Do Kegels work? Are Kegels bad for you? It Depends.

There are plenty of online articles describing how to do Kegel exercises (or ‘Kegels’), and many more hyping their benefits. But if you look a little deeper you will also find dissenting voices. This article digs into the clinical research to answer two key questions: Do Kegels work? and Are Kegels bad for you?

The pelvic floor exercise known as the ‘Kegel’ has become a very popular and much publicized exercise in women’s health, and more recently in men’s health – and not without good reason. Pelvic floor disorders such as incontinence, prolapse, pelvic pain, pain with intercourse, and others are surprisingly common (for example, 10% of Canadians experience urinary incontinence), and targeted strengthening of the pelvic floor is an integral component of pelvic floor physiotherapy, a recommended first-line treatment. Having a strong pelvic floor can also be preventative against developing pelvic floor disorders.

As an added bonus, Kegels are a discrete exercise that you can do just about anywhere, and have a snappy and easy to remember name. So, shouldn’t we all be doing Kegels? In short, no.

1.     Do Kegels work?

Kegel exercises work for many people, but not for everyone.

Assuming your underlying pelvic floor disorder or strength deficiency is one that can be addressed with the help of Kegel exercises (and this may not be the case – see ‘Are Kegels bad?’ below), you may not experience noticeable benefit from doing them.

Why Kegels may not work for you

• You may not be performing Kegels correctly. There is a sizable chance that you are not performing the exercise correctly, and this may be due to faulty instruction. One Toronto-based colleague recently did an informal review of Kegel smartphone Apps and concluded that most of them “provide the user with a generic exercise routine of contractions and relaxations of these muscles, that is not based on current research” (ref 1). But assuming that you DID download a good Kegel App, or found a good Kegel ‘how-to’ article, studies suggest that many people are still unable to do Kegels correctly after simple instruction (such as short verbal instruction or online ‘how-to do Kegels’ article). This is because pelvic floor muscles are internal, hard to visualize, and hard to feel. Unfortunately, if you have a pelvic floor weakness or dysfunction you are even LESS likely to learn to do Kegels correctly on your own, and may even continue having difficulty after expert instruction (ref 2,3). Over 30% of women seeking help with urinary incontinence are at first unable to contract the Levator ani muscles of the pelvic floor when instructed to perform a Kegel, and instead mistakenly contract the abdominals, gluteal muscles or hip adductor muscles (ref 3). Not surprisingly, women with urinary incontinence are recommended to seek the guidance of a pelvic floor physiotherapist before beginning a pelvic floor strengthening program (ref 3). In addition to expert instruction, a pelvic floor physiotherapist can perform external and internal examinations to ensure proper Kegel technique.
• You may need more than Kegel exercises to address your deficiency. Even if you are doing Kegels correctly, solving some pelvic floor disorders require more than just Kegels. The pelvic floor works in conjunction with other muscles of the ‘inner core’ (the diaphragm, transverse abdominals and multifidus) to control pressure within the pelvis and abdomen to stabilize the trunk of the body during movement. Proper recruitment and coordination of these muscles may also need to be addressed. Not surprisingly, a recent review paper found that women who receive weekly supervision by a pelvic physiotherapist are more likely to see improvement in their urinary incontinence symptoms compared to women who regularly perform a pelvic floor strengthening program with little or no supervision (ref 4). Pelvic floor physiotherapists offer a variety of tools including targeted exercise (not just Kegels), manual therapy, and education on postural and behavioural interventions including bathroom routine and diet. If you are looking for more evidence-based self-help tips for treating stress incontinence (urine leakage caused by physical exertion), see: How to Stop Stress Incontinence – Self-Help Tips from a Physio and Mom.

Or perhaps you just need to drink more coffee? Interestingly, one study found an association between regular consumption of caffeinated beverages and the ability to correctly contract the pelvic floor (ref 3). While the researchers acknowledged that more research is needed to confirm this possible association, they hypothesized that since caffeine is a diuretic, regularly drinking it may train people to control their pelvic floor muscles better. While this is interesting, if you do suffer from urinary incontinence caffeine consumption is something that you should probably try to limit, to help lessen your symptoms.

How do you know if you’re doing you Kegels correctly?

In the absence of seeing a pelvic floor physiotherapist, here are a few simple ways that you can try to assess the effectiveness of your Kegel exercise efforts:

• • Try to stop urinating mid-stream. A correctly performed Kegel should accomplish this. Keep in mind that practicing Kegels during urination can result in bladder infection, so use this as an infrequent test only.
  • Lift up and in only. Your goal is to activate the pelvic floor without activating other muscles of your abdomen or buttocks, or holding your breath. Compensatory actions such as holding your breath or tightening your abdominals will increase intraabdominal pressure which can exacerbate some symptoms including incontinence, instead you want to encourage a normal and optimal activation of your pelvic floor. With a properly performed contraction you should experience a ‘lifting up and in’ of the area spanning from the front to the back of the pelvic floor (pelvic bone to tail bone). If you just experience this feeling around your anus then you are not performing it correctly. You may find that the position of your body will make it easier or harder to perform a proper contraction; it is naturally more difficult to contract the front of your pelvic floor if you are leaning backwards and vice versa.
  • If you are a woman you can do an internal check. A properly performed Kegel should squeeze and draw in the vagina, which you can feel by inserting your finger. See Figure 1. If you are a man you can do an internal check too. Men often get forgotten when it comes to discussing Kegels; there is not a lot of great information out there for how to check if you’re doing a proper Kegel. A properly performed Kegel should squeeze and draw in the anus as well, which you can feel by inserting your finger just at the anal opening (women can do this too). Feeling a bit squeamish about an internal check? Try a mirror. Another option for both men and women, and especially for visual learners is to observe the contraction and relaxation with a mirror. This approach isn’t quite as reliable, but can still be beneficial.

Figure 1: A properly performed Kegel exercise should tighten and draw in the vagina. Image courtesy of http://en.wikipedia.org/wiki/Kegel_exercise

• Try a Kegel exercise device. Instead of isometrically contracting and releasing the muscles, it might be significantly easier for you to hold a weight in your vagina instead. For some women this can make finding the correct muscles easier, and it can also be an effective Kegel training tool for those women where Kegel training is appropriate. There are many different variations available, so look around to find the right product for you. Choose one that is the appropriate size (1-inch diameter should fit most women), that includes a variety of weights, that comes with good instruction, and that is safe and hygenic. One example we like is the Intimate Rose Kegel Exercise System. Or if you are looking for something a little more sophisticated, devices like the Elvie Trainer can connect to your smartphone via Bluetooth and guide you through your Kegel training in more detail. Instead of simply holding a weight, this device measures your contractions as you squeeze and release the device, and offers feedback including guidance and workout routines. [Small disclaimer: if you purchase either of these items after clicking through the above links we may receive a very small fee which we use to help support our blog.]

2.     Are Kegels bad?

Kegels may be harmful for some people

A pelvic floor exercise program involving Kegels can help treat and prevent a whole host of pelvic floor disorders, from urinary incontinence to prolapse (ref 5,6) – BUT Kegel effectiveness depends on your underlying physiological issue. For some people Kegels will worsen your symptoms, or predispose you to a pelvic floor disorder.

Why Kegels may be bad for you

• Your problem may not be weakness but overactivity. How do you know that you should be doing Kegels? How do you know that you need to strengthen the muscles of your pelvic floor at all? It’s true that pelvic floor dysfunction is often the result of muscle weakness or injury/childbirth, but not always. Pelvic floor dysfunction is also very common in exercise instructors and elite athletes – and often not because of muscle weakness. Many people suffering from pelvic floor dysfunction mistakenly believe that their problem is weakness (‘hypotonicity’), when instead the cause of their symptoms is an overactive pelvic floor (‘hypertonicity’). An overactive pelvic floor is one that is ‘turned on’ or contracted for too much of the time. This basal muscular activity reduces the stamina of the pelvic floor muscles and their ability to contract when called upon. If you have an overactive pelvic floor, Kegels will likely worsen your symptoms or predispose you to developing symptoms if you are currently asymptomatic. Kegels are ‘bad’ in this case, and rehabilitation should focus on learning proper muscle control and muscle relaxation techniques (using exercises such as the so-called ‘reverse Kegel’). You may also benefit from other treatments from the pelvic floor physiotherapist’s toolbox including manual therapy in the form of internal massage, as well as education on pain, relaxation, and activities to avoid or modify.
• You may be performing Kegels incorrectly to the point of harm. As we saw above, it can be difficult to learn proper Kegel technique, especially for those with a pelvic floor disorder. Interestingly, one classic study found that 50% of women in their study group that were given a simple oral or written instruction could perform an ‘ideal’ Kegel, while 25% were found to perform Kegels in a way that “could potentially promote incontinence” (ref 2).

How do you know if Kegels are bad for you?

Determining if Kegels are bad for you requires insight into your underlying condition, so this can be hard to figure out on your own. However, there are some common symptoms of pelvic floor overactivity that you can watch out for, but please keep in mind that these symptoms are shared by other pelvic floor disorders as well:

• Pain in your low back or pelvic region including hips, genital and rectal areas.
• Urinary issues such as needing to go frequently, with great urgency, interruption of the urine stream, inability to completely empty, pain with urination, etc.
• Leakage when performing athletic activities, high intensity exercise, and so on.

If you have been preforming Kegels and your symptoms have not improved (or have worsened), you should consider the possibility that Kegels may not be the right exercise for you, or may even be harmful.

Seeking out the expert guidance of a pelvic floor physiotherapist can help put your pelvic floor rehabilitation program on the right track.

Summary

Popular opinion says that everyone should be doing Kegel exercises, and most people would benefit from this advice, but a sizable minority will not. And if you suffer from a pelvic floor disorder this advice will often be inadequate, frequently be ineffective, and on occasion be harmful to your pelvic health and function.

If you suffer from a pelvic floor disorder, or suspect you do, it is recommended that you get the advice of a pelvic floor physiotherapist before starting any pelvic floor strengthening routine.

A pelvic floor physiotherapist can assess your underlying condition and determine whether and what type of strengthening will help, and teach you how to do it correctly. They can also offer you a wealth of additional information, treatment and tools, including manual therapy in the form of internal massage or stretching; modifications to diet, posture, bathroom routines, and more.

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References

1. Can “Kegel Apps” help your clients? by Nelly Faghani. Physiotherapy Today. Winter Issue 2015; pp 5. www.opa.on.ca
2. Bump RC, Hurt WG, Fantl JA, Wyman JF. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol. 1991 Aug; 165(2):322-7.  https://doi.org/10.1016/0002-9378(91)90085-6
3. Welles Henderson J, Wang S, Egger MJ, Masters M, Nygaard I. Can women correctly contract their pelvic floor muscles without formal instruction? Female Pelvic Med Reconstr Surg. 2013 Jan-Feb; 19(1): 8-12. http://doi.org/10.1097/SPV.0b013e31827ab9d0
4. Hay-Smith EJ, Herderschee R, Dumoulin C, Herbison GP. Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev. 2011 Dec 7;(12). abstract
5. Braekken IH, Majida M, Engh ME, Bo K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol. 2010 Aug; 203(2):170. https://doi.org/10.1016/j.ajog.2010.02.037
6. Dumoulin C, Hay-Smith J, Mac Habee-Seguin G. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2014 May 14;(5). https://doi.org//10.1002/14651858.CD005654.pub3