A proposed anxiety–hypertonic pelvic floor axis in postpartum women: a narrative review of mechanistic links and rehabilitation implications

Pelvic floor dysfunction (PFD) and postpartum anxiety are commonly assessed and treated separately, although accumulating evidence suggests that psychological distress and pelvic floor muscle over activity may interact. This narrative review synthesizes epidemiological, neurobiological, and rehabilitation evidence and proposes the Anxiety–Hypertonic Pelvic Floor Axis as a framework for this bidirectional association. Postpartum anxiety and chronic stress may contribute to hypothalamic–pituitary–adrenal axis dysregulation, sympathetic predominance, inflammatory signaling, and central sensitization. These processes may contribute to pelvic floor guarding and hypertonicity and may be associated with chronic pelvic pain, dyssynergic defecation, urinary symptoms, and sexual dysfunction. Persistent symptoms may, in turn, intensify anxiety, pain catastrophizing, and fear-avoidance behavior. This framework challenges the assumption that postpartum PFD primarily reflects muscle weakness and that strengthening exercises are universally appropriate. We therefore propose a phenotype-guided, biopsychosocial approach that combines psychological screening with assessment of pelvic floor resting tone and coordination. For women with an anxiety-related hypertonic phenotype, management may integrate cognitive behavioral therapy, mindfulness-based interventions, trauma-informed care, diaphragmatic breathing, reverse Kegels, biofeedback down-training, and manual therapy. Recognition of this potential phenotype may support more individualized clinical assessment and may help avoid indiscriminate strengthening-based treatment. Prospective studies are needed to determine whether phenotype-specific care improves postpartum outcomes.