by Sue Croft Physiotherapist
First published Jun 5, 2022 at SueCroftPhysiotherapist.com.au
In recent times, there’s been a growing trend on platforms like. Instagram advocating to “ditch Kegels”. As a pelvic health physiotherapist, I feel compelled to present an alternative perspective. While Kegel exercises (or pelvic floor muscle training-PFMT exercises) are not a one-size-fits-all solution, they remain a value component of a comprehensive pelvic health strategy.
Understanding Pelvic Floor Muscle Training (PFMT)
Pelvic floor muscle training involves exercises designed to strengthen the levator ani muscles, which support the bladder, uterus, and rectum. These muscles can be overstretched during vaginal childbirth, leading to conditions like urinary incontinence, pelvic organ prolapse, or pelvic pain. PFMT aims to restore muscle strength and function, contributing to improved pelvic health.
It is important to understand that PFMT or Kegels exercises are just one part of a bigger program and addressing all components of a program can lead to alleviating symptoms and enhancing quality of life.
What affects the pelvic floor muscle strength?
The levator ani (pelvic floor) muscles are stretched by 1.5 to 3 times their normal length during a vaginal birth, depending on the size of the baby, the baby’s head circumference and the mother’s pelvic outlet.
Structural damage can occur to the PF muscles by directly tearing the muscles partially or completely from their attachment on the pelvis (called levator avulsion), from micro-tearing within the muscles which can lead to overdistensibility of the muscles or nerve damage (by compression or traction) – which causes temporary or permanent weakness of the muscles.
Levator avulsion occurs in about 20% of all vaginal births and is strongly associated with:
- the age of the mother, (occurrence more than triples during the reproductive years from below 15% – when the mother is aged 20 years, to over 50% when aged 40 years)(1)
- long second stage of labour; posterior presentation of the baby; head circumference > 36cm(2)
- baby’s weight over 4kg and the use of forceps, but it can also happen in vaginal deliveries with no instruments.(3)
Determine which pelvic floor muscles you need to strengthen
A pelvic health physiotherapist can provide insight into the possible changes that have occurred to the muscles, and also encourage and focus on ways to regain strength through targeted strategies such as: education regarding the correct activation of the muscles, biofeedback, electrical stimulation to the muscles through a hand held machine, weighted cones and especially functional pelvic floor strength work through supervised exercise.
As a pelvic health physiotherapist, I have a strong evidence-based opinion on the value of actually seeking a pelvic health physiotherapy consultation to internally examine (with your consent) the status of your pelvic floor muscles and to validate what your best treatment programme might be to help your ‘pelvic floor distress’.
When Kegels may not be appropriate
Kegels or pelvic floor muscle training (PFMT) exercises can seem worthless or useless if you have sustained a significant injury from a vaginal birth, because you can’t seem to make the muscles work. Kegels subsequently lose credibility if that is all that has been offered to the patient.
Pelvic floor muscle training (PFMT) is a well-researched treatment strategy which is one (important) aspect of any pelvic health management plan, but may be completely inappropriate as a “one treatment fits all” package.
A woman with pelvic pain, overactive bladder and or constipation, may initially be asked to focus on muscle relaxing techniques, rather than strengthening. In these instances, it is crucial to consult with the pelvic health physiotherapist to determine the most appropriate treatment plan.
Key points for performing Kegels or pelvic floor muscle training (PFMT) exercises
- Do not hold your breath at all. Learn to breathe normally as you do any exercise. This is very important. Learning to exhale on effort will protect your pelvic floor rather than holding your breath.
- Do not try too hard at first and stop if you sense any pushing down or bulging around the vagina. Check this by feeling with your hand. This is called ‘bearing down’ and can make your prolapse or incontinence worse if you continue.
- It’s all about the timing and endurance of the muscles not just strength. If you have had nerve damage or muscle avulsion then we cannot cure that at this point in time. If your muscles are very weak, then it is imperative that you recruit and strengthen what is available to you at the correct time.
- Use reminders for your exercise session: Perhaps use coloured stickers around the house to remind yourself, or when you clean your teeth, turn on the kettle or whenever you walk through a doorway. If you have poor sensation and difficulty in recruiting the muscles, then it is best to do your exercises in a quiet room, in a very focused way, so you are sure you are doing the exercises correctly. Using an image of the pelvic floor muscles will get your brain involved and remember you do not have to get on the floor to exercise these muscles!
- Remember to brace or engage before effort. Gently draw in your pelvic floor muscles before and as you cough, sneeze, lift a weight (especially toddlers), get out of bed or a chair, and anything that is strenuous. It will become a life-long habit or ‘knack’.
- Relaxation of your tummy and pelvic floor muscles is very important especially if you have any pelvic pain. Balance all tightening with plenty of relaxation.
- Move so you decrease strains on your body. When getting out of bed move through your side; divide heavy loads into smaller parcels; be aware when picking up toddlers (especially in the early days after a new baby); and teach young children to be independent to minimise lifting them.
- Regular pelvic floor muscle training is for life and can improve stress incontinence and severity of prolapse. Incorporate these exercises into your activities of daily living. Allow time for improvement and ensure all strategies become life-time habits.
- Set 3-monthly calendar or phone diary prompts to remind you of all those strategies-with no end date!
- After your bladder, bowel or prolapse issues have been managed, consider having a yearly review from a pelvic health physiotherapist, so any deterioration in function over time is detected and addressed early.
A Holistic Approach to Pelvic Health
PFMT is just one aspect of a comprehensive pelvic health strategy. A well-rounded approach includes:
- Breathing exercises
- Postural awareness
- Core strengthening
- Lifestyle modifications
Conclusion
While the debate around Kegel exercises continues, it’s important to recognise that pelvic floor muscle training remains a valuable tool in managing various pelvic health issues. However, it’s not a universal solution. Consulting with a qualified pelvic health physiotherapist can help determine the most effective treatment plan for your needs.
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References:
- Dietz HP (2009). Pelvic Floor Assessment. Fetal and Maternal Medicine Review, 20(1), 49-66. 10.1017/S096553950900237X.
- Rostaminia G, Peck J, Van Delft K, Thakar R, Sultan A, Shobeiri SA (2017). New measures for predicting birth related pelvic floor trauma Female Pelvic Med Reconstr Surg 22(5): 292-296
- Dietz HP (2013). Pelvic floor trauma in childbirth. Australian and New Zealand Journal of Obstetrics and Gynaecology, 53(3), 220-230. 10.1111/ajo.12059.
- Sue Croft (2022) Pelvic Floor Essentials book
