Part of Pelvic floor weakness

Can a weak pelvic floor cause lower back pain or hip pain?

Can a weak pelvic floor cause lower back pain? It is linked to it, and linked is a weaker word than causes, which is the honest place to start. In a survey of 38,050 Australian women, those who often leaked urine had about two to two and a half times the odds of frequent back pain, depending on the age group, while body mass index and activity level were not consistently related to back pain once leaking and breathing difficulties were in the same model (Smith 2006). Among 85 women seen in Canadian orthopedic clinics for low back or pelvic girdle pain, 95 percent had some sign of pelvic floor dysfunction on examination, although tenderness, in 71 percent, was more common than weakness, in 66 percent (Dufour 2018). Treating the pelvic floor does seem to help the back: across 19 randomized trials, adding pelvic floor muscle training to usual physical therapy reduced pain and disability, and the authors rated the certainty of both results as low (Lim 2024). What none of this establishes is direction. These studies cannot tell you whether a weak pelvic floor brought the back pain on, whether months of back pain changed how the pelvic floor works, or whether one thing is driving both. Hip pain is thinner still. We could find no study that tested a weak pelvic floor as a cause of hip pain. What has been studied runs the other way, or is about a tender pelvic floor rather than a weak one, so nobody should be telling you that weakness is what your hip pain is.

Warning signs, and when to get help

Can a weak pelvic floor cause lower back pain?

The association is real and it has been measured more than once. Causation is a different claim, and the studies we have cannot carry it.

The largest piece of evidence first, because it is the one that changed how physios think about this. Smith and colleagues took postal survey data from 38,050 women in three age groups and asked which factors went with frequent back pain. Women who often had incontinence had roughly two and a half times the odds of frequent back pain in the youngest group, and a little over twice the odds in the two older groups. The finding people quote, though, is the comparison: once incontinence and breathing difficulties were in the model, body mass index and activity level were not consistently related to back pain at all.

Smaller studies looked at the muscle rather than the symptom. Arab and colleagues used ultrasound over the lower abdomen to watch the bladder base lift in 40 women, half of them with low back pain, and found a difference between the groups. Twenty women per group is a small sample, and the p value was 0.04 with the confidence interval for the difference running from 0.002 to 0.27, so the lower end of it is almost nothing. That is a result sitting close to the line. Treat it as pointing in the same direction as the big survey rather than as proof of anything on its own.

One more thing is worth knowing before you read any of this as your own answer. Every study above was done in women.

Can a weak pelvic floor cause hip pain?

Nobody has tested it, and we are not going to fill that gap with a plausible-sounding mechanism.

We looked for studies on pelvic floor weakness and hip pain and found none that asked the question directly. What exists is work on lumbopelvic pain, which covers the low back and the pelvic girdle, the area around the joints at the back of the pelvis. That is not the same as the hip. Pain felt at the side of the hip, over the bony point, most often comes from the tendons there, and outer hip pain is a well described problem with its own treatment.

Two pieces of research do sit next to the question, and both are worth knowing because neither says what people assume. Dune and colleagues examined 177 women attending a pelvic pain clinic and found that those reporting lumbar, hip or pelvic girdle pain were more likely to have pain on internal pelvic floor muscle examination than those without that history, with an odds ratio of 7.24 (95 percent confidence interval 1.95 to 26.93), and they argued that the examination belongs in the assessment of all women with pain in those areas. Read what that measures: tenderness, not weakness, in women already referred for pelvic pain, so it does not transfer to everyone with a sore hip. Tamaki and colleagues went the opposite way, following 189 women having a hip replacement: 43 percent reported leaking before the operation, and of those, 64 percent said it had improved 3 months afterwards, which points to a stiff, painful hip affecting the pelvic floor rather than the reverse.

Two things in this region do sit close enough to the pelvic floor to confuse matters. Pain around the tailbone, covered on our tailbone pain page, often involves the pelvic floor muscles directly. And pain at the back of the pelvis can be felt into the buttock and groin in a way that people reasonably call hip pain. Neither of those is evidence that a weak pelvic floor causes pain in the hip joint.

What the research actually shows

There is one piece of treatment evidence, and it is more useful than all the association studies put together, because it changed something rather than just observing it.

Lim and colleagues reviewed 19 randomized trials of pelvic floor muscle training in people with low back pain. For pain the standardized mean difference was reported as -0.73 (95 percent confidence interval -1.10 to -0.36), and for disability the mean difference was -5.21 points (95 percent confidence interval -7.15 to -3.26). The minus signs mean less pain and less disability in the groups that trained, and the authors called the pain reduction clinically meaningful. Using GRADE, they rated the certainty of both results as low, and the disability result was affected by high variation between the studies. They suggested the benefit may be largest in pregnancy-related cases.

Low certainty is not the same as no effect, and it is not a reason to skip the training. It means the true effect could be considerably smaller or larger than the number above, and that better trials could move it. If you are being sold a guaranteed result on the back of this literature, the literature does not support it.

The mechanism work is more settled than the clinical work, oddly enough. Hodges and colleagues recorded pelvic floor activity while people moved an arm quickly and while they breathed, and found the pelvic floor switching on before the shoulder muscle did, in every direction of movement, and changing with each breath out. So the pelvic floor is part of how the trunk is held steady and part of how you breathe. That makes a connection to back pain believable. Believable is where it stops.

What makes the pelvic floor a likely part of your back pain

Nothing on this list proves it. These are the features that make us examine the pelvic floor in clinic instead of leaving it out, and the ones to mention to whoever is treating your back.

Your back pain and your bladder behave as a pair. Flares arrive together, and the weeks when you leak more are the weeks your back is worse.
It started with a pregnancy or a birth. Pregnancy-related back and pelvic pain has its own pattern and its own program, and Lim's review suggests this is the group with the most to gain from training the pelvic floor.
There is heaviness, dragging or a bulge sensation low down, which belongs in the warning list at the foot of this page rather than in a program.
You strain on the toilet, or constipation is a regular part of your week. The NHS puts it bluntly on its own page about leaks: straining to poo weakens the pelvic floor muscles and makes urinary incontinence worse.
You hold your breath or pull your tummy in hard whenever you lift, which loads the floor from above at the moment it needs to lift.

Can a weak pelvic floor cause lower back pain in men?

Men have the same muscle layer doing the same job, and almost none of this research includes them.

That is not a throwaway caveat. The 38,050 person survey was a women's health study. The ultrasound study was in women. The Canadian clinic study was in women. We found no male equivalent of any of them, which means the honest position for a man reading this page is that the association has not been measured in you, even though the anatomy makes it plausible.

What is published for men is practical rather than epidemiological. POGP, the UK group of pelvic health physiotherapists, puts out a separate exercise leaflet for men, and Continence Health Australia has a men's page describing how to find the muscles, with the penis drawing slightly in toward the tummy and the testicles lifting as you squeeze. Both sources are about continence, not back pain. So a man whose back pain and bladder symptoms arrived together has a reasonable case for having both assessed, and no study to point at. If he does start the squeezes, the timescale in the men's leaflet is 3 to 6 months before expecting to notice a difference, rather than the 3 to 5 months POGP gives on its general page.

When tightness rather than weakness is the link

Get this the wrong way round and you can lose months to it.

Look again at the Canadian figures. Of 85 women with low back or pelvic girdle pain, 71 percent had tenderness of the pelvic floor muscles and 66 percent had weakness, and the commonest single finding was increased pressure-pain sensitivity. A floor that is tender and will not let go can test as weak, because a muscle held short cannot produce a strong contraction from where it already sits. If that is what is going on, a program of harder and longer squeezes is the wrong instruction, and the usual result is more pelvic ache and no change in the back.

Three things make us suspect tightness over weakness: pain instead of leaking as the main symptom, pain with sex or with tampons, and a sense that you can never fully relax down there. None of those is a test, and an internal examination by a pelvic health physio is what settles it. POGP's advice is simply to ask a specialist physiotherapist if you find the exercises difficult, which is the same point put politely.

What to do if both are going on, and in what order

One program at a time, and the back usually goes first.

Standard care for back pain has not changed and does not depend on the pelvic floor: the NHS says to stay active and keep going with your daily activities rather than resting in bed, and lists walking, swimming, yoga and pilates among the things that may ease it. Our low back pain program sets that out in stages. Doing that well, for a few weeks, also tells you how much of the picture the back accounts for.

Then add the pelvic floor squeezes if the features above fit you, because they are the part with evidence behind them. One reader does not start here at all. If you have had an operation for prolapse or for leaking, or prostate or other urological surgery, your surgical team sets when the squeezes start and how many of them, and Continence Health Australia's instruction to men is to wait until your surgeon has checked your healing before starting.

POGP suggests working toward 10 long squeezes of up to 10 seconds, then 10 quick squeezes, at least 3 times a day, letting the muscle go fully after each one. If you can only hold for 2 or 3 seconds, start there and build.

Expect to be judging this in months, not weeks: POGP says to look for an improvement in 3 to 5 months. Your physio will adjust this. If you have recently given birth, including by cesarean section, or you have a gap down the middle of your stomach muscles (diastasis recti), ask your physio, midwife or doctor first.

What we would not do is start the squeezes and a new trunk program in the same week, because then you cannot tell which one did anything. The staged pelvic floor program keeps the plain squeezes separate from the movement work for the same reason. If you want one exercise that bridges the two, transverse abdominis activation teaches the gentle lower tummy hold without the breath holding, and the glute bridge loads the hips and trunk while you keep breathing.

Keep two rules whatever you do. Never hold your breath through an effort, and stop and ask if an exercise brings on heaviness, dragging or a leak.

When back or hip pain needs checking first

Some back pain is not a pelvic floor question or a physio question, and that decision comes before any program.

The full list sits at the foot of this page. Read it once properly instead of skimming it. The lines that send you to an emergency department are about the nerves at the base of the spine: altered feeling around the genitals or bottom, new trouble controlling your bladder or bowels alongside back or leg symptoms, symptoms in both legs, and not being able to pee at all. A fever with new leg weakness or new bladder trouble is on the same list.

Same-day advice covers a fall or strain in anyone with thinning bones, a leg or foot that is getting weaker, pain that is worse at night or does not ease with rest, unexplained weight loss, and any back pain in someone who has had cancer. Red flags in physiotherapy explains why these are treated as their own set of questions rather than as a footnote.

For everything else, the NHS threshold is simple enough: see a doctor if back pain has not improved after a few weeks of treating it at home. Ask about a pelvic health physio at the same appointment if the features earlier on this page fit you, because in some areas you can refer yourself.

For physiotherapists

The association is consistent and the causal claim is not available. Smith (2006) is the dataset worth knowing, with incontinence outperforming BMI and activity as a correlate of frequent back pain across three cohorts. Dufour (2018) is the clinic-facing one, and its distribution matters more than its headline: tenderness at 71 percent above weakness at 66 percent in a lumbopelvic pain sample argues for examination before prescription. Lim (2024) gives the first poolable treatment signal, 19 trials, low certainty by GRADE for both pain and disability, with the pregnancy-related subgroup flagged as the likeliest responders. Nothing in this literature supports pelvic floor training as a stand-alone intervention for mechanical low back pain.

For the hip, nothing tests weakness as a cause: Dune (2023) adds pelvic floor myofascial tenderness in a pelvic pain clinic cohort reporting lumbar, hip or pelvic girdle pain (OR 7.24, 1.95 to 26.93), and Tamaki (2014) runs the other way, with 64 percent of the 43 percent who leaked before a total hip replacement reporting improvement at 3 months.

Related exercise programs

Warning signs

Get emergency help now

Emergency: numbness, tingling or altered feeling around or under your genitals, between your inner thighs, or around your bottom (anus), for example it feels different when you wipe after using the toilet. Call emergency services or go to an emergency department straight away. This can be a sign of pressure on the bundle of nerves at the base of the spine (cauda equina syndrome), which needs emergency treatment.
Emergency: you suddenly cannot control your bladder or bowels at all. The same applies to new leaking of pee or poo, new trouble starting to pee, not being able to feel yourself peeing, not noticing when you need to poo, a new change in how your genitals feel during sex, or new trouble getting an erection or ejaculating, if it comes with back pain, sciatica, or pain, tingling, numbness or weakness in one or both legs. Call emergency services or go to an emergency department straight away. These can also be signs of cauda equina syndrome.
Emergency: you cannot pee at all, especially if your lower tummy feels full and painful. Call emergency services or go to an emergency department straight away.
Emergency: sciatica in both legs, or pain, tingling, numbness or weakness in both legs. The same applies if you lose feeling in one leg. Call emergency services or go to an emergency department straight away.
Emergency: back or leg pain that started after a serious accident, such as a car crash or a fall from a height, or back pain with chest pain. Call emergency services. If the pain started straight after the accident, keep still while you wait.
Emergency: sudden, severe pain in your lower back or tummy that is not like your usual back pain, if you have been told you have a swelling of the main blood vessel in your tummy (abdominal aortic aneurysm), you are over 60, you smoke or used to smoke, or you have high blood pressure. The same applies if sudden, severe back or tummy pain comes with feeling faint or passing out, pale, sweaty or clammy skin, a racing heartbeat or being short of breath. Call emergency services straight away. This can be a sign of an aneurysm bursting, which needs treatment in hospital at once.
Emergency: back pain with a fever, or you feel hot, shivery or very unwell, and you also have new weakness, numbness or tingling in one or both legs, or new trouble with your bladder or bowels. Call emergency services or go to an emergency department straight away. This can be an infection pressing on the nerves in the spine (spinal epidural abscess), which needs emergency treatment.
Emergency: you have had cancer, now or in the past, and your back or neck pain feels like a tight band around your body, or comes with pain spreading down an arm or leg, weakness, numbness or pins and needles in your arms or legs, trouble walking, or trouble controlling your bladder or bowels. Call your cancer team's emergency number straight away, or go to an emergency department if you do not have one or cannot get through. This can be cancer pressing on the spinal cord (metastatic spinal cord compression), which needs treatment straight away.
Emergency: since any operation in your pelvis, including an operation for prolapse or for leaking, removal of the womb (hysterectomy) or removal of the prostate gland, you have pain in your tummy or pelvis that is severe or came on suddenly, a wound from the operation that opens up, bleeding that suddenly becomes much heavier or that soaks a pad within an hour, or you feel faint, dizzy or breathless, your heart is pounding, or you feel very unwell. Stop your pelvic floor exercises and call emergency services or go to an emergency department straight away, and do not drive yourself.

Get help today

Same day: a leg or foot that is getting weaker, for example your foot drags, catches on the ground or slaps down when you walk (foot drop). Get medical advice the same day. If the weakness is getting worse by the hour, go to an emergency department.
Same day: back pain after a minor fall or strain if you are older, have low bone density (osteoporosis) or have taken steroid tablets for a long time. Get medical advice the same day. Until it has been checked, stop the exercises and keep away from lifting, bending forward and twisting, because those load a bone in the spine that may be broken.
Same day: back or leg pain with a fever, or you feel hot, cold, shivery or generally unwell. Get medical advice the same day, and go to an emergency department if you feel very unwell.
Same day: pain or burning when you pee together with a high or very low temperature, feeling hot or cold and shivery, or pain in your back just under the ribs. Get medical advice the same day, as this can be a kidney infection. If you also become confused, very drowsy or have trouble speaking, call emergency services or go to an emergency department straight away.
Same day: blood in your pee, which may look pink, red or dark brown, even a small amount, even once, and even with no pain. Get medical advice the same day. It needs checking even if it goes away.
Same day: you have back pain and have lost weight without trying. Get medical advice the same day and mention the weight loss.
Same day: new back pain and you have had cancer, now or in the past. Get medical advice the same day and mention your cancer history. If you are being treated for cancer now, contact your cancer team the same day.
Same day: severe pain that comes on suddenly or is getting worse quickly. Get medical advice the same day.
Same day: pain that is worse at night, or does not ease at all when you rest. If you have had cancer, now or in the past, or you have lost weight without trying, get medical advice the same day.
Same day: since an operation for prolapse or for leaking, you have a fever or feel hot, cold or shivery, heavy bleeding from your vagina or blood clots, discharge that smells, a wound from the operation that is oozing or whose edges are coming apart, or pain in your pelvis that is new or getting worse quickly. Stop your pelvic floor exercises and contact your surgical team, or the ward you went home from, the same day, and if you cannot reach them get medical help the same day anyway, for example at urgent care or an emergency department. These can be signs of an infection or of bleeding from the repair. If the pain becomes severe or comes on suddenly, a wound from the operation opens up, the bleeding suddenly becomes much heavier, or you feel faint, dizzy, breathless or very unwell, call emergency services or go to an emergency department straight away rather than waiting for a call back, and do not drive yourself.
Same day: since an operation in your pelvis for any other reason, for example removal of the womb (hysterectomy) or removal of the prostate gland, you have a fever or feel hot, cold or shivery, heavy bleeding, discharge that smells, a wound from the operation that is oozing or whose edges are coming apart, or pain in your pelvis that is new or getting worse quickly. Stop your pelvic floor exercises and contact your surgical team, or the ward you went home from, the same day, and if you cannot reach them get medical help the same day anyway, for example at urgent care or an emergency department. These can be signs of an infection or of bleeding. If the pain becomes severe or comes on suddenly, a wound from the operation opens up, the bleeding suddenly becomes much heavier, or you feel faint, dizzy, breathless or very unwell, call emergency services or go to an emergency department straight away rather than waiting for a call back, and do not drive yourself.
Same day: since any operation in your pelvis, a calf or thigh that is newly swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that feels different from normal muscle soreness. Stop your pelvic floor exercises and get medical advice the same day, because surgery in the pelvis raises the risk of a blood clot (deep vein thrombosis). If you are also short of breath or have chest pain, call emergency services.

Book an appointment

Within a few days: pain that is worse at night, or does not ease at all when you rest. See your doctor within a few days.
Within a few days: any bleeding from your vagina after your menopause, including spotting or pink or brown discharge, even if it is only a small amount, only happened once, or came on during or after sex. Book an appointment with your doctor within a few days. Bleeding after the menopause is usually not serious, but it has to be checked, because it can be a sign of cancer, and cancer found early is easier to treat.
Routine: a bulge or lump you can feel or see inside or coming out of your vagina, or a feeling of heaviness or pressure in your lower tummy or vagina. Book an appointment with your doctor. This can be a sign of pelvic organ prolapse, and pelvic floor exercises are often part of the treatment once it has been checked.
Routine: since an operation for prolapse or for leaking, the bulge, the heaviness or the leaking you had it done for has come back or is getting worse, or you have new pain, new bleeding or discharge from your vagina, or new trouble peeing or pooing. Stop your pelvic floor exercises and book an appointment with your surgical team rather than waiting for your next routine review. A repair can give way, and after mesh surgery these are also the symptoms a specialist checks the mesh for. Which of those it is takes an examination, and it is not something this page or a physiotherapist can tell you.

Common questions

Can pelvic floor dysfunction cause lower back pain?

The two travel together often enough that it is worth checking, and that is as far as the evidence goes. Pelvic floor dysfunction is the clinical umbrella term, and it covers a floor that is weak, one that is tender and will not relax, and a prolapse. In the Canadian study of 85 women with low back or pelvic girdle pain, 95 percent had at least one of those findings, and the commonest single one was pressure-pain sensitivity rather than weakness (Dufour 2018). That matters for what you do next, because the treatment for a tender, overactive floor is not the treatment for a weak one.

Can a weak pelvic floor cause hip pain?

We found nothing that tested it, so the fair answer is that we do not know. The Canadian study included women with pelvic girdle pain, which is felt around the back of the pelvis and the buttock rather than at the hip joint, so even that does not answer the question. The nearest studies point elsewhere: in a pelvic pain clinic, women reporting hip, back or pelvic girdle pain more often had a tender pelvic floor on examination (Dufour 2018, Dune 2023), and in women having a hip replacement, leaking often improved after the hip was fixed (Tamaki 2014), which is the opposite direction to the one people assume. Pain at the side of the hip usually has a better explanation close by, and outer hip pain from the tendons there is the common one. If your hip pain has been put down to your pelvic floor without an examination of the hip, that is worth going back and asking about.

Does a weak pelvic floor cause pain?

Weakness itself is a quiet problem. A weak pelvic floor usually announces itself as leaking, heaviness or trouble holding on rather than as pain, and that is one of the clues that pain in this area often comes from a floor that is overactive and tender instead. Pelvic pain, pain during sex or pain around the tailbone all deserve an assessment before any strengthening program, because squeezing a muscle that is already working too hard tends to make it sorer.

Can lower back pain affect your pelvis?

Yes, and the traffic runs in both directions, which is part of why direction is so hard to prove. The pelvic floor fires before you move your arm and alters with your breathing, so it is part of the system that holds the trunk steady (Hodges 2007). Pain anywhere in that system changes how the rest of it behaves. In practice we treat whichever part has the clearest findings first and watch what happens to the other.

References

Smith MD, Russell A, Hodges PW. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Australian Journal of Physiotherapy. 2006;52(1):11-16. https://doi.org/10.1016/S0004-9514(06)70057-5
Dufour S, Vandyken B, Forget MJ, Vandyken C. Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskeletal Science and Practice. 2018;34:47-53. https://doi.org/10.1016/j.msksp.2017.12.001
Arab AM, Behbahani RB, Lorestani L, Azari A. Assessment of pelvic floor muscle function in women with and without low back pain using transabdominal ultrasound. Manual Therapy. 2010;15(3):235-239. https://doi.org/10.1016/j.math.2009.12.005
Dune TJ, Griffin A, Hoffman EG, Joyce C, Taege S, Brubaker L, Fitzgerald CM. Importance of internal vaginal pelvic floor muscle exams for women with external lumbar/hip/pelvic girdle pain. International Urogynecology Journal. 2023;34(7):1471-1476. https://doi.org/10.1007/s00192-022-05390-4
Tamaki T, Oinuma K, Shiratsuchi H, Akita K, Iida S. Hip dysfunction-related urinary incontinence: a prospective analysis of 189 female patients undergoing total hip arthroplasty. International Journal of Urology. 2014;21(7):729-731. https://doi.org/10.1111/iju.12404
Hodges PW, Sapsford R, Pengel LH. Postural and respiratory functions of the pelvic floor muscles. Neurourology and Urodynamics. 2007;26(3):362-371. https://doi.org/10.1002/nau.20232
Lim Y, Do Y, Lee SH, Lee H. Efficacy of pelvic floor muscle training with physical therapy for low back pain: A systematic review and meta-analysis. Clinical Rehabilitation. 2024;38(12):1590-1608. https://doi.org/10.1177/02692155241287766
Pelvic, Obstetric and Gynaecological Physiotherapy (POGP). Pelvic floor muscles. https://thepogp.co.uk/patients/pelvic_health_advice/pelvic_floor_muscles.aspx
Pelvic, Obstetric and Gynaecological Physiotherapy (POGP). Pelvic floor muscle exercises (for men). 2021. https://thepogp.co.uk/Resources/122/pelvic_floor_muscle_exercises_for_men/
Continence Health Australia. Pelvic floor exercises for men. https://www.continence.org.au/living-with-incontinence/pelvic-floor-exercises/pelvic-floor-exercises-for-men/
NHS. Back pain. Page last reviewed 5 March 2026. https://www.nhs.uk/conditions/back-pain/
NHS. Urinary incontinence: 10 ways to stop leaks. Page last reviewed 15 June 2023. https://www.nhs.uk/conditions/urinary-incontinence/10-ways-to-stop-leaks/
NHS. Postmenopausal bleeding. Page last reviewed 24 September 2026. https://www.nhs.uk/conditions/post-menopausal-bleeding/

Written and checked by the PocketPhysio editorial team. Last updated 2026-10-22.

This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.