The Kegels Debate. Here’s my view. What do you think?

Is there anything controversial about the Kegel Exercise?

This may come as a shock to some, that there might be a Kegels debate

For those of you who don’t know, it is the most commonly practiced non surgical intervention for a weak Pelvic Floor.  It was developed by its eponymous creator, Arnold Kegel.

He was an American gynaecologist who first published his ideas about the exercises in 1948.  He also developed a Perineometer, a device for measuring the strength of the Pelvic Floor.  This has largely been superseded by use of EMG assessment to measure the strength of the muscles.   Specially trained Physiotherapists can assess the Pelvic Floor too, using internal examination.

Direct assessment of the pelvic floor function is extremely helpful in order to determine potential suitability of  Kegel Exercises to improve Pelvic Floor (PF) function

I’m not going to describe the exercises themselves but here is a link to an excellent website giving details. I’ve stuck with the NHS because it is a trusted source and free of pop up adverts: https://www.nhs.uk/common-health-questions/womens-health/what-are-pelvic-floor-exercises/

Interestingly and surprisingly the Men’s section of the NHS website did not mention pelvic floor issues.  However, this is aimed specifically at men: https://www.continence.org.au/who-it-affects/men/male-pelvic-floor-muscles.

There is a mass of evidence to support their success and many people both men and women report them to be beneficial.  If you google pelvic floor weakness the overwhelming mass of responses is suggesting Kegels or trying to sell you kit to enhance your Kegels.  How very Google, eh?

So why is there a Kegels Debate? Why the controversy?

There is a growing band of movement based practitioners such as Pilates instructors like myself, or Yoga instructors and the like, Physiotherapists and other body workers who believe that there is a valid alternative to the Kegel.    We have sound reasons for this and this has finally sparked the Kegels debate and put into the mix that there might be another way to address PF dysfunction.

Hypertonic vs Hypotonic Pelvic Floor

In plain English, what this means is, a tight pelvic floor (PF) as opposed to a lax one.  We tend to assume that if the pelvic floor is not working well, then it is “obviously” due to a Pelvic Floor that is weak and well, kind of floppy.  The pelvic floor may very well be dysfunctional but it doesn’t follow that it is lax/floppy and weak.   Like any muscles it could be tight and weak.  This may also be a shock to read. That tight muscles might be dysfunctional, however buff and ripped. These are ones which are too tight to relax and work through their full range of movements.  This applies to all muscles, and yes, to Pelvic Floors.

If your pelvic floor is tight then you really shouldn’t be doing Kegels because they will make it even tighter.  After all the whole point of the Kegel is to contract/lift/grip and teach the muscle to be in a more contracted state

How do you know if you are hyper or hypotonic ? Well you don’t unless you have an internal examination of some kind.

This fact alone makes “just doing” Kegels risky, because we don’t know in which people they are specifically contra indicated.

Now this is a really big deal because estimates of hypertonicity are pretty high

It may very well be tight in people with pelvic pain.  A tight, over worked, over active and generally over wrought pelvic floor can be a culprit in some sexual dysfunction issues in both men and women.  With these things going on, Kegels are best avoided unless prescribed by a qualified professional.   The majority of people don’t get referred and seen by a Specialist but might think “I must do Kegels because my pelvic floor must be weak”.

A Separate Note on Being too Grippy or Overdoing the Kegels

Another matter, pertaining the a tight, grippy Pelvic floor is that there is a tendency to focus on the contraction/lift of the Kegel, and to forget or even omit the lowering phase

A lot of people think “I want my pelvic floor to be strong and tight” so more squeezing,  more pull, more effort”   More must be preferable.  Higher must be better.  Longer must be good

No!  Honestly really no.     You want it to be dynamic, supple and responsive.   With Pelvic Floors, what goes up must come down.  Always and completely

How do you know if you are truly working the pelvic floor when you do a Kegel Exercise?

This may also come as another shock, but there is an evidence base to suggest that people who dutifully perform their Kegels may not actually be working the Pelvic Floor.    EMG studies of muscle activation during Kegels show that some people are actually bearing down and outwards when they think they are lifting.  Some don’t activate it at all, instead contracting the abdominals, the inner thighs or the gluteals of the buttocks.

This is not so much a reason for avoiding the Kegel but it is a reason for being very careful with practice and taking instruction from a qualified teacher or information from a trusted source.

“Just” lifting is simply not good enough.  nor is “squeezing”.  Nor is randomly doing them.  Great care, and particular focus needs to be brought to bear on these exercises if you are going to do them

The way Kegels are performed don’t reflect how the body works

As a Pilates Instructor this is the clincher for me.  It is this element of the Kegels debate that made me really reflect carefully about how best to serve clients who come to me with PF weakness and issues.

Muscles respond to load.   A classic and simple example would be a dumbbell bicep curl. (The bicep is the muscle at the front of the upper arm)   You hold the weight in your hand, bend at the elbow and the arm muscle shortens/contracts and then lengthens back under load when the elbow straightens out.

Alternatively muscles  tense up but remain the same length, known as an isometric contraction.  A classic example is what happens to the abdominals during a plank.  The muscles are massively loaded but they don’t change their shape.   In fact the same goes for the abdominals during the bicep curl

The pelvic floor behaves in the same way.  Like the elbow bending with the bicep curl, when the bones that the pelvic floor attaches to move, the pelvic floor is placed under increased tension and the muscle fibres either contract or relax, depending upon what the bones do.

This isn’t what happens in a Kegel Exercise.

When you Kegel you are contracting the muscles up and in, without reference to the surrounding structure of the pelvis.  There is no load and no body weight because no bones are moving.  You might suggest that the bones are somehow dragged along with the upwards movement of the Kegel contraction, but that doesn’t happen either because the bones are busily doing something else entirely

In order to really understand this you have to have a basic understanding of where the pelvic floor is and what it attaches too.   Entirely understandably, until now you probably never considered the Pelvic Floor in the wider context of the Pelvis

Anatomy of the Pelvis

I’ve popped this is for reference , knowing that it doesn’t do much to translate into feeling or knowing how your body works and feels

The pelvic floor is

Coccygeus muscle (formally our tail wag muscle)

Iliococcygeus

Pubococcygeus

Not labelled is the very inner layer: Puborectalis and Pubovaginalis.  The ones most closely involved  with with bladder and bowel control

Also shown, two buttock muscles intimately connected with and who profoundly influence pelvic floor:

Piriformis

Obturator Internus

In very simple terms, the pelvic floor attaches to the Tail Bone, the Pubic Bone and the Sit Bones.  Move them and you move the Pelvic Floor.    If you want to beef up your pelvic floor function you need to move the bones thereby causing contraction and relaxation of the pelvic floor

When do these bones move?

Every time you squat the sit bones widen and PF is stretched UNDER LOAD.  The load is body weight.   A good Squat is an example of a phenomenal good PF workout

When do you move the tail bone?  Every time you do a Cat/Cow exercise or a Pelvic Tilt, for example

When is the time when you most move the pelvis?  During walking.  With each and every step your pelvis gently and subtly moves (unless it is super tight and that is another story.  Also, a tight pelvic floor will prevent the pelvis from moving freely)

The pelvic floor is very closely connected to Obturator Internus via mutually integrated connective tissue.  Obturator Internus, like Piriformis, attaches to the thigh bone.   Move the thigh bones (well and properly) and you will tension, load and work your pelvic floor.

All movement done well,  done properly is good for the pelvic floor.  Conversely inactivity is its enemy.  On a very fundamental level if we want to help our beleaguered pelvic floors when we need to get up from our collective chairs.

Now I need to explain another important principle regarding muscles.

Eccentric vs Concentric Loading

The most potent strength gains in muscles is during the eccentric lengthening phase NOT during the concentric shortening phase. To return to the example of the Bicep Curl, the strength gains in the muscle  are not in the elbow bend to take the hand towards the shoulder, but as the muscle lengthens as the elbow straightens back out again.

Just squeezing and contracting the Pelvic Floor upwards and with no load and no bone movement is not the best way to strengthen the muscle.  There is no lengthening down phase under load.  You just kind of let go/let down.  You feel (if you’re lucky) the shortening up phase of the Kegel, but the lengthening return eccentric phase is, less strong, less present, if indeed you feel and control it at all

If you move the pelvis bones  the pelvic floor is eccentrically moved under load and the pelvic floor gets a workout.

So when might that that happen?

When you move and walk

When you squat, or Sit/Stand from a chair, or hinge back from an all fours position

When you do Glute Bridges

I could go on: pelvic clock, pelvic tilt, Cat/Cow, even the good old Clam, side leg raises, lying on your back and doing leg circles.

Now to throw something else into the Kegels debate

I’ve outlined that there is an alternative way to work the pelvic floor and develop improved function

Not consider the causes of dysfunction in the first place

We tend to assume that Pelvic Floor weakness is caused by child birth and it is, for sure.  However, men get Pelvic Floor dysfunction,  older women who have never had children get pelvic Floor dysfunction, younger women who haven’t had children develop issues.  It is a growing problem.  It seems that the risk factors have changed.  Also though, people are more prepared to talk about it and not suffer in silence so maybe we are more aware of the problem than we used to be

What is this new risk factor?   Inactivity.

The pelvic floor needs you to move and not to sit down any more than is strictly necessary.  That is a lot of load bearing down on the pelvic floor with no respite, no altered blood flow, and often with the tail bone “trapped” underneath you.

So a fundamental way to address dysfunction is to be more active

Activity in general as a start, although with the massive proviso that if you have PF dysfunction it may prevent you from walking or taking exercise.  This is when a careful focussed programme of exercises may be vital, alongside learning all the tips and ideas for addressing things like Urge incontinence: the sudden and frequent need to rush to the toilet.

There is another risk factor too:  when breathing patterns are off kilter.    This can be due to a variety of factors like: tending to breathe in the upper chest: associated with anxiety and in extremis, hyperventilating .   A tendency to belly suck constantly or wear clothes that restricts the abdominals, or having super tight “ripped” abdominals.  All of these things prevent the big breathing muscle, the diaphragm from working properly and that DIRECTLY disrupts the PF which works in tandem with the diaphragm.  When the latter contracts, the PF relaxes, and vice versa.

Disrupt normal breathing and you disrupt PF function.   Conversely, restore good breathing and you will really help your PF.  This is rarely discussed sufficiently when people learn to do their Kegels.

So there is the one half of the Kegels Debate

The other half is basically , well, the internet

There is currently very little evidence base to support the non use of Kegels vs the use of them.  Post Covid we all know about randomised control trials don’t we.  Well, this is what we need

People calling into question the Kegels hegemony are a growing band of activists but we are drowned out or not believed.  I hope that this article at least sets the record straight as to why there is an alternative to Kegels and why there even is a Kegels Debate.    Please bear in mind that I have talked about the Kegels debate and not talked about over turning the idea of Kegels.  There is a time and a place for Kegels,  also for more activity, more walking, more breath work and definitely for more awareness and talk about what might be the best course of action if your PF is not as good as you’d like, or if you have incontinence issues.

But where to go from here:

Well, if you really want to do Kegels, be careful, focussed and trust your teaching source.  Make sure you always relax as well as contract.  Don’t do them if you have Pelvic Pain or Bladder issues such as bladder pain, burning bladder.  Try and get referred for specialist help.

Add the other stuff into your daily life.  Are you breathing properly?   Reserve the slimming pants for special occasions.  Keep active.  If you are in the gym be careful with your heavy lifting technique and no breath holding

If you would like to know more about how Pilates might be a form of movement to help improve your Pelvic Floor function I have talked about that in this blog post https://www.pilates-leeds.com/help-with-my-pelvic-floor-problems/

In addition I run a 5 week course of online sessions designed to Restore Your Pelvic Floor.   Click here to see more details or book onto the next set of sessions