The Art of Kegeling

Most women have no idea what the pelvic floor muscles (PFMs) are or where they are located. This is one of the primary reasons why women do not perform a proper PFM contraction, otherwise known as Kegel exercises. Studies have also shown that 50% of women given Kegel exercises perform them incorrectly. Clinically this is often a primary complaint and assessment finding.

Most women have no idea what the pelvic floor muscles (PFMs) are or where they are located. This is one of the primary reasons why women do not perform a proper PFM contraction, otherwise known as Kegel exercises. Studies have also shown that 50% of women given Kegel exercises perform them incorrectly. Clinically this is often a primary complaint and assessment finding.

The PFMs are a group of funnel-shaped muscles that line the bottom of the pelvis.  (See diagrams below).

THE PELVIC FLOOR MUSCLES

They are attached to the pubic bone anteriorly and the coccyx and sacrum or tailbone posteriorly (like a sling or hammock).  The PFMs provide two primary functions:

1. They support the pelvic organs and surrounding structures (like the bottom of a purse or sling).
2. They act as the primary active control mechanism of urine and stool continence by enabling full closure at the anus and urethra.

In order for the PFMs to function properly they need to have normal endurance, strength and balanced tone.

One of the most common mistakes I see clinically is that most women do not recruit the PFMs properly. They often don’t know where the muscles are, how to isolate them or contract them properly.  Often they will compensate with other muscles such as the abdominals, gluteal or adductors. (See diagram below which illustrates the close anatomical association with the gluteus maximus (or “butt”) muscles, which can be used to compensate for weak PFMs).

Another mistake most women make is they do not fully relax the PFMs between contractions.  This is important as it ensures the PFMs are recruited through the entire range of the muscle contraction and the full relaxation avoids developing hypertonic (tight) PFMs, which will consequently result in an ineffective muscle contraction.

To effectively contract the PFMs you need to focus on where the muscle is. Imagine contracting or squeezing the funnel shaped muscle toward your pubic bone (front of the pelvis) by drawing the sacrum toward your pubic bone and at the same time lifting in and up.  Another analogy is visualizing drawing a tampon in, lifting it up inside you and squeezing it towards your pubic bone. Visualizing drawing a “J” type movement also works as you lift in and squeeze toward your pubic bone. Often, this recruitment pattern is weak. Pelvic floor physiotherapy is essential in establishing the correct technique and reawakening all the muscles to properly contract all the PFMs effectively.

Because the PFMs work all day throughout your daily activities, like standing and sitting (endurance) and through more strenuous activities like running, sneezing or coughing (power), the PFMs exercises must target both the endurance (Type I or slow twitch) and power (Type II or fast twitch) muscle fibers.

The following exercises will train the PFMs and facilitate proper function. The easiest position to start the exercises is lying down, where you can focus on the PFMs more effectively because all the other muscles are the most relaxed; however as you get better with recruiting these muscles, it should be done in all functional positions.

Start with 10 repetitions of each of the below exercises, 2-3 times a day.  Maintain a natural breathing pattern as you perform the exercises and do not hold your breath. To progress and challenge the PFMs, increase the number of repetitions and sets, and try performing the exercises in various functional positions such as sitting, standing, squatting and lunging.  Standing positions will be more challenging because you have to pull up against gravity— so it’s like adding progressive weights to your exercises.

Remember not to perform your exercises while going to the bathroom as it can affect the normal reflex loop of the bladder and if done excessively can cause bladder issues.

These are the two exercises I often have my clients begin with.

Exercises:

Elevator

This exercise targets all of the muscle fibers while also increasing your awareness or proprioception of the tone of the PFMs (i.e. the PFMs will only work effectively if the tone is normal—not too tight or too loose).

  • Contract the PFMs gradually; imagine a full contraction spans three floors and contract one floor at a time (Solid line in illustration below).
  • Hold each floor for 5-10 seconds until you are contracting maximally at the top floor.
  • Release the PFMs completely (i.e.  let your pelvic floor drop) until you are fully relaxed.
  • Progress to moving gradually down the floors until your PFMs are fully relaxed (Dotted line in illustration below).

Wave

This exercise makes you more aware of where the PFMs are located and teaches you how to focus on the different regions.

  • Contract the most posterior PFMs around your anus by imaging you are controlling flatulence. Hold for 5 seconds
  • Next, contract the PFMs in the middle by imagining you are trying to hold a tampon and lifting it in and up.
  • Finally contract the PFMs most anterior around the urethra (where the urine comes out) by imagining you are trying to stop your flow of urine (i.e. squeezing toward your pubic bone or the curl of the ‘J’ ).

The other exercises will be explained in more detail after the initial assessment. They will include endurance, speed, strength and functional exercises. Performing all of the above exercises is the key to establishing your total pelvic floor health.

If you are pregnant or trying to get pregnant, it is the optimal time to start doing your Kegel exercises. Creating a muscle memory or imprint of how to recruit the PFMs properly prior to the trauma incurred during birth will facilitate the faster return of normal PFM function post-partum. The added bonus is that this will also speed up your healing and prevent PF dysfunctions in the future. PFM exercises can be started as early as 24 hours post-delivery.

Having a strong core, in particular the TA (transversus abdominus muscles or “the core” muscle), will also assist in improving your PFM recruitment. The PFMs and TA work together or synergistically to effectively contract the core and improve pelvic and lumbar support and function. (Please see article on core stability/Pilates and diastasis recti for additional information on the core). Progressions that will enhance your PFM strength can include core exercises such as Pilates, PFilates (Pelvic floor Pilates), ball exercises and yoga.

It is never too late to start training your PFMs. Because the PFMs play such a vital role in pelvic floor function and health, a lifelong commitment to your PFM program is important.  The PFMs are an integral component of your core, which is the foundation to good posture and optimal performance of all daily activities.

In order to keep your PFMs working effectively, regular weekly maintenance is recommended.   Once the PFMs are in good shape, continuing with your home pelvic floor rehabilitation program 2-3 times a week should be adequate to keep it in fine form and to prevent pelvic floor dysfunction. Like any regular fitness or health regime that will keep your body performing optimally through the years, you will be thankful that you started it early!

If you have symptoms of incontinence that do not improve with these exercises, pelvic pain or a sense of vaginal heaviness (i.e. prolapse), further treatment by a pelvic floor physiotherapist may be required.