How to Avoid the 5 Most Common Kegel Pitfalls

Your doctor may have told you to do kegels to strengthen your pelvic floor muscles for symptoms of incontinence, prolapse, or general pregnancy and postpartum health. You do what you are told to do - you do them while you are brushing your teeth, doing dishes, and while you are stopped at red lights. You are told they are easy to do, that they can be done anywhere, anytime. Yet, to your dismay, your symptoms, or perception of pelvic floor strength, are not improving. Here are the top 5 reasons why you may not be getting the results you want, and what to do about it.

Visualize

Studies show that a whopping 40-50% of women perform kegels incorrectly with verbal instruction alone. The typical instructions you may have heard are "Squeeze your pelvic muscles as if you are stopping a urinary flow." Many women, while they may be somewhat contracting their pelvic floor muscles, are also squeezing their inner thigh muscles, buttocks, abdominal muscles, or even worse, holding their breath. For better visualization, I prefer to break the kegel into two components: closure and lift. First, visualize the vaginal opening closing like a mouth, or puckering your lips. Then, lift the vaginal area, or perineum, up towards your head, like an elevator with three floors. We have three layers of pelvic floor muscles going from superficial, closer to the vaginal opening, to deep in the vaginal canal. The more you lift, the more you engage the deeper layers of your pelvic floor. To ensure proper breathing, always perform your kegel on the exhale. This will not only prevent you from holding your breath, which can actually damage your pelvic floor and pelvic organs, but it helps to promote a better pelvic floor contraction as well. This is due to the relationship between the respiratory diaphragm and the pelvic floor as part of our core.

Learn How to Relax Your Pelvic Floor First

This is a biggie. In order to be able to effectively contract our pelvic floor muscles, we first must be able to relax them. Many women have overactive pelvic floor muscle dysfunction, where the pelvic floor has a high resting tone and/ or the woman is unable to consciously relax her pelvic floor. Symptoms of an overactive pelvic floor may include urinary urgency and frequency, vulvar, vaginal and pelvic pain, and painful sexual intercourse. In fact, women who are experiencing pain due to overactive pelvic floor muscle dysfunction may actually be aggravating their symptoms by doing regular Kegels. Pelvic floor physical therapy is very effective treatment approach for these issues. A woman may have an overactive pelvic floor even without these symptoms. In this case, her overactive pelvic floor may be making pelvic floor muscle strengthening more difficult, and she would need to learn how to effectively relax her pelvic floor before initiating Kegels for strengthening. For those of you that do not have an overactive pelvic floor, keep in mind that the rest time between Kegels should always be about double the hold time, making sure to fully relax your pelvic floor. This is to ensure that you are able to do each Kegel more effectively, and to avoid creating excess tension in your pelvic floor.

Avoid Distractions

Doing your Kegels during other daily activities may be convenient, but it is not the best way of ensuring that you are doing them well. Doing a good quality pelvic floor muscle contraction requires a lot of focused attention. It is best to perform them without any distractions. Also, when you are distracted, it is much more difficult to keep track of how long you are holding your Kegels and how many Kegels you did.

Choose the Body Position that is Appropriate for You

You may have been doing your kegels standing, but this will not do you any good if your pelvic floor muscles are very weak. You need to do your Kegels in a position that is appropriate for your strength level. Positions for kegels from easiest to most challenging are as follows:

• Laying on your back with pillows or a wedge under your buttocks to elevate your pelvis. This allows gravity to assist you in the lift component of your Kegel (this is a good start for anyone who has prolapse, regardless of muscle strength, since it unloads the pelvic organs).
• Laying flat on your back (no gravity resisting your Kegel).
• Sitting in a chair.
• Standing up.
• During other functional activities or exercises. 

Try your Kegel in these different positions. Can you feel a good closure and lift of your pelvic floor muscles in all of these positions? If not, work at the level that is slightly challenging to you, but you are still able to get a good quality pelvic floor contraction. 

Take Advantage of Hold Time Variations

How long and how strongly you hold your kegel are important factors in an effective pelvic floor muscle strengthening program. This is due to the fact that our pelvic floor muscles are comprised of two types of muscle fibers:

• Fast Twitch Muscle Fibers - These fibers are important for times of increased stress on the pelvic floor such as during coughing, sneezing, brief jumping, and lifting. These muscle fibers are strong, but tire quickly. To work these fibers you want to hold your Kegel at your maximum effort for a 2 second hold followed by a 5 second relaxation time between contractions.
• Slow Twitch Muscle Fibers - These are our endurance fibers. They work for us all day long to support our pelvic organs and as part of our core. Think walking and standing. These fibers work for longer, but are not as strong. To work these fibers you need to hold them at submaximal effort for longer periods. Typically, this is a 10 second hold and a 20 second rest. If your endurance is poor, hold your Kegel for less time until you build up your endurance.For example, if you can only hold the Kegel for 5 seconds without losing the Kegel, then start there. Progress the hold by 1 second weekly until you are able to reach a 10 second hold.

Effective pelvic floor muscle strengthening can be quite complex. The key is quality over quantity. A skilled Pelvic Floor Physical Therapist can assess your pelvic floor muscle function and design a program that is best suited to your individual needs. The above tips may be sufficient for a woman who is not experiencing symptoms of pelvic floor muscle dysfunction and has good awareness of her pelvic floor. However, for women experiencing symptoms such as incontinence, urinary urgency and frequency, pelvic organ prolapse, vaginal heaviness or pressure, and vulvar, vaginal or pelvic pain, pelvic floor physical therapy can be an invaluable and life changing resource.

About the Author

Dr. Rivka Friedman, PT, MS, DPT has been helping women since 2008. She holds a doctorate degree in Physical Therapy and has taken numerous courses with the American Physical Therapy Association Section on Women's Heath, among other specialty training courses and residency training. Utilizing a holistic approach, she has helped many women suffering from pelvic floor dysfunction, bladder and bowel problems, pelvic pain, and pregnancy & postpartum related issues. Passionate about her profession, Dr. Friedman lectures in the community to promote awareness about the various women's health issues that she addresses. Dr. Friedman is frequently sought out by patients and professionals alike for her expert knowledge and compassionate care.​ She currently practices in Miami, FL. For her complete CV, visit her LinkedIn page.