By Dr. Brianna Durand, PT, DPT of Empower Physio
A note about terminology:
In this blog post, I will be using certain anatomical terms including vagina, penis, scrotum, clitoris, etc. These words are often heavily gendered, including in the medical field. The intention of using these terms here is only for clarity of explanation and by no means an indication of gender or sex based on genitals. Please read with caution and feel free to substitute your own terms that feel more authentic for you. For example, many of my patients like to refer to their anatomy with words like canal, shaft, interior, exterior, etc.
“Squeeze the muscles you would as though you were trying to stop the flow of urine”
This is a common cue that people hear when learning how to do a kegel for the first time. Pro tip – don’t do that while you are actually peeing! (You can get a UTI, which I had to learn from experience). This cue works for many people, but for others it can be pretty tricky to figure out just how to engage the pelvic floor muscles.
First, I’d like to say that this makes a ton of sense as we may have been taught not to pay much attention to this part of our bodies. Additionally, for folks who are queer, trans, and genderdiverse, this can be especially daunting due to dysphoria and other concerns. With that in mind, not all of the suggestions below work for everyone. Please only do what feels comfortable and authentic for you!
So, what exactly *is* a kegel? Well, if you click here you can read my prior blog that goes into detail about all of the functions of your pelvic floor muscles. Essentially, a kegel is a contraction of a muscle, just like anywhere else in your body. As it can be difficult to initiate the mind-muscle connection, let’s start with positioning. Ultimately, you want to be comfortable, so choose whichever of the following you like best:
- Laying down on your back with legs out straight
- Laying down on your back with legs slightly bent and propped up on a pillow or bolster under the knees
- Laying down on your side with knees and hips slightly bent, preferably with a pillow or foam roller between the legs
These are the most ideal positions because you are fighting gravity the least. In other words, if your muscles are less strong right now, it will be easiest to activate them here. However, if you don’t want to lay down, you can sit upright, preferably in a comfortable chair with back support and feet on the floor. Wearing comfortable, unrestrictive clothing can also help to make this easier.
If you like hands-on feedback, you can place your hand(s) on your belly, bum, or inner thighs. The purpose for this is because, at first, we want to try and keep all other muscles soft. It is really common for folx to have their abdominals, glute, and inner thigh muscles try to kick on and help out, but we want to isolate as best we can. Once that is set up, try the following cues and see which you like most.
Cues:
- Contract the muscles you would if you were trying not to pass gas
- Nod the clitoris down towards the vaginal opening
- Imagine that you are walking into a very cold pool. Imagine the feeling of the scrotum moving up and in towards the body. Contract your muscles as though to recreate that feeling.
- Contract the muscles you would as though to move the penis up and down.
- Try to close urethra, vagina, and anus all at once
- Imagine the opening of the vagina or anus is an elevator. Start by closing the elevator door, then try to go up a floor (should feel like you are pulling up and in)
- Draw pubic bone at the front and tailbone at the back together
- Imagine there is a straw coming out of the vaginal or anal opening. Now think about the kind of suction you would make if drinking a thick smoothie. Contract your muscles like your pelvic floor is drinking the smoothie, pulling it up and in.
Techniques to self-check if you are doing it correctly:
- If you are comfortable with looking at this part of your body, try using a small mirror. You should see the perineum (space between vagina & anus, or scrotum & anus) pull away from the mirror and into your body. *Remember to try to keep all other muscles relaxed here* It may be best to prop yourself up against a wall or pillow.
- Again, if you are comfortable, insert one clean finger into the vagina or anus. You don’t have to go very far. Use the cues above and you should feel a squeeze and gentle pull in, almost like if a baby was sucking on your finger.
- If you have a partner that is open to the idea, sometimes it can help to have them try to feel and give you feedback, or for you to try to feel it on them.
“I can’t feel anything!”
Although we want to focus on the muscles in isolation first, if that is still too challenging, using other nearby muscles can be helpful. Some of the same muscles I listed above can help us temporarily get these muscles to fire up, if we are having trouble locating them. Try some of these exercises, first on their own and then with a kegel:
Most often, these strategies help people to at least initially figure out where these muscles are and how to activate them. Once you have that down, it is really important to next incorporate the breath. Why? Because our abdomen is kind of like a pressurized canister – some people compare it to a soda can. We have different components that help stabilize this canister, but right now let’s look at the top and bottom.
The diaphragm, one of our main breathing muscles, is at the top of the can, and the pelvic floor is at the bottom. These two need to work in concert together, otherwise you end up with an accordion-like compression (not great for a lot of different reasons). Now, how do we do this? It’s simple, really. Just take a big belly breath in and exhale while you do your kegel. Some people like to add a “Shh” sound like they are telling someone to be quiet in the library.
Deep breath in → exhale & kegel at the same time
You might even notice that your pelvic floor feels stronger when you add the breath!
Once you’ve gotten the hang of contracting your muscles and coordinating that with the breath, it is important to work on a few different types of contractions.
We have multiple kinds of muscle fibers in our bodies: Type I (slow twitch) and Type II (fast twitch). Both are vital, but serve different functions.
Type I (slow twitch) are our endurance muscles. They don’t have a lot of force, but also don’t fatigue quickly. They’re the muscles that can support our organs during a run.
Type II (fast twitch) are our power muscles. When we’re talking about kegels, they’re the ones that have the strength to avoid leaking while sneezing. They fatigue faster than Type I muscles.
Try these techniques to develop both fiber types:
- Using the above cues, do a kegel and try to hold it for 10 seconds. Notice if the quality starts to waver before the 10 seconds are up. If so, feel free to start at 5 or even 3 seconds to start. Goal: 3 sets of 10 seconds hold. Make sure to rest in between each set for at least 30 seconds.
- Quick flicks: here you will kegel as hard as you can and then release fully, but do so rapidly! The difficulty here is making sure you relax completely in between. For example, if contracting fully is 100% of your strength, make sure to return all the way to 0% before contracting again. On first try, I notice that many of my patients will only relax back to 50% or so before contracting again. We don’t want to do this because then we aren’t strengthening through all of our available range of motion. In the next blog, you will learn more about how to fully relax and elongate these muscles, but for now just imagine returning to your baseline or starting point from where you began this movement!
As you continue to get even stronger, you can progress to doing contractions in these postures:
- Sitting upright with knees and feet together
- Sitting upright with knees and feet apart
- Standing with feet together
- Standing with feet apart
- During dynamic movements like: walking, squatting, stair climbing, etc
These are all more challenging because you are fighting gravity. Also, your other postural muscles are working harder here too, so your kegel may feel weaker when you first start training in these positions and that’s totally okay.
Now you know how to contract your pelvic floor!
But, do you really “just need to do your kegels”?
Not quite… Some folks won’t benefit from doing kegel exercises, and in fact, kegels could make some symptoms worse.
Who may benefit from kegels? Most people, but especially those with:
- Hormonal transitions (starting or stopping gender affirming medical care with HRT)
- Folx pre/post bottom surgery
- Folx who have difficulty achieving orgasm, or have low strength orgasms
- Folx who have dribbling after going pee
- Folx who experience stress urinary incontinence (leakage with laughing, coughing, sneezing, running, jumping, etc) or fecal and gas incontinence.
- Folx with lower back pain or hip pain
- Folx with prolapse of the uterus or rectum
- Folx with hypermobility syndromes
- Those in the 1st or 2nd trimester of pregnancy
- Those with a weakened pelvic floor, such as around the 6 week postpartum time frame.
- Folx in menopause or perimenopause
*However* these situations are unique to every individual and it is possible kegels are not the best option for them. Seeing a provider for an assessment first is the safest bet.
Folx with any of the following experiences should avoid kegels until they’ve had proper evaluation/guidance:
- Pelvic pain of any type
- Patients who have undergone pelvic surgery
- Interstitial cystitis or bladder pain syndrome
- High urinary urgency and frequency (overactive bladder)
- Constipation
- Tailbone pain
- Active UTI or yeast infection
A great rule of thumb is: if it makes your symptoms worse, don’t do them!
About our guest blogger:
Brianna earned her Doctor of Physical Therapy at Texas Woman’s University in Houston, TX and her Bachelor’s of Athletic Medicine at University of Texas San Antonio. During and after graduate school, she received training on pelvic floor physical therapy in addition to her orthopedic manual skillset. As a competitive powerlifter, Brianna enjoys working with female athletes who experience stress urinary incontinence. She is passionate about providing care to individuals in the LGBTQ+ community, especially those undergoing hormonal/surgical transition. Additional clinical interests of her’s include: prenatal/postpartum care, vestibular and balance rehab, and sports-related injuries. In her spare time, Brianna enjoys playing board games, lifting heavy, and watching stand-up comedy.
