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When Kegels aren't enough

To paraphrase comedian Whoopi Goldberg, incontinence is "A little laugh, a little 'spritz.' " Goldberg, who served as a spokesperson for a bladder protection product, admitted to being one of about 25 million American women and men who suffer from urinary incontinence. With this condition, any slight pressure on the bladder, such as a laugh, a sneeze, a cough or exercise, triggers the release of a small amount of urine. While a pad, such as Goldberg promoted, helps with the consequences, it doesn't address the source of the incontinence. Thankfully, there is help and hope.  

If you experience urinary incontinence, your first step is to consult with your primary care provider. Causes of urinary incontinence include: 

  • Weak or tight pelvic floor muscles
  • Overactive bladder
  • Pregnancy
  • Childbirth
  • Constipation
  • Uncoordinated pelvic floor muscles
  • Pelvic floor organ prolapse
  • Urinary tract infection
  • Disease, such as diabetes, Parkinson's disease or multiple sclerosis
  • Enlarged prostate
  • Post-operative dysfunction i.e. bladder, hysterectomy, prostatectomy
  • Diet
  • Medication
  • Obesity
  • Age
  • Spinal cord injury

Once the cause has been identified and addressed, your provider may recommend pelvic floor exercise, or Kegels, as part of your treatment. In this exercise, you isolate, tighten, hold and then relax the pelvic muscles. Studies show that 50 to 75 percent of patients with incontinence experience substantial improvement with pelvic floor exercise.  

But if done incorrectly, Kegels can actually cause more problems. There are four steps to a correct Kegel: awareness, strengthening, relaxation and coordination.  


The first step in strengthening the pelvic floor is awareness. The pelvic floor muscles are shaped like a figure eight around the urethra, anus and vagina for females, and help support the bladder, bowels and uterus. Men have the same basic muscle structure as women which surprises many.

Your goal in a Kegel is to isolate these muscles, and exercise them without involving the abdominal, buttocks or thigh muscles. Problems can be worsened if the muscles aren't isolated.  

To help you understand which muscles are involved, when first learning to strengthen your pelvic floor muscles you should start by emptying your bladder. While on the toilet, try to stop the flow of urine. The muscles involved are the ones you want to isolate. However, don't make performing Kegels while urinating a habit. It can lead to problems with emptying your bladder and potentially bladder infections. It is a onetime test to identify the muscles you need to strengthen. If you still have difficulty, consult a physical therapist trained in pelvic floor therapy. A therapist can help you determine whether you should lengthen or strengthen the pelvic floor muscles. 

Sometimes we need to actually be able to relax a muscle before we strengthen it!  


Once you are aware of the pelvic floor muscles, you want to do a series of exercises that involved tightening and then relaxing these muscles. When you tighten the pelvic floor muscles you should feel these muscles lift up and draw in. Think of it as an elevator moving up the floors.  Hold this position for five seconds and then relax. Be sure to breathe normally, and don't tighten your abdominals, buttocks or leg muscles during the exercise. Aim for three sets of ten repetitions a day. It is important to relax fully between contractions. It takes time to build up endurance so be patient with yourself! The quality of the contraction is more important than the quantity.

Relaxation (Lengthening)

Once you are aware of the pelvic floor muscles you can determine if it's a weakness problem or tightness problem.  It's important to completely relax the muscles following the tightening portion of the exercise. There should be no stress or strain. Not relaxing the muscles completely can contribute to additional problems, such as pelvic pain, spasms and poor emptying of the bladder.

Also, if your incontinence is caused by an overly tight pelvic floor, you will need to learn how to relax rather than contract these muscles. The physical therapist or your primary care provider can help you determine if you have this problem. This is quite common.

Pelvic floor physical therapists are experts at teaching relaxation as it relates to urinary and bowel issues. Once you can train your muscles to relax properly you can start functional strengthening.


Muscle coordination is key!  Because the pelvic floor is made up of two types of muscle fibers, you need to work both. You'll want to do short quick tightening for the fast-twitch muscle fibers, we call them "quick flicks," and you will need to do a longer contraction, sometimes called a "long hold," for the slow-twitch fibers. Both of these types of contractions affect different functions. Depending if you have urgency issues or leakage your therapist can start you on the appropriate exercise plan.

Our pelvic floor muscles work in concert with our abdominal muscles and our diaphragm. Many people strain as they naturally feel this is how to empty their bladder more completely. They use every muscle from their chest down to create pressure. This actually inhibits and creates more problems for the bladder to empty and gives the opposite effect. Your therapist can teach you how to effectively empty your bladder and bowel through proper breathing and relaxation techniques.  

Still need help?

If you are still having difficulty, your health care provider may recommend pelvic floor dysfunction therapy. Physical therapists can fine-tune and individualize your treatment beyond the basic Kegel. They are knowledgeable about a variety of individualized techniques, including: 

  • Manual therapy
  • Behavior changes
  • Biofeedback
  • Overactive bladder training
  • Electrical stimulation

 If there is still no improvement, medication or surgery may be prescribed.


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Surgery options for pelvic organ prolapse

Pelvic organ prolapse (POP) is a weakening of the support structures that hold a woman’s pelvic organs in place (bladder, uterus, top of the vagina, and rectum). This prolapse is often noticed as a bulging of tissue in or coming out of your vagina. Read more about pelvic organ prolapse and non-surgical treatment options.

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