Hi Pelvic Care Family,

This month we’re tackling the topic, To kegel or not to kegel. How fun! This is a contentious issue on social media and in the world of pelvic floor physical therapy. I’ll do my best to deconstruct what the debate is all about, and to give you my personal/professional take as a doctor of physical therapy who specializes in pelvic floor health. I’ll also say, since this is a contentious issue–we’d love to hear your opinion, too! Disagree with what I say? Please, tell us why! Agree? What’s your personal experience? We’re hungry for more knowledge on this topic, so if you have some useful insights for us, we’re all ears.

Until recently, talk about pelvic floor dysfunction outside of the pelvic floor specialist realms was almost wholly concerned with pelvic floor strengthening. Aka: Kegels! When people talk about kegels, they are talking about pelvic floor contractions. The usual cue is: Squeeze like you are trying to stop the flow of urine, or trying to hold back a fart in a crowded elevator. That’s a kegel! That’s a pelvic floor contraction!

There is nothing wrong, per se, with strengthening your pelvic floor. It’s a region of musculature just like any other in your body, and it’s good for it to be strong. The wrong-ness came in because ALL that anyone was talking about was kegels. Meanwhile, there are a host of dysfunctions–ahem, the majority of pelvic floor dysfunctions–where starting treatment with kegels leads the WRONG direction. What are these pelvic floor dysfunctions you ask? Any where the heart of the problem involves the pelvic floor having an already elevated muscle tone.

There are certain pelvic floor issues where we think: Yes, increased pelvic floor strength is needed! These include but are not limited to: urinary incontinence, fecal incontinence, prolapse, diminished sexual sensation (sometimes), postpartum pain syndromes (most of the time). And when we think pelvic floor strength, yes we think kegels! But before we start kegels, we first must ask:

• Does the pelvic floor have elevated muscle tone? (aka, is it “tight” and full of knots?)

• Is the pelvic floor not able to relax back to its baseline level of tone, after a max contraction? What about after several quick contractions? What about after an endurance contraction/10 second hold?

If the answer to any of these questions is yes, then we need to start pelvic floor rehab with work to relax and re-coordinate the pelvic floor before we start kegels. Kegels may be a part of the treatment at some point, but at the beginning they may just lead to more elevated muscle tone, discoordination, and/or pain. 

Here are two examples of situations where starting treatment with kegels sounds at first like a good idea–but is actually a bad idea. A person has urinary incontinence (UI) with running, and they also have constipation and pain with sex. This person is leaking urine–of course they need kegels, right? Actually, no. Their constipation and pain with sex is indicating that they likely have elevated muscle tone in their pelvic floor. They do need a more coordinated pelvic floor to help them with their running UI, but they need to tackle their overactive pelvic floor and learn to relax this region of their body, first. 

Another example: A person has interstitial cystitis and post void dribble. This is jargon that means this person has urinary urgency and frequency, pain with the urge to pee, and is also leaking urine right after they pee. Especially if this person is male, their primary care provider will likely give them meds to handle their bladder pain and tell them to do kegels to target their post void dribble. The kegels might make their pain worse. Instead, this person needs pelvic floor relaxation training–manual therapy, breath work, and targeted exercises to restore muscle balance and coordination–to train their pelvic floor and lower abdomen to let go and permit the bladder to have more balanced reflexive function. Perhaps down the line, once other symptoms are well managed, some pelvic floor strengthening can carefully be pursued to help with the post void dribble. At first, however, we tackle the urinary pain, urgency, and frequency, which are primarily associated with elevated pelvic floor muscle tone rather than weakness.

So, as we’ve already discussed, there are times where we need to work on RELAXING the pelvic floor before we can work on STRENGTHENING it. But wait–there’s more! Part of the kegel debate has to do with not just whether kegels are appropriate for everyone (they’re not), but also with whether kegels are the most efficient way to rehab pelvic floor problems (it depends), and whether they are sufficient to provide lasting relief/prevent recurrence (nope!). Here we get into the issue of how boring kegels are. Let’s admit it–I’m a pelvic floor PT and I’ll admit it–kegels are B-o-r-i-n-g with a capital B! Also, we seldom need the pelvic floor to work in isolation–so why are we training it in isolation? Most incontinence, prolapse, diastasis, and weakness-associated pain syndromes require whole body strength and coordination training to get better. They require a mix of manual therapy and movement focused techniques. If we spend all our time just focusing on kegels, we are really narrowing in on just one piece of the puzzle, and we are likely to make slow progress and have a high rate of recurrence.

Traditionally, pelvic floor physical therapists really focused in on the pelvic floor, and treated it in isolation. Everyone and every field has to start somewhere, ya know? But now that this field is well established and we’ve got more great research and experience under our belt, we’re realizing we need to train the pelvic floor to work as a component of the entire core system, which is responsible for stabilizing the spine during complex, three dimensional movement (aka, “functional movement,” which means, the types of movements you do in your everyday life.) When I say entire core system, I mean: abs, back muscles, butt muscles, thigh muscles. I also mean: the lat complex, serratus anterior, foot muscles, deep neck muscles, etc. I mean, our definition of “core” or “stabilizing musculature” can expand out and in, depending on our purpose. 

Here’s how and when I personally, as a doctor of physical therapy and pelvic floor specialist, use kegels. I really hone in on training kegels when people have a weak pelvic floor.  In these instances, I consider it of utmost importance to “activate” the pelvic floor so that it can participate as a component of the core/stabilizing system. As described above, I am very thoughtful about the TIMING of when we begin doing kegels. I work hard not to do them too soon, and to layer in adequate relaxation and/or functional movement training to help the body incorporate the new input. Are kegels the only way to activate the pelvic floor? No! And there are some awesome pelvic floor pts who get the pelvic floor to start working without kegels, and that’s fabulous. I just happen to have been trained in great, evidence based, efficient techniques for activating the pelvic floor that include kegels, so I use kegels for this job! 

What does kegel training look like? We start out doing kegels laying down, then gradually progress to seated, then standing, then possibly jumping (if someone’s issue is leaking with jumping rope or jumping jacks or box jumps) or lunging or other single leg/unilateral work (if someone leaks with running). We progress through these phases because with each phase there is more gravity loading, and more complexity of movement/coordination. We work on different types of kegels. There are what I call simple kegels (inhale relax, exhale squeeze) to train the ability to relax after squeezing, endurance kegels (goal of holding for 10 seconds or more, depending on goals/symptoms), and fast twitch kegels (for power, to address leaking with quick changes in abdominal pressure like leaking with sneeze, cough, laugh, jump).

 We don’t just think about the kegels while we are kegeling. We also pay attention to what other muscles are getting involved. Are we squeezing too much in the back or just bracing our butt with no action in the front? This is common with people who present with tailbone pain or constipation plus urinary incontinence. Are we bearing/pushing down instead of squeezing (common with people who overactivate their upper abdominals, including a lot of fitness and pilates fans!) Are we barely squeezing and can’t feel anything/can’t tell what’s going on down there? For each of these different presentations, we can do customized biofeedback together to help you get more coordinated. Biofeedback may look like myself providing verbal, tactile, or visual cues during internal digital vaginal or anorectal treatment. For example, I may gently tap with a gloved finger inserted vaginally along the levator ani muscular line, as I direct a client in doing kegels, to help the pelvic floor to activate (tactile cue).  Biofeedback can also look like using a specific device/probe inserted vaginally or anorectally to give visual and auditory electronic biofeedback (this is the type of biofeedback that we have the most research on, in the pt literature). Biofeedback can look like balloon training, for anorectal concerns. Biofeedback can also look like sitting on a towel roll, or a therapy ball, and getting sensory input from these tools while doing kegels. 

Sometimes, when people have just a trace contraction, we do electrical stimulation to help teach the nerves how to talk to the pelvic floor muscles again. We always do kegels while the stimulation is happening, we don’t just sit there and let the machine do the work for us. For electrical stimulation, we can use just external electrodes (typically positioned medial to the sits bones), or we can use an internal probe. In my experience, external electrodes work just as well and are less invasive and expensive, so I prefer this approach because it prioritizes client comfort with comparable results.

Whenever I incorporate kegels into a client’s routine, my end goal is always, eventually or concurrently, to also provide full body strength, mobility, and coordination training that is functional and specific to a client’s needs and lifestyle, to ensure a client graduates PT 110% better than when they began, with very low risk of recurring symptoms. 

Have questions, comments, concerns? We’re all ears.