, they emphasize that PFMs play a key part when females experience an orgasm. They refer to previous research that supports a relation between PFM strength and sexual function including a study by Graber and Kline–Graber, reporting that the strength of the pubococcygeus muscle could positively affect sexual function. The researchers also refer to other studies that found that Kegel exercises improved sexual arousal for women in the study. 

In the second section, titled “Methods,” the authors explain that to conduct their study they gathered data from previous patients who experienced sexual dysfunctions and performed examinations that evaluated their participants’ PFM strength. The authors state that they gathered their data from medical charts of the women who visited Lowenstein and colleagues’ urogynecology clinic between October 1999 and January 2009. They describe that their examination began with a standardized clinical evaluation, which, with their patients’ permission, included assessing the PFM strength. To do so, the team explains that they asked the women to lie down with their back to the exam table. They explain that one physician conducted all of the exams by placing their index finger at the entrance of the vagina. The researchers state that the physician told the women to contract their PFMs in an upward and inward motion, which allowed the physician to evaluate the strength of the PFM. The physicians then ranked the strength of the PFM contraction from zero being weak to two being strong. According to the researchers, the examiner ranked the PFMs as weak when they could not or could barely feel the PFM contraction. When the examiner could feel the PFM contraction, but the contraction could not continue when the examiner’s finger applied pressure to it, the researchers defined that as medium PFM strength. Finally, they state that a strong PFM strength was when the examiner felt maximum contraction, and when there was strong resistance to the examiner’s finger when pressure was applied.

Continuing into the "Methods,” Lowenstein and colleagues explain that in their study, they also evaluated the duration that the patients could hold their PFMs at full strength and how each woman assessed their own sexual function by filling out a questionnaire. The authors explain that to evaluate the duration of a PFM contraction, the examiner told the women to contract their PFM for as long and as hard as they could. They then recorded the duration in seconds. In addition to that measure, the women filled out the Female Sexual Function Index, or FSFI, a self-reporting questionnaire to assess their sexual function by rating six domains of it, which included arousal, desire, lubrication, orgasm, satisfaction, and pain. The authors state that each of those domains are rated with zero being the lowest and exhibiting poor sexual function and six being the highest exhibiting better sexual function. Lowenstein and colleagues relay that the total scores of the patients in their study ranged from two to thirty-six.  

In the “Results” section, the authors note that those who had stronger PFM contraction also had higher scores on the orgasmic and sexual arousal domains on the questionnaire. Lowenstein and colleagues state that based on their examinations, ten percent of women had strong PFM contractions, while forty-one percent had moderate PFM contractions, and another forty-one percent had weak PFM contractions. The authors also note that woman with stronger or moderate PFM contractions had higher scores on the arousal and orgasmic portions of the questionnaire. Additionally, they explain that there was a moderate correlation between the length of time the PFM contraction was held and scores on the orgasmic and arousal sections on the questionnaire. The authors state that they did not observe a correlation or difference between women’s PFM strength and their demographic or medical history. 

In the “Discussion” section, the authors reference prior research articles such as Kegel’s to support their conclusion that sexual function, or in their case orgasm and arousal, are directly associated with PFM strength. The authors conclude that their study found a connection between PFM strength and both orgasm and arousal. However, Lowenstein and colleagues state that there is still not yet enough data, including from other studies, to verify the idea of an association between PFM strength and sexual function, even though researchers understand the function of PFM contractions during orgasm. However, their conclusions support both Kegel’s research suggesting that having stronger PFMs results in better sexual function as well as Graber and Kline–Graber’s findings, which demonstrated that weak PFM hinders what the researchers refer to as orgasmic potential. Since Kegel’s and Graber and Kline–Graber’s work supports the theory of the PFMs being associated with sexual function, the authors propose that strengthening weak PFMs may in turn improve sexual functioning. Furthermore, they continue to reference other research articles that used pelvic floor muscle rehabilitation or training to treat other health conditions, or to see how they influence the various domains of sexual function. The authors emphasize that they are one of the first to test the correlation between the different FSFI domains and PFM strength. 

Continuing in the “Discussion,” the authors address potential limitations of their study, including the subjective nature of PFM strength evaluation. They state that they attempted to overcome those limitations by evaluating muscle strength using two different parameters, rather than only one. First, an examiner performed a subjective evaluation of PFM contraction with their finger, but then, they also used an objective measure of the endurance of the PFM contractions. Lowenstein and colleagues conclude that since there was a direct association between the endurance testing on the PFM contractions of their subjects, and their orgasmic and arousal scores, PFM strength must be important in sexual function. Additionally, the authors acknowledge that there was inherent bias in the study. For example, they explain that since the clinic in the study was referral-based, the diversity of conditions may differ from those in the general populations. Thus, they conclude the section by stating that researchers need to conduct further studies on women with typical sexual functioning to see if the correlations they found in their study apply elsewhere.

In the final section, titled “Conclusion,” the authors summarize that they found that those with stronger PFM also had higher arousal and orgasmic scores on the questionnaire they used, and thus had better sexual functioning. However, they researchers propose further research to examine the use of exercises on the pelvic floors and how it affects sexual function and orgasm.

Impact

As of 2024, according to Google Scholar, researchers have cited “Stronger Pelvic Muscle Floor” 150 times. Since Lowenstein and colleagues’ paper, other researchers have published many articles exploring the efficacy of pelvic floor exercises or training to strengthen PFMs and as a result improve sexual function. For example, “Stronger Pelvic Muscle Floor” was cited in a 2016 article written by Laura B. Huffman and colleagues, a research team primarily working in obstetrics and gynecology, about maintaining sexual health in those who have experienced gynecological cancer. The authors refer to “Stronger Pelvic Muscle Floor” to support the idea that PFM contraction strength plays a part in improved sexual functioning, and additionally, that those who have feel pain during sex or vaginal narrowing, should receive pelvic floor therapy. Lowenstein and colleague’s work was also cited in an article by Ui-jae Hwang and colleagues, a group of individuals who work in the field of gynecology, published 2021, in which they assess the sexual function, PFM strength, and hip strength in females with stress urinary incontinence. Stress urinary incontinence is a sudden loss of bladder control due to pressure, such as coughing. Hwang and colleagues conclude that PFM functions and hip muscle strength in women with stress urinary incontinence is related to their sexual function. Referencing Lowenstein and colleagues’ research on sexual function and PFM, Hwang and colleagues were able to build upon the connection already found to show that among females with stress urinary incontinence, sexual function is related to both hip strength and PFM function.

“Stronger Pelvic Muscle Floor” and publications that have followed have given more insight into the association between PFMs and sexual function. That has allowed researchers to find ways to improve the female sexual health, through methods such as pelvic floor therapy or exercise. The article provided understanding of the value of improving PFM strength and the positive impact PFM strength has on sexual function.