The Problem with Kegels

"Kegel" is the term used in North America for a pelvic floor contraction, named after gynaecologist Dr. Arnold Kegel (I hadn't heard the term before I moved to Canada!) and they are often taught (world-wide) as a strengthening exercise pre and post natally, or for anybody who has a pelvic floor-related problem. Performing isolated “Kegels” (pelvic floor contractions) can be helpful in the short term, especially early postpartum (eg. within the first 48hrs) to improve the control and awareness of the muscle. However, when performed by already hypertonic muscles, Kegels can lead to an even tighter pelvic floor and cause more serious problems to occur throughout the body.
Most people with pelvic floor issues are not simply suffering from muscle weakness, but rather from a tightness or shortening of the pelvic floor muscles (See Too Long, Too Short or Just Right? for more info). Most often, the muscles need to be released and trained to relax first, prior to any strengthening. 

Simply having a strong pelvic floor contraction does not necessarily mean that the muscles are functioning appropriately. I have many patients who are able to produce a very strong pelvic floor contraction yet still experience urinary leaking, prolapse, lack of sexual orgasm, or pelvic pain. The ability of the pelvic floor muscles to perform their desired roles depends on the tensegrity of the entire web and function of all of the surrounding structures, especially the gluteals, diaphragm, and core abdominals.

Another difficulty with practicing Kegels is that it is often hard to know if you are doing the exercise correctly since it is not easy to see movement created by the muscles and most of us have limited awareness of how the muscles contract. A literature review published in 2010 showed that pelvic floor exercise programs were much more effective when they consulted a pelvic health physiotherapist or continence nurse to learn how to perform the exercises, compared to learning the exercises from a pamphlet[1]. Without proper instruction, it is sometimes hard to tell if you are doing the exercises correctly and some women are actually doing more harm than good – creating pressure and bearing downwards on the pelvic organs and muscles.

How do the Pelvic Floor Muscles Work?

The pelvic floor muscles contract (and lift) in response to loads placed upon them in order to support the weight of your pelvic organs, close openings and allow for healthy sexual function. The degree of pelvic floor muscle contraction is dependant on your position and how you are moving. Since gravity (as far as we know) is vertical, whenever you are upright, these muscles are constantly working and responding to the loads above them. 


This diagram shows how gravity acts vertically on the muscles of the pelvic floor. The picture on the left is what I was trying to draw and yes the muscles should attach higher up anteriorly. Sorry! Pretty close though.. amiright? ;)

Ideally, this is how the muscles should react to gravity to help support the weight of the pelvic organs and perform their various functions. 

If you are carrying a weight, walking or squatting, then the pelvic floor is working at a higher level than if you are simply sitting, or lying down. Therefore, doing isolated contractions to strengthen your pelvic floor may be too much, and at the same time, not enough. You may be generating too much tension in the (already tight) pelvic floor muscles compared the loads being placed on them. Additionally, as a primarily sedentary culture, we do not allow the pelvic floor muscles the opportunity to experience a variety of loads (in a range of different positions) throughout the day, every day.

The Pelvic Floor and your Butt

The smooth functioning of the pelvic floor muscles depends on the health of all of the surrounding muscles and tissues, particularly those of the gluteals, i.e. your butt. One of the functions of the gluteus maximus is to stabilise the sacrum, pulling it back and out. This action provides a stable anchor point for the pelvic floor muscles to work from, allowing for the best functional leverage as the muscles become taut in order to support the pelvic organs and close various openings. If the gluteal muscles are not working appropriately when the pelvic floor muscles contract, the result becomes net movement of the tailbone towards the pubic bone, resulting in a much less effective action of the pelvic floor. 
This is my very sophisticated attempt at showing how the gluteal muscles help to stabilize the sacrum by pulling backwards while the pelvic floor is contracting, with a net result of a functional pelvic floor action against gravity. This happens when you are upright and moving, especially when you are squatting and walking - if you are using your butt. (This is an ideal situation!)


And how, in the absence of the butt contraction/stabilisation, the sacrum will be pulled forward as the pelvic floor muscles contract (as seen when doing Kegels if you are lying down or sitting). This results in a less functional contraction with decreased support against gravity and suboptimal control of the bladder and bowel. (Not an ideal situation)

Over time, the pelvic floor muscles can become shorter (adapting to the most frequented shape of the pelvis) causing the sacrum to rest even closer toward the front of the pubic bone and resulting in a more narrow pelvic outlet - not so great for birthing mechanics! When this becomes the default position of the sacrum, the muscles are not longer able to contract as effectively. Similarly, the mobility of the spine and pelvis is decreased, inhibiting the action of the gluteals, and pressures within the abdominal and pelvic areas are no longer able to be maintained.

In summary, Kegel contractions can be helpful to bring your awareness to the muscles and to learn how to control them. However, repetitive Kegel contractions every day for the rest of your life are not necessary to maintain functional pelvic floor strength. Rather, these muscles (and your whole body) must to first be restored to their correct length and tension and will be functionally strengthened via a variety of movement every day. So go get moving! 

 For more detailed info about pelvic floors, how to use your butt and more, visit Katy Bowman's blog www.katysays.com or read her amazing book "Move Your DNA".





[1] Price, N., Dawood, R. & Jackson, S. (2010) Pelvic Floor Exercise in Urinary Incontinence: A Systematic Literature Review', Maturitas, 10.1016/j.maturitas.2010.08.004.


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