I’ve noticed a lot of physical therapists moving away from the Kegel. Usually, this retreat is about providing “better options” for their patients and a more “integrative” approach to pelvic floor function. From what I can tell, this move is based on new theoretical trends in physical therapy and not on any new emerging evidence.
Abandoning the Kegel is foolhardy for women who need to build strength, but admittedly, so is relying on a maximal isolated contraction to single-handedly combat incontinence or prolapse.
When Higher Reps of a Maximal Kegel are a Good Idea
Most of the pelvic floor literature suggests more is indeed better when trying to build strength. Some physical therapists worry about over-contracting the pelvic floor muscles, but an inability to contract the muscles through a full range of motion (i.e. an inability to relax it completely) does not mean fewer contractions is better if strength is the goal. (But, it does mean Kegel technique needs to be checked by a medical professional.)
According to exercise science, a muscle builds strength by working to the point of, but not beyond, fatigue. Going beyond fatigue will probably cause injury, but going too far below fatigue doesn’t tax the muscle enough. Consequently, weak pelvic floor muscles presumably need to be exercised close to fatigue to build strength. To do this, I like a maximal Kegel.
Remember, these Kegels, like any strength exercise, need a full range of motion, which is why you must properly relax the pelvic floor before contracting. This is also why mindless Kegeling = not great idea. 100 mindless Kegels without proper intra-Kegel relaxation will be less helpful than say 3 sets of 10 maximal Kegels.
Different Kegel Goals
Much of the Kegel confusion appears to revolve around different goals, as well as different theories about why women experience incontinence or even prolapse. If your pelvic floor dysfunction is the result of weak muscles, building strength with a maximal Kegel is a good idea.
But, if your pelvic floor dysfunction is the result of an uncoordinated pelvic floor, maximal Kegels are not the best route.
And, if your pelvic floor dysfunction is the result of structural changes, like torn ligaments and connective tissue, the Kegel can help strengthen and coordinate the parts of the pelvic floor that have not been damaged, but will not fix the parts of the pelvic floor that have.
Clearly, the benefits of the Kegel are pelvic floor specific, and many pelvic floors will have all 3 of those issues.
Therefore, I agree that the maximal and isolated Kegel is not the only route to pelvic floor function. But, I also reject new approaches that vilify the maximal Kegel.
A Proportionate Kegel
Physical therapists who dislike an isolated Kegel recommend coordinating the strength of a pelvic floor contraction to the task at hand and to the breath. They argue that women need to know how to contract and relax their pelvic floor muscles in the real world, not as an isolated, disembodied squeeze.
Yes. I totally agree. In my mind (and I suppose now on a blog) I call this a proportionate Kegel because the level of pelvic floor contraction should be proportionate to the level of stress placed on it.
There is no need to squeeze the pelvic floor into oblivion if you aren’t creating much intra-abdominal pressure in the first place. And, if you are creating a moderate amount of intra-abdominal pressure through an exercise or activity of daily living, the pelvic floor should only contract a moderate amount in response. This situation specific advice has been very helpful for me in terms of coordination. But… not so much in terms of strength.
Again, to build strength, maximal contractions are necessary. In the “real world,” I’m not going to encounter enough maximal contraction situations to safely build strength. True, my pelvic floor should do a maximal Kegel when I sneeze or cough, but training my pelvic floor beforehand feels like a much better way to build strength than to wait for a situation specific event to present itself.
How I Combine the Old and New Physical Therapy Advice
Too much of the popular advice about how to improve pelvic floor dysfunction lacks nuance. Many many websites simply say “Kegel,” but then don’t say much else. (Telling women to “pretend they are stopping the flow of urine” is not comprehensive advice).
Conversely, some physical therapists have reacted against this bad advice by coming up with new ways to “integrate” the pelvic floor. As I said, some even tell women not to do an isolated Kegel (I put “integrate” in quotes because the applied definition is amorphous, not because I think the word is bad).
I’ve tried to sift through professional, and often conflicting, advice to come up with a self-care plan of my own. I have seen physical therapists, multiple doctors, and have read some of the pretty boring physical therapy textbooks, so this plan is not out of thin air.
This is My Routine
- I pay attention to my pelvic floor when exercising, lifting, or performing any activity of daily living that creates intra-abdominal pressure. Most of the time, my pelvic floor automatically performs a “proportionate Kegel” without me thinking about it. After childbirth, this wasn’t the case. I had to painstakingly re-learn how to coordinate the timing of the Kegel with my movement.
- I also perform at least one set of 15 maximal Kegels every day. In the beginning, I did more like 2–5 sets every day. This definitely helped me build strength.
- I’m realistic. I have structural damage from childbirth, and I know proportionate and maximal Kegels will not solve my pelvic floor problems. They have been immensely helpful, but they aren’t going to fix my anatomy. I’ve seen gynecologists and have worked with them on personalized interventions (such as a removable pessary, activity changes, etc..). Additionally, I workout consistently and try to balance my desire to progress my overall physical fitness with my desire to protect my damaged pelvic floor. This means I don’t run or do intense plyometric exercises. But, it does not mean I’m afraid to move. In fact, being afraid to move will just make pelvic floor disorder worse. Having a strong body takes pressure off the pelvic floor, even as the exercises themselves sometimes create pressure. It’s a dance.
I also know surgery is likely (I’ve been told a “when, not if” scenario). I have tried to accept this, rather than ruminate on it. When the time comes, I will find a good surgeon and ask lots of questions. The failure rate for pelvic floor surgery is high, and that is unfortunate. Nonetheless, I try to stop myself from getting upset about a future that hasn’t even happened yet.
Ultimately, knowing how to Kegel, when to Kegel, and how much to Kegel is incredibly important, but it isn’t a cure-all for pelvic floor dysfunction. Disorder with multiple antecedents will have multiple approaches. A more “integrative” approach to pelvic floor dysfunction is a great idea.
But, abandoning a maximal Kegel? From personal experience I know that’s not a great idea. The Kegel can be an essential part of a self-care plan.
- Evidence-based Physical Therapy for the Pelvic Floor: Bridging Science and Clinical Practice. Edinburgh: Churchill Livingstone, 2015. ↩