Lesli Lo, DPT, women’s health physical therapist, Northwestern Medical Groupand instructor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine, both in Chicago.
If you’re a woman who pees when you laugh or cough or sometimes feels overcome with a sudden nearly uncontrollable urge to pee—that is, if you have urinary incontinence—you’ve undoubtedly heard of Kegel exercises, and maybe even tried them. The simple do-anywhere pelvic exercises often are recommended for this condition—and a wide variety of other pelvic problems including fecal (bowel) incontinence, chronic pain and pelvic organ prolapse, in which the bladder or uterus can bulge into the vagina.
But doing Kegels may be exactly the wrong thing for you. They actually could be making your problem worse. It’s not that you’re doing them wrong, although many people do. In fact, it’s especially an issue if you do Kegels right.
If you suffer from incontinence and have performed hundreds of Kegels with no improvement or if you have chronic pelvic pain but think it can’t be fixed, you are not alone—and there is help. Eventually, Kegels can be part of the solution, but there are steps you need to take first.
Read on to learn new ways to beat incontinence and other pelvic floor disorders.
The pelvic floor is a network of muscles, ligaments and tissue that acts like a sling to support a woman’s pelvic organs—the uterus, vagina, bladder/urethra and rectum. You control your bowel and bladder by contracting and relaxing these muscles and tissues. Twenty-seven percent of women ages 40 to 59 will experience pelvic floor dysfunction (PFD) in their lifetime.
There’s a strong menopause link: The estrogen drop that typically begins some time in your 40s during perimenopause and is typically complete when you enter menopause (usually by your early 50s) can cause the pelvic floor to thin out, making prolapse more likely. Plus age, obesity, repeated heavy lifting, traumatic injury—such as may happen during childbirth or from a hip or back injury—can cause pelvic muscles and connective tissues to become sensitive, strained and weak. Over time, the likelihood of a pelvic floor disorder increases.
Women with PFD often think their internal muscles are too weak and do Kegels in an effort to strengthen them. While that often is true, it’s not the biggest problem. For 99% of my patients, the real problem is muscles that are too tight.
These too-tight muscles often get stuck in a contracted position, unable to control the flow of urine or to fully relax and contract in a pleasurable way during intercourse. For these women, Kegels can worsen the situation by strengthening already too-tight muscles. What they really need is to relax them.
The first step: Bring up your symptoms with your internist, ob/gyn, urogynecologist or urologist. He/she can rule out any concerns that are not musculoskeletal, and if physical therapy is the next best course of treatment, he can refer you to a women’s health physical therapist (WHPT). WHPTs partner with ob/gyns, urologists and other specialists to diagnose and treat not just the pelvic floor, but the body as a whole. Three to six months of weekly or biweekly manual therapy sessions, combined with homework, can typically ease symptoms of urinary incontinence, painful intercourse and/or pelvic pain.
A WHPT will perform an internal exam to assess your areas of strength and weakness and design a plan to retrain your muscles. You can find a WHPT with the locator on the website of the American Physical Therapy Association. Insurance typically covers these services. (Note: Some chiropractors, occupational therapists and naturopaths may also perform similar treatments, but I am not familiar enough with their exact practices to recommend them. Midwives are typically not trained in these techniques.)
A crucial component of treatment with a WHPT is manual therapy. It may take some getting used to, but it’s the gold standard of practice. In manual therapy, a WHPT uses her hands to gently massage, stretch and release spasms and trigger points within the deep and soft tissues of the vagina. This helps reduce tightness and tension and can even break up scar tissue that’s further restricting tissues, allowing the pelvic floor muscles to fully relax and contract. Though manual therapy can feel uncomfortable initially, any pain quickly recedes as the muscles and tissues relax.
Manual therapy is a prime opportunity to assess how you do Kegels. Many women do it so that it only strengthens, never relaxes. During such therapy, I will insert one finger into the vagina and then ask my patient to perform a Kegel by imagining she is stopping the flow of urine midstream. (Once a woman learns how to do this correctly, she can do it herself.) Two out of three women do this incorrectly, tightening their pelvic floor muscles but not releasing them all the way back down—or not tightening their pelvic floor at all, recruiting their abs or glutes instead. The goal is to teach them how to relax their muscles all the way down to starting position. Some ways to teach this technique…
• Reverse Kegels. In a conventional Kegel, you tighten your pelvic floor muscles, hold the contraction for 10 seconds, then fully relax back down, maintaining the relaxed position for 10 seconds. (Sometimes I tell patients to imagine they are controlling an elevator with their vagina and send it to the top floor, hold it there, then send it down to the basement.) In a reverse Kegel, you begin “in the basement,” so to speak, relaxing the muscles as you do when you’ve just sat down on the toilet with a full bladder and are able to urinate. You should feel your anus relax as well. After relaxing for 10 seconds, send the elevator back up to the top and hold 10 seconds, then release again.
• This pain-free, nonsurgical technique allows patients to see their pelvic muscles at rest and while contracted—and improves their ability to retrain the pelvic floor. A sensor or small weight is inserted into the vagina, while a nearby computer provides visual feedback. More than 75% of PFD patients who try biofeedback benefit from it.
• New: Home biofeedback. The apps Elvie ($199, Apple/Android) and PeriCoach ($249, Apple/Android) use intravaginal devices to assess the strength and endurance of vaginal contractions, and then send data to your smartphone via Bluetooth. I only recommend them for women who’ve had a professional pelvic floor assessment, because if you’re not performing Kegels correctly, a product like this could contribute to further tightness/tension. But if you’ve learned to do Kegels so that you relax as well as strengthen, they can be helpful.
Shallow chest breathing also can contribute to pelvic floor disorders. Reason: The diaphragm, a sheet of muscle that separates the chest cavity from the abdomen, gets stuck in a contracted position—causing pelvic muscles to contract, too.
Solution: Learn diaphragmatic (belly) breathing. Lying down, pretend your belly is a balloon and fill it with air, keeping your chest still (you may need to start with shallow breaths). Now exhale, deflating the balloon. Try this once an hour for five breaths, and again for five minutes before bed. In two to three weeks, you should notice a change in the way you breathe. (To learn more, see Bottom Line’s “Breathe Like a Baby.”)
In general, chronic stress can make urinary incontinence worse, so mind-body relaxation methods, such as meditation and yoga, also help. One final tip: Sit-ups can put even asymptomatic women at risk of developing incontinence, prolapse or other PFD issues. A better way to strengthen your abs: Plank.