Fiona McMahon PT, DPT
I was walking north up Park Avenue in New York City on a snowy morning last December, tip-tapping away on my phone responding to a friend and fellow physical therapist (PT) who had sent me an article outlining what pelvic floor dysfunction is and how to set about treating it. The article proposed Kegels as a great start to treating the pelvic floor on your own. My friend, who does not practice pelvic floor PT texted, “Wow! What a great article!”. I texted back that I didn’t think the article was so good. She was confused by my response and thought I would be pleased to see an article in such a prestigious publication spreading awareness of pelvic floor dysfunction. Although I was pleased about that, (because let’s face it, pelvic floor dysfunction needs all the awareness it can get), whenever I see Kegels presented as a blanket cure for pelvic floor dysfunction my blood begins to boil. Text messaging is not the ideal place to present your opposition to blanket recommendations of starting a Kegel program, so I hope to do so in this article.
“Why are you so anti kegel, Fiona?” You may be asking while you’re reading this. The truth is I’m not, but Kegels are not appropriate for everyone, and in my almost decade at Beyond Basics Physical Therapy, I can honestly tell you that with at least 90% percent of my patients Kegels would also actually delay and/or harm their progress. When an article presents Kegels as a cure-all for incontinence, pain, and other pelvic floor issues it is clear to me that the author truly does not understand the physiology of the pelvic floor, and a good signal to take the information presented in that article with a New York City pretzel sized grain of salt.
Kegels certainly have their place in a rehab paradigm and if they have worked for you, excellent! They can do so much, but like the adage goes in medicine, “ a cure for everything, is a cure for nothing”. So let’s jump into what Kegels are and how you, no matter what gender you are, can find out if they could be helpful to you.
What Are Kegels
Kegels are essentially a contraction of the pelvic floor. The pelvic floor is the group of muscles that lives between your pubic bone and tailbone. Another way to think of the pelvic floor is the area that would make contact with your bicycle seat. These muscles are, in a word, AMAZING. They have many important jobs in the body. The pelvic floor muscles are responsible for keeping us continent, supporting our pelvic organs, maintaining sexual function, stabilizing the spine, and helping to return blood and lymphatic flow back into the body so it doesn’t stagnate in the pelvis and/or lower extremities. You can clearly see that something going wrong with your pelvic floor could cause a ton of distress and impairment. Typically, folks are taught to kegel by attempting to stop the flow of urine (though this is helpful to learn how to use these muscles, I would not recommend this regularly as it can make it harder to pee). Other cues for learning Kegels are to draw the penis in, stop a fart, or pick up pearls with your vagina or rectum. We are odd ducks, us pelvic floor PTs.
Kegels were first described by Arnold Kegel in 1948 (a dude!). These puppies have been around for a long time. We typically hear about Kegels in reference to folks who are recently post-partum, but when appropriate, folks of any gender whether they have been pregnant or not can benefit from them. The key caveat is, when appropriate.
Kegels are meant to strengthen a weak pelvic floor. The problem with the Kegels for everyone philosophy is that the base assumption is that all people with pelvic floor dysfunction have weak, floppy pelvic floors. That assumption misses the vast majority of folks with pelvic pain, and many folks with incontinence, prolapse, constipation, as well as other urinary issues. How is that? We will get into that in the next section.
Why Kegels are Not for Everyone
When we think of weakness, we often think of loose, lax muscles, which is certainly a form of weakness; however, what we often don’t think of is the other side of the weakness coin, tight immobile muscles, that can only yield but a tiny quiver when asked to contract. Tight immobile muscles can be weak too.
The problem with prescribing Kegels to folks with tight poorly mobile pelvic floors is it can encourage further shortening and weakness, and can actually be painful in some individuals. Before starting Kegels, you really want to be sure you know what type of pelvic floor you are working with, tight and weak, loose and weak, or something different entirely. A trained pelvic floor physical therapist can help you with that.
For folks experiencing incontinence, you may think that a weak and loose diagnosis of pelvic floor dysfunction is a sure thing, a slam dunk as it were. But it’s not. For many folks with incontinence, the pelvic floor lacks the range of motion to generate enough force to keep pee and poop on the inside. If you think back to high school physics (it’s okay if this hasn’t stayed top of mind), you may remember that force is a function of acceleration and acceleration function of distance. Without sufficient distance (mobility in the muscles) it is really difficult to generate enough force to remain dry. Excessive kegeling may not do much to help you in this case and may further shorten your pelvic floor.
Now let’s talk prolapse. Prolapse is when the pelvic organs, (bladder, uterus, and or rectum) drop and protrude into or sometimes out of the anus or vagina. It can happen to folks of either anatomy. Prolapse can occur when the ligaments of these organs become overstretched, usually the result of excessive straining in lifting, defecating, or childbirth. People are understandably terrified of developing or worsening pelvic organ prolapse. Given the pelvic floor’s integral role in supporting the pelvic organs, it is extremely logical that one would jump on Kegels to treat and prevent it. In many cases, this can be helpful, but if the pelvic floor is short and weak, the anus will have a hard time opening to have a bowel movement, resulting in the individual having to strain excessively to defecate and placing further strain on the organs of the pelvis. It is important for those with pelvic organ prolapse to ensure they are defecating well and efficiently before starting a kegel program.
For Trouble Going to the Bathroom
The next two symptoms of pelvic floor dysfunction, difficulty toileting, and pain, are problems that I absolutely would not recommend Kegels for without examining the patient first, and would implore you to visit a pelvic floor physical therapist as soon as possible to get treatment started if you have these symptoms.
You can experience difficulty defecating (constipation), and or difficulty urinating (hesitancy) secondary to a tight and weak pelvic floor.
The problem with a tight pelvic floor and constipation seems obvious and in this case, it really is! If the pelvic floor muscles are too tight and can’t relax, it can be really hard to expel poo out. What you may not know, is that the pelvic floor muscles are also super important in telling us it’s time to poop. When stool begins to fill the rectum, a stretch is felt in the pelvic floor and it sends a signal to the brain saying, “it’s time to poop!”. If the pelvic floor is tight and rigid and cannot stretch well the signal doesn’t always get sent to the brain time, which can lead to stool sitting in the rectum and drying out worsening constipation. In severe cases, the stool can become so backed up that softer stool slips around the solid stuff leading to incontinence and fecal smearing.
When you have difficulty starting urination, we call it hesitancy. Hesitancy can be really awful for those who experience it. In order to pee, your pelvic floor has to relax in order to let the involuntary muscle of the bladder squeeze. If you have a nonrelaxing pelvic floor, you might experience hesitancy, stop and go peeing, splayed stream, urinary frequency, and post pee dribbling.
For folks with pain, I would not even consider Kegels until your pelvic floor has been thoroughly assessed. Many pain conditions of the pelvic floor occur when the pelvic floor muscles are tight and spasmed. People with pelvic floor dysfunction resulting in pelvic pain often can experience pain with contraction of the pelvic floor. A useful analogy for Kegels on a painful pelvic floor, is flexing your calf whilst you are experiencing a calf cramp, it isn’t going to feel good! Furthermore, because most pelvic floor pain is caused by tight irritable muscles that don’t relax well, continuing to tighten the pelvic through Kegelling can make your pelvic floor harder to correct once you do end up in physical therapy, resulting in more time and money spent trying to improve your condition.
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When are Kegels the Right Move?
As I said before Kegels do have their place in pelvic floor rehab and I, myself, the Anti-Kegel Queen (AKQ), will prescribe them from time to time. Kegels are a great thing to start if you have a loose and weak pelvic floor. The thing is, it can be really hard to tell if you have a weak and loose pelvic floor on your own. This is where I really encourage you to get an assessment from a qualified professional.
Though I do not recommend sets of Kegels for everyone, there are a few times that no matter the state of your pelvic floor, there are times where a few Kegels can be helpful. The Knack, not a romantic comedy starring Kate Hudson, is a trick where you kegel and hold right before sneezing or coughing. This can be really helpful for those of us experiencing stress incontinence. You can also use something called quick flicks to ease urinary urgency. Quick flicks are rapid gentle pelvic floor squeezes, usually 5 in a session, which can ease the strong urge to buy you a little bit of time to get to the toilet.
These two kegel tools are appropriate for just about anyone because they aren’t just squeezing for the sake of squeezing over and over again. They are 1-5 contractions of the pelvic floor to achieve a certain task. Kegeling with such a low number of repetitions is fairly unlikely to contribute to a tight pelvic floor.
If Kegels Aren’t for Everyone, Are There Better Exercises That I Can Be Doing?
Yes! And less boring ones to boot! The deal with Kegels is that although many folks may have heard of them, studies have found that 24% of folks aware of what Kegels are, do them incorrectly. In another study that surveyed a large group of people identified as women, 92.5% of respondents were aware of Kegels, but only 42.6% did them and out of the folks that did do Kegels, the majority responded that they only did them when they remembered.
So we’ve established that Kegels are 1.) Not for everyone and may do more harm than good 2.) Not always done correctly when they are indeed indicated 3.) Not usually done in an organized or consistent manner. So what can we tell folks to do, who are waiting to get into pelvic physical therapy or those who may not have access to pelvic floor physical therapy services? A ton and a half is the answer! Let’s read on.
Pelvic Floor Relaxation- Four Point Breathing
Even the strongest powerlifters stretch their muscles. Regardless of whether you have a tight weak pelvic floor or a loose and weak pelvic floor, this exercise is safe to do and won’t overstretch loose muscles.
In sitting, become aware of your pelvis and think of it as having four individual points, the pubic bone in front, the ischial tuberosities (sit bones) on the sides, and the tail bone in the back. As you breathe in, without bearing down, bring awareness to these 4 points. As you breathe in, imagine those four points expanding away from each other. As you breathe out, imagine the four points recoiling back to their original position. You can try 10 deep breaths or set a timer for 2-5 minutes. This exercise is designed to be super gentle and relaxing. For folks with tight and weak muscles, it can be a great way to start teaching the pelvic floor muscles to relax. For those individuals with loose and weak pelvic floors, it can provide gentle movement which can help lymph and blood circulate more effectively and deliver much-needed nutrition to those weak muscles.
Even if you are tight and weak, the pelvic floor does have to contract throughout the day to keep you continent, as well as blood and lymph circulating in the pelvis, and the spine and organs supported. You don’t have to be afraid of a pelvic floor contraction here and there, but I still wouldn’t perform excessive Kegels if your pelvic floor is not weak and loose. Strengthening the muscles surrounding the pelvic floor can be helpful to take the burden off of the pelvic floor if it is overworking to support the spine and can also teach it to “play nice” with the other core muscles.
Conversely, exercises that offer a little more “bang for your buck” or benefit for your time can be helpful for those who have loose and weak pelvic floors. In addition, these exercises can be added to an existing workout routine to ensure that they do in fact get done. Bridges, clamshells, squats, and pliés have been found to offer pelvic floor activation similar to that of a kegel but also have the added benefit of strengthening other muscle groups. For those who wish to do these exercises but suspect their pelvic floor is tight, I would suggest a round of the four-point breathing described earlier to help the pelvic floor relax after it has been activated. For those experiencing pain, I would wait until you see a pelvic floor physical therapist before engaging in these exercises.
Putting it All Together
Like any exercise, there are certain cases that make Kegels more appropriate for some and less appropriate for others. For individuals with pelvic floor tightness caused by weakness, all the Kegels in the world probably won’t help; however, there are better exercises that can help support the whole body and push you towards your goals. That being said, finding the most efficient exercise for your body can be difficult if you don’t know the state of your pelvic floor. A trained pelvic floor physical therapist is uniquely qualified to guide you through the most effective exercises for your body and your goals. Your time is far too valuable to waste doing exercises that don’t help you. Seeing a pelvic floor physical therapist is SO worth it.
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- FitzGerald M, Kotarinos R. Rehabilitation of the short pelvic floor. 1: Background and patient evaluation. Int Urogynecol J. 14. 2003
- Goodridge S, Chisholm L, Heft J. Association of knowledge and presence of pelvic floor disorders and participation in pelvic floor exercises: a cross-sectional study. Female Pelvic Medicine & Reconstructive Surgery.2021 27 (5)
- Siff L, Hill A, Walters S, et al. The effect of commonly performed exercise on the levator hiatus area and the length and strength of the pelvic floor muscles in postpartum women. Female Pelvic Medicine & Reconstructive Surgery. 00 (00) 2018
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