Hypermobility, hypermobile Ehlers–Danlos syndrome (hEDS) and the pelvic floor

Hypermobility and hypermobile Ehlers–Danlos syndrome (hEDS) can affect the body in many different ways, and the pelvic floor is no exception.

Some hypermobile people experience pelvic pain, bladder or bowel symptoms, prolapse, or pelvic girdle pain. Others may have very few pelvic symptoms at all. There is no single “EDS presentation”, and symptoms can change over time, across life stages, or with stress, illness, pregnancy, or hormonal shifts.

Pelvic health physiotherapy can play an important role in helping people with hypermobility better understand their bodies, manage symptoms, and improve function without assuming everything needs to be “strengthened” or “tightened”.

A quick note on hypermobility and connective tissue

In hypermobility and hEDS, connective tissue (including ligaments, fascia and collagen) behaves differently. This can affect:

Joint stability and proprioception
How load is transferred through the pelvis and spine
Tissue support for pelvic organs
Pain processing and nervous system sensitivity

Because connective tissue is found everywhere, pelvic floor symptoms often sit alongside more global issues such as widespread pain, fatigue, gut symptoms, or autonomic nervous system dysfunction.

Pelvic pain

Pelvic pain is common in people with hypermobility and hEDS, but the drivers are often multifactorial, rather than purely muscular.

Contributing factors may include:

Reduced joint stability leading to overworking muscles
Poor proprioceptive input (the body struggling to “sense” where it is in space)
Central sensitisation (where the nervous system amplifies incoming sensory information, increasing the likelihood that the brain produces a pain experience even when tissues are not damaged).
Autonomic nervous system dysfunction (often referred to as dysautonomia), which can influence pain, gut function, bladder urgency and sexual pain.

Importantly, pelvic pain in hypermobile people is not always due to a tight pelvic floor and strengthening alone is rarely the full answer.

Pelvic health physiotherapy may help by:

Improving coordination and load sharing through the pelvis and trunk
Addressing overactivity and underactivity where relevant
Working with the nervous system to reduce pain sensitivity
Supporting pacing, flare management and body awareness

Pelvic girdle pain

Pelvic girdle pain (pain around the pubic bone, sacroiliac joints or hips) is particularly common in hypermobile people, including outside of pregnancy.

Increased joint range combined with reduced passive stability can mean muscles are asked to do more work than they’re designed for, often leading to:

Deep aching or sharp pelvic pain
Pain with walking, standing, rolling in bed or single-leg tasks
Flare-ups with fatigue or increased activity

Management usually focuses on:

Improving muscular support without over-bracing
Targeted strength and control rather than maximal loading
Movement strategies that reduce joint shear
Education around activity modification and pacing

Prolapse

People with hypermobility or hEDS may be at increased risk of pelvic organ prolapse due to differences in connective tissue support.

It’s important to know:

Prolapse severity does not always correlate with symptoms
Not everyone with hypermobility will develop prolapse
Pelvic floor strength is only one part of organ support

Pelvic health physiotherapy can assist with:

Optimising pelvic floor and abdominal wall coordination
Reducing downward pressure during daily tasks
Education around bowel habits, lifting and exercise
Supporting symptom management alongside medical care if needed

Read more about how physiotherapy can help with prolapse, and all about pessaries for prolapse.

Urinary incontinence and bladder symptoms

Bladder symptoms in hypermobile people can include:

Stress urinary incontinence (leakage with cough, laugh or exercise)
Urgency and urge incontinence
Frequency or difficulty fully emptying

These symptoms may relate to:

Reduced connective tissue support
Altered pelvic floor timing and coordination
Nervous system involvement affecting bladder signalling

A note on mast cell activation and bladder symptoms

There is emerging evidence suggesting mast cell activation may play a role in some bladder conditions, particularly those involving bladder pain, urgency or irritation (such as bladder pain syndrome/interstitial cystitis). Mast cells release inflammatory mediators that can irritate bladder nerves and tissue in susceptible individuals.

While this area is still evolving, it may help explain why some people with hypermobility experience bladder symptoms that don’t fit neatly into strength-based models alone. Management is usually multidisciplinary and individualised.

Bowel dysfunction

Bowel symptoms are very common in people with hypermobility and hEDS, and may include:

Constipation
Difficulty with evacuation
Urgency or bowel leakage
Abdominal bloating or discomfort

Contributing factors can include altered gut motility, connective tissue differences, pelvic floor coordination issues, and autonomic nervous system involvement.

Pelvic health physiotherapy may help with:

Improving pelvic floor relaxation and coordination
Optimising toileting posture and habits
Reducing strain and pelvic pressure
Supporting symptom management alongside medical care

How pelvic health physiotherapy can help

Pelvic health physiotherapy for hypermobility is not a one-size-fits-all approach. Treatment is tailored to the individual and may include:

Education about how hypermobility affects the pelvic floor
Targeted exercises focused on control, coordination and endurance
Nervous system-informed pain management strategies
Support with pacing, flare-ups and long-term symptom management

A personal note

I also bring a lived experience of hypermobility to my clinical work, and I regularly work with hypermobile clients. This combination of professional training and personal insight helps inform a thoughtful, individualised and realistic approach to care.

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