The Kegel Myth

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The Kegel Myth

Author: Lisa Cheek, PT, DPT, CLT-LANA

In the age of information, we are constantly bombarded with advice about how to be our best selves.  It seems that every week, there is a new supplement du-jour, or some new exercise fad that we should be following.  There is one perennial piece of advice that women are bombarded with day in and day out- “DO YOUR KEGELS”. Kegels, or pelvic floor exercises, were first described by Dr. Arnold Kegel in the 1950’s as a treatment for stress urinary incontinence and pelvic organ prolapse.1   Since then, the notion that all women should be Kegel-ing on a regular schedule has become ubiquitous.  A recent article in Self Magazine kicks off with the headline: “So you did your squats, your planks, and your push-ups. But have you toned your vag today?”2

A cottage industry has even sprung up around the Kegel, with products like the Elvie (which claims to be the “No. 1 Kegel trainer worldwide”), Yoni Eggs, Kegel training apps, and more.  Kegels have been touted as a cure for incontinence and pelvic organ prolapse, and have also been billed as a magic bullet to enhance sexual performance.  There is good evidence 2,3,4 that a properly prescribed pelvic floor exercise program can indeed help with the aforementioned pelvic floor disorders, but are Kegels the whole story?  How do you even a Kegel in the first place? Should we doing Kegels right now? Let’s unpack some of the mystery surrounding the Kegel, and learn about alternative ways to keep our pelvic floors healthy and happy.

Myth #1: Kegels are the best way to strengthen the pelvic floor.

In the world of physical therapy, it is well known that pelvic floor disorders are much more common than one might think.  One large study5 estimated the prevalence of pelvic floor disorders in women (urinary or fecal incontinence, pelvic organ prolapse) at 25.0%, with the largest number of women experiencing moderate to severe urinary incontinence.  We also know that there is some degree of correlation between pelvic floor muscle strength and pelvic floor disorders6.  The Kegel has become synonymous with pelvic floor strengthening, but is it really the best way to strengthen the pelvic floor?  More importantly, is it the only way to treat and prevent pelvic floor dysfunction?

We know that the pelvic floor does not work in isolation.  It works in conjunction with the muscles of the core, hips, and other areas of the body to provide maximum stability for the midsection (learn more about this relationship here).  When we are trying to strengthen our arms, we don’t just do bicep curls- we work all the muscles in and around the arms in order to get the best results.  Why, then, would we focus on strengthening just the pelvic floor if we want to see the most benefit? Additionally, there is evidence to show that the Kegel is not even the most effective exercise for the pelvic floor.  One study7 using EMG evaluation showed that upright, functional exercises like lunges and squats produced better activation of the pelvic floor than a traditional Kegel.  Another study8 showed that women made significant gains in pelvic floor force production with an exercise program aimed solely at the lateral hip rotators and obturator internus muscle.  In this light, it seems that Kegels are one way to strengthen the pelvic floor, but they certainly aren’t the only way—and they may not even be the most effective!

Myth #2: Practice Kegels by stopping the flow of urine.

One myth that seems to be particularly prevalent is that the best place to practice your Kegels is while going to the bathroom.  The theory behind this myth actually sound- the pelvic floor muscles create increased pressure in the urethra, which holds urine in until it is time to go.  Hence, contracting the pelvic floor will stop the flow of urine. That said, and repeat after me, DO NOT DO KEGELS WHILE EMPTYING YOUR BLADDER. Doing so can lead to urine backflow into the urethra, increasing your risk of a urinary tract infection.  Additionally, habitually stopping the flow of urine by contracting your muscles can interrupt the normal reflex of bladder emptying, setting you up for problems down the road.  Bladder emptying, also known as the micturition reflex, depends upon feedback mechanisms between the bladder and the pelvic floor– when the bladder is emptying the pelvic floor should relax, and when the bladder is empty the pelvic floor should contract.  If we get into the habit of contracting the pelvic floor when it should be relaxing, this disrupts the reflex and can lead to incomplete bladder emptying, urinary urgency, etc. Stopping the flow of urine once to identify the pelvic floor muscles probably won’t hurt, but making of a habit of it just might.  Don’t do it.

Myth #3: You should be doing (insert arbitrary number here) Kegels every day.

I have a Google Alert set up to notify me about the latest trending article about pelvic floor health, mainly because I like to stay ahead of whatever information/misinformation is being fed to the masses.  An article9 popped up recently from Goop, Gwyneth Paltrow’s online repository for dubious health and lifestyle advice.  The first line reads: “One hundred Kegels a day. That’s what it takes to make an enormous difference to our health and well-being…”, and then goes on to quote a recent study from the American Journal of Obstetrics and Gynecology.  The study10 looked at women with urinary incontinence, and compared women who did 100 Kegels per day to women who did none.  They concluded that some women who did Kegels scored higher on quality of life scales than those who did not. Should we conclude from this study that 100 Kegels per day is the optimal dosage for everyone?  We can look at a number of other studies5 that point to radically different exercise protocols, ranging from 3 sets of 10 once a day to 100 per day to 20 minutes two times per week.  All studies reported various levels of success in mitigating the effects of pelvic floor dysfunction. A recent systematic review11 concluded that the evidence regarding pelvic floor muscle training as an adjunct to other treatments for stress incontinence is inconclusive and should be interpreted with caution due to small sample sizes.  This is not to say that we should conclude that pelvic floor muscle training is ineffective, only that we should not base our recommendations on one single study.

The pelvic floor is made up of two types of muscle fibers: slow twitch and fast twitch5.  The slow twitch fibers fire constantly when we are upright in order to support the pelvic organs and spine.  The fast twitch fibers activate quickly to counteract abdominal pressures during coughing, sneezing, jumping, etc. in order to maintain continence.  From this, we can conclude that it is not only the number of Kegels that we do, but the type of Kegels that matters.  The right type of Kegel will be different for every person and depends upon the gains we wish to see.  For some, this might mean squeezing the muscles quickly with maximum force to keep urine in when jumping.  For others, this means practicing long, slow, submaximal contractions in order to gain stability.  In all cases, it is equally important to learn how to relax the pelvic floor as it is to achieve a contraction.

To add another layer of complexity, it must be said the not everyone needs to do Kegels.  There is a subset of the population that might need to strengthen the pelvic floor, but there is another subset that absolutely does not need strengthening.  Another type of pelvic floor dysfunction exists, known as non-relaxing pelvic floor dysfunction.12  In this case, the pelvic floor muscles are tight and tender, and symptoms might include urinary urgency/frequency, constipation, pelvic pain, or dyspareunia (painful intercourse).  In this case, pelvic floor strengthening will not only be ineffective but might even make problems worse.

There is so much information available, and it is hard to know what to advice to follow.  Luckily, there is a whole profession dedicated to pelvic floor rehabilitation and finding the right treatment program for each person’s individual needs.

Myth #4: Pelvic floor physical therapy is just about doing Kegels.

Some lucky people end up in pelvic floor physical therapy, either by recommendation from their doctor or by their own impetus.  Most patient do not know what to expect when they walk through the doors, and we often hear patients ask, “So are you just going to tell me to do Kegels?” This is a common misconception about pelvic floor physical therapy, and often could not be farther from the truth.  The fact is that the pelvic floor does not work in isolation, and pelvic floor dysfunction is rarely attributed solely to the pelvic floor muscles. So many different factors affect the pelvic floor, including posture, muscle strength, movement patterns, nerve function, diet, emotional health, etc.  In order to treat the pelvic floor effectively, we need to treat the whole person. This sometimes involvedsKegels, but it should never involve just Kegels if it is to be successful.

Pelvic floor physical therapy is the best way to find the right exercise program for your individual needs.  Before you take the advice from a magazine or website, try contacting a specialist first. We can help you look past the myths and find the most effective, practical solution for you and your pelvic floor.

Reference

  1. Kegel AH. Physiologic Therapy for Urinary Stress Incontinence. J Am Med Assoc. 1951;146(10):915. doi:10.1001/jama.1951.03670100035008
  2. Schupak A. Here is the right way to do Kegel exercises. SELF Mag. December 2015. https://www.self.com/story/here-is-the-right-way-to-do-kegel-exercises.
  3. Lagro-Janssen TL, Debruyne FM, Smits AJ, van Weel C. Controlled trial of pelvic floor exercises in the treatment of urinary stress incontinence in general practice. Br J Gen Pract J R Coll Gen Pract. 1991;41(352):445-449.
  4. Bø K. Pelvic floor muscle exercise for the treatment of stress urinary incontinence: An exercise physiology perspective. Int Urogynecol J Pelvic Floor Dysfunct. 1995;6(5):282-291. doi:10.1007/BF01901527
  5. Marques A, Stothers L, Macnab A. The status of pelvic floor muscle training for women. Can Urol Assoc J J Assoc Urol Can. 2010;4(6):419-424.
  6. Wu JM, Vaughan CP, Goode PS, et al. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women: Obstet Gynecol. 2014;123(1):141-148. doi:10.1097/AOG.0000000000000057
  7. Borello-France DF, Handa VL, Brown MB, et al. Pelvic-Floor Muscle Function in Women With Pelvic Organ Prolapse. Phys Ther. 2007;87(4):399-407. doi:10.2522/ptj.20060160
  8. Crawford B. Pelvic floor muscle motor unit recruitment: Kegels vs specialized movement. Am J Obstet Gynecol. 2016;214(4):S468. doi:10.1016/j.ajog.2016.01.033
  9. Superpower Your Kegels for a Healthy Pelvic Floor—and Better Sex. https://goop.com/wellness/sexual-health/superpower-your-kegels-for-a-healthy-pelvic-floor-and-better-sex/.
  10. Cavkaytar S, Kokanali MK, Topcu HO, Aksakal OS, Doğanay M. Effect of home-based Kegel exercises on quality of life in women with stress and mixed urinary incontinence. J Obstet Gynaecol. 2015;35(4):407-410. doi:10.3109/01443615.2014.960831
  11. Ayeleke RO, Hay-Smith EJC, Omar MI. Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary incontinence in women. Cochrane Database Syst Rev. 2015;(11):CD010551. doi:10.1002/14651858.CD010551.pub3
  12. Faubion SS, Shuster LT, Bharucha AE. Recognition and Management of Nonrelaxing Pelvic Floor Dysfunction. Mayo Clin Proc. 2012;87(2):187-193. doi:10.1016/j.mayocp.2011.09.004

Images:

  1. http://www.sacredbombshell.com/kegels-exercises-for-women/
  2. http://everydaypeoplecartoons.com/cartoon/628/Kegel-Exercises
  3. https://www.flaticon.com/free-icon/man-sitting-on-the-toilet_14644
  4. https://www.sixpad.jp/sp/en/emsrevolution/index.html
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About the Author:

Lisa Cheek, PT, DPT, CLT-LANA
Lisa received her Doctorate of Physical Therapy from Regis University in Denver, Colorado. She was born in New Mexico, and relocated to Denver to pursue a Bachelor of Arts at Regis University. Lisa’s yoga practice inspired an interest in the “medicine of movement,” and ultimately led to her passion and life’s work in Physical Therapy. She has a strong background in Orthopedics and she is passionate for helping underserved communities including the LGBTQIA+ population and people with pelvic floor dysfunction, lymphedema, oncology, pregnancy, and chronic pain syndromes. She is progressing through her pelvic health certification through the Women’s Health APTA, and is a Certified Lymphedema Therapist through Klose Training. Her treatment philosophy emphasizes care for the whole person, and considering the big picture when treating musculoskeletal dysfunction. Lisa believes in empowering patients through education and incorporating principles of modern pain science.