Are Kegels Worth the Squeeze?
Today I want to talk to you about why Kegels might not be “worth the squeeze” and explain why we need a wider perspective on pelvic floor muscle training.
The standard protocol for pelvic floor muscle training is the Kegel- an isolated voluntary contraction of the pelvic floor muscles - usually described as a squeezing action of the pelvic floor. You might have been prescribed Kegels during pregnancy to prevent pelvic floor issues or as a treatment if you have a pelvic floor disorder (e.g. prolapse or urine leakage with exertion or urgency). In clinical trials Kegels have been shown to be most effective for stress incontinence (leakage with exertion - exercise, sneezing or coughing) but they still fail to cure the problem in close to 50% of people.
As Kegels fail for many people, I believe we urgently need to widen our perspective on pelvic floor training. You, as an amazingly intricate human being, are a system not a bunch of parts and isolating out parts from a system is only going to get you so far. Let us look at just one limitation of an all-Kegel approach to the pelvic floor: the type of muscle contraction.
For robust strength we need muscles to work well under a variety of situations including at different joint positions and therefore muscle lengths. Picture a bicep curl with a heavy weight. As you bring the weight up to your shoulder, your bicep contracts, shortens and gets ‘bunchy’ ( the technical term for this is a concentric muscle contraction). When you slowly lower the weight back to your side, the bicep is still working but it is getting longer (the technical term for this is an eccentric muscle contraction). Without strength of the bicep at longer lengths, the weight would drop without control, possibly wrenching your shoulder or elbow.
A Kegel is a shortening and lifting (concentric contraction) of the pelvic floor analogous to the ‘up’ part of the bicep curl only. It is a good skill to have for sure. But here's the rub, the pelvic floor often ‘fails’ in situations where lengthening with control is also required. During a sneeze or a jump there is an increase in pressure in the abdominal and pelvic cavities and the pelvic floor has to accommodate that by lengthening. If the pelvic floor is missing strength or control in longer ranges you can get leaking of pressure and leaking of urine or worsening of prolapse symptoms over time.
The long and short of it is we need to train and move the pelvic floor muscles, at long and short lengths -and everything in between- for robust strength and control.
When we use an all-kegel or all-pelvic floor approach we cannot train longer positions of the pelvic floor. To do this we need to look beyond the muscles of the pelvic floor since lengthening (and shortening) of the pelvic floor happens naturally as a result of muscles outside of the pelvic floor moving the bones of the pelvis or leg around. One of the best exercises to train the pelvic floor at longer ranges - while simultaneously strengthening the muscles of the hip, lower leg and the spine - is a squat. In the lowering phase of a squat the sit bones move apart from each other as the hip flexes, widening the pelvic floor side-to-side. In addition the sacrum (back of the pelvis) is pulled backwards thus also lengthening the pelvic floor front-to-back.
I hope you might be convinced to begin some squat work. But, before you dive into working on upright squats, I suggest beginning with supported variations, especially if you have a pelvic floor or core issue. Supported variations give you the opportunity to map out the exercise and work on any compensations before you progress to upright squats which create much higher loads on the pelvic floor.
The form of a squat matters here: we are trying to cultivate a squat that uses maximal hip flexion and pelvic floor lengthening on the way down. It is common to see a squatting strategy which uses more spinal movement than hip movement and this won’t get you the lengthening of the pelvic floor that we are after. Take a look at these three photos of a hands and knees squat.
The first photo is my starting position: a relaxed spine with the normal spinal curves. Note particularly the concave curve in my lower back.
In the second photo I am moving into a ‘squat’ shape with my bum moving closer to my heels. The movement however comes mostly from my spine rounding with little hip movement.
In the third photo I am moving into a squat by flexing my hips. There is little change in the shape of the spine from the starting photo but the angle between my legs and torso is considerably smaller.
I want you to explore how much you can squat without the spine moving (photo 3). This is the version in which your pelvic floor will be moved the most.
The video tutorial that follows will help guide you through this, starting with a squat on your back and then progressing to the hands and knees version.
Neutral
Lumbar Flexion
Hip Flexion