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To Kegel or Not to Kegel


If you have spent any time examining the social media accounts of prolific and well-followed pelvic floor professionals, you may have encountered conflicting opinions on the value of the infamous “Kegel” exercise. A Kegel is simply put a pelvic floor muscle contraction or what you do to stop the flow of urine or hold back gas. These contractions can be performed much like in the way you might train other muscle groups at the gym (i.e. in varying sets and reps, sustained holds, maximum versus sub maximum contractions).


pelvic floor PT explains pelvic anatomy with 3D model to a patient
Pelvic floor physical therapy

You may have even seen many well-respected members of the pelvic health community adamantly waving a banner of “Stop the Kegel” or claiming to effectively strengthen the pelvic floor without Kegels. Statements such as these, while pithy and attention-grabbing, are baffling to me. Pelvic floor muscle training, i.e. Kegels, is one of the most well-researched and highly-supported treatments we have in evidence-based pelvic floor physical therapy practice. It almost feels akin to the anti-vaccination stance in the medical profession. That begs the question, why?


Why the Controversy?


Why are some pelvic floor physical therapists increasingly contributing the Kegel smear campaign?


One motive might be clinical in nature. The truth is you might get better without doing a single Kegel. You might actually get worse by doing Kegels. You might benefit from learning how to properly Kegel and that is all. Or you might not be able to see full symptom-resolution without a structured, high-volume Kegel program. No one knows which recipe will work for you without expert evaluation and treatment. This is why pelvic floor physical therapists matter. Treating and training the pelvic floor is nuanced, each plan as unique as the individual for whom it is designed.


Some practitioners may have had enough bad experiences with patients developing new symptoms from doing Kegels that they simply wish to write them out of their practice altogether. This is each clinician’s choice and duty to provide treatments that they feel most equipped and comfortable delivering. But this is a far cry from no one should Kegel ever.


Rather than shouting “Stop the Kegel,” the mantra we as pelvic health professionals should be preaching is “Stop the UNSUPERVISED Kegel”— meaning that verbal instruction to contract the pelvic floor is wholly insufficient to improve pelvic floor function and prevent unwanted side effects from practicing Kegels incorrectly. If you want to improve your pelvic floor without throwing darts blindfolded, seek a professional’s guidance.


So it makes me wonder if a second motive for this anti-Kegel trend is more shock value— the thrill and notoriety of flying in the face of literally thousands of years of pelvic health practice. Taking a controversial position is often an effective way of grabbing attention, and these days to surf above the tsunami of content that floods social media platforms is no small feat. But I wonder if we have lost some substance and nuance to a deleterious end by choosing pizazz over accuracy. If budding therapists see these messages and then develop attitudes that prescribing or teaching Kegels will make them a less effective or “less cool” clinician, then their potential patients may miss a critical part of their rehabilitation. If patients see these messages and believe that Kegels are harmful, how confused might they feel if their qualified practitioner then incorporates Kegels into their treatment plan? It muddies the waters, not clarifies and potentially makes the journey to improvement longer.



I think if you asked most trained specialists what their true attitudes on Kegels are, the honest answer would be: it depends. Each patient is different and value of Kegels varies on a case-by-case basis. There are no simple, absolute answers and that is why I find this reductive picket-sign messaging dangerous.


The Evidence for Kegels to Improve Pelvic Floor Strength and Function


When considering evidence, we need to look at the quality of the data and whether it has been replicated to make a determination on its overall value for clinical decision-making. A systematic review is a synthesis of data from many studies, which typically means that its conclusions can hold more weight than a single study. A Cochrane Review is typically considered the most rigorous and comprehensive analysis of the evidence on a particular research question. Much of the time, the authors of a Cochrane Review report that more evidence is needed to draw any conclusions so when a different recommendation is made it tends to be a big deal in the research and clinical worlds.


  • We have Cochrane Review level evidence to support the use of pelvic floor muscle training for the treatment of stress urinary incontinence. In fact, the evidence was so high that authors, Dumoulin et al recommended pelvic floor muscle training as the first line of treatment for this condition.


  • In their 2014 systematic review, Bo et al recommend pelvic floor muscle training during pregnancy and postpartum for the treatment of urinary incontinence.


An important caveat is that SUPERVISION of pelvic floor muscle training has been demonstrated to have a significant impact on the efficacy of the intervention (Bo et al 1990). Meaning symptom reduction or resolution is more likely when pelvic floor muscle training or Kegel training is provided under the “frequent supervision” of a qualified specialist. So go to pelvic floor physical therapy. You are worth it and you deserve the best outcome!


The Evidence for Other Exercise to Improve Pelvic Floor Strength and Function


There have been some single studies that demonstrate an effect of common exercises of pelvic floor muscle function:


  • Siff et al reported that bird dog, plank, and leg lift exercises produced similar effects to a Kegel. They even reported that leg lifts generate a stronger contraction than a Kegel. However, this study did not evaluate the impact of these exercises on patient symptoms so the clinical value is unknown.


  • Blagg et al reported that yoga movements locust pose, side angle pose, front and side plank all activated pelvic floor muscles enough to confer a strength, endurance, or motor control benefit. However, this was a cross-sectional study design and not an intervention trial so no conclusions on efficacy as treatment can be made.


While this area of research on alternative pelvic floor muscle training is fascinating, there has not been a systematic review to date that has concluded that alternative exercise regimens surpass pelvic floor muscle training in terms of increasing pelvic floor muscle strength or decreasing symptoms associated with pelvic organ prolapse or urinary incontinence:


  • Bo et al reported in their 2013 systematic review that there is not strong enough evidence to support that an exercise regimen other than pelvic floor muscle training can reduce stress urinary incontinence. The other exercise methods included in this review were the Paula method, Pilates, and abdominal training. Tai Chi, yoga, breathing exercises, general fitness training, and postural training were notably not included due to a lack of research.


  • In 2020 Jacomo et al drew similar conclusions in their systematic review comparing Kegels to Pilates, hypopressives, and the Paula Method, stating that “pelvic floor muscle training continues to be the gold standard for increased pelvic muscle strength.”


  • In 2023 Bo et al included yoga, breathing/hypopressives, and hip exercises in a similar systematic review and published the conclusion that there is insufficient evidence to recommend other exercise programs to pelvic floor muscle training for the treatment of pelvic organ prolapse.


  • In a 2023 systematic review Bo et al reported that breathing exercises were not as effective as pelvic floor muscle training for generating a strong pelvic floor muscle contraction, reducing urinary incontinence, or improving pelvic organ prolapse.


Now just as important to note, there is also no conclusive evidence that these types of exercise are harmful to the pelvic floor. But I will save this discussion for another post.


The Value of Expert Opinion and Anecdotal Evidence


Some may say that there is more to clinical practice than can possibly be well researched. And I would agree. There is certainly value in years of experience, number of patients treated, and data informally collected over the course of a career. Expert opinion panels exist for this very reason. Furthermore, if we waited to employ an intervention (especially a low-risk one) until we had Cochrane Review evidence to support it, patients would be waiting for ages, in some cases forever, for treatment. But that’s the thing, we do have Cochran Review evidence… for Kegels (for the treatment of stress urinary incontinence)! This is not to say that Kegels are a one-size-fits-all treatment. They absolutely are not! Which again, is why expert supervision is critical.


It is also important to acknowledge that much of the evidence we have to date in pelvic health examines typically underactive pelvic floor conditions like urinary incontinence and pelvic organ prolapse. Pelvic floor physical therapists certainly see more diagnoses than these and while Kegels may be well-researched interventions for some pelvic health conditions, that does not mean they are appropriate for all.


In terms of anecdotal evidence to support not using Kegels, there may be some value in these claims, especially for some diagnoses more than others. If a clinician is promoting that they rarely use Kegels, ask yourself what patient population are they typically treating? Are they patients who experience pelvic pain, urgency/frequency, pain with sex, constipation, and difficulty emptying— all symptoms of an overactive, nonrelaxing pelvic floor? Well then, heck, it might make perfect sense that they aren’t doing many Kegels. That is not to say that all patients with those symptoms absolutely and unequivocally should never do Kegels. Again, it depends. Some of my patients with highly stiff and tense pelvic floors respond much better to contract-relax drills (meaning submaximal Kegel and release) than they do to soft tissue massage. Each patient is different, which is why no treatment option should be taken off the list of potential ingredients for that patient’s pelvic health recipe until it is tested.


Generally speaking, and this is entirely based on my experience, patients with elevated stress, pain and anxiety, high-demand roles, or little time for self-care and relaxation tend to have a harder time with Kegel training and thus are likely to benefit from closely supervised instruction or perhaps minimal to no intentional pelvic floor muscle training at all.


Pilates teaser
Exercise like Pilates and core training can be complementary components of a pelvic floor rehab plan of care

I also wish to say that I include Pilates, abdominal training, yoga, breathing exercises, resistance training, postural re-education, and beyond in my physical therapy treatment practice. I find them extremely valuable for most of my patients. Do I use Kegels too? Yes, sometimes. What I don’t do is categorically dismiss an intervention that has good evidence to support its use. I also don’t prescribe Kegels and send people on their merry way. The research indicates this is not as effective as supervised training and my own personal practice suggests it is potentially dangerous. So I do not prescribe UNSUPERVISED Kegels. We are regularly checking in to ensure that coordination and muscle tension are appropriate in order to avoid unwanted setbacks and achieve patient goals.


My point is the crusade against Kegels may not be the right message we want to be flashing to the public. To completely deny the evidence we have supporting their value seems in conflict with our doctorate-level education. We may consider our clinical experiences to guide our interventions, but we should not turn our eyes from our research partners who work to strengthen support for our profession and help guide best practice to the benefit of our patients.


The Long and Short of It


Kegels are not the devil. Sadly, it isn’t that simple. Nothing is all good or all bad. Kegels may actually be the key to your recovery. On the other hand, they may not be the right choice for you.


We have good evidence to support the use of Kegels for the treatment of some pelvic health conditions and for strengthening of the pelvic floor muscles.


We do not yet have adequate evidence to support the use of any other type of exercise— including yoga, Pilates, resistance training, hypopressives, breathing, etc— for the strengthening of pelvic floor muscles.


Verbal instruction is inadequate for effective pelvic floor muscle training. Receiving instructions from your OBGYN or other medical professional to “do your Kegels” is not equivalent to receiving supervised instruction from a qualified pelvic health specialist.


Expert supervision is critical to ensure appropriate pelvic floor muscle coordination and reduce unwanted consequences like overactive pelvic floor and its associated symptoms.


Do not be afraid to see a pelvic floor physical therapist. In my opinion this should absolutely be standard:

  • Post-surgically: prolapse repair, post-prostatectomy, hysterectomy, abdominopelvic lapropscopy, hernia repair

  • Postpartum

  • Perimenopause

  • Post-urogenital cancer treatment

  • In the presence of symptoms like leaking pee or poop


Words matter. Saying “Kegels are not pelvic floor physical therapy” is not the same thing as saying “Kegels ONLY are not pelvic floor physical therapy.” Waving a banner of “Stop the Kegel” does not equal “Stop the UNSUPERVISED Kegel,” or even better yet “Stop the Leak, See a Pelvic Floor Geek.” If we want to use platforms like social media to expand our reach and visibility, we have a responsibility to curate our message so as not to scare young therapists away from the evidence or confuse patients who are receiving appropriate guidance from qualified experts.


Rather than speaking in absolutes or vilifying certain treatment styles or approaches, I prefer to think of pelvic floor physical therapy like a recipe. Each patient will require a variety of ingredients in different amounts to achieve the results they desire. Kegels are one possible ingredient in the recipe that patient and therapist discover together. They aren’t the answer in and of themselves, but they may be part of it. And demonizing a potential solution, making the road to recovery potentially longer and more convoluted than it already is for these patients, is the last thing we should be doing as pelvic health care providers. Catchy slogans can be effective so long as they first do no harm.



References


Blagg, M, Bolgla, L. (2023) The relative activation of pelvic floor muscles during selected yoga poses. Complemtary Therapies in Clinical Practice. 52, 101768.

Bo, K, Herbert R. (2013). There is not yet strong evidence that exercise regimens other than pelvic floor muscle training can reduce stress urinary incontinence in women: a systematic review. Journal of Physiotherapy. 59, 159-168.

Bo, K, Driusso, P, Jorge C. (2023). Can you breathe yourself to better pelvic floor? A systematic review. Neurourology and Urodynamics. 42. 1261-1279.

Bo, K, Angles-Acedo, S, Batra, A. (2023). Are hypopressives and other exercise programs effective for the treatment of pelvic organ prolapse? International Urogynecology Journal. 34, 43-52.

Bo, K, Hagen, R, Kvarstein, B. (1990). Pelvic floor muscle exercise for the treatment female stress urinary incontinence: effects of two difference degrees of pelvic floor muscle exercises. Neurourology and Urodynamics. 9, 489-502.

Dumoulin C, Hay-Smith EJC, Habee-Seguin G. (2014). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. The Cochrane Collaboaration. 5, 1-119.


Jacomo, R, Nascimento, T, da Siva, M, Salta, M. (2020). exercise regiments other than pelvic floor muscle training cannot increase pelvic muscle strength- a systematic review. Journal of Bodywork and Movement Therapies. 24(4), 568-574.

Morkved S, Bo K. (2014). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: A systematic review. British Journal of Sports Medicine. 48, s299-310.


Siff L, Hill, A, Walter S, Walters M. (2020). The effect of commonly performed exercises on the elevator hiatus area and length and strength of pelvic floor muscles in postpartum women. Female Pelvic medicine and Reconstructive Surgery. 26(1), 61-66.



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