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 urinates when you laugh or cough, or sometimes feels overcome by a sudden, nearly uncontrollable urge to urinate—that is, if you have urinary incontinence—you’ve undoubtedly heard of Kegel exercises…and maybe even tried them. The do-anywhere pelvic exercises are often recommended for this condition—and a wide variety of other pelvic problems, including fecal (bowel) incontinence and pelvic organ prolapse, in which the bladder or uterus bulges into the vagina.
But doing Kegels may be making your problem worse. Eventually, Kegels can be part of the solution, but you need to take these steps first.
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. About 25% of women ages 40 to 59 will suffer pelvic floor dysfunction (PFD) in their lifetime. Risk factors for PFD include menopause, age, obesity, repeated heavy lifting and traumatic injury—as may happen during childbirth, for example, or from a hip or back injury. Over time, the likelihood of a pelvic floor disorder increases.
Women with PFD often think their internal muscles are too weak and do Kegels to strengthen them. That’s often true, but it isn’t the biggest problem. For 99% of my patients, those muscles are too tight, so they 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. Kegels can worsen the situation by strengthening already too-tight muscles. What these patients really need is to relax these muscles.
The first step: Bring up your symptoms with your internist, ob/gyn, urogynecologist or urologist, who can rule out issues that aren’t musculoskeletal. If physical therapy is the next best course of treatment, he/she can refer you to a women’s health physical therapist (WHPT). WHPTs treat not just the pelvic floor but the body as a whole. Three to six months of weekly manual therapy sessions, combined with homework, usually 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. To find a WHPT in your area, go to WomensHealthAPTA.org for a locator from the American Physical Therapy Association. Insurance typically covers these services.
A crucial component of treatment is 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 it 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. During such therapy, I will insert one finger into the vagina and then ask my patient to perform a Kegel by imagining that 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. The goal is to fully relax these muscles. What helps…
• Reverse Kegels. In a conventional Kegel, you tighten your pelvic floor muscles, hold the contraction for 10 seconds, then fully relax back down. In a reverse Kegel, you begin by 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. Hold for 10 seconds while you continue to breathe. Then return to normal for 10 seconds. Repeat the reverse Kegel 10 times, two to three times daily.
• Biofeedback. 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.
• New: Home biofeedback. The apps Elvie ($199, Apple/Android, Elvie.com) and PeriCoach ($249, Apple/Android, PeriCoach.com) use intravaginal devices to assess the strength and endurance of vaginal contractions, and then send data to your smartphone via Bluetooth. If you’ve already had a professional pelvic assessment and know how to do Kegels the right way, these products can be helpful.
Shallow breathing also contributes to pelvic floor disorders. Why: 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 breathing. Lying down, pretend your belly is a balloon and fill it with air, keeping your chest still. Now exhale, deflating the balloon. Do this once an hour for five breaths…and for five minutes before bed. In two to three weeks, you should notice a change in the way you breathe.
Men have a pelvic floor, too. It supports the prostate, bladder and rectum. Age, a hip or back injury or surgical inguinal hernia repair can weaken pelvic floor muscles. This can lead to urinary incontinence, an inability to maintain an erection without pain, and pelvic pain and tightness. Like women, many men can benefit from pelvic floor muscle relaxation, manual therapy and reverse Kegels. Ask your internist or urologist for a referral to a pelvic floor physical therapist—especially if you’re scheduled for prostate surgery.