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August 5, 2021

Why Kegels are Not Always the Answer

Imagine waking up in the morning with your bicep flexed. You go to work and spend all day at your desk with your bicep flexed. After work you grab a few things at the store, but the whole time you are walking around, your bicep is still flexed. When you get home from your busy day, you decide to put in a quick workout. You pick up ten pound weights and start pumping out some bicep curls on your already clenched, flexed, tightened bicep. 

That sounds absurd, right? No one flexes their biceps, as if admiring their muscles in the mirror, from sun up to sun down and then still proceeds to “curl” an already “curled” bicep. 

While this is a silly and seemingly unrealistic example, I hope you’ll stick with me. This analogy will make much more sense as we discuss why kegel exercises are not always the answer to your incontinence, feelings of weakness and looseness, prolapse, etc. 

I will refer back to this bicep analogy, an area of the body that is easily felt and seen, in hopes of helping you connect with your pelvic floor, an area of your body that is rarely felt and almost impossible to see without the right tools. 

When treating patients with urinary incontinence, fecal incontinence, pelvic organ prolapse, feelings of looseness and poor support of their pelvic floors, I commonly hear patients report that they have been doing kegel exercises for a long time with no improvement in symptoms...honestly, they often see worsening of symptoms. 

I can imagine how frustrating this is for patients who feel like they are being diligent to strengthen their pelvic floor muscles yet seeing no positive results. Why is that?! Rest assured, this is not alarming to your pelvic floor physical therapist. This actually gives us deeper insight into how your muscles are functioning. 

While the symptoms and dysfunctions mentioned above are most likely weakness related, usually what we find is that your pelvic floor muscles are not totally floppy, flaccid, or not activating at all. Often what we find is that your pelvic floor muscles have developed a habit of constant tension, guarding, and clenching to support you with all the strength they have left. This muscle tension does not mean strength; this tension has most likely developed due to muscle weakness, but your muscles are trying as hard as they can to keep supporting you. 

Muscle weakness and the resulting muscle tension and clenching can occur for a lot of different reasons: pregnancy, delivery, strenuous exercise, stress, trauma, aging and associated tissue and hormone changes, just to name a few. If your muscles are already in this tense state, kegels are only exacerbating the muscle tension - tightening what is already tight. This pattern of constant tension contributes to soreness and fatigue of your muscles. 

Let’s go back to the bicep analogy to explain this point. If your bicep is flexed as tight as possible for several hours (like curling a ten pound weight for several hours without a break), your muscle is getting more and more tired the longer you clench. When you try to pick up a gallon of milk at the store, your muscle is not going to be able to pick up that gallon because it is so sore and fatigued. In the same way, if our pelvic floor muscles are clenched tightly for hours on end, when you sneeze, cough, jump, hurry to the bathroom with a full bladder, your muscles are not going to have the strength necessary to support you and prevent leakage because they are already worn out. If you try to do kegels in this state, your kegels will not be effective and minimal tightening will occur if you are already tight to begin with. 

Optimal pelvic floor muscle strength starts from a resting position (like your bicep hanging loosely by your side) and then contracting fully. THIS is where you will start to experience improvement in your symptoms.

Constant tension in your pelvic floor not only decreases pelvic floor muscle strength and endurance, but it also contributes to pelvic or vaginal pain, lower abdominal pain, menstrual cramping, pain and difficulty with urinary and bowel function, and several other symptoms. 

One of the primary functions of any muscle is the muscle pumping mechanism that assists with optimal blood and oxygen flow through your body, to your tissues, and back to your heart. If your muscles are constantly tight, not remembering how to contract and relax appropriately, you will have decreased oxygen and blood flow to the surrounding muscles and tissues. This contributes to pain, cramping, and shooting sensations as your muscles and tissues are deprived of the oxygen that they need to function properly; this is called hypoxia. If your muscles are already in this tense or hypoxic state, continued kegels will only exacerbate the problem. 

If your pelvic floor muscles are tense, and now you know not to perform kegels, what should you do?

First, we have to work on releasing your pelvic floor muscle tension. Most likely that pattern of muscle tension is a habit that has gradually built up over a long period of time, therefore, breaking that habit and regaining proper resting tone will also take some time. We have to focus on retraining your muscles, how to relax, how to have proper resting tone, and how to be coordinated enough to contract when needed but then return to a rested position afterwards, rather than staying constantly contracted. 

We can work on regaining proper relaxation and lengthening of your pelvic floor muscles by deep breathing exercises, stretches, relaxation techniques, and pelvic floor coordination exercises. 

All of this information may come as a complete shock to some of you and may sound completely contrary to anything that you have been told about pelvic floor strength and the ability to avoid pelvic floor dysfunction of various types. Please hear me say that kegels are not all bad in themselves. Just like most things in life, kegels have their place and can be very effective in some situations if performed appropriately. If you are struggling with any degree of pelvic floor pain or dysfunction or if you are simply curious about your pelvic floor health and ability to maintain healthy habits long-term, I highly suggest that you schedule an appointment with a pelvic floor physical therapist. 

A pelvic floor physical therapist will perform an assessment that may include: posture assessment, muscle strength testing, breathing pattern assessment, internal and/or external pelvic floor muscle assessment, and other potential components. 

A thorough assessment by a specialist is the best way to determine the state that your muscles are in and appropriate exercises or stretches to resolve your symptoms or maintain long-term health and optimal pelvic floor function. It’s easy to look at your bicep and recognize if it is relaxed by your side or flexed up by your shoulder, however, it is not this easy for us to recognize what our pelvic floor muscles are doing throughout the day. 

Instead of just guessing about what shape your pelvic floor muscles are in, the pelvic floor physical therapists at MOJO Pelvic Health would be honored to help you connect with your body, your pelvic floor muscles, and regain or maintain the function that you deserve for an optimal quality of life! 

Our motto at MOJO Pelvic Health is: We Hear You. We See You.  We Understand You. No problem is too small or too large, and we desire to educate and empower you while also helping restore optimal physical function. 

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