Kegel - an exercise performed to strengthen the muscles of the pelvic floor, in order to control incontinence, improve sexual response, etc. - named after Arnold H. Kegel (1894–1981), American gynecologist.
You finally worked up the courage to speak to your doctor about your leaking problems. And she didn't have any great answers for you. Yes, you know its very common for women to have these types of problems. Yes, you know there is a surgical "fix" but you're not ready to go there yet. Maybe your doctor mentioned getting fitted for a pessary, which she thinks could possibly help? If your doctor is well informed, you might even get a referral to a pelvic floor physical therapist. And the most often heard advice... "remember to do your kegels."
You decide you're going to really go after the kegel exercises again. They're easy, they don't cost anything to do and there's no way you're having surgery for this. Obviously, the more you work a muscle the better (not true!) After researching online how to do kegels properly, you start doing them at least 3 times a day. You do them laying in bed in the morning and at night, you do them driving in the car (at every stoplight, right?) and while watching TV. But after a couple of weeks, you've seen absolutely no improvement. In fact, maybe you're imagining it, but your leaking problem seems to be getting worse. What's going on?
Why aren't kegel exercises working for you?
Unfortunately, the advice to just do more kegels is at best incomplete and given in the wrong circumstances, kegels CAN make leaking problems worse. Here are a few of the top reasons why kegels may not work for you.
1. You aren't doing them correctly.
The typical advice on how to do kegels starts with "finding" your pelvic floor muscles. This includes finding the muscles that will stop the flow of urine or the muscles that you would use to stop gas from escaping. While this is a great starting point, there's a lot of information missing in this advice. In general, women may be completely disconnected from this area of their body. It is very easy to confuse bearing down with lifting up when you don't have a great connection with your pelvic floor muscles.
Furthermore, the muscles of your pelvic floor can be isolated so that you are working the back of the pelvic floor and/or the front of the pelvic floor. If you spend all your kegel time working the muscles more toward the back (think stopping gas) then that's not going to be as helpful if you have problems leaking urine. Kegels should include both a lift up and a squeeze.
If you're not sure whether you are doing your kegels correctly, seeing a pelvic floor PT will be a great starting point.
2. You aren't working your pelvic floor muscles in concert with the rest of your system.
Your pelvic floor needs to work with your diaphragm. Breathing correctly is key to proper pelvic floor function. When you inhale, your abdominal canister should expand out in all directions as well as expand down. 360 degrees of expansion should accompany your inhale - back, rib and belly expansion. You should feel a very mild pressure on your pelvic floor when you inhale deeply. When you exhale, all the outward and downward pressure releases. Your diaphragm descends on inhale and releases up on exhale. This release of pressure helps your pelvic floor muscles to recoil on exhale. Ideally, your pelvic floor will go through a relaxation phase on each inhale and a gentle contraction phase on exhale.
Check out this video to see if you are breathing correctly.
Just as important as breathing is your body alignment. Take a side-on selfie. Your head should line up with your shoulders, hips, knees and feet if you draw a plumb line down this picture starting at your head.
Check out your rib and hip alignment. Your ribcage should be stacked over your hips.
Check that your ribs are not flared out in front.
Check your pelvis (hips.) Are they level front to back and side to side?
Finally, how is the pressure in your abdominal canister? Do you suck in your abs? Are you constantly gripping down with your ribcage? Do you carry tension across your belly button? Drawing in your belly button causes constant pressure down on your pelvic floor muscles. This, in turn, can cause your pelvic floor muscles to tighten up in reaction to that pressure. Your diaphragm will not be able to descend properly on inhale if you are constantly drawing in your abdomen. Practice letting go!
3. You only do kegels laying down. (or driving ;-) )
If you leak when you run, when you exercise, when you jump, you may need to practice kegels with movement. This is another factor in getting your pelvic floor muscles to work with your body as a whole. It's very easy to contract muscles when you are lying flat on your back and doing nothing else but managing that single contraction. Much more difficult to work the pelvic floor in time with other body movements while maintaining the correct contraction and not allowing accessory muscles to take over. What do I mean by this? Can you contract your pelvic floor muscles while at the same time squeezing your adductors (inner thighs) but not your glutes? What happens when you squat? Your glutes are needed for the main (squatting) motion. Can you rise from a squat and contract your pelvic floor muscles as well? Do your back (paraspinal) muscles want to take over?
In short, if you leak with movement, you need to look at what is going wrong with your system when you perform that particular movement.
4. Your pelvic floor muscles are too tight (hypertonic) to contract properly.
This is one circumstance when kegels can actually make your leaking problem worse. Tight pelvic floor muscles can cause a range of problems including leaking, pelvic pain, or back pain and can sometimes mimic the symptoms of a UTI. Frequently, a tight pelvic floor can go unnoticed for years. You may have no symptoms at all or just not realize that your symptoms are caused by the fact that your pelvic floor muscles are tight.
Common symptoms of a tight pelvic floor include:
•Difficulty starting to pee or difficulty fully emptying your bladder
•Constipation
•Pain during sex or tampon insertion
•Increased UTI risk due to urine retention
•Leaking with sneezing, coughing, jumping or heavy lifting
•Feels like you can't get a good contraction (kegel) or weak when trying to contract
•Difficult to get a full deep breath in, stuck in a shallow (chest) breathing pattern
•SI joint pain and hip pain
Not sure what I'm talking about? Make a fist with your hand and lightly squeeze it. Now, squeeze it more. It's hard to get much movement between lightly squeezing and then squeezing more. When a muscle is held tight, there isn't any room left for it to contract more. This is what makes your kegels ineffective for tight pelvic floor muscles. Not to mention that tight muscles will frequently become aggravated muscles when you try to work them more.
Tight muscles are not necessarily strong muscles either. In fact, usually tight muscles are weak. Take your arm and extend it out to the side of your body and hold it there for a few minutes. Still holding? Now imagine holding it there all day long. Your shoulder muscles would be tight and also exhausted! They would be weak from being told to work in a way they weren't meant to work.
5. You need to overload your pelvic floor muscles just like any other muscle.
Maybe your pelvic floor isn't tight. It may be loose and weak (low tone.) The muscles at the bottom of your abdominal canister (pelvic floor and lower transverse abdominis) need to be just as strong as the muscles at the top (external obliques, rectus abdominis, diaphragm.) When the muscles at the bottom aren't as strong, they will be the muscles that give way in the face of any type of abdominal pressure (sneezing, coughing, laughing.)
How do you strengthen your pelvic floor muscles? You do kegels with intention. You connect your kegels with breath work, working the relaxation phase on inhale and the contraction phase on exhale. To get a muscle stronger, you need to use progressive overload. Balloons are great for overloading your breathing system and connecting your kegel to your breath. There are also a myriad of devices out there (some better than others) for exercising your pelvic floor. Be consistent. You may need to stick with it for at least 4-6 weeks before you notice any significant changes.
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