Why Kegels Can’t Fix Every Pelvic Floor Problem

In thousands of social media posts, women are urged to exercise their pelvic floor—sometimes via musical “squeeze-along” routines or inserting vaginal weights. The posts describe the pelvic floor as a sling below the torso and claim that Kegel exercises can cure problems involving the bladder, bowels, or reproductive organs.

But experts say this two-dimensional vision is too simple. Pelvic floor muscle strengthening does benefit some women with pelvic floor problems, but it doesn’t help every condition or every body.

“You can have the strongest pelvic floor muscles in the world but lack connective tissue supports for those muscles. Or you could have really strong muscles, but the sphincter muscle inside your urethra is not strong,” says Linda McLean, a pelvic health researcher at the University of Ottawa. For example, her research found that women whose bladder sits lower in the pelvis are less likely to benefit from strengthening routines.

Complicating the picture, some women have pelvic pain because their muscles are too taut, not too loose, says Leslie Rickey, a urogynecological researcher at the Yale School of Medicine. “When someone has tightness, strengthening exercises can actually worsen the problem,” she says.

Researchers are now gaining a fuller understanding of just how complex and dynamic the female pelvis is, encompassing extensive muscle groups, nerves, connective tissue, and bones. “It’s a three-dimensional structure. There are areas where muscles are broad, areas where they're thicker, areas where they're wrapping around organs, and others where they form a kind of shelf,” says Steven Abramowitch, a bioengineer and pelvic researcher at the University of Pittsburgh. The pelvis is also continually subjected to forces from gravity, movement, stretching, and pressure from the bladder and bowels—not to mention pregnancy and childbirth.

Getting a handle on all these dynamics will be key to providing better treatment to the 62 percent of American women who suffer from urinary incontinence. That includes stress incontinence, in which a sudden increase in intra-abdominal pressure—from a laugh or cough—causes urine to leak. Chronic pelvic pain, which can have many causes, affects an estimated 15 to 26 percent of women worldwide. In comparison, 3 percent or more experience pelvic organ prolapse, in which the uterus, cervix, or bladder drops into the vagina.

The challenge now is to determine what part of this system is driving an individual woman’s symptoms—and match the treatment to the cause rather than prescribing the same exercise to everyone.

A key insight in recent years is that the muscles at the base of the pelvis—the ones toned with Kegel exercises—may not be the only ones that matter. Other muscles help elevate the pelvic organs from above, much as a guy wire holds up a telephone pole. “The lifters that support against gravitational loads seem to be really important,” McLean says.

(These overlooked muscles are the key to aging well)

Not surprisingly, childbirth can place extraordinary strain on this system. One MRI study found abnormalities in the levator ani—the group of muscles supporting the pelvic organs—in about 20 percent of women after their first vaginal delivery. The muscle can even detach from the pubic bone, “where it tries to generate force as it contracts, but is no longer very effective,” Abramowitch says.

Postpartum women are not routinely imaged for this injury, Abramowitch says, in part because no established treatment exists. His lab is studying whether the muscle could feasibly be reattached, much as detached muscles and tendons are repaired elsewhere in the body.

Other factors may alter pelvic support over time. Hormonal shifts during menopause can change pelvic tissues, while chronic constipation and obesity increase the pressure they must withstand. Researchers are also trying to understand the role of high-impact exercise. One recent study found that pelvic floor symptoms were common among female marathon runners, although it could not determine whether running caused them.

McLean’s lab has recently turned its focus beyond the muscles themselves. Because pelvic floor muscles contain extensive fascia and other connective tissue, her team is investigating whether changes in those tissues contribute to leakage.

(The pelvic floor is critical for men’s health too)

How certain anatomical problems link to function problems remains another unanswered question. Without this knowledge, experts can’t reliably predict which women will respond best to a specific treatment, Abramowitch says.

Researchers also need to understand how pregnancy and menopause remodel pelvic tissue—and what role estrogen therapy might play. A 2022 report by the American Urogynecologic Society and the International Urogynecological Association identified the effects of hormone treatments as an important area for further study.

Ideally performed under the instruction of a pelvic floor physical therapist, Kegel exercises remain a first-line treatment for mild prolapse, urinary stress incontinence, and urge incontinence—in which a sudden need to urinate is followed by leakage.

Inserting a pessary—a removable silicone device similar to a birth-control diaphragm—also reduces leaks. In an unpublished study presented at the International Urogynecological Association’s annual conference in June, McLean found that pessaries helped female runners when worn during exercise.

Scientists are also exploring other non-surgical approaches, such as low-energy shock wave therapy, which has been beneficial in small pilot studies.

Other treatments depend on the condition. For some forms of stress incontinence, urogynecologists may inject a bulking agent into the urethra, including a gel approved by the Food and Drug Administration in 2020. Urge incontinence can be treated with medications or a newer nerve-stimulating device implanted near the ankle.

Still, an American woman’s lifetime risk of undergoing surgery for stress incontinence or prolapse by age 80 is about one in five. Stress incontinence can be treated with a small mesh sling placed around the urethra, while prolapse surgery can sometimes use the woman’s own tissue instead of mesh.

“When Kegel exercises are not successful, I don't think we should be blaming women that they're not doing a sufficient job,” Abramowitch says. “Instead, there’s likely an important physiologic reason for its lack of success.”