Fixing urinary incontinence: Why Kegels alone didn’t fix your leaking

When you do a quick search on urinary leaking or incontinence, you are almost guaranteed to find the advice to do “kegels for your pelvic floor” or “pelvic floor exercises (kegels)”. Unfortunately I’ve heard from many patients that they have been told by their physician to do kegels instead of pelvic floor therapy, that they have tried kegel trainers they found online, or they paid an arm and a leg to use an Emsella chair - and they are still leaking. In this blog post I’m going to discuss different factors that cause urinary incontinence, why kegels and pelvic floor trainers may not be the answer for you, and why pelvic floor therapy is way more than just kegels.

First, let’s discuss how your bladder and pelvic floor should work together.

One of the main roles of your pelvic floor muscles is to support your pelvic organs, including your bladder, uterus/prostate, and rectum. Your bladder has a layer of smooth muscle in its wall called the detrusor muscle, which relaxes to store urine and contracts to expel urine.

As urine moves into your bladder from your kidneys, your detrusor muscle is relaxed to allow your bladder to fill while your internal urethral sphincter and pelvic floor muscles are contracted at a nice baseline tension. This means the pressure outside of the urethra is higher than in the bladder, allowing the bladder to fill without urine leaking out.

As the bladder fills, it will send a signal to your brain when it has 150-200 ml of urine in it. This is about when the bladder is about half full. At this point, your brain should interpret this signal and gently notify you that the bladder is filling. Your brain will continue to postpone voiding until you are able to sit down, maintaining the higher pressure outside the urethra than in the bladder.

Once you are able to get to the bathroom, your brain signals your pelvic floor muscles and internal urethral sphincter to relax and your detrusor muscle to contract, emptying urine out of your bladder through your urethra. Once your bladder is empty, your detrusor muscle relaxes and your pelvic floor muscles and internal urethral sphincter return to their baseline tension to once again create more pressure outside of the urethra than in the bladder.

Here is where things can go wrong.

There are several different bladder problems that can occur if something in the process above gets disrupted. Some reasons this process could be disrupted (outside of neurological injury or disease) include daily habits, consuming bladder irritants, or pelvic floor muscle dysfunction. Disruptions in this process can cause symptoms of overactive bladder, incomplete emptying of the bladder, and urinary incontinence.

Let’s quickly cover the different types of urinary incontinence. 

There are a few types of urinary incontinence you may experience.

1)    Urge incontinence – you may experience a strong urge to urinate, often following a trigger (pulling into your driveway, putting your key in your door, running water). If the urge is too strong, the detrusor muscle may contract and you may involuntarily pee.

2)    Stress incontinence – leaking caused by external pressure placed on your bladder such as coughing, sneezing, jumping, or running.

3)    Mixed incontinence – when a person experiences both urge and stress incontinence.

What is a kegel, why are they suggested for urinary incontinence, and why is this often problematic? 

A kegel is a voluntary contraction of the pelvic floor muscles. Common cues for a kegel include “picking up a blueberry with your vagina”, “stopping the flow of urine and stopping gas”, or “sucking a milkshake up your vagina”.

The assumption in prescribing a kegel for urinary incontinence is that the pelvic floor muscles are weak (hypotonic or low tone), leading to a lower baseline tension. That means as your bladder fills with urine, the pressure inside of the bladder may become higher than the pressure produced by the internal urethral sphincter and pelvic floor muscles, which causes urine to leak. The idea is kegels will strengthen and increase tone in the pelvic floor muscles to allow a better baseline tension, improve bladder support, and therefore stop the bladder from leaking.

In some cases, when patients truly do have hypotonic pelvic floor muscles, kegels may be helpful in reducing leaking. However, a hypotonic pelvic floor is not the only cause of urinary incontinence. If the cause of leaking is not a hypotonic pelvic floor alone (spoiler alert: there is always more to the story!!), kegels may not be helpful for long term relief and in some cases, could actually make your symptoms worse.

Now let’s talk about what I assess with patients experiencing incontinence, and how we may prescribe treatment based on our findings. 

1)    Pelvic floor muscle function. Assessing your pelvic floor muscles is helpful in determining how your bladder is being supported. Above I discussed how patients may have a hypotonic, or weak, pelvic floor. Reduced pelvic floor muscle strength/tone could be idiopathic, can occur following pregnancy and delivery, or can occur due to hormonal changes in menopause and perimenopause. It is important to assess all of these factors to determine the best treatment strategy, rather than just prescribing kegels because the pelvic floor is “weak”. 

Pelvic floor muscles can also be more tense, or hypertonic. I typically see this more often in my practice than hypotonic pelvic floor muscles. Tense pelvic floor muscles can cause symptoms such as painful intercourse, UTI-like symptoms, vaginismus, and yes – urinary incontinence. Imagine a sudden increase in pressure on your bladder from a cough or a sneeze. If your pelvic floor muscles are tense, they are unable to absorb force well from the downward pressure of a cough or sneeze, so your bladder is essentially pushed down on a concrete pad rather than a trampoline. Without this force absorption, leaking can occur.

If your pelvic floor muscles are tense, squeezing them over and over again with kegels won’t change that. They need to learn to lengthen, then move through their full range of motion. Additionally, other factors contributing to this tension need to be addressed, which can include gripping patterns in the abdominal muscles and pelvis, high stress/anxiety, constipation, and possible fascial restrictions from abdominal surgeries or reduced organ mobility in the pelvis and abdomen (you can learn more about visceral manipulation for the pelvic organs here).

2)    Pressure management. I talked a lot above about how your pelvic floor muscles and bladder work together. Your pelvic floor muscles also work in tandem with your diaphragm and abdominal muscles to manage pressure in your abdomen. I always assess breathing, rib cage mechanics, and abdominal strength/coordination in patients with urinary incontinence.

If pressure management is off in the rib cage and abdomen, it can increase pressure down on your pelvic organs. Imagine pressure pushing down on your bladder from above – it is harder to maintain continence with increased pressure down on your bladder.

So how do we treat this? It depends! If you are belly breathing or a shallow breather, we would work on retraining your diaphragm muscle so your rib cage can expand. If your abdominal muscles are weak, you are dominant in your upper abs, or your obliques are more dominant, we would prescribe specific exercises to address these issues.

3)    Basic orthopedic assessments. Strength, range of motion, and any associated pain/discomfort are all important to get a better picture of how your entire system is working together.

If your pelvic floor muscles are tense, they may be gripping to find stability that you are missing in your core or hips. If you leak every time you jump, your foot and hip may not be absorbing force well, which means your pelvic floor has to absorb a lot more force than it is able to. Rather than just doing kegels or pelvic floor relaxation exercises, you can make a greater impact by strengthening your hips and feet to improve your ability to absorb force, reducing the stress on the pelvic floor. Learn more about this by checking out my free download yes, you can run, jump, and lift without peeing your pants here.

It is also important to assess hip rotation, thoracic mobility, any SI joint dysfunction, the lumbar spine, and more. These areas we consider “orthopedic” greatly impact your pelvic floor function, and your pelvic floor impacts these areas. I firmly believe that treating patients through both and orthopedic and pelvic health lens at the same time leads to the best results.

4)    Assessing any scars and deeper structures. After I began training through the Barral Institute, I realized how impactful visceral manipulation assessment and treatment can be for so many orthopedic and pelvic floor conditions.

When there are restrictions in deeper structures, such as organs, blood vessels, and nerves, your muscles can respond by guarding. Some patients will get temporary relief with treatment of tight muscles, but until we reduce the deeper restrictions the muscles will continue to guard.

Check out the links below for more specific blog posts about visceral manipulation to learn more.

What is Visceral Manipulation?

Visceral Manipulation and Your Pelvic Floor - Why Organ Mobility is Key for Pelvic Health

5)    Daily habits and lifestyle factors contributing to bladder function. If a patient is experiencing urge incontinence or mixed incontinence, it is crucial that we assess and treat urgency right away. This is often done through urge suppression techniques and improving healthy bladder habits.

We will discuss bladder irritants (and if they matter for you), when you experience leaking, and so much more. Each patient I treat is given individualized recommendations to improve bladder function.

As you can see, there are a lot of different factors that can contribute to incontinence and bladder function. Simply recommending kegels for urinary leaking is incomplete advice. If you’re experiencing urinary incontinence, I work with patients in my offices in East Memphis and Collierville, TN and virtually and I would love to help! You can schedule your evaluation or free 15 minute phone consult here.

Blog post written by Dr. Alexis Hutchison, PT, DPT, OCS, PCES