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There has been some recent bagging of Kegels (aka pelvic floor exercises) on Instagram and other important sources of life information and seeing as Influencers only need a good PR team and some sassy photos to extend their reach into the millions, I thought I’d post a very quick, short blog to put the alternative, supportive argument to not ditch Kegels before it was too late. In Australia, we actually don’t tend to use the term Kegels much but as this new trend is saying to Ditch Kegels, I am using that term in this blog.

I am immediately stating my natural bias, that 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’.

The important thing to understand is that PF exercises or Kegels are just one part of a Big Apple Pie of treatment strategies. What that means is that addressing all components of a programme will lead to an excellent outcome for improving urinary leakage or bladder urgency or obstructed defaecation or faecal incontinence or pelvic organ prolapse or pelvic pain – NOT just Kegels.

Let’s briefly dive into 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% at 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)

A pelvic health physiotherapist can give you insight into the possible changes that have occurred to the muscles, but 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.

Kegels or pelvic floor 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 and therefore Kegels lose credibilty if that is all that has been offered to the patient (who then may go on to become an Influencer). 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 – particularly if a woman’s main complaint is pelvic pain. In fact if you have pelvic pain, you may be asked to focus on relaxing your pelvic floor (and tummy) muscles and avoid Kegels until the pain has resolved.

So what are ten quick points to pay attention to when performing Kegels or pelvic floor 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. So 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 minimize 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.
• These strategies are for life! 3 monthly phone diary prompts to remind you of all those strategies.

And NUMBER 10: Once you have sorted your bladder, bowel or prolapse issues consider having a review from a pelvic health physiotherapist yearly. This way you will get on to any deterioration in function early.

References:

(1) Dietz HP (2009). Pelvic Floor Assessment. Fetal and Maternal Medicine Review, 20(1), 49-66. 10.1017/S096553950900237X.

(2) 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

(3) 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.

(4) Sue Croft (2022) Pelvic Floor Essentials book

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