Pelvic Floor Muscles &
How to do Kegels
Physical Therapists are specialists in the musculoskeletal system—how the muscles and bones of our body work together to allow us to function in our daily lives with strength and without pain. Pelvic Floor Physical Therapists have undergone significant additional training in how to assess and treat the specific muscles of the pelvic region, in order to assist in your recovery from injury, childbirth, or sometimes, just to connect you to these groups for the first time in your life! Pelvic Floor Physical Therapists are the BEST and most qualified person to teach you how to do kegels correctly.
The success rate of pelvic floor physical therapy exercises for conditions like incontinence, pelvic organ prolapse, and back injuries rivals that of surgery, with considerably less cost and minimal potential side effects. It is DEFINITELY worth your while to read on…
The pelvic floor muscles are a hammock of amazing muscles at the bottom of our pelvis. They have millions of functions, but primarily sphincteric (control things going in or out when we want them to), supportive (support weight of our abdominal fat and organs) and sexual (the fun parts, as well as the harder parts like birthing). The pelvic muscles are unique. Just like we have a left arm and a right arm, we have a left pelvic floor and a right pelvic floor.
And it’s not just one muscle—in fact, there are more than six per side on the outer layers alone!
How Pelvic Floor Muscles Should Feel
The muscles, which start about ONE knuckle width deep in the vaginal or rectal vaults, at rest ought to feel like a little donut, & feel soft and springy, like a trampoline (or soft-ish butter) to the touch.
THEY SHOULD NEVER HURT TO TOUCH.
They do hold some amount of normal resting tension with daily activities, just like your other muscles.
And just like your other muscles, too much or too little resting tension is problematic. So, if the muscles feel like a solid brick wall, or like a bruise on an apple or pear, you have some work to do.
Breath & Kegel
When you breathe in and out with a relaxed belly, your belly should move OUT and DOWN with each inhale, then passively rebound back with each exhale. There ought to be no movement in your upper or middle chest here.
If you are able to tune into your pelvic floor muscles (the muscles around your v@g and rectum…the parts that would rest on a bike seat, or be covered by a bikini)…as you breathe inwards into your belly, these same pelvic muscles should passively elongate and drop down towards your heels a bit, and with each exhale, they should passively rebound up and in towards the resting position.
But for most of us with pelvic dysfunction…this doesn’t happen. Most of us, upon first examination, have NO passive movement of the pelvic muscles with belly breathing.
And if the pelvic muscles aren’t moving with relaxed breath…then nothing else matters because they aren’t going to be healthy muscles.
So if you think this is you…STOP reading right now and go watch this Post about how to relax your pelvic floor with breathing. (Spoiler, it also covers the next exercises, too…)
When you “kegel” in the traditional sense of the word, it is like “you are stopping the flow of urine” if you have female anatomy, “lifting the twigs and berries out of cold water” if you have male anatomy, or “lifting up the rectum” if you have either anatomy.
A side note, please don’t ever repeatedly stop the flow of urine to “strengthen” your pelvic floor muscles. This can be an interesting ‘test’ to do, to see how strong you are, but it is against so many natural functions of the pelvis and can cause much harm….so please only do this occasionally out of curiosity if you must, and NEVER more than once a month.
But I digress…back to the pelvic floor muscles…
With the traditional kegel (up and in) contraction, the resting donut of pelvic floor muscles constrict and lifts up towards the belly button, ideally with equal contraction contribution from left and right sides, and front and back muscles. They ought to remain there as long as you tell them to, then when you relax, the muscles should return to their usual resting state, about 75% elongated and nicely springy.
And that’s just half the battle. From this resting position, there is a SECOND contraction the pelvic muscles can do—it’s called ‘Bearing Down’ and is an eccentric (contracting while elongating) contraction. From the resting position, you GENTLY push down with JUST YOUR BIKE SEAT, while your tummy is relaxed. The bike seat muscles elongate to the bottom, or longest part of their range. They are now 100% lengthened.
Regardless of female or male anatomy, your cue is that your rectum is now long and low, and you maintain this contraction for 3-5 seconds. Then you relax again, but this time, ‘relaxation’ is a passive tightening-lifting that brings the pelvic floor back ‘up’ to its proper resting position.
Oh, and you ought to be able to do the Kegel, relax, bear down, relax with the tummy relaxed OR the tummy engaged….and with breathing in OR out…essentially we need to know how to do ‘all the movements’ at all different times and never in “Just one” scenario.
Phew. Crazy huh? That’s why this training is so important.
Training Someone To Do Kegels (or, more accurately, pelvic floor physical therapy exercises) Works Miracles
Many of you have heard that “just telling someone to do kegels” doesn’t work. That is absolutely true. Just telling someone to do kegels does not work. What?!?
If I tell four people with vaginas to do kegels, two of them will do it wrong and get no benefit. One will do it so wrong, they’ll make themselves worse, and only one will do it well enough to get benefit, and probably from chance. This is because of our brain-body disconnect, and us not understanding about these parts. And while just telling someone to do kegels does not work, training someone to do kegelsin a way that is appropriate for their own personal body, absolutely works miracles. In fact, as I’ve demonstrated in earlier blogs, TRAINING individuals to do kegels correctly can actually save the world.
Pelvic Floor Physical Therapy Exercises Can Save the World!
I will, in fact, be studying the effects of better cues for pelvic floor physical therapy exercises in the near future, but for now, nothing can replace having hands on these parts of your body to attempt to figure out what’s happening “down there”. Try these exercises as a start, preferably with one hand on your lower abdomen and one hand touching your bike seat parts, to get a better sense of what’s happening down there. If you are having urgency or leakage or overactive pelvic floor muscles, practice the bearing down part many times a day, as it is likely that pelvic floor muscle hypertonicity is contributing. There is also additional up-training of abs and butt that is vital here, but that’s beyond the scope of this post.
Please consider seeing a pelvic floor physical therapist if you are able, (check out this post for tips on finding one near you), but if you are not able, for any reason, I have options for you!!
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For now, check out these Evidence-Based Exercises to address many common pelvic, low back and hip complaints!
Best Starter Pelvic Floor Physical Therapy Exercises to Reduce Urinary Urgency and Frequency
Relaxed (Diaphragmatic) Breathing
In a comfortable position, RELAX your core and breathe. In this relaxed breathing, your diaphragm will contract down into your belly, your belly and pelvic floor should passively expand outwards with each inhale, then passively rebound back in and up on the exhale. There should be minimal to no movement in the chest here, and the neck should be relaxed. Often after injury, we lose this, and the pelvic floor specifically, becomes stiff and rigid, and doesn’t move like it should in relaxed breathing.
Stiff isn’t strong, and we need to reconnect the brain to the pelvic floor muscles, so with your next inhale, tune in to your bike seat: does it passively press down into your seated surface (or down towards your heels if you are laying down) with each inhale? Does it rebound back up, passively, with each exhale? Take 5-10 breaths to tune in to this. This is how your body ought to breathe as you sleep and rest.
Now that we’ve reminded your brain that the diaphragm is for relaxed breathing, let’s teach the brain that the abs are for stabilizing your lumbar spine, not breathing. When your brain doesn’t understand this, you end up holding your breath when you exercise, which isn’t good. In this exercise, you inhale with a relaxed belly and pelvic floor, then as you exhale, you gently draw in your lower abdomen (near belt line) like you are trying to pull your belly button in towards your spine, or zip into a tight pair of pants. Your pelvic floor should be relaxed here. You tighten the lower tummy as though you are pushing the air out of your lungs gently, then relax it as you inhale again. Do this 5-10x, keeping your neck and your pelvic floor relaxed.
Here’s the money maker. Appropriately doing kegels is one of the hardest things anyone could ever do, which is also why they get a bad rep.
When kegels ‘don’t work’ for individuals, it is usually because they are missing EVERYTHING except the up and in contraction, which is only a small piece of the pie. The bigger piece is ensuring that the muscles of the abdomen and pelvic floor and hips can activate independently of each other, as well as together, as well as ensuring that the abdomen or gluteals can remain engaged while the pelvic floor relaxes. I just blew your mind, didn’t I? I know. Happens every day.
So, after you’ve mastered exercises 1 and 2 above, you are ready to try a Kegel. Put one hand on your lower abdomen and one hand on your bike seat parts. Or, if you’re sitting, sit on a towel, or the edge of a sofa to have some position-sense feedback to the bike seat parts.
- Gently tighten the lowest abdominal muscles, so that your belly button comes close to your spine. This takes the weight of the organs off your pelvic floor. You should still be able to breathe here. If you can’t, stay with the above 2 exercises until you can do this while still breathing. Your pelvic floor should not have moved here at all.
- To this abdominal brace, add a Kegel contraction, picturing the muscles that lay between your sit bones, and contract them, and only them, to pull your sit bones together underneath you. The muscles pull your pubic bone towards your tailbone, and lift your bike seat parts up and away from whatever you’re sitting on….but the butt shouldn’t move…the head shouldn’t bob. There should be ZERO physical evidence that you are kegeling, if you do it well. The only physical evidence is that if you have a finger inserted in your vagina or rectum, that you feel those muscles tighten like a donut and attempt to pull your finger inwards. You’re still breathing. You hold this contraction for 3-5 seconds.
- Then you MAINTAIN your deep ab contraction, and relax your pelvic floor back to the starting point. This is hard. Many of you will say, ‘nope’, not happening. Do your best to try to keep abs engaged and relax your pelvic muscles….try for 5-10 seconds.
- Now, relax your abs. Were you accidentally holding some tension in your pelvic floor along with your abs? Welcome to the club. Many individuals with pelvic complaints have this ‘dissociation deficit’ where they cannot relax the pelvic floor muscles independently once they fire with abs or glutes. This is a huge contributor to your functional limitations.
- From this resting position, now elongate the pelvic floor and Bear Down, pressing down NOT with the belly, but just with your bike seat parts. Hold this for 3-5 seconds, then ‘relax’ and notice the muscle passively return to their resting contraction level (which, in this case is a slight tightening).
Told you that was hard 😊 It will get easier, though. Try that sequence 5x in a row, 2-3x a day and watch the miracles begin! The first great challenge is training your brain to recognize these parts, and as you sleep tonight, your brain is going to have a Board Meeting and say “Diaphragm, Pelvic Floor, Deep Abs, I need a word with you. I tried to isolate you today and couldn’t. We should improve the nerve network to you, so we do better tomorrow” (for real, this happens!) and then tomorrow, these exercises are a bit easier.
Now, I am VERY good at what I do, and I love it, and I hope you are able to get some help from this post. If you need more help, though, please don’t be afraid to reach out to a pelvic floor PT or physio in your area (check out the APTA Find a PT site, the Herman Wallace Pelvic Rehab Search Site, or simply Google “Pelvic Floor PT/physio near [town]”).
In the immediate term, join my mailing list to be kept up to date on evidence based updates related to pelvic health, and to receive exclusive discounts and access to subscriber-only live events. Check out my website to purchase the AMAZING Signature Pelvic Floored Lecture and Exercise Series and spread the word that our pelvises are worth fighting for.
This blog post is the tip of the iceberg, and help is available. You are not alone, and you are not permanently broken. You will not regret reaching out, because YOU ARE WORTH IT.
Thanks for reading!
xoxo, Dr. Kelly