The Kegel, the black box of the exercise world.
Are you really doing it right?
In today’s post we are going to review some simple exercises to help get to know the pelvic floor muscles. Now, I strongly recommend going through my past post “Exercises for Short/Tight Pelvic Floor” first. Generally speaking, patients with pelvic pain should not kegel as a therapeutic exercise. Kegel exercises may be better suited for postpartum women or those with prolapse or stress urinary incontinence, but not always. Of course, a pelvic floor physical therapist is the best judge of where you fall on the spectrum of pelvic floor muscle function and if you need to lengthen or strengthen your muscles. With that said, this post is to teach people, who should kegel, how to kegel.
Okay, that said I will proceed. Remember, if you have any discomfort or negative change in function, stop the exercises and go find your nearest friendly- neighborhood pelvic floor PT.
So, Dr. Kegel had a reasonable idea. Let’s have people, women mostly, start strengthening the muscles of their pelvis so they don’t have to have surgery and can do self rehab. Now, barring the fact that many people, women and men, don’t need to do Kegels, there was one other fault to this idea. Pelvic floor muscles are intricately connected to the rest of the body, meaning a kegel by itself can’t do very much. Its isolation limits its power. Using other muscles can help facilitate a full pelvic floor contraction and core recruitment. Ideally, this should occur automatically, but we’ll talk about that another day. So, we’ll start with some basic individual muscle contractions of the pelvic floor then move to more integrated exercises. To understand this a bit more take a look at what Diane Lee says about the “core”.
Week 1: Synchronizing Superficial Sphincters!
So let’s start with the first level of the pelvic floor, the most superficial (most close to the surface). This is the sphincter work. You can try 1-2 sets of these a day for a week just to get the sensation of recruiting these superficial muscles.
Start sitting in a neutral position, equally weighted on your sits bones right to left and back to front. It can be very helpful to do this on a yoga ball.
Or, if you don’t have a yoga ball you could sit upright on a firm chair on a folded hand towel. If using a hand towel, it is helpful to orient it with each corner matching the pubic bone, tailbone and two sits bones,so the square towel is rotated to make a diamond. This just gives better feedback to the muscles since they attach from the pubic bone, coccyx and sits bone.
Take a couple moments to relax and breathe easy, relax your breath and diaphragm, let your belly drop. Once you feel comfortable you can try some of these cues to activate your superficial muscles of your pelvic floor.
Exercise 1: Wink
There is a small thin sphincter around your anus. It has quick movement.
Very lightly try to wink your anus. Then relax. Wink your anus. Relax.
Try this a couple times, then breathe and let go all the way.
Exercise 2: Nod
There are some muscles that attach right below your pubic bone, to the fascia around your urethra and clitoris/penis. Try to nod the clitoris/penis. Relax. Nod. Relax. Nod. Relax.
You can also try the cue lift or flick the clitoris/penis (just don’t actually flick it with your finger ;).
Try this a couple times and relax and breathe.
Exercise 3: Draw
Now we are going to think a bit more globally.
A. Try to draw your pubic bone to your tailbone, or draw front to back and back to front, lightly. Relax. This should not engage your belly, hips or thighs, it should be very light.
B. Now try to draw sit bone to sit bone to meet in the middle, lightly. Relax. This should not engage your belly, hips or thighs, it should be very light.
C. Now try both at once, draw the Four Corners* together to meet in the middle, front and back draw towards the center, right and left draw to the center, lightly. Relax. Same as above, keep it light.
*remember Four Corners exercise for later
Note: There is a tendency to overdo this one, so keep it easy. It should feel like a hint of a movement. As with all the above exercises, your glutes, belly, jaw, shoulders are relaxed.
After you do all these exercises, go into a child’s pose or happy baby posture to help your pelvic floor let go and stretch. After you exercise a muscle it is helpful to stretch it to keep it mobile.
Week 2: Diving into the Deep End
So after a week or so of Synchronized Sphincter work, if you have no increased symptoms and no pain, you can now dive into the deep end. In Week 1 the focus is on layer 1 of the pelvic floor, which tends to be flat muscles, primarily in charge of closing, hence “sphincteric”. Now, in week 2, we’ll focus on the deeper pelvic floor muscles. These muscles are in charge of supporting the pelvic organs and are considered part of our “core”.
If you’re a visual learner take a look at the pictures below. If they just confuse you, skip it.
From the Side
Okay, now that you are thoroughly confused let’s just get down to business: how to facilitate the deep pelvic floor muscles.
Pick up the Hankie
In this exercise we transition from superficial to deep muscles. So start sitting on a yoga ball, or on a firm surface with a folded hand towel, like before.
1. Inhale feel the relaxation and drop of pelvic floor muscles into the surface (ball, towel).
2. Exhale, draw the Four Corners to the center.
3. Inhale, relax, feel the drop/bulge of the pelvic floor.
4. Exhale, draw the Four Corners to the center, imagining you are drawing the corners of a hankie together…. then, once the four corners are gathered, slowly lift the hankie deep into the pelvis.
(If you are sitting on the towel you can imagine you are drawing the corners of the towel together then lifting it up in the center)
5. Inhale, relax, everything.
6. You can repeat this ~ 5 times. If you’re doing this correctly you should feel your low abdomen tighten on it’s own and you should be able to breathe normally.
A. Maintain the contraction for 2 easy breaths, then relax. Make sure you keep breathing the whole time- don’t hold your breath, that’s cheating 😉
B. Instead of “picking up the hankie” straight up, try picking it up on a diagonal. If you look at the orientation of the pelvic floor muscles they are actually like a sling, coming off the pubic bone, wrapping around the anus and back up to the pubic bone. This may be helpful in actually feeling the work. So, draw the anus towards the pubic bone.
C. If you feel like you just keep squeezing your butt you probably are. You can tell when you relax your muscles, your butt or hips relax too, meaning these extra muscles were working as well. If this is happening, then try laying down on your back and bring your legs up to your chest and hold them there with your arms, kinda like happy baby. This position inhibits you hips from working and relaxes your pelvic floor. That way you can sense when you are using your pelvic floor muscles versus your butt.
Move and Grove
Once you tap into your pelvic floor muscles you can try adding this contraction to everyday activities or exercise routines. What you should find is you have more stability and power, it will take you less effort lift, swim, walk, hike, ski, etc. Below are just a couple ideas to connect the pelvic floor with bigger movements.
1. Arm pulls/flutter arms
Using light resistance, stand comfortably with slightly soft knees (you can do this seated or on your back knees bent in neutral spine). Inhale to prepare, exhale draw your pelvic floor muscles deep and slightly up towards the pubic bone (same contraction as we’ve been doing). Now to feel the connection you can pull your arms straight down in front of you, or in a slight “V”. Inhale, keep the arms down, Exhale slowly bring the arms up and rest. Repeat as you’d like.
2. Hover Planks
On your hands and knees position, keep your spine in neutral. Inhale, exhale and draw your pelvic floor muscles in, and your navel to spine. Then hover your knees just above the ground. Take 5-10 breaths maintaining the alignment, slowly lower, and relax. Repeat as you’d like.
3. The sky’s the limit, just see if you can incorporate in your favorite exercises.
I hope you enjoyed this cursory introduction to your pelvic floor muscles. Hopefully this shed a bit more light on that black box. Remember, the strength of a kegel is not measured by the squeeze, but how it supports the rest of our movement and function.