Are Kegels a Good Idea for All Women?

Of the many things women feel they are supposed to do every day but don’t quite get to, squeezing in some “Kegels” (pelvic floor muscle exercises) may appear somewhere on that list.

Part of the reason Kegel exercises may fall to the wayside is that some women don’t know how to do them properly—or if they even should do them. Also known as pelvic floor muscle contractions, Kegels are named after American gynecologist Arnold Kegel, who, in 1948, described a set of exercises meant to strengthen the pelvic floor muscles.

The pelvic floor muscles run beneath the pelvis and help support the bladder, vagina, and rectum. The bladder rests on this sheet of muscles, and the urethra (a tube that transports urine out of the body) runs through them.

Kegels are a first-line treatment for urinary incontinence—the involuntary loss of urine or urine leakage. The exercises entail tightening the pelvic floor muscles for two to 10 seconds, relaxing them, and then repeating that movement about 10 times. Kegels can be done at home or under the guidance of a physical therapist.

“When you cough or sneeze or lift something, you increase your abdominal pressure, and that exerts force on the bladder, which may push out urine and result in leakage,” says Leslie Rickey, MD, MPH, a Yale Medicine urogynecologist. “The thought is that strengthening the pelvic floor muscles with Kegel exercises can increase resistance around the urethra, allowing it to withstand higher abdominal pressure and, thus, control urinary incontinence.”

Below, Dr. Rickey talks more about who could benefit from Kegel exercises and offers tips on doing them.

An estimated 24% of women in the United States have a pelvic floor disorder, which includes urinary incontinence, bowel incontinence, and pelvic organ prolapse (when a pelvic organ drops from its position). The most common causes of urinary incontinence include aging, pregnancy, vaginal birth, menopause, and obesity.

Pelvic floor muscle exercises are helpful in treating two types of urinary incontinence—stress and urgency incontinence, Dr. Rickey says. Stress incontinence occurs when someone experiences urine leakage with an activity that increases abdominal pressure, such as exercising, coughing, laughing, or sneezing. Urgency incontinence occurs when someone leaks on the way to the bathroom because they can’t hold it in.

Pelvic floor strengthening can also help treat other pelvic floor disorders, including stool incontinence and pelvic organ prolapse. As these conditions often co-exist with urinary incontinence, pelvic muscle strengthening is frequently discussed as a first-line treatment to help manage symptoms for all of these conditions, Dr. Rickey says.

Pregnant women are often encouraged to do Kegels during pregnancy and postpartum (after delivery). “Because there’s such significant trauma to the pelvic floor with nerve and muscle damage during delivery, it’s a major risk factor for developing future pelvic floor disorders and urinary symptoms,” Dr. Rickey says.

Studies have shown that if women do pelvic floor strengthening during pregnancy and after delivery, they are less likely to experience urine leakage 12 months postpartum, she adds.

Dr. Rickey notes that not all women who have children will experience urinary incontinence. “Many women heal after pregnancy and delivery, but there is a proportion of women who have ongoing pelvic floor issues after childbirth. The problem is that we don't have a way of identifying who's more at risk before and after delivery,” she says.

Furthermore, women who have never had children also experience pelvic floor disorders, including urinary incontinence. “Urinary incontinence is more common in women who have gone through childbirth, but there are women who haven’t been pregnant who will still develop issues over time,” Dr. Rickey says.

While stress incontinence is more common in women who have had children, the more relevant risk factor for urgency incontinence is age, Dr. Rickey notes. “It’s not clear whether this is due to age-related changes, hormonal factors such as menopause, or the effect of increasing co-morbidities [co-occurring medical conditions] as people age,” she says.

However, pelvic floor muscle exercises can be effective in treating and even preventing incontinence at any age. One study looked at women 60 and older who were experiencing either mild or no urinary incontinence and had them do pelvic floor muscle exercises for 12 months. The researchers then compared the results from these women to those of a similar group who did not do the exercises.

“The women who participated in the exercise program were less likely to have leakage at one year. If they had leakage at baseline, they were more likely to improve. And if they didn’t have incontinence at baseline, they were less likely to develop it compared to their counterparts who did not do the program,” Dr. Rickey says.

The American Urogynecologic Society and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction offer the following tips on how to do Kegels:

• Sit in a chair with your feet and knees wide apart, or lie flat on your back with your legs slightly apart. Keep breathing and relax your stomach, leg, and buttock muscles.
• Imagine yourself controlling the passing of gas, holding back a bowel movement, or holding in urine. Then, without using the muscles in your legs, buttocks, or stomach, tighten or squeeze the ring of muscles around your anus and vagina as though you are trying to hold in gas and urine at the same time. Picture what it looks like to draw your pelvic floor up and inward as you do this.
• Pull in and hold a pelvic muscle squeeze for 3 seconds, and then relax for 3 seconds. Try this for 10 repetitions three times a day. Try to hold for 1 second longer each week until you can get to a 10-second squeeze.

Additional coaching can help, Dr. Rickey adds. “I tell people that you don't want to clench your whole body or your legs or just contract the buttock muscles. I share what one of my mentors used to say, which is to pretend you’re pulling a marble into the vagina using just your vaginal muscles—and release,” she says. “You're pulling up and releasing. It’s less of a clench and more like you're pulling up or lifting your pelvic floor muscles.”

“In an ideal world, I tell people to start with three sets of 10 contractions a day; however, I think consistency is more important. Even if someone does one set a day, that can be helpful if they are doing that on a consistent basis over the long term, instead of, say, three sets of 10 contractions every one or two weeks when they remember,” Dr. Rickey says. “And it’s also good to start off slowly with shorter holds, because by the time you get to the fifth or sixth one in a set, you will start to notice some fatigue. You need to build up the muscle.”

Dr. Rickey also recommends finding a few set times of day to do pelvic floor exercises. “I hear a lot of people say, ‘I do them at the stoplight when I’m in the car.’ But, in order to make it a part of your daily routine, it’s better to link it to some other habit, like right after you brush your teeth,” she says.

It’s unclear if doing Kegels early in life will prevent future urinary incontinence.

“There’s probably a group of people that, for a variety of reasons, including genetics, lifestyle, hormonal events, and childbirth—or all those things together—are at a higher risk for developing more significant urinary symptoms as they get older, and they would probably benefit from more intense prevention,” Dr. Rickey says. “We just don't know who those women are yet."

At Yale, we’re part of a multi-center National Institutes of Health [NIH]-sponsored trial designed to look at the prevention of lower urinary tract symptoms in women, which will help us answer that question, she adds.

But given that incontinence increases in prevalence, frequency, and severity of symptoms as women age, Dr. Rickey says it wouldn’t be a bad idea to build pelvic floor exercises into a daily routine.

“If you consider that some women are exercising several days a week, it’s reasonable to incorporate some of the pelvic floor muscle-strengthening exercises into those regimens,” Dr. Rickey says. “It's been shown that even in people who are very fit, the pelvic floor can still be weak if it's not intentionally strengthened along with other muscle groups.”

Pelvic floor strengthening can help women with incontinence, but if there is pelvic pain or urgency and frequency without leakage, trying to strengthen those muscles could cause soreness or might even make the urgency worse, Dr. Rickey says.

“For some women who are urinating very frequently but not leaking, the cause could be pelvic muscle pain versus weakness. Those women are probably better off seeing a pelvic floor physical therapist right off the bat,” Dr. Rickey says. “A pelvic floor therapist can help them with the pain, and the strengthening has to be done in a more thoughtful, supervised manner than trying exercises at home.”

When a woman with complaints of urinary incontinence visits a medical provider—for instance, a primary care physician, Ob/Gyn, urologist, or urogynecologist—she should be offered information on how to do the exercises at home or be referred to a pelvic floor physical therapist.

“Many women like the idea of doing the exercises in a supervised environment because it helps them follow through. Plus, pelvic floor physical therapists also focus on core strength, which is necessary for the pelvic floor muscles to work at their best,” Dr. Rickey says.

And though pelvic floor therapy is usually covered by insurance, not everyone has insurance or the time or means to go to physical therapy, so the at-home exercises are a good option, she adds.