What’s the deal with Kegels?

"No one should ever do Kegels." "Kegels won't solve your problem." "I did Kegels based off of what I read online, and they didn't work for me."

Let's play a game and replace the word "Kegel" with "squat." What happens now? I think most people would agree that when we start talking about a movement like a squat, there's immediately room for nuance. We can start having a conversation about for whom squats are appropriate and at what point in rehab, what types of squats might be more or less effective, and how different cues and expert instruction can be essential in finding the right variation for someone's current abilities and future goals. Discussing an exercise in this way doesn't feel so fraught with emotion and heavy with expectation - exercise and rehab professionals are routinely having (relatively) objective discussions about exercise with their clients and patients.

So, why do Kegels carry so much baggage?

First, assigning someone's last name to a movement (Dr. Arnold Kegel was the first to document an effect of Kegels in medical literature in 1948) can distract from what the movement actually is - a Kegel is a concentric (shortening) pelvic floor muscle contraction, plain and simple. When we talk about flexing (concentrically contracting) your biceps, for example, we are naming the action itself. Perhaps because it’s not yet commonplace to discuss the pelvic floor muscles in the same way we would others in the body, we assigned a unique name to define the action of the pelvic floor muscles. The ability to contract the pelvic floor has always existed, but it was Arnold Kegel’s discussion that led to a specific name for this action.

Kegels also suffer from a reputation built as the result of good intentions but misunderstanding from health professionals and society at large. Anytime you tell everyone to do the same thing, it will inevitably work well for some, do nothing for others, and create harm in the last group. With all of the enthusiasm surrounding the *discovery* of Kegels and a lack of perspective about the pelvic floor as a muscle group that requires the same individualized training as any other, there were unfortunately many people whose symptoms were worsened by doing this one-size-fits-all prescription. It makes absolute sense that there would be a reaction against Kegels driven by this community of people who suffered as a result. However, this strong reactionary stance also doesn't leave room for the group that had been significantly helped by the exercise. The truth, of course, lies in the gray area. Not only are Kegels not appropriate for everyone, but whether or not they're appropriate for an individual could change at different points in their life. As soon as we stop being able to discuss Kegels like any other exercise, they stop being as effective as they could be for the population that needs them. I prefer to call Kegels "pelvic floor muscle contractions" when I'm discussing them with my patients because it helps avoid emotional connotation, historical baggage, and keeps perspective on what we're working on. As a musculoskeletal and movement expert, I want the freedom to determine on a given day what exercise prescription a person needs to achieve their goals, without the ambivalence or even fear that discussing Kegels can trigger. For the rest of this article, though, I'm going to keep using the word Kegel in order to try to recondition us a bit! In general, a Kegel is used to increase the power, endurance, and/or coordination of the pelvic floor. To fully appreciate the appropriate application of Kegels, we need to also understand why the pelvic floor is not currently demonstrating the desired muscle tone, power, endurance, or coordination. Different concerns involving the pelvic floor (the ability to withstand pressure and forces from above in the event of a cough, sneeze, or jump; incontinence; maintaining arousal, etc.) will require a different approach. As is the case with any other desired training adaptation, we can refer to the SAID principle: Specific Adaptations to Imposed Demands. We get better at what we train, and what we train should be specific to the result we’re looking to achieve.

If someone’s pelvic floor is “weak” because it’s being chronically held in a “shortened” position (frequently referred to as a “hypertonic” pelvic floor), does it make sense to further prioritize the lifting and shortening action of the pelvic floor? Going back to the biceps example: if you are already at the end of your bicep curl, would it be productive to keep trying to squeeze your hand closer to your shoulder, or might it make more sense to return the weight down to your side before starting again? Simply “doing Kegels” with a pelvic floor that is already in a shortened position is the same idea as only holding your biceps muscle in its most shortened position and calling it a comprehensive arm training plan. If someone has "weak and short" pelvic floor muscles, doing an exercise that focuses on shortening the muscles may be counterproductive or worsen symptoms at that time. Instead, this person would benefit from a return to a more balanced muscle function that allows for the full range of a muscle contraction to be achieved. Addressing the deficit in strength or endurance means creating an environment where the pelvic floor can “let go” a bit. Perhaps this person needs to address breathing strategies, the strength of surrounding muscle groups, or even underlying anxiety that is triggering a guarding response of the pelvic floor. ...BUT!...Once we address the relative overactivity of the pelvic floor and restore normal resting muscle tone, this person’s strength or endurance concerns might still exist - deficits that could very well be addressed, in part, with Kegels. If we don't allow a flexible view of Kegels, this person may be told that they should never do them - even if their changing presentation makes them the most appropriate exercise in that phase of their rehab.

Isn't the Squat the "New Kegel"?

The newest challenge to the prescription of Kegels is the idea that we can accomplish pelvic floor strengthening through larger movements and general exercise alone. This isn't currently supported by research (those who engage in exercise have not been shown to have improved pelvic floor muscle strength compared to those who do not), and logically speaking, it doesn't stand up to our understanding of how muscles adapt. Yes, the pelvic floor is absolutely contracting when someone does a squat - in fact, it's constantly shortening and lengthening in its role as a core stabilizer and participant in breathing. However, in scenarios where the pelvic floor specifically is weak, evidence indicates that we need to specifically train it. For example, during pregnancy and into the postpartum chapter, the pelvic floor undergoes significant changes and is placed under increased demands. These changes often result in a decline in the performance of the pelvic floor muscles. When someone is coming from a significant strength and muscle tone deficit, it doesn't make sense not to prescribe a strengthening exercise that prioritizes the pelvic floor, in addition to generalized exercise that helps maintain pelvic floor strength that someone builds.

The Bottom Line

Continuing to see Kegels in black and white will continue to limit us in our ability to discuss pelvic floor interventions and effectively treat individuals throughout their lifespans. We would never say "never" or "always" to any other exercise, so we need to allow Kegels the same nuance.

Are Kegels Right for You?

Now that we're discussed the importance for approaching Kegels with an "it depends" mindset, we can start discussing the determining factors that go into deciding whether Kegels are right for you right now.

About the Author: Annemarie Everett, DPT, WCS is a pelvic floor physical therapist and co-founder of POP UP. She currently practices in San Francisco, CA.