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Understanding the Pelvic Floor: What No One Tells You About Kegels

Understanding the Pelvic Floor: What No One Tells You About Kegels

I want you to come on a journey with me. Let’s travel to a yoga class, one in which you’re in your flow, landed in your body and breath, inseparable from your intention. Ready for that next exhale to move deeper into your practice, you hear: “exhale, contract your pelvic floor.” 

What do you do?

Do you scratch your head? Look up at the ceiling and squeeze the living bejesus down there? Does a circus of interrupting thoughts arrive? Like, “How?” “What the hell is that?” “Am I doing it right?” 

Maybe you’ve actually been here before. I have. And as a pelvic floor specialist, I wanted to facepalm. I can’t tell you how many times I’ve had women come into my office after reading they should do 100 Kegels a day with their kegel weights, arriving with new symptoms of pelvic pain, urgency, and even incontinence. Many women are completely unaware that they already hold tension in these muscles. 

Of course, I don’t blame them. This area of the body is not a hot dinner table topic, and it’s complex. These muscles are intimately woven in our bodies, hidden from our view, and frankly, are hard to feel without practice. 

Casually encouraging people to blindly “contract the pelvic floor” is as dangerous as never squeezing anywhere ever again. This phrase is still thrown around today, even 72 years after a male gynecologist had success in a study to treat incontinence in postpartum women. While it showed some benefit to these women, it’s imperative that these exercises are prescribed to the appropriate women and taught in the correct way. And, unfortunately, on a spectrum of laypeople to birth professionals, I have found time and time again that pelvic floor contractions, or kegels, are completely misunderstood and misused. 

Kegels, the holy grail of pelvic health, the solution to all of your problems, the one-size-fits you and you more please! Let’s take a moment, zoom out, and stop passing this fad saying along before anybody else gets hurt. Because, seriously, doing kegels can be damaging. 

If I had to have one slogan, it’d be: “Kegels, don’t try them at home.” 

Of course, with the subtext of, “without a pelvic floor therapist.” Yet, avoiding kegels all together isn’t helpful either, so I have something you can try at home as a first step. 

By the end of this article, I’ll have you connecting with your true core in one simple exercise.

So, I’m here to tell you the good, the bad, the ugly of these exercises, and provide a foundational understanding of your pelvis first, so that you can connect with your pelvic floor for real strength. 

It’s hard to get these exercises right unless we get the full view. 

Like everything in our body, the pelvic floor musculature is beautifully complex. It deserves the right attention, and the most up-to-date application of knowledge we as professionals have of this area.

Why is the pelvic floor important?

You may have experienced something in your life to make you more aware of the pelvic floor: leaking during exercise or with a sneeze, urinary urgency or frequency (going more than seven times a day), bowel issues like constipation or IBS, or pain. 

Did you know that low back pain is correlated with a weakened pelvic floor? Often, sacro-iliac (SI) pain, or pain in the lumbar spine is due to instability in the pelvis, which is held together by your pelvic floor muscles. 

During pregnancy, or in your postpartum recovery, you most certainly became aware of these muscles. Tearing, or an episiotomy (a purposeful cut to the perineum) can occur because of the lack of awareness, control, and ability to completely coordinate and relax down there. Hormone changes at any stage in a woman’s life can reveal that these tissues are susceptible to change, causing microtears, dryness, and discomfort in sex. 

One thing is for sure: whether or not you’ve had to pay attention to these muscles before, they tirelessly work for you, providing you some of the most essential support for your organs, posture and movement. 

What is the pelvic floor?

The pelvic floor is a hammock-like group of sixteen muscles that are suspended in the pelvis, woven around the vagina, anus, clitoris, and urethra. The pelvic floor musculature provides three of your most essential functions:

Support: the pelvic floor muscles support not only our most vital organs (bladder, uterus, and rectum), but also the weight of our head. 

Elimination and continence: the pelvic floor muscles help you control the bladder and bowel by relaxing to let waste come out, and contracting to hold things in when you need to.

Sexual Appreciation: the pelvic floor muscles help us to experience comfortable intimacy. One muscle, for example, erects the penis or clitoris. Our muscles down there also need to relax and contract properly to achieve climax.  

Amazing, right? But there’s more to what makes this such an essential part of our body. What most people don’t know is that it is one of three diaphragms in our body. It is the upside-down parentheses to our respiratory diaphragm. Like a trampoline, these muscles are buoyant and respond to our breath to make room for more air in our abdominal canister, and to simultaneously maintain healthy intra-abdominal pressure. 

When you inhale, the diaphragm drops down like a parachute, and the pelvic floor responds by lengthening and softening. The pelvic floor also coordinates with your diaphragm on exhale, by gently shortening and compressing in and up. These two diaphragms coordinate when you breathe, and are connected through two other muscles, the transverse abdominis and multifidus. 

The Core is More

When most people think of the core, they think of the rectus muscles, or the “six-pack” muscles. But what really supports our spine and respiration are the deep core muscles. I call them the “core four:” the pelvic floor, transverse abdominis (TA), multifidus, and respiratory diaphragm. The TA muscle is deep, and connects to the ribcage and the pelvis.  It is also connected through fascia, or connective tissue, at the diaphragm muscle and to the lumbar spine. If you’re a visual learner like me, you’ll appreciate the following images. 

All together, the “core four” close your abdominal container, and coordinate to maintain healthy pressure internally to protect your vital organs for elimination and sex. They also work to manage added pressure when we exercise, lift our baby, or sneeze. Without this core stability, pressure can escape up (acid reflux much?) or can press down on our pelvic floor muscles. 

Continuous pressure downward can result in the muscles becoming fatigued, weak, tense, and even painful. The muscles are like an overworked employee; they are constantly being recruited to hold against this pressure. The muscles, overactive, get knots of tension from constantly straining, just like muscles in your shoulder or neck. Over time, these strained muscles can no longer hold things together effectively, and eventually lead to dysfunction like incontinence, pelvic pain, and even organ prolapse.

Kegels: the good, the bad, and the ugly

So, wait, why wouldn’t we want to go home and pump some iron down there? Don’t those muscles need to get stronger?

Imagine holding a ten-pound weight in your hand, and continually pumping the bicep muscle without ever giving it a break, or letting your elbow completely extend. Would that create a strong muscle? No. In this example, if your elbow doesn’t extend to its full range of motion, the bicep muscle never turns off. It will keep working and working, and the muscle will get tighter and tighter. To get stronger, these muscles need a break. 

Posture is also a major component. Remember when I told you we have sixteen muscles down there? Even a minor imbalance in your pelvis can pull one side of the muscles to have more tension and be overly tight, while the others get stretched and weak.  

Most patients I see have overactive muscles or a combination of underactive and overactive muscles. Even postpartum moms have tension patterns that develop from carrying a baby during pregnancy, and from tissue healing postpartum. Doing 100 Kegels a day, especially without good core awareness and a full breath, would just tighten the tight ones more. 

Of course, kegels aren’t all bad. Done properly, they help pump blood and oxygen down to our organs. Practicing kegels at certain stages of your pregnancy can help you increase awareness of the muscles and coordinate the muscles consciously. Yet, no amount of kegels will help you unless you’re able to relax your pelvic floor completely. Focusing on just these muscles without the support from the “core four” is often tiring, fatiguing, and not effective. It’s not effective because the musculature is reflexive in nature; it turns on in coordination with our core as long as it’s buoyant and springy. Let’s help you get your inner core online, so that you can experience the natural rhythm of your pelvic floor muscles.

Try This at Home 

First things first, let’s get you to connect to your true core. Go ahead and try this at home:

Start by lying on your back, with knees bent and soles of the feet on the floor.

Place your hands on your belly inside your front hip bones, and take several rounds of breath inhaling through the nose and exhaling through the mouth. Allow your belly to expand on the inhale and stay soft on the exhale. 

Once your belly is soft (think: Buddha belly), exhale with a “shhh” sound until you can’t exhale anymore.

Stay soft; let the belly drop from the exhale, but without gripping or pulling it in. 

Keep the ab muscles relaxed and keep exhaling to feel your deeper, inner core. You may feel under your fingers a deep core muscle turn on; the TA may press out into your hands.

If you don’t feel it, you can lift just your head off the floor 1-2 inches and you will feel the TA activate.

This deep core muscle should feel firm, but should never dome, cone, or “poof” the belly.

Now that you’ve felt it, try to use the technique above to contract the TA without lifting your head.

Now, let’s find the pelvic floor.

Bring your awareness to the muscles between your sitz bones. As you breathe deeply with the “shhh” breath, notice any change in pressure in your perineum (space between your vagina and anus).

If you don’t feel it, place your hand at your perineum for feedback, and focus your awareness there. You can also sit up on a yoga ball or chair, with a rolled up towel under your perineum for extra feedback. 

If you feel tension down there that won’t fully release, this is your practice.

If you feel like the muscles are very relaxed, you can use an exhale to contract the muscles, pulling them in and up. Hold for 3-5 seconds or until the muscle fatigues.

Are you able to fully relax after the contraction? Try taking those muscles down an elevator to the ground floor, and then the basement. 

If you notice increased tension down there that is hard to let go, your muscles are likely overactive and you’ll need to just use the first breathing exercise above. 

If you’re able to fully relax them, you can do 5-10 repetitions. 

Don’t go crazy, unless you’ve gotten clearance to do so. Do use them to increase your awareness down there, and to focus more on the relaxation or release afterward. 

Let Go

Just like our breathing, the pelvic floor muscles are reflexive, their response automatic. They are already connected to our breath. And like our breath, they already know what to do. The only thing in the way is us: in our constant gripping of the abs, learned tension patterns in the body, and limits in taking a full, deep breath. 

The secret is to let go. Our entire body has a natural rhythm. Sometimes we need to relearn that rhythm. One thing I can promise you, is that it is often that simple. Once a woman is able to fully relax her pelvic floor, that next pelvic floor muscle contraction is much stronger. My clients are amazed when they realize, all they had to do was drop the weight. It's the patterns of clenching that get in the way. It isn’t about working harder. Most of the time, what women need is to relearn to use the muscles again correctly with the breath, allow their full range of motion, so that the muscles can switch on when they need them to.

Whether you are a pregnant or postpartum woman, or you’re a person who has experienced any kind of pelvic dysfunction, becoming aware of your pelvis is an exciting opportunity. These muscles, organs, and structures communicate to us when there is a problem so that we can come more into balance with them.

Health is a lifelong pursuit.

Maybe you didn’t notice before, or maybe you even ignored the signals, but now you have the knowledge to get the support you need and to optimize your pelvic health. Take it as a jump-off point. 

So next time you hear a teacher say “contract your pelvic floor,” I encourage you to slow down, soften, and bring your breath all the way down there. Relax any clenching, and give your floor a break. Then, if you want to pick up that weight, go for it. See if you can coordinate it, see how long your muscle will contract before it gets tired. But make sure you can relax. The power is more so in your softness, in your allowing. Awareness is key, and I promise you’ll likely be surprised to find you already have the strength you need. You might find, all you really needed all along was to reconnect with your breath.

By Emily Merollis

Emily Merollis, OTR/L, RYT is an occupational therapist with a private practice named The Integrated Feminine, specializing in pelvic health. Her practice is located in Portland, OR, and she offers consultations online.  Merollis is offering a 90 minute online course, The Essential Guide to Kegels (spoiler alert: it’s about much more than just kegels!). The course guides you in a self-assessment of your own pelvic floor muscles to see if they are overactive or underactive, and where to go from there, at an affordable $39.

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