Short answer
Learn a correct contraction and full release first; then emphasize the quality most relevant to the assessed goal. Strength is the ability to generate force, while endurance is the ability to sustain or repeat useful force. Neither must always come first.
If you cannot create a clear inward lift, breathe, and release, both strength and endurance loading are premature. If pain, persistent tension, or emptying difficulty is present, relaxation or assessment may take priority over either.
Strength and endurance answer different questions
Strength asks, “How much controlled force can the pelvic floor produce?” Endurance asks, “How long or how repeatedly can useful force be maintained before performance declines?” The ICS terminology report separates these qualities from power, coordination, and relaxation.
A person can have a noticeable strong contraction that fades quickly. Another may sustain low force but struggle to generate enough force for a specific task. These patterns need different emphases.
What must come before both
Before loading, establish:
- the intended inward direction;
- a comfortable resting state;
- ordinary breathing;
- limited substitution from nearby muscles;
- complete release after every contraction; and
- a clear reason for training.
Motor learning is not wasted time. Loading an incorrect push or a persistent clench can reinforce the wrong task.
When strength may be emphasized first
A strength emphasis may fit when assessment shows limited force for a force-dependent goal and the person can already contract and release correctly. Work uses a higher controlled effort with enough recovery to preserve quality.
Strength work is not simply maximal squeezing. The set ends when the lift fades, breathing changes, or other muscles dominate. A stronger sensation does not prove greater pelvic-floor force.
When endurance may be emphasized first
An endurance emphasis may fit when a person can produce adequate initial force but cannot sustain or repeat it for the relevant task. Effort often needs to be below maximum so the contraction remains useful.
Elapsed seconds do not equal endurance if force has faded. Stop the hold when direction or quality changes, then recover fully.
When coordination should come first
For functional leakage, timing may be as important as force. A person may need to learn a brief contraction before a specific pressure event. For urinary or bowel emptying, the required skill may be relaxation rather than contraction.
Coordination work often uses lower effort so the person can manage breathing, movement, and release. It should not be buried under a strength-versus-endurance choice.
Use the real-world task
Ask what the pelvic floor needs to do:
- produce force promptly around a cough;
- sustain support for a defined interval;
- repeat contractions without quality loss;
- release for emptying;
- reduce unnecessary tension; or
- coordinate with movement.
The answer guides the starting emphasis. One symptom can have multiple causes, so task analysis does not replace diagnosis.
A conservative decision process
- Confirm the movement and release.
- Define one functional outcome.
- Identify the quality most directly related to that outcome.
- Choose a quality-limited baseline.
- Train one main variable while preserving the others.
- Review technique, recovery, symptoms, and function.
- Add the second quality only when it serves the plan.
A programme may eventually combine strength and endurance. Combining them does not mean maximizing both at once.
Common mistakes
- assuming all leakage proves weak strength;
- treating a long low-level clench as endurance;
- using maximum effort for every hold;
- adding long holds before release is clear;
- ignoring speed, timing, and relaxation;
- progressing both effort and duration together; and
- using workout completion instead of function as the outcome.
Evidence limits
The ICI/ICS reference describes PFMT as training different qualities. Exercise principles in Bø and colleagues support specificity and progression, but clinical protocols vary and do not establish one universal ordering.
NICE guidance emphasizes tailoring PFMT to ability, discomfort, needs, and goals. A clinician can assess which quality is limited more directly than a planner or preview, which cannot execute or verify a contraction.
Safety and scope
Pain, inability to relax, pressure, heaviness, urinary retention, or bowel-emptying difficulty are reasons not to default to more loading. Follow individualized guidance after pelvic or prostate surgery, during pregnancy or postpartum recovery, with neurological conditions, or during cancer treatment.
Stop if symptoms worsen or tension lingers. Seek urgent care for sudden inability to urinate or new saddle/genital numbness with acute bladder, bowel, or leg changes.
What to do next
Use training qualities explained to define the target and effort for strength, endurance, and control to choose a quality-limited task.
Reassess the priority over time
The first emphasis does not need to remain permanent. Once a person develops enough force for the task, endurance or timing may become the limiting quality. Conversely, an endurance-focused programme may reveal that the starting contraction is too small for a force-dependent goal.
Review the priority using the same functional outcome rather than switching because one exercise feels boring. If leakage occurs only with a sudden event, timing and prompt force may deserve attention. If performance declines during a prolonged task, endurance may be more relevant. These observations guide questions; they do not diagnose the mechanism.
Avoid competing fatigue
If strength and endurance tasks are combined, their order and volume affect performance. A demanding endurance block can reduce force in a later strength block, while repeated high-force contractions can shorten later holds. Keep blocks distinct and record which came first.
Early in training, one main quality can make response easier to interpret. A clinician may deliberately combine qualities when assessment and programme goals support it.
Neither quality replaces release
Strength and endurance describe contraction performance. The ability to return to rest remains a separate requirement. A person who can hold longer but cannot release has not demonstrated universally better function.
Track release and symptom response alongside force and time. Pain, persistent tension, or emptying difficulty changes the priority away from generic loading.
A sample reasoning example
Consider a person who can produce a clear inward contraction but loses it quickly during a sustained task. If assessment confirms that sustained capacity relates to the goal, endurance may be emphasized while force is maintained. Another person may hold a very gentle contraction for a long time but cannot produce enough controlled force for a defined pressure event; strength or prompt force may be the priority.
These examples illustrate reasoning, not self-diagnosis. Leakage or another symptom alone cannot establish which profile applies.
The decision should also consider adherence. A technically suitable emphasis that is too long, fatiguing, or complex to perform consistently may need a simpler starting task. Simplification should preserve the target quality rather than replace the programme with random easy contractions.
When both qualities are relevant, establish one stable block before adding the other. Record separate responses so improvement in sustained time does not hide declining force, or vice versa.
Sources
- Frawley H et al. “ICS report on terminology for pelvic floor muscle assessment.” Official report.
- Cardozo L et al., editors. Incontinence. 7th edition. Official ICS publication.
- National Institute for Health and Care Excellence. Pelvic floor dysfunction. NG210. Recommendations.
- Bø K et al., editors. Evidence-Based Physical Therapy for the Pelvic Floor. 3rd edition. Chapter 6. Official Elsevier record.