TO KEGEL OR NOT TO KEGEL. THAT IS THE QUESTION.
Updated: Jun 29, 2022
Do you, or someone you know:
A. Cough, sneeze, laugh, or jump and then leak?
B. Come from a morning of doing errands, put your key in the door and then leak a little due to an uncontrollable urge to urinate?
c. Feel a heaviness or pressure in your pelvis or abdomen after doing strenuous exercise, hiking or jogging?
d. Feel like something is falling out of your vagina at times?
e. Have frequent debilitating menstrual cycles?
f. Have pain with sex?
g. Have a decreased sense of libido, sexual response and/or sensuality?
h. Experienced vaginal gas such as in down dog or during sex?
I. Been unable to connect with or engage your pelvic floor muscles, or not sure if you are able to do a correct Kegel?
J. Do extensive core work with only fair results?
K. Have chronic low back pain that did not seem to respond to more common treatments?
L.. Have postpartum common injuries and complications from pregnancy and delivery:?
Have you been told to just go home and do your Kegels, and that will address these challenges?
Dr. Kegel and your medical providers mean well when they suggested you should do 100 Kegels a day. This has been the gold standard that was taught to professionals. The newer research has revealed that this may in fact be counter productive.
As a pelvic floor PT, we know that in some circumstances, Kegels can actually cause harm, and in other circumstances they are warranted in a prescriptive and progressive manner.
Getting women to stop doing Kegels is a bit of an uphill battle because it’s advice that’s seeped into the mainstream consciousness and mainstream media.
The heart of the problem with doing kegels to strengthen the pelvic floor is a theory in biomechanics called: “Overgeneralized Theory of Strength. When you do a kegel, you are doing a muscular contraction, and if you already have a tight pelvic floor, contracting these muscles will only make it tighter, making your pelvic floor problems worse.
If you’re not someone who has dealt with the symptoms of a tight pelvic floor, you might wonder why a tight muscle is a bad thing. We usually equate tight muscle with “toned” muscle.
A toned muscle is not a bad thing Unfortunately, however, if you “over do it” with your pelvic floor muscles, they do not just rest and relax, and recover like other muscles in the body. Your pelvic floor muscles are the only group of muscles in the body that never get to rest, ever. If they completely relaxed we would be incontinent and our pelvic organs would drop. So, they are working all the time to maintain continence, to support our pelvic organs, and to contribute to our posture and stability.
Therefore, these muscles are “working out” all the time, and don’t follow the same rules as the other muscle groups in our body. If you do get carried away with Kegels and over-strengthen your pelvic floor muscles, they can become too tight, which in turn can cause dysfunction and symptoms, such as pain, urinary urgency and frequency, leaking, among others. I have seen this happen with a Pilates teacher who become incontinent. Also, many women body builders joke about leaking when doing heavy lifting….this is common….not normal.
So, the pelvic floor muscles do not need extra strengthening from doing Kegels, unless something has happened that has overstretched them or injured them in some way that has made them truly weak (not weak AND TIGHT) Your pelvic floor muscles can become overstretched and weak after childbirth, around menopause, and after some gynaecological surgeries. And this overstretching and weakening can lead to organ prolapse.
So Kegels are appropriate when the pelvic floor is truly weak and/or overstretched. For these women, I teach how to do Kegels all the time. There are many experts in the field of pelvic floor rehabilitation that will strongly agree that doing Kegels are appropriate when pelvic floor muscles are overstretched and/or weak.
So tight muscles = Kegels bad. Weak and/or overstretched muscles = Kegels okay. Oh, if only we could end things here. But as anyone who has researched the pelvic floor knows, there is no black and white when it comes to this part of our anatomy.
OK, now for the grey area: it is possible for a weak pelvic floor to also be tight and/or to contain active trigger points or fascial restriction, or presents with a core imbalance. In this situation, it is NOT okay to do Kegels.
So what does someone who has both a tight ,or fascially restricted and a weak pelvic floor do, especially if he or she has a prolapse or other symptoms caused by the weakness. The appropriate course of action in this situation would be to first work to clear up the tightness, trigger points, fascial restrictions, and the core imbalance. Doing Kegels will not accomplish this nor will it restore balance to the core.
An effective therapeutic approach is using vaginal massage, (internal myofascial work) which works primarily by restoring the balance and tensile qualities of the fascia and also in clearing pelvic congestion. Once the pelvic floor muscles are at a healthy tone–no longer too tight, and all active trigger points gone, then it is time to do Kegel exercises in a slow and progressive manner if needed. Oftentimes, just restoring balance in the core, can functionally activate our pelvic floor muscles.
One more consideration is whether a pelvic organ prolapse is present. Do you sometimes go for a hike or a jog, or stand in one place for too long and feel a heaviness or pressure in your pelvis or perhaps even a sensation of “something falling out”? A prolapse of the bladder, uterus or rectum is a possible cause. Doing a Kegel when feeling this heaviness is kind of like squeezing the toothpaste tube in the middle. There are inversion breathing techniques that an give a gravity assist and can be combined with Kegels when they are appropriate.
So, to summarize: Kegels are not appropriate for all women with a tight pelvic floor, with active trigger points, with fascial restrictions, with a core imbalance, or if you have a weak AND TIGHT pelvic floor. But, it’s okay to do Kegels to strengthen a weak or overstretched pelvic floor, without any of the above considerations.
Now the question is: What can I do to strengthen my core that includes the pelvic floor? A great way to understand what is needed is to understand what the core is comprised of using a pressurized canister model. Your core is like a canister. The top is the breathing diaphragm, the bottom is the pelvic floor, and the side pressure and strength is created by the transverse abdominal muscles and your gluts. Think of it like a pressurized canister. If any part of the can is not aligned and active, it effects the entire core. Every time you take a deep inhale, your diaphragm lengthens and synchonistically so does your pelvic floor. On the inhale, think about your lungs and your abdomen expanding in all directions (front, back and sides). When you do a full exhale, your diaphragm contracts up. What is cool is that this causes your pelvic floor and lower belly muscles (transverse abdominus) to synergistically contract at the same time. Two enemies to this fabulous and natural core activator are poor posture and shallow breathing. There were many reasons you were told to sit and stand with good posture when you were younger. Paradoxically, this becomes more imperative as we get older! So, open up your chest, drop your shoulders, and align your shoulders over your hips. In this position you can begin conscious breathing. Breath in slowly through your nose for a count of 3-6 seconds, and exhale, as if blowing through a straw, one second longer than the inhale. .It is near the end of the exhale that you will become more aware of the synchronistic magic of the lower abdomen and pelvic floor kicking in. Do several of these “canister breaths” throughout the day and in time, good posture and deep breathing may become more of your normal way of breathing and moving through your day.
Adrienne Thomason, PT