Author: Darla Cathcart, PhD, PT, DPT
Reviewed by: Callie Krajcir, RD
For people who have interstitial cystitis (IC) and painful bladder syndrome (PBS), (combined IC/PBS) there is a good chance they have heard that pelvic floor exercises or training and kegels are bad and should be avoided. A recent study by Wan-Ru, et al, (2022) found that in 65 women with IC/PBS, 85% of them had tender points in their pelvic floor, which often coincides with too much tension in these muscles. Other studies in the past have indicated similarly high percentages.
Physical therapists specializing in pelvic health are great providers to examine and assess the pelvic floor muscles (PFM) and determine the best treatments to address this component related to bladder pain. Truly, traditional “Kegels” are a treatment that will likely exacerbate symptoms for most people with IC/PBS. However, some appropriate training could be helpful for some people – think like “yoga for the pelvic floor.”
Let’s explore if some modifications on the old “Kegel” might be an appropriate component of your IC symptom management strategies!
So first, what exactly is a "Kegel"?
Many of you may already have some familiarity with this term and its history, but in short: In the 1940s, Dr. Arnold Kegel developed an exercise to help women prevent or stop urine leakage after childbirth. The exercise involved inserting a device called a perineometer (shaped kind of like a tampon) and squeezing the PFM around it. The perineometer showed how strongly the PFM squeezed (kind of like a blood pressure cuff reading). Dr. Kegel found that women who could squeeze at higher pressure readings were less likely to have bladder leakage.
You can contract these muscles without that inserted device. If you have a vagina, you can squeeze the muscles of the vagina upward and inward (or same for the anus if you don’t have a vagina); you can also squeeze as if using your labia to pick up a marble off your chair, or squeeze and hold onto a tampon, or hold in gas without clinching the butt cheeks.
The opposite motion, bearing down, would be to relax the PFM, then gently push out as if pushing your anus away from your body or pushing a tampon out of your vagina, with a gentle bulging outward of the vulva and anus.
Are Kegels different from "pelvic floor muscle training"?
Fast forward nearly 80 years, and there is now an entire profession of pelvic health therapists who have taken this very basic exercise and figured out how to prescribe variations of it specifically to an individual person’s needs. The therapist will examine the PFM, which typically would be done by inserting one gloved, lubricated finger into the vaginal or anal opening (depending on the anatomy present).
The following is assessed:
1. The tone of the muscle. When the examining finger presses gently on this muscle, does it have “normal” tone (is spongy and has some give, like sponge cake); or have low tone (feels soft and flaccid; less likely to occur in people with IC/PBS); or have too much tone (is tight, tense, and stiff, like a hard brownie; more common in folks with IC/PBS).
2. The muscle function and performance – can the PFM contract, relax, and bear down correctly? Often with IC/PBS, people will have difficulty relaxing the muscle after contracting it, or will have a hard time bearing down. Some people will even contract when trying to bear down, because the muscle does not have good control. All three of these motions are needed for good pelvic health; a few examples:
PFM contraction is needed to prevent bladder or gas and bowel leakage (squeeze to hold it in while you cough)
PFM relaxation allows the urethra to open for the bladder to empty
Bearing down is needed to release gas or to gently push out a bowel movement.
The PFM examination then helps to determine what kind of treatment is needed. This could involve down training, or learning how to relax the muscles or to bear down. Or it could involve coordination training, or learning how to coordinate PFM movement with certain activities; for example, can I squeeze the PFM to stop bladder leakage when I sneeze or laugh. These are the two types of training most commonly needed for patients with IC/PBS. Sometimes, uptraining is needed, which involves strengthening and increasing the tone of the PFM (i.e., the traditional “Kegel”) – and this is typically not the type of training needed for addressing IC/PBS symptoms.
So then, PFM training has a lot of variation, depending on how a muscle needs to be trained?
Yes, exactly! When we think about exercise in general, it can be very nuanced! Throughout the body, we can work a muscle group in different ways - we can do simple isometrics, perform slow active range of motion exercises, use rapid movements, add resistance (weights, cables, bands), focus on concentric (shortening) or eccentric (lengthening) contractions, or focus on stretching and flexibility. It all depends on what the muscle needs based on its current state (tone, performance – discussed earlier) and for its desired function!
For someone with low tone and weakness, the traditional Kegel is great! For someone with too much tone and difficulty relaxing (those with IC/PBS), the old Kegel is problematic. But, there are other types of muscle training to address the tense, tender pelvic floor muscles as well!
Kegels For Interstitial Cystitis...Why Do Some People Harshly Advise Against Them?
Is a blanket statement of "never contract your PFM!" appropriate for people with IC?
As physical therapists, we should avoid inducing movement fear - a lot of people are afraid to move or to use their PFM, which can actually make the pain worse. But first, let’s talk about why and how Kegels can be bad. As mentioned before, for many people with IC, there is tenderness and too much tone in the PFM. Because of this, doing a lot of maximally-squeezing, old-fashioned kegels may make an already "angry" muscle work harder and make symptoms worse. Thus, through the years, the blanket advice of “never do kegels” is born out of recognition of this common finding.
However, it can swing a little too far to say "never" do PFM exercise; someone may just need a modified version. Interestingly, the American Urologic Association (AUA) (Hanno et al, 2022) last year updated their guidelines to say folks with IC should NOT do Kegels, but then when you go in and actually read the article, they don't have evidence to support this stance. There currently is not evidence that doing some type of appropriate PFM exercise makes symptoms worse.
An example in the body could be related to having stiffness and pain in my neck muscles. If I have a lot of trigger points and tension, then I don't want to go lift heavy weights overhead, as the muscle tension could worsen and make my pain and stiffness worse.
First, I want to do some treatment to calm that muscle down, such as massage, heat or cold packs over the area, and gentle stretches. Once the muscle tone has normalized and the tenderness has decreased, if I want to increase the function and ability of that muscle to be able to lift a heavy weight overhead, then I have to eventually train and strengthen that muscle for that task. There is a balance in the treatments - calming the unhealthy tension and pain down and then working on strengthening or gently training in a healthy way.
It could be that some appropriately timed and prescribed PFM exercises could be very helpful for keeping those muscles healthy and controlling symptoms since controlled use of these muscles can at times be helpful for controlling urgency and engaging in bladder retraining. Those are examples of ways that appropriate PFM training may be prescribed to someone with IC in a functional way, likely along with other measures to work on getting and keeping the tone normalized (such as pelvic floor muscle “massage” or other relaxation treatments). But, this does NOT mean that a lot of repetitions of “hard squeezes” should be performed all day, which could make symptoms worse!
Now the real problem becomes - what if those trigger points keep coming back? Now we have to figure out WHY that is happening. . . are you tensing your PFM every time you're stressed or just throughout the day as a habit, or have poor posture on a computer all day (as staying a slumped position can cause increased PFM tension)? Or are you lacking enough vitamin D, magnesium, iron, or other vitamin/nutrient levels, which can result in some general muscle aches and pains? These are just a few examples of causes for PFM tension and tenderness.
What if the PFM keep getting tense again, even after working those spots out with manual therapy or massage, soaking in a warm tub, etc.?
There are a couple of ways to address this. First, check in with this question at regular intervals throughout the day "What are my PFM doing?" Are they squeezing? Are they at rest? What's going on down there? And then, if you catch yourself just squeezing the PFM for no good reason, then start taking notes of the situations in which this seems to occur (in traffic, on phone call, concentrating on work task, more stressed, during exercise or specific activities, etc.).
Then, start working on the control - can you let it go? It can be helpful to take a breath in, exhale and gently squeeze, and inhale again and release, then release some more, and keep releasing, like an elevator dropping; you can even add some gentle bearing down at the end. Identifying unnecessary squeezing and then working on eliminating that habit is a big start!
When you reach the point of not squeezing the PFM unconsciously all day, then the muscles often can stop having all that excessive tone. Now in some cases, the problem is the muscles tense to protect against bladder pain (though sometimes they cause the pain), or they tense up because there is weakness or spasm or both elsewhere in the core - and in those cases a broader approach is needed - where maybe work is needed on other muscles first, such as through the trunk and hips and thighs so that the PFM can let go of some tension. This is where someone probably needs the help of a well-trained pelvic health physical therapist.
Can I try gentle PFM training on my own?
A pelvic health physical therapist can really assess and determine the condition of the PFM and how they fit into the whole body of an individual, and create an individualized plan for them. Are there some ways that someone might try some gentle PFM training on their own? How can someone know that this might be helpful for them? Or how can they know if it might not be right for them?
You can definitely try some things on your own! You won't hurt anything by trying!
First, assess your own muscle tone. Insert a thumb or finger into the vagina and gently press against the back wall (toward rectum) and side walls (toward the hips), and answer these questions for yourself:
Is it painful? If so, keep any contractions "light" - we'll discuss more later.
How does the muscle feel to you? Hard like a brownie, or spongy like a sponge cake – for both of these, still keep the contractions “light.” (If it feels very loose, you may be able to perform “medium to strong” contractions, but again, this is less likely for most people with IC/PBS.)
Side note: If touching your own vagina seems weird and gross and scary - you may be experiencing some "fear avoidance" or "sexual disgust" related to the vagina - a whole other topic! But that can contribute to pain. Be kind to yourself and go at your own pace - again, consider getting professional help (pelvic health physical therapist, counselor, etc.) to address this component.
Second, can you gently squeeze your muscles around your thumb/finger? Do that a couple times in a row. After the third or fourth repetition, how does that feel - does it get less painful, more painful, or maybe it is not painful at all? If it gets more painful, you likely should not be doing these exercises at this point and may need a pelvic physical therapist to help you. If it gets less painful after a couple of gentle squeezes, keep going . . .
Now we can use some breathing and gentle contract-relax for pain relief and to help with muscle relaxation. The steps (finger or thumb still inserted - could later do with wand, trainers, dilators, vibrator, etc.):
Take in a slow breath, as if smelling freshly baked cookies, pause briefly, then as you exhale, very gently squeeze PFM around finger - hold through the exhale, then release and inhale again - repeat this series 3-4 times.
After the last release (make sure to release fully) – use your thumb or finger to give a very gentle stretch to the muscle - not to a point of “pain” (keep this at a 2-3/10 or less on the pain scale)! Hold this gentle stretch through 5 slow breaths. Let the pressure off. Reassess that location. Is pain better? This can help you then! Is the pain worse? Then this may not be the best treatment for you right now.
You can repeat the first two steps against the side walls (giving pressure inside the vagina toward the hips on each side). Thus, working in a “U” pattern (back, right side, and left side walls of the vagina).
If at any point the pain or symptoms worsen, just stop and breathe - again, you may need professional help to work on tone before this can be helpful.
Start with doing this routine for 3-5 minutes daily, or every other day. You can lengthen the time after you’ve practiced this for a while as you feel it is helpful. Just don’t overdo it, as you can make yourself sore (which you know is not helpful!). Keep the mantra “less is more” in mind.
You can also follow up these self-directed manual therapy/contract-relax sessions by soaking in a tub of warm water or sitting on a cold pack.
It bears repeating: Don't overdo it! You won't hurt anything or damage your muscles or vagina if you create soreness accidentally, but it also doesn't help to overdo it.
So how can this "contract-relax" technique work for alleviating pain and too much tone in the muscles?
This is for the nerds in the audience :)
From a physiological standpoint, controlled, gentle, active, voluntary muscle contraction does several things to help reduce excessive tone and pain (again, think "yoga" for the PFM):
Activates the Golgi tendon organs (GTO) of the PFM – when GTOs are turned on, they cause the muscle to not contract as easily, thus resulting in the muscle relaxing more easily.
Activates the motor cortex, or the part of the brain that controls the PFM – when the motor cortex is turned on, it limits pain pathways from the brain, thus resulting in less pain.
Activating the motor cortex also increases the connection between the brain and the PFM, which can reduce fear and anxiety around the PFM, resulting in less pain.
Releases endogenous opioids that the body and brain make, thus getting your body’s own little internal pharmacy working to reduce pain!
The intentional breathing (“inhale, exhale and gently squeeze”) helps to stoke the parasympathetic nervous system, which also calms the whole system and reduces pain.
Are there other techniques that could be used with this gentle PFM contract-relax and breathing combination?
Yes! You can combine the contract-relax and breathing with various techniques, or perform them by themselves: meditation, soaking in a warm tub of water, listening to calming music, using good smelling, relaxing candles, use of calming essential oils – basically anything that takes you into your healing space. One other technique you can try is IMAGERY use. Here’s how to combine it with your contract-relax techniques and breathing (or it can be done on its own):
With the finger or thumb inserted in the vagina, perform your contract-relax routine with breathing (described previously).
After the last release, continue with slow, gentle breaths, and as you take a breath in imagine . . .
There is a warm dot of color at the tip of your thumb/finger, and with each slow breath you take in, imagine that dot of color slowly spreading through the muscles, urethra, bladder, pelvis – basically anywhere that you need the release of tension and pain. OR . . .
That your pelvic floor muscles are made of taffy, out in the warm sun, and that with each breath you take in, this taffy softens and gently lengthens and expands – again, imagining anywhere in the pelvis where you need the release of muscle tension and pain. OR . . .
That you are sitting in the warm beach sand at the edge of an ocean (this one only works if you like the beach!), and with each breath, the warm water flows up over your legs and pelvis, and your sit bones sink into the warm sand, with your body feeling relaxed and supported, and the muscles are able to fully release in the sand.
Those are just a few imagery examples! There are many more, and you can also make up your own!
PFM training is not necessarily helpful for EVERY person with IC/PBS, but when used appropriately, it can be helpful for reducing excessive tone and pain in the PFM for some folks.
PFM training should not be painful or make symptoms worse - if you try it, and you get more pain or worsening of symptoms, don’t use it, or find a pelvic physical therapist who can help you!
PFM training may be most helpful in conjunction with or after doing other treatments to normalize the PFM tone (if there is too much tension and tenderness).
Hanno, P. M., Burks, D. A., Clemens, J. Q., Dmochowski, R. R., Erickson, D., FitzGerald, M. P., ... & Faraday, M. M. (2011). AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. The Journal of urology, 185(6), 2162-2170.
Wan-Ru Yu, M. S., Fei-Chi Chuang, M. D., Wei-Chuan Chang, M. S., & Hann-Chorng Kuo, M. D. (2022). Pelvic Floor Myofascial Pain Might Influence Treatment Outcome of Interstitial Cystitis/Bladder Pain Syndrome: A Prospective Study. Pain Physician, 25, E1315-E1322.