To Kegel or NOT to Kegel
Do Kegels really help? How often have you been told that doing Kegels is the answer to your problems? And how do you know if you are even doing them correctly?
Dr. Arnold Kegel, a physician and pioneer in the field of gynecology, coined the term "Kegel" in 1948, when he found that women experienced an improvement in urinary leaking by contracting the pelvic floor muscles. This is based on the premise that the pelvic floor muscles are weak. Although there is evidence that performing Kegel exercises can help to reduce stress urinary incontinence, along with maintaining normal body weight, as many as 50% of women are NOT performing Kegels correctly. In addition, the problem is often due to tightness in the pelvic floor, not weakness. Physical Therapist Rhonda Kostarinos referred to this as a "short pelvic floor." She found that a weak abdominal wall can cause compensations in the pelvic floor and render the pelvic floor muscles incapable of contracting since they are already in a contracted, or short state. This is exactly what I see in my clinical practice with Kegels often worsening symptoms if done without restoring normal length to the muscles first.
Pelvic floor dysfunction is a collective term that includes many different symptoms. It simply means that the pelvic floor muscles are not functioning as they are meant to, which can affect the support of pelvic organs, urinary function, bowel function and sexual function. Myofascial pelvic pain can occur when the pelvic muscles are abnormally tight. Common symptoms include tailbone pain, hip/back pain, abdominal pain, menstrual cramps (dysmenorrhea), pain with penetration (dyspareunia), rectal muscle spasms, vaginal spasms, bladder pain and/or poor sitting tolerance. Individuals with pelvic pain should not tighten, but rather lengthen, the pelvic floor muscles. This is referred to as a reverse Kegel.
Urinary incontinence, or the involuntary loss of urine, is not normal AT ANY AGE. It can be slight, such as a mild leak with a cough or sneeze, otherwise known as stress incontinence, or it can be due to an overactive bladder or urgency (a sudden need to use the bathroom). Frequent urination/frequency (more than 8 voids in a 24 hour period) is also not normal and neither is nocturia (getting out of bed to urinate). Urinary dysfunction is often the result of weakness and dysfunction in one or more of the four deep core muscles and can be brought on by pregnancy, delivery, abdominal surgery, lifting improperly, coughing, bearing down (from chronic constipation or straining to get out of a chair), trauma to the pelvic girdle or from falling. It is estimated that between 30 and 40% of middle aged women and 50% of older women experience this nuisance and often do not even know that help is available. Often the pelvic floor muscles are in a shortened position and cannot contract in a timely fashion. Lengthening the pelvic floor muscles is necessary first, in most cases. This may be the reason Kegels are not working.
At Healthy Core, we do not believe in putting on a Band-Aid or covering up the problem with unnecessary medication, expensive pads or surgery. Our conservative approach can resolve the issue in as little as four visits to our clinic and is actually quite simple. We address motor control issues in the deep core muscles through re-education and work on lengthening the tight or dysfunctional muscles.
So what is the answer to this public health issue that is literally draining the healthcare system and costing billions of dollars each year, not to mention risk of embarrassment and lost productivity?
1. Relax the muscles of the pelvic floor, through deep diaphragmatic breathing or stretching. The pelvic diaphragm (pelvic floor muscles) and respiratory diaphragm are parallel and actually work like a piston. With normal inhalation, the pelvic floor should relax. With normal exhalation, the pelvic floor should contract (Kegel). Once the muscles are lengthened properly, they will have an improved ability to contract and move through the full muscle range of motion. Think "lengthen before you strengthen."
2. Improve the motor control of all 4 deep core muscles, namely the pelvic floor, transversus abdominus, diaphragm and multifidus (deep spinal stabilizers). This can be accomplished by muscle retraining, hands-on treatment or DRY NEEDLING to balance out the neuromuscular system and encouraging the correct muscles to activate. Also performing certain exercises to engage these muscles is essential while avoiding exercises that do not help, such as sit-ups and crunches. Research has shown that the best way to engage the core system is to begin with a proper pelvic floor contraction. In other words, it is difficult to contract the transversus abdominus and multifidus without performing a Kegel correctly (and could be a waste of time for you). Therefore, a properly functioning pelvic floor is essential to lumbopelvic stabilization.
3. Provide a fascial lift from the hip rotator muscles, where the pelvic floor attaches (see top photo of the muscles looking down into the pelvis). The obturator internus muscle is on the inside of each hip and is what the pelvic floor hammock is attached to. Its main job is to rotate the hip externally and when contracted it facilitates a pelvic floor contraction: imagine a hammock being lifting from the ends. Often one hip (right >left) is limited in range of motion or flexibility due to adhesions in the abdominal wall that restrict the hip capsule. This can only be improved through visceral mobilization by addressing the fascial restrictions around the abdominal organs along with mobilization of the hip joint, in some cases. The pelvic floor will not contract properly if there is resistance or loss of motion in one or both hips due to its fascial connection to the hip rotators, namely the obturator internus muscle.
4. Avoid bearing down or straining the pelvic floor when lifting, exercising or going to the bathroom. This does not get enough emphasis and is so simple to do during every day activities. It requires EXHALING during the strenuous part of an exercise. For some people, getting out of a chair, or lifting groceries could prompt holding the breath and cause the pelvic diaphragm/floor to work in opposition of the respiratory diaphragm. Remember the piston action of the two diaphragms? Remember to EXHALE through the mouth when EXERTING or lifting.
In short (pun intended), Kegels alone are NOT the answer to all urinary and bladder issues. While eventually learning how to do a Kegel can help with lumbopelvic stabilization by its integral role of core muscle activation, it is not the most effective solution unless the deep core myofascial system is restored and balanced. If doing a Kegel makes your condition worse, you should STOP and seek the help of a qualified women's health therapist.
Healthy Core is the only clinic of its kind in northeast Ohio dedicated solely to the unique needs of men and women with core and pelvic girdle dysfunctions. We are honored to compassionately share our expertise so you can be the "best version" of yourself to be free of pain and dysfunction. We should never celebrate that "pee happens" but rather find a cure!
Hodges P, Cholewicki J (2007). Functional control of the spine. Movement, Stability & Lumbopelvic Pain. Chapter 33
Kotarinos and Fitzgerald (2003). Rehabilitation of the short pelvic floor I: background and patient evaluation. International Urogynecology Journal: (14) 261-268.