Q: To Kegel or not to Kegel?- Asking for a friend.

A: Short Answer: Both/and, not either/or. Long Answer: Let’s move the conversation forward and ask new questions.

What’s the Issue?

To Kegel or not to Kegel is a hot topic these days. However, the controversy and conversation is not new. The concern is that the promotion of Kegels (a contraction and hold of the pelvic floor, followed by relaxation) may not be appropriate for everyone. However, it remains the go-to suggestion for anything related to pelvic health. Kegels are intended to strengthen. If someone’s pelvic health issues might be irritated by strengthening or if a strength deficit isn’t the problem, then symptoms may worsen or not resolve (Not to Kegel).

This can add to frustrations and potentially really challenge recovery. It can also make folks doubt the availability of a solution. However, the use of them to raise awareness of and strengthen the pelvic floor, still has merit for those who need that type of help (To Kegel).

So how do we decide?

Part of the issue and the confusion is the nature of the Kegel itself. It is important to understand the thought process that has led to Kegels being the primary activity offered. When we unpack this history, and take a look at our evolving understanding of care for pelvic health needs, we can move beyond this either/or quandary. Then the question isn’t to Kegel or not to Kegel, it’s can we change the focus of our conversations? Let’s consider a shift.

Where We’ve Been

Kegels have been the only option for pelvic floor exercise for decades. Kegel-type activities have been the universally offered exercise for anything related to pregnancy, postpartum, or pelvic health needs. This idea has been embedded in medical, physiotherapy, fitness, and pop culture.

The good news is we have evolved a lot in those decades. A one-size-fits-all, or one-muscle-solves-all approach is not reflective of best practices in any area of clinical care or physical training. The idea that one exercise and one muscle group would solve the complexity of pregnancy, postpartum, and pelvic health needs must be reconsidered.

Where We Are Headed

• Let’s expand our language, and start discussing pelvic health, not pelvic floors. A focus on a muscle group, well, keeps the conversation on the muscle group. This limits how folks interpret needs that involve the pelvic floor- incontinence, pelvic pain, prolapse, pain with sex. Then the pelvic floor is considered both the only source, and the solution to these needs. A shift in language fosters a shift in thought. When we understand the range of direct and indirect factors that play into these issues, we broaden our investigation of other contributing considerations AND our options to bring change.

• To clarify, this isn’t an anti-Kegel or an anti-treating the pelvic floor post. It’s not. Instead, it’s an understand the whole picture post. Yes, the capacity and quality of pelvic floor engagement has a contributing role in pelvic health challenges. By all means, bring awareness to the pelvic floor and learn to engage or relax it through an activity like a Kegel. However, the quicker we look for why the pelvic floor is being overwhelmed or overused, the sooner we will know how to use or not use a Kegel.
• It also moves us beyond only considering only the characteristics and behavior of the pelvic floor as our solution. We can consider:
  • pressure systems
  • muscular relationships
  • exercise habits 
  • lack of exercise
  • social supports and influences
  • sleep
  • stress 
  • And more

Let’s Shift- Pros

• In clinical care, we learn to ALWAYS look above and below the joint and musculature that is experiencing symptoms. For example, for a knee, we always consider the hip and the ankle/foot. Use that same understanding here, consider above and below the pelvic floor/pelvis:
  • ABOVE: What’s happening in the trunk musculature? Intra-abdominal pressure? Rib cage?
  • BELOW: What’s up with the hip? How is their closed chain control? How is their impact control? Can they generate power out of the legs to lift, to assist the trunk/pelvic muscles?
• If we look at it this way, then pelvic floor weakness/underuse (To Kegel) or over-strengthened/over-recruited (Not to Kegel), becomes a less pressing question. Instead, we have so many more questions we can ask! We start to get at the WHY the pelvic floor issues and pelvic health needs may be a part of our clients whole picture.
• If we look ABOVE, we can appreciate that the pelvic floor may be plenty strong. However, it is being overwhelmed by high Intra-abdominal pressure from above contributing to leaks or prolapse symptoms. Therefore, strengthening the pelvic floor may not solve the issue, but managing intra-abdominal pressure is critical.
• If we look BELOW, we can understand that the pelvic floor may be over-recruited due to a lack of support from the hip musculature in their exercise patterns. This may result in painful sex, or pelvic pain. Thus, efforts to get the pelvic floor to relax will be challenged (even a Not to Kegel strategy), if the hips and leg power continue to be lacking while they exercise.
• To be clear I am not suggesting an either/or scenario: pelvic floor OR hip strength; pelvic floor OR pressure control. I am suggesting, both/and here too. Integrate them in a balanced way within function and fitness activities.

Let’s Shift- Individuals

• If you feel caught in the middle and are unsure what to do, here is a shift. If you are practicing Kegels, change them from a one-size-fits-all, contract/relax activity that isolates the pelvic floor, to integrating the pelvic floor in a controlled way into movements and fitness you enjoy. As a result, this will strengthen the pelvic floor(To Kegel), but because the focus is on control, it will reduce the possibility of overusing it (Not to Kegel).
• A cue I use to help folks learn to coordinate the pelvic floor without overuse is asking patients to predict the amount of pelvic floor lift they need for a particular activity, e.g. “Are you lifting a couch or a pencil? How much pelvic floor do you need for the pencil vs the couch?”.
• If it is an athlete who is lifting heavy weights, I ask “What would the lift feel if you were doing 50% of your max? 30%? 80%?”.
• Control driven work is less likely to become an over-recruiting activity. Accordingly, this helps folks distinguish their need for added oomph for a challenge at the gym vs simply air squatting to pick up an abandoned pacifier (or pencil). The strategy for how you use your pelvic floor must meet the demands placed on it.

Moving Forward

All things considered, these shifts will go a long way toward moving us beyond an either/or choice and a debate that really isn’t new. Our understanding has evolved, we can impact pelvic health without a solo focus on the pelvic floor. Research is now exploring these new ideas and asking new questions! We are moving forward.

Finally, many are now joining in the conversation, and want to understand this piece of the puzzle in their care and training. This is awesome, we need you! So if you are new here….let’s start here. With a deeper, more robust appreciation for how the pelvic floor fits into our clinical and fitness puzzles versus as a stand alone entity. Tell your friend, it’s both/and.

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