First of all, the pelvic floor is a group of muscles, which extends from the pubic bone in the front to the tailbone in the back, and it forms the bottom of your abdominal container. It is in the shape of a kite since it widens at the sitz bones (which are the bony structures you feel when you sit on your hand on a hard wooden chair). If you think about a kite, it is like two triangles back to back. The triangle in the front is called the urogenital triangle, and the back, the rectal triangle. The front triangle has the urethral and vaginal openings, and the back triangle, the rectal opening.
Refer to the picture of the pelvic floor muscles frequently while you are learning how to do these exercises. You need to be able to visualize where these muscles are and how the muscle fibres are oriented in order to be effective in strengthening these muscles.
The first thing that you want to do is to make sure that you are contracting both triangles equally while doing a Kegel, or if anything, slightly stronger in the front triangle. How do you know which triangle you are using? Stopping the passage of gas is contracting the back triangle, and stopping your urine stream, is contracting the front triangle. Since stopping gas or urine is a bit abstract, we tend to use more visual tools to help people understand how to find these muscles. The other thing to remember before we go any further is that you can never contract the front triangle without the back triangle, and vice versa; however, focusing on one triangle at a time initially will teach your brain to equally locate muscles in both triangles so that one triangle doesn’t become stronger than the other.
To contract the front triangle imagine that there is a ping pong ball sitting right outside your vagina. Squeeze the ping pong ball with your vaginal muscles, and draw the ping pong ball inward. To verify that you are doing this correctly, place one finger inside your vagina to feel the tightening and lifting inside of these muscles. This is the front triangle. The back triangle is engaged by imagining drawing a marble into your rectum. Close your eyes as you are visualizing these things since these muscles work well under visual guidance. Hold each area for several seconds, and repeat 10-15 of each type of contraction, once per day.
For several days or weeks, just practice engaging the vaginal/ping pong ball and rectal/marble on their own (remember, you will feel tightening in the other triangle as you work, but your focus is going to be on the triangle that you are visualizing). Once you feel that you are equally engaging your muscles in both triangles, and your brain recognizes that the pelvic floor has both vaginal and rectal components, you are ready to contract the pelvic floor as a whole.
Just a word about exercise frequency and repetitions: with exercises 1-3 below, do 10 repetitions of each exercise holding for 10 seconds, and resting for 10-20 seconds (provides support to the pelvic floor and resists fatigue), and the same amount holding for 2 seconds, resting for 2 seconds (helps open and close bowel/bladder and for sexual function). You can repeat these combined exercises 1-2x/day. If you do them daily for 3-4 months, you will definitely see the benefits of training your pelvic floor.
You will need to build up your tolerance to doing these exercises for ten seconds. To start, test how long you can hold the contraction without feeling the muscles let go, and add one second. That will be your starting point. Slowly, over the following weeks of practice, you can build up to the ten second holds.
Muscular action of the pelvic floor uses both areas together, and contracts the pelvic floor in the direction of the muscle fibers. If you look at the picture again above, you can see that the pelvic floor muscles go lengthwise (from front to back), sideways (from sitz bone to sitz bone) and diagonally from one sitz bone to the opposite pubic bone. Take some time to orient yourself with this drawing so that you can visualize and feel what you are doing.
The Kegel exercises are as follows:
Review the picture attached again to see how the muscles go in three directions- front to back from tailbone to pubic bone, side to side joining your sitz bones together, and the most superficial layer, the Ischiocavernosus muscle, which forms a diagonal line from the sitz bone to the opposite pubic bone.
Pelvic Floor Exercises (Kegels)
- Lying on your back, put all three areas of the pelvic floor together, by contracting your pelvic floor from the front to the back; imagine drawing your pubic bone and tailbone together and inwards. Hold for five seconds or whatever you are able to do initially. DON’T use your buttocks, inner thighs or abdominal wall.
Progression: When this gets easy, imagine that your pelvic floor is on an elevator, and after 5 seconds, draw the muscle up “one more floor”; hold for 5 seconds longer.
- Again using all three areas of the pelvic floor, lie on your back, knees bent and feet comfortably on the floor, draw in the edges of the front triangle (draw the two sitz bones together); let the sitz bones move back to their resting position again when you let go of the contraction. This is a side-to-side contraction. Visualization cues: images a magnet drawing your sitz bones together or squeezing out a stone with your vagina. Hold for 5 seconds. Progression: In the same position, draw the sitz bones together, lift inside for 5 seconds; then add a 5 second elevator.
- To increase sexual awareness and to strengthen the superficial layer of the front triangle of the pelvic floor, lie down with your knees bent and your feet flat on the floor. Imagine drawing a diagonal “X” pattern by imagining a line going from your right sitz bone towards your pubic bone, and vice versa (look at the picture carefully again- you are contracting the Ischiocavernosus muscle). Use your pelvic floor to draw this line. Your contraction should feel like you are moving your one sitz bone inwards towards the midline, up the midline and across to the opposite pubic bone. Repeat 5x on each side, holding for up to five seconds, and eventually for 10 seconds.
You must also practice getting the timing of these muscle contractions during activity. See The Knack (What Is The Knack) for more information on using the pelvic floor muscles at the right time to help with stress incontinence.
Be diligent and purposeful in your practice. These muscles take a little bit of concentration, but with some effort your brain will learn how to reuse them and make them strong again. If you are not getting stronger, or this is too abstract to learn without someone palpating (touching) those muscles to give you feedback, seek out the help of a Pelvic Health Physiotherapist who specializes in internal palpation of the pelvic floor muscles.