If you read In Defense of the Kegel, you’ll know I am a Kegel fangirl. You’ll also know not everyone is. Read that post first and then come back. I’ll wait.
Welcome back. Let’s get to work.
Who Should Kegel
Most pelvic floor professionals recommend the Kegel. I’m sure you’ve been told to do your Kegels at stoplights or when waiting in line, among other places. These blanket recommendations gloss over Kegel complexities and fail to answer the first obvious question: Who should Kegel?
For example, a woman suffering with pelvic pain shouldn’t start squeezing her vagina in the grocery store line. A too tight pelvic floor could be causing this pain. According to many physical therapists, if tight muscles are the cause of pelvic pain, isolating your muscles is good, but isolating them simply to contract further is not good. In other words, you might be involuntarily contracting the muscles all the time or at inappropriate times, so you should learn how to voluntarily RELAX first.
On the other hand, if your muscles are loose and weak, very common after pregnancy and childbirth, you need to build strength. The best way to build strength is through muscle isolation a.k.a the Kegel.
I like analogies and the best analogy I can come up with is a clenched fist. [Side-note: DO NOT google “vagina and fist.” In my EXTREME NAIVETE, I made this mistake. I wanted to see if anyone else had used the fist analogy. Instead, I lost faith in humanity.] A fist is tense, but your clenched hand (the fist) is useless if it can’t move. In this case, tension does not equal function.
Conversely, a floppy hand, although not generating the tension of a fist, is also functionally unhelpful. A floppy hand tries to grip something, but the fingers barely move. [Another side-note: What boredom to play rock, paper, scissors with fisted and floppy hand syndrome sufferers.]
Is a clenched hand a strong hand?
Not necessarily. Maybe your clenched hand when unclenched will be able to generate the appropriate tension to grip a pencil, or maybe not. You won’t know that until you unclench it. Thus, you need to learn how to voluntarily relax before learning how to voluntarily grip. Eventually, the voluntary relaxing and contracting should again become involuntary.
How do you know if your hand is fisted or floppy?
You might tell based on your symptoms. But not always. This is why someone should evaluate your hand. If holding anything in your hand is painful, it’s probably clenched. If everything falls out of your hand, it’s probably floppy.
To hit the analogy head with the hammer that my unclenched hand is holding, the hand is your pelvic floor.
Weak and tight pelvic floors plus weak and loose pelvic floors could both benefit from Kegels, as long as the Kegeling is customized.
However, if your pelvic floor disorder has nothing to do with the muscles (e.g. is neural or structural), the Kegel might not do much by itself. It would be as if your fingers dislocated or the nerves to your fingers stopped working, but everyone kept on telling you to do more finger strengthening exercises. It ain’t gonna do much.
What Does the Research Say?
Let’s leave the convoluted analogies behind. Analogy is not evidence.
Some health professionals think too much emphasis has been placed on the Kegel at the expense of full body movement, posture, breathing, synergistic muscles, etc… This may be true, but the evidence doesn’t know yet. However, pelvic floor exercise a.k.a the Kegel has been studied. The other modalities, for all intents and purposes, have not.
Therefore, let’s look at the evidence.
Is the Kegel worth your time?
Yes. But it is not a panacea.
Analogies are tidy. Evidence can be messy.
Although Kegels have helped me, hence my fangirl appellation, I was suspicious of the clinical evidence I’d find. How would you actually study a Kegel? How do you blind women to muscle contractions? How do you blind the practitioners?
Blinding means a group doesn’t know if it is the one receiving an intervention (the muscle training) or if it is a control group (those not receiving the exercises). Blinding is pretty essential for preventing what is called confirmation bias, which relates to the placebo effect: a belief one is getting better or worse simply because of expectations.
I also had questions about how pelvic floor muscle strength is measured and about study length.
Therefore, I expected to find mostly ambivalent evidence about the benefits of Kegels (I’m using “Kegel” and “pelvic floor muscle exercise” interchangeably).
After spending way too many hours perusing Pubmed, I discovered my off the cuff concerns are real concerns for real researchers. Blinding is not possible. Strength analysis is not systematized (But much better than I had expected. The studies seem to use reliable methods for measuring strength, but the studies don’t always use the same methods, meaning inter-study comparisons are hard to make).
Thank You, Systematic Review
I read a handful of studies, felt overwhelmed, and thought “I really wish someone could save me time and compare all these studies.” After all, at its core, MOTHERFIGURE is just a mommy blog, and I’ve got other stuff to do. Then I remembered those clever scientists do things called meta-analyses. Duh. I should be looking for those.
I found systematic reviews instead. In fact, one group of researchers had set out to do a meta-analysis. Unfortunately, they had to abandon the meta-analysis because the studies were too dissimilar to be meaningfully compared.
Nevertheless, their 2014 systematic review is thorough (and luckily rentable, great for a budget conscious blogger). It has the exciting title “Pelvic Floor Muscle Activation and Strength Components Influencing Female Urinary Continence and Stress Incontinence.” Luginbuehl et al. wanted to figure out the best pelvic floor muscle training regimen for achieving continence.
I didn’t find their systematic review interesting because of its conclusions— their thesis is that the studies are heterogeneous—but rather because of the breadth of their analysis. They highlight many inherent weaknesses in studying pelvic floor interventions. As I said, I had wondered how patients would be blinded to the type of intervention. Luginbuehl et al. note in the “Risk of Bias” section that “All studies showed a high risk concerning performance bias, due to impossibility of blinding patients and staff against intervention. None of the studies addressed detection bias.” Oh, of course. No one is blinded. Major limitation.
However, even with these limitations in the primary studies, the review is meticulous and concludes,
Taking into account the limitation of the high methodological variability across the studies under investigation, this systematic review suggests that PFM activation and strength components are associated with female urinary continence and SUI and, therefore generally supports the importance of PFM-training for SUI patients as improvements of PFM function may be related to improvement in incontinence symptoms.
I’ll pretend like I’m Luginbuehl et al. and rephrase their findings:
After looking at over two thousand studies, throwing out the bad ones, and choosing the best ones, which were only about a dozen, we think Kegels (what we are calling pelvic floor muscle training or PFMT) strengthen the muscles and that strengthening the muscles can improve stress urinary incontinence. Maybe. The studies we systematically reviewed usually show positive effects, but they differ so much they are hard to compare.
Anyway, the Luginbuehl et al. systematic review linked to the famous (in pelvic floor circles) 2012 Review by Physical Therapist Kari Bo in the World Journal of Urology called “Pelvic floor muscle training in treatment of female stress urinary incontinence, pelvic organ prolapse and sexual dysfunction.” I didn’t read this review in full because it was out of my budget, but it is referenced a ton, and I’m willing to take the abstract on faith.
There is Level 1, Grade A evidence that PFM [pelvic floor muscle] training is effective in treatment of SUI [stress urinary incontinence]. To date there are 5 RCTs [randomized controlled trials] showing significant effect of PFM training on either POP stage, symptoms or PFM morphology. Supervised and more intensive training is more effective than unsupervised training. There are no adverse effects. There is a lack of RCTs addressing the effect of PFM training on sexual dysfunction.
Again, in plain English this says:
Pelvic floor muscle training is effective. This doesn’t mean it is always effective, but it is effective enough to get a Grade A. That’s good.
The Cochrane Collaboration also did a systematic review in 2011 (A Review the 2012 Review includes. Perhaps it does not deserve its own mention, but Cochrane is the gold standard, so I will). The Cochrane Review concludes that PFMT can improve stress urinary incontinence, muscle strength, and prolapse.
Slam dunk right?
Well, not really. The 3 Reviews note the same thing: Nothing is standardized and lack of standardization makes the evidence confusing. Enough evidence has been amassed to show a real and measurable positive effect of pelvic floor muscle training on incontinence and prolapse, but randomized controlled trials haven’t looked at “different regimens of PFMT” or “trials aimed at prevention of prolapse” or “trials of one type of conservative intervention versus another” (Cochrane).
To muddy the waters, another long-term trial out of the UK and New Zealand showed no statistical difference between the outcomes of two trial groups 12 years after childbirth. They were evaluating nurse-led pelvic floor muscle training on postnatal incontinence and prolapse. Although those in the group with the training versus the control group showed improvement 3 months after childbirth, this improvement was not maintained at the 12 year mark. Basically, those who were assigned to the PFMT group peed themselves less at 3 months, but they did not have fewer cases of pelvic organ prolapse after 12 years. That’s disappointing. Still, the authors conclude the effect might have persisted “for longer if there had been continuing reinforcement or if it had been carried out by pelvic floor physiotherapists…” To me, this study says more about habit formation than about PFMT specifically.
Kegel’s magic is dimmed a bit more by a study looking at postpartum pelvic floor muscle training. The study did not show improvement in pelvic organ prolapse or bladder neck support in a randomized trial of moms who had just given birth vaginally. The authors note that other studies of middle aged women had shown the benefits of PFMT on POP. Therefore, they don’t dismiss PFMT. Instead, they note the control group might not have been a true control group since the postpartum women had volunteered for an exercise program (Bo is again one of the researchers). Therefore, the control group women might have exercised anyway, thus skewing the results. Maybe. Maybe not. Either way, Kegels are not vindicated by this study.
This is why systematic reviews are handy. Studies will go back and forth. A good systematic review will tease out these differences. As of now, the systematic reviews support PFMT (Kegels) as a first line conservative Grade A treatment for stress urinary incontinence and prolapse.
I believe a lot of women misread this interpretation as evidence Kegels are foolproof. They aren’t. They are just the best we have for now until someone can come up with and study a more specific strengthening routine.
In the meantime, if you struggle with incontinence and pelvic organ prolapse, do your Kegels and do enough to feel strength improve. I know the fear of a too tight pelvic floor is real, but if you are weak, the best way to get strong is to strengthen, not to abandon the only Grade A conservative treatment we have right now.
Does this mean Kegels work but some other conservative (i.e. nonsurgical) treatment would work better?
Many practitioners who reject Kegels recommend some other intervention for preventing and managing incontinence and prolapse. Even the Cochrane Review mentioned that the primary studies in their Review compared pelvic floor muscle training to no training, but not to another treatment. Maybe something else could work as well or better.
This question bothered me. Again, Pubmed helped me out. (Unfailingly, whenever I think I’m broaching a new question, it is one researchers have already addressed). Enter another systematic review. This was from 2013, again by Physical Therapist Kari Bo, called “There is not yet strong evidence that exercise regimens other than pelvic floor muscle training can reduce stress urinary incontinence in women.” That title sums up her conclusions.
Bo explains, “theoretically non-specific exercises could strengthen pelvic floor muscles,” but that no randomized controlled trials have shown this. She continues, “It is not yet known whether it is possible to teach women participating in a general group-based exercise class [specifically yoga or Pilates] to contract the pelvic floor muscles.” Additionally, she notes that the “association or causal link between breathing, posture, and pelvic floor muscle dysfunction should be tested in case-control or cohort studies with blinded assessors.”
Bo’s conclusion: Whereas multiple systematic reviews have shown “clinically important effects” of pelvic floor muscle training, all other conservative treatments are still in a “Development or Testing phase.”
An earlier review by Bo and others confirms her thesis, this time in regards to transverse abdominis activation over PFMT. Essentially, the studies haven’t shown an additional effect of adding TrA training to PFMT. This doesn’t mean the TrA isn’t important, just that isolating it hasn’t been shown to do “extra.” Usually the TrA contracts with the pelvic floor, so this evidence is neither here nor there for me.
Where Does This Leave Us?
Back at the beginning.
Do your Kegels. But do them right (again, reread In Defense of the Kegel).
Don’t expect them to be magic vagina transformers. Statistics are impersonal. They don’t care who you are. The Kegel may not help you. But the Kegel just might…
As for other recommendations–like Pilates, yoga, postural improvements, or breath work– they could be great too. The evidence isn’t there yet. Nevertheless, it may catch up. In the meantime, the Kegel has been studied, rather poorly in many cases, but studied nonetheless, and based on that evidence, I would say, yes, Kegels do work. Sometimes.
- Luginbuehl et al., “Pelvic Floor Muscle Activation and Strength Components Influencing Female Urinary Continence and Stress Incontinence,” Neurourology and Urodynamics, 2014 9 April. ↩
- Kari Bo, “Pelvic floor muscle training in treatment of female stress urinary incontinence, pelvic organ prolapse and sexual dysfunction,” World Journal of Urology, 2012 August, Volume 30, Issue 4, pp 437–443. ↩
- Suzanne Hagen and Diane Stark, ed. Cochrane Incontinence Group, “Conservative prevention and management of pelvic organ prolapse in women,” The Cochrane Library, 7 December 2011. ↩
- Glazer et al., “Twelve-year follow-up of conservative management of postnatal urinary and faecal incontinence and prolapse outcomes: randomised controlled trial,” BJOG, 2014 Jan, Volume 121, Issue 1, pp112–20. ↩
- Bo et al. “Postpartum pelvic floor muscle training and pelvic organ prolapse-a randomized trial of primiparous women,” American Journal of Obstetrics and Gynecology, 2015 Jan, Volume 212, Issue 1. ↩
- Kari Bo and Robert Herbert, “There is not yet strong evidence that exercise regimens other than pelvic floor muscle training can reduce stress urinary incontinence in women: a systematic review,” Journal of Physiotherapy, 2013 September, Volume 59, Issue 3, Pages 159–168 ↩
- Bo et al. “Evidence for benefit of transversus abdominis training alone or in combination with pelvic floor muscle training to treat female urinary incontinence: A systematic review,” Neurourology and Urodynamics, 2009, Volume 28, Issue 5, pp. 368–73. ↩