Sunday, November 5, 2017
Recently, I was on a plane flight and sat next to two women. They were very chatty with one another and quickly swept me up into their conversation. Inevitably, in situations like this, everyone asks “So what do you do for a living?”. My answer always used to be “I’m a physical therapist”. The past couple of years, however, my standard response is “I’m a physical therapist, but let me tell you about what kind of physical therapist I am”. Then I go into the diagnoses I treat related to bowel, bladder and sexual health and, in general, how I treat them. Across the board, their reaction is a mix of astonishment and genuine interest. The follow up dialogue is always eye-opening for them, and more often than not, they will report either knowing someone close to them as having one of these pelvic floor issues, or they have it themselves.
In my early days of being a pelvic floor PT, I was convinced I had the answer to all the woes of the pelvic floor. One word – Kegels. As I’ve developed professionally over more than 15 years, I realized Kegels have their place. However, they are not the answer for all things pelvic floor. They should be used, in general, if muscles are weak because they are overlengthened/overstretched, or in a good place, just weak. There are specific instances when Kegels (also known as PC or pelvic floor muscle contractions) are the answer. I’m a firm believer in doing a Kegel program combined with a core strengthening program that will address the bigger picture. Here’s who should be doing Kegels and why:
1) Most men and women that experience urinary incontinence
a. A thorough physical exam can identify if postural dysfunction and weakness in your pelvic floor and what I call “pelvic floor accessory muscles” that are contributing to your incontinence.
b. There are 3 primary types of urinary incontinence that physical therapy can treat:
i. Stress Urinary Incontinence (SUI)
1. Involuntary urine leakage with coughing, laughing, sneezing, exercise
ii. Urge Urinary Incontinence (UUI)
What are Kegels?
Kegels are a contraction of a group of muscles known as "pelvic floor muscles", sometimes referred to as the "PC muscle". PC is short for “pubococcygeus”, the name of just one of the many pelvic floor muscles.
However, over 15 years of practice, I have found that simply telling a patient to “Do Kegels” is usually not enough. Often, women perform pelvic floor exercises incorrectly, or do not do an amount appropriate for their strength levels. This finding has been confirmed by Bump et al in an August 1991 article from the American Journal of Obstetrics & Gynecology, “Assessment of Kegel pelvic muscles exercise performance after brief verbal instruction”. While the article was published quite some time ago, the data is still relevant and referred to frequently in current research studies. The results of that study on verbal instruction were 60/40 (60% could/40% could not perform a pelvic floor contraction or, Kegel, correctly). This article also stated that a very high percentage of women that were doing Kegels incorrectly were not only doing them wrong, but doing them in such a way that they were actually making their incontinence (or light bladder leakage) WORSE (about 25% of the women studied). I have seen this initial frustration with many of my own patients over the years, not realizing before they started physical therapy why they were getting worse. I continue to cite this study, as despite it’s age, it was really revolutionary in identifying why so many women think Kegels do not work.
But I'm a male with incontinence. Should I be doing Kegels, too?
YES! Men have a pelvic floor, too and should absolutely be doing Kegels if there is weakness in that area.
How do I know if I am doing Kegels correctly?
Chances are if you have basic stress, urge or mixed incontinence or light bladder leakage, and see no improvement in your symptoms, you may not be doing your Kegels appropriately. This is not to say that you don’t know how to do a Kegel, but you many not be doing the proper routine based on your strength levels.
How many do I do? How long should I hold them for? There are different types of Kegels?!
I am proud to announce the official book release today of Sex Without Pain: A Self-Treatment Guide To The Sex Life You Deserve. It is available on Amazon.com, iBooks and other retailers.
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Join us in helping to increase the awareness of female sexual dysfunction, including vaginismus, vulvodynia, vulvar vestibulitis, overactive pelvic floor and more. You are not alone if you or your loved one are experiencing painful intercourse. There is help!
In my last post, “Why You Should Be Doing Kegels NOW”, I went over the various diagnoses that tend to benefit most from doing pelvic floor muscle exercises. However, there are MANY issues and diagnoses related to the pelvic floor that are NOT appropriate to prescribe pelvic floor muscle exercises for. In fact, with certain diagnoses, doing Kegels can actually be harmful and counterproductive to your symptoms. When treating patients, physical therapists should always keep in mind that there are proper and improper times to strengthen a muscle. Generally speaking, you should only strengthen a muscle that is weak and overly lengthened. If a muscle in a high state of rest (guarded, hypertonic, in spasm or with limited flexibility), the LAST thing you should do is continually contract it. This will only further shorten/tighten an already short/tight muscle and likely make your problem worse, or at the very least, prevent if from getting better. In the case of the pelvic floor, this could exacerbate symptoms such as painful intercourse, urinary urgency and/or frequency, and more.
Here are the primary diagnoses that I generally recommend avoiding Kegel exercises (and even core strengthening) with, at least in the early stages of treatment:
2) Vulvodynia/Vulvar Vestibulitis/Vestibulodynia/Provoked Vestibulodynia
3) Overactive Pelvic Floor
4) Genito-Pelvic Pain/Penetration Disorder (GPPD)
5) Introidal Dyspareunia
6) Interstitial Cystitis
7) Urinary Urgency & Frequency
The above diagnoses are frequently in need of muscle relaxation and stretching to get the muscle to