Kegels 101: Who Needs Them and How to Do Them Right

By Dr. Sonali Patel, PT, DPT, LPF-CT

All about Kegels

As a physical therapist working in pelvic health, I notice a shift away from placing too much emphasis on Kegels. Overall, this shift is a positive and important one. It allows individuals facing pelvic floor dysfunction along with others in the medical field to understand the broad scope of treatment for pelvic floor dysfunction. Talk is changing from medical practitioners for pelvic floor related dysfunction, and we are hearing the phase “just do Kegels” a lot less. That said, there is definitely still a time and place to do Kegels and for some, it can be critical.

What are Kegel Exercises?

Kegel exercises are pelvic floor muscle contractions. Like any other muscle in our body, our pelvic muscles can be contracted, creating muscle activation and shortening. Our pelvic floor sits in the shape of a sling at the bottom-most aspect of our core muscles. Some find it helpful to think about our core muscles as a can that sits in the lower part of our torso. The deep layer of muscles that make up the core are the diaphragm (top), transversus abdominis (front), multifidus (back) and pelvic floor (bottom). These muscles together make up the deepest layer of our stabilizing muscles in our trunk. When we contract our pelvic floor muscles to perform a Kegel, we are activating the bottom part of our core. Going back to the analogy of the sling – when the pelvic floor contracts, the sling is shortening and tightening. This creates squeeze pressure and lift pressure upwards and inwards. There are multiple dimensions of this movement – tightening and lifting – both aspects of movement are important to create an effective Kegel. When a Kegel is performed, it is important that we contract all three layers of pelvic muscles. The pelvic floor has three layers of muscles, layer one being most superficial and layer three being the deepest layer of pelvic muscles. When we perform a Kegel, we are contracting these muscles together.

Why are Kegels Important?

Just like exercising other parts of our body to maintain strength, endurance and power, exercising our pelvic floor muscles provides us this same benefit. It is important to exercise this group of muscles to maintain strength at the deep layer of our core muscles. Our deep core muscles work together to provide us stability in our abdominal region. Core stability and strength is important for daily function – your core should be the driver of all movement. From daily tasks like walking, navigating stairs, sitting up from bed and running to more complex movements like doing box jumps at the gym, performing a headstand or doing a cartwheel on the beach – your core should be driving much of the work involved in these motions. In addition, if your pelvic floor becomes weak, you may be more susceptible to symptoms of urinary leakage, fecal leakage, or even pelvic organ prolapse. Our pelvic floor muscles serve to provide support on the bottom of our abdominal region. It supports everything that sits above it that lies in the belly. If you think about it, that’s a lot of things to support – your intestines, bladder and rectum. If we don’t exercise our pelvic floor, this can lead to support issues.

Pelvic organ prolapse occurs when an organ starts to descend low into the pelvic cavity. This may be attributed to weakness of the muscles of the pelvic floor. Bladder leakage or fecal leakage may at times be due to weakness of the pelvic muscles as well. For example, if the muscles are weak in the pelvic floor when you laugh, cough or sneeze, the muscles may not be able to support this increase in pressure leading to leakage. In other cases, if the endurance of your pelvic muscles is low and you are holding or suppressing an urge to urinate for an extended period of time, your muscles may not be able to support the bladder above for that extended period and this can also lead to leakage. Similarly, fecal incontinence can occur when the muscles in the posterior aspect of the pelvic floor are weak. Many times, this can be from disuse of the muscles rectally or lack of connection to movement of these muscles leading to low tone. With an increase in pressure from things including running, coughing, sneezing or even just moving from sit to stand – depending on the degree of weakness, this can sometimes lead to incontinence.

Who can perform Kegel exercises?

Pelvic floor physical therapy and Kegel exercises can be performed by people with both female and male anatomy. All individuals have a pelvic floor. Just as we exercise other parts of our bodies and have voluntary control of movement of our body parts, knowing how to do a Kegel allows us to exercise and activate our pelvic floor muscles. Knowing how to do a Kegel is important and if you are experiencing pelvic floor dysfunction related to weakness of the pelvic area or issues with coordination of the muscles of this area, your physical therapist can evaluate, teach and prescribe proper dosage for this exercise if they find it to be a contributing factor to your dysfunction.

While kegels can be performed by anyone, they are not always appropriate for everyone to perform. Kegel exercises may be harmful in cases where an individual already has adequate pelvic floor muscle strength and/or has a lot of tightness or restriction of the pelvic floor muscles. If the muscles are too tight or restricted, doing too many Kegels can enhance this restriction. It can make an area with a lot of tension even worse – putting more pressure on nerves that run through the area, possibly creating more pain sensations if this is something you are experiencing.

who should do kegels?

How can I locate my Pelvic Floor Muscles?

In learning how to properly do a Kegel exercise, it’s important that you first are able to properly locate the pelvic floor muscles. The pelvic floor muscles are comprised of three layers of muscles that lie between your pubic symphysis, sits bones (ischial tuberosities), and tailbone. There are the bony landmarks of the pelvis bone that create the boundaries of the pelvic floor muscles. The pubic symphysis is the bone in the front of the body that you can feel by sliding your hand downwards from the midline belly button. The sits bones are two broad bones that lie under your gluteal muscles. If you are sitting, try sliding your hands under your bottom – you will feel two large bones. The tailbone lies midline between the gluteal folds (it’s a small triangle-shaped bone). The center of the most superficial layer of your pelvic floor muscles is called your perineal body. This is the central area of the outermost part of the pelvic floor. This is located above the rectal opening. Once you locate this spot, you’re in the central region of the pelvic floor muscles. The pelvic floor muscles are surrounding this point from superficial to deep. At the deeper layer, realize the pelvic floor muscles take the shape of a sling from pubic symphysis in the front to tailbone in the back. Together all these muscles have many functions, including support, sphincteric control, sexual function, sump pump and stability.

How can I perform a Kegel exercise correctly?

Now that you know where the muscles of the pelvic floor area are located, let’s talk about how to activate these muscles to perform a Kegel exercise correctly. To perform a Kegel, think about creating both a squeeze and lift pressure in this group of muscles. It may be helpful to think about the movement you may do when trying to hold in a stream of urine or you can try imagining the movement you create when you are trying to wear a tight pair of pants.

Despite trying to work with these cues, some individuals may have trouble turning on the muscles of this area and may benefit from tactile or visual feedback. For tactile cueing, you can try lying on your back with your knees bent or sitting in an upright position with the pad of one of your fingers at the perineal body (the tissue in front of the rectal opening). With your hand in this spot, try lifting the tissue inwards or upwards, creating less pressure on your finger pad. If you feel an increase in pressure on the pad of your finger, this can mean you are accidentally creating a bulge pressure. Be patient with yourself – give your brain and body some time to try to create this connection and movement pattern.

If this isn’t working or you feel uncomfortable placing your finger on this area, you can also try using a towel under the perineum in an upright seated position. I recommend using a hand towel, folding it long ways and creating a roll. Place this roll long ways under your pelvis. Your perineal body will be resting on the towel. Try lifting the perineum upwards or inwards, creating less pressure on the towel. Keep in mind, this movement is small. Unlike in other parts of our body, our pelvic floor muscles create very small movements. You may find it challenging at first tuning into the subtlety of this motion.

Is this not working either? If you are more of a visual learner, it may be helpful to use a mirror for self-visualization to contract the muscles of the pelvic floor. You may try using a small handheld mirror in front of the pelvic region to recruit these muscles. If you work with a pelvic floor physical therapist, they can also introduce you to biofeedback machines. These machines are used to read the signal created by the muscles of the pelvic floor. The machine can be connected to external pads or a sensor that can be used internally in the pelvic floor to pick up signals of movement. The machine can signal through lights or graphics (depending on the exact machine used) the movement of the muscles. It can be a useful tool to help you begin to retrain your muscles.

Can I do Kegel exercises anywhere?

After learning how to perform a Kegel correctly, you can perform a Kegel anywhere. Provided it is a small movement, you can exercise your pelvic muscles in any position, anywhere. That being said, when first learning how to do a Kegel, it is easiest to perform this movement lying on your back to eliminate gravity, thus making it easier to contract the muscles than if you are in a seated/standing position.

What else can my pelvic floor do?

We should all have voluntary control of movement in our pelvic muscles, and you should know how to properly contract, relax and bulge these areas when appropriate.

The 3 different actions of pelvic muscle movement:

Contracting refers to shortening, tightening, and lifting the muscles. Allows us to brace the area during coughing/sneezing to prevent leakage. Without being able to contract the area, we would not be able to strengthen it
Relaxing the area is letting go of any tension in the muscles. Allows the area to move flexibly, supporting things above when you are jumping/running. It can also help decrease tension in the pelvic region, which can be helpful for those with pelvic pain
Bulging is the opposite of contracting – it refers to pushing downwards, outwards, and opening and lengthening the muscle. Allows for bowel emptying and even for pushing during a vaginal birth

Each action of the pelvic muscle is critical for different purposes. This relatively small area is critical for many of our daily functions. If you are experiencing any dysfunction, it can be helpful to see a pelvic floor specialist for evaluation and examination.

Sonali Patel is a pelvic PT at Beyond Basics in New York City. She earned her Doctorate in Physical Therapy at Columbia University, where she began her continued education in pelvic health through the Herman and Wallace Institute. She has completed advanced courses in manual therapy, orthopedics & pelvic health through the Institute of Physical Art, Pelvic Global, McKenzie Institute and the Integrative Women’s Health Institute. She is a certified low pressure fitness instructor; this method addresses the core and pelvic floor muscles by targeting posture and breathing. To further support her patients, she has trained in and has received her mat-based Pilates teaching certification. She is also a co-author of a textbook by The International Society for the Study of Vulvovaginal Disease on Lichen Sclerosus.

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