“I know I should be doing my Kegels” is a statement I hear often from my clients. They say this with guilt and shame in their voice, like they are just waiting for me to scold them. In some camps, Kegels are the one and only answer that has been preached to every woman who has ever given birth. Doing Kegels has been promised to stop urine leakage, make your pelvic floor strong enough to pick up a surfboard and return your vagina to sex ready status. Then in other circles: women are told to stop doing Kegels and squat instead, which made women everywhere cheer to know they never have to do another Kegel because they never knew if they were doing them right anyways.
So how do you know what camp to follow? The answer: It depends on your pelvic floor. There are some screening characteristics to help you figure out what camp you might want to follow but the only way you will know for sure is if you have a pelvic floor assessment by a Women’s Health/Pelvic Floor Physical Therapist. We should never give general advice that falls on either end of the spectrum (Kegels For All or Never Kegel Again) because we are human beings and we know we never fall fully into one category or another!
Just so we are all on the same page, a Kegel is defined as repetitive contraction and relaxation of the pelvic floor muscles. An elevator analogy works well here: the elevator needs to go down fully to the basement and open its doors (Pelvic Floor Relaxation) then it needs to close its doors and lift up (Pelvic Floor Activation). If you have been given any instruction on how to do a Kegel, it probably was to contract your muscles “like you are stopping the stream of urine”. This description isn’t fully accurate because the muscles that stop the flow of urine are only a portion of the pelvic floor muscle group. There is research that tells us that with basic verbal or written instruction of pelvic floor contraction, 40% of women had an ineffective muscle effort and 25% of those women had a muscle pattern that would actually promote urinary incontinence because they were creating pelvic floor pressure. (Bump 1991).
The pelvic floor is a responsive and dynamic muscle group that is adapting it’s muscle force all day depending on what your body is doing. It should be working harder when you are climbing stairs while holding your toddler or grocery bags than when you are standing in the kitchen washing the dishes. Like any muscle, it should be able to contract fully and relax fully. Since we can’t see our own pelvic floor, this range of motion can be a mysterious concept for many women.
When someone has a pelvic floor dysfunction, the pelvic floor can be operating on either end of the spectrum of muscle function. The pelvic floor may be on the Hypotonic/Underactive side: using the analogy of the elevator, this pelvic floor is hanging out at the basement and maybe the lobby but can’t generate enough force to fully close its doors and lift up to get to the 2nd floor. Symptoms that are common when someone has an Underactive pelvic floor:
• Stress incontinence (Leak with cough, laugh, sneeze, jump, run)
• Lack of sensation w/sex
• Prolapse or presence of heaviness in the vagina
• Pass of air thru vagina w/inversions
• Tampon falls out
• Recurring pain in lower back, sacroiliac joint or pubic bone.
On the other end of the spectrum is a pelvic floor that is Hypertonic/Overactive. This pelvic floor does not fully relax so the muscles are working too hard even when the body is at rest. This elevator lives up at the 2nd floor and only goes between the 2nd and 10th floor and cannot fully lengthen to get down to the basement. The signs and symptoms that are common in this category are:
• Stress incontinence: Yup – this happens on this end of the spectrum too
• Urge incontinence: leak happens when the urge to urinate occurs, without a load like a sneeze or jump
• Urinary Frequency: the need to pee more often than every 2 hours on a regular basis
• Urinary Frequency due to the presence of pain when the bladder gets full
• Pain w/sex (pain that is deep in vagina vs pain at site of perineum scar), Pain w/ tampon use and/or speculum exam: pelvic floor does not like to be stretched
• Constipation is a frequent complaint
• History of sexual abuse: high correlation with pelvic pain
• Recurring pain or chronic tightness in lower back, sacroiliac joint, hips or pubic bone.
So what does all this mean? This means that you need to know where your pelvic floor is before you start to follow the advice of doing Kegels or not doing Kegels. In an ideal world, every woman would get at least 1 visit to a pelvic floor physical therapist so that they can get this information and also get hands on training on how to do a Kegel correctly.
Women who fall into the Underactive category commonly need to be taught how to activate their pelvic floor muscles correctly and nothing is more helpful than real time feedback from the therapist who is assessing what the muscles are doing when the woman is doing it. Many of my clients will say “I just want to know if I’m doing it right”. I’ve met pelvic floors that are barely making a flicker of muscle activation even though the woman has been doing Kegels because her brain didn’t understand what to do without the tactile feedback of the pelvic floor exam. If you are going to do a workout program aimed to strengthen your pelvic floor and core, let’s make sure you are doing what you need to do to get the results you are after!
Women who fall into the Overactive category will need to learn how to do a Reverse Kegel or Pelvic Floor Down-Training, which means teaching the muscles to let go of the unnecessary muscle tension. Many of these women have no idea that these muscles have been working so hard because they are not consciously activating their pelvic floor on purpose. You know how sore your quads get to the touch after you’ve done a leg workout?….muscles that are sore to the touch are sore for a reason so when a pelvic floor muscle is sore to the touch (penetration, tampon use, speculum, pelvic floor exam) then we know that the muscle is likely working too hard. If a woman with an Overactive pelvic floor followed a Kegel program because she is leaking urine, she likely will have an increase or development of the symptoms listed above. Doing Kegels or core work should never cause any of those symptoms and if it does – then its highly recommended that you get yourself to a pelvic floor therapist for a full assessment and treatment plan. The rule is that if pelvic floor overactivity is found, then the first goal is to decrease that muscle tension so that the elevator can reach the basement and then train it to use the full range of motion when in use.
And just a reminder that the pelvic floor does not and should not work alone. The pelvic floor works together with the abdominals, hips and gluteals so when working on the pelvic floor, you must also work on the surrounding muscles to address the entire system. Kegels alone are never a comprehensive treatment plan. Posture also plays into the pelvic floor’s function and efficiency and therefore also needs to be considered. As an Orthopedic and Women’s Health Physical Therapist, I work with my clients on the whole body level to make sure that we address all layers to the dynamic body to get the results we are after.