Who should perform pelvic floor (Kegel) exercises, and what is the recommended technique, frequency, and duration?

Pelvic Floor (Kegel) Exercises: Who, How, and When

Pelvic floor muscle training (PFMT) should be offered as first-line treatment to all women with urinary incontinence—particularly stress incontinence—and to appropriately selected patients with neurogenic lower urinary tract dysfunction, especially those with multiple sclerosis or cerebrovascular accident. 1, 2

Who Should Perform Pelvic Floor Exercises

Primary Indications

• Women with stress urinary incontinence (involuntary urine loss with coughing, sneezing, or physical exertion): PFMT achieves up to 70% symptom improvement and is the definitive first-line therapy 1, 2, 3
• Women with urgency urinary incontinence: PFMT combined with bladder training is recommended 2
• Women with mixed urinary incontinence: Combined PFMT plus bladder training addresses both stress and urgency components simultaneously 1, 2
• Patients with neurogenic lower urinary tract dysfunction, particularly those with multiple sclerosis or cerebrovascular accident, to improve urinary symptoms and quality of life 4
• Women during pregnancy: May reduce the risk of developing urinary incontinence, though evidence quality is lower 1

Contraindications and Cautions

• Patients with interstitial cystitis/bladder pain syndrome who have pelvic floor tenderness should AVOID pelvic floor strengthening exercises (Kegel exercises), as these can worsen symptoms; manual physical therapy to release trigger points is appropriate instead 4
• Patients with pelvic floor muscle spasm or overactivity may require muscle relaxation techniques rather than strengthening 5

Proper Technique

Essential Components

PFMT must involve repeated voluntary pelvic floor muscle contractions taught and supervised by a trained healthcare professional (physiotherapist or continence nurse) to maximize effectiveness and prevent incorrect muscle activation. 1, 2

Specific Exercise Protocol

• Contraction duration: Hold each pelvic floor muscle contraction for 6-8 seconds 1, 6
• Rest period: 6 seconds of rest between each contraction 1, 6
• Session frequency: Twice daily 1, 6
• Session duration: 15 minutes per session 1, 6
• Breathing: Maintain normal breathing throughout—never hold your breath or strain to avoid Valsalva maneuver 1
• Muscle isolation: Focus on isolated pelvic floor muscle contractions without engaging abdominal, gluteal, or thigh muscles 1

Frequency and Duration

Minimum Treatment Duration

• At least 3 months of supervised PFMT is required before considering the intervention unsuccessful or moving to second-line treatments 1, 2, 3
• Improvements in symptoms, quality of life, and continence rates become evident across all age groups with appropriately performed exercises over this timeframe 3

Long-Term Adherence

• Long-term adherence to PFMT maintains benefits; exercises should be continued indefinitely to sustain improvements 1
• Daily practice is essential for optimal outcomes 1

Expected Outcomes and Success Metrics

Definition of Success

• Clinically successful treatment is defined as ≥50% reduction in incontinence episodes 2
• Up to 70% improvement in stress incontinence symptoms is achievable with proper technique 1, 3
• Women receiving supervised PFMT are more than 5 times as effective as those receiving no active treatment 2

Superiority of Supervised Training

• Supervised PFMT by healthcare professionals shows significantly better outcomes than unsupervised training or leaflet-based care 2, 3
• Instruction on proper technique by trained personnel is essential to obtain optimal benefits 1
• Success rates with comprehensive supervised approaches can reach 90-100% 1

Common Pitfalls and How to Avoid Them

Critical Errors to Prevent

• Do not proceed to pharmacologic or surgical treatment without a minimum 3-month trial of supervised PFMT; this wastes the opportunity for effective, harm-free intervention 2
• Do not rely on unsupervised or leaflet-based instruction; professional supervision is essential for proper technique and optimal outcomes 1, 2, 3
• Do not prescribe Kegel exercises to patients with interstitial cystitis/bladder pain syndrome and pelvic floor tenderness; this can worsen their condition 4
• Do not use systemic pharmacologic therapy for stress incontinence; no medication has demonstrated efficacy and represents inappropriate treatment 2

Optimizing Treatment Success

• Ensure patients understand correct muscle isolation—many women initially contract the wrong muscle groups 1
• Address behavioral or psychiatric comorbidities concurrently, as these affect treatment adherence 1
• Combine PFMT with lifestyle modifications including weight loss for obese patients (BMI ≥30), with a number needed to treat of 4 for symptom improvement 2
• For mixed incontinence, always combine PFMT with bladder training rather than using either intervention alone 2