When "Just Do Your Kegels" Is the Wrong Advice

A Piece of Advice That Follows Women Everywhere

If you have ever mentioned bladder leakage, pelvic pressure, or pain during sex to a friend, a nurse, or even a doctor who does not specialize in this area, you have probably heard the same response: do your Kegels. It is the default advice for almost any pelvic floor complaint, and it gets repeated so often that most women assume it applies to them automatically.

Sometimes it does. Often it does not. I see women every week who have spent months, even years, squeezing and holding exercises that were never going to fix their problem, and in some cases, were making it worse.

The Assumption Behind the Advice

Kegel exercises strengthen a weak pelvic floor. That is the whole premise. The advice works well for women whose muscles are underactive: loose, understretched, slow to respond, often after childbirth or with age-related changes in tissue support.

But a pelvic floor can also be too tight. Muscles that are already in a state of chronic tension do not need more contraction. They need to release. Asking an overactive pelvic floor to do more Kegels is like telling someone with a clenched jaw to clench harder because their teeth hurt.

This matters because the symptoms can look identical from the outside. Leakage, urgency, a feeling of heaviness, pain with intercourse: all of these can come from a pelvic floor that is too weak, or from one that is too tight and cannot relax enough to function normally. Without an exam that actually assesses muscle tone, nobody can tell which one they are dealing with just from the symptom list.

How I Tell the Difference

When a patient comes in describing pelvic pain, urgency, or difficulty emptying her bladder fully, I do not start with an exercise handout. I do a physical exam that includes checking the resting tone of the pelvic floor muscles, not just whether she can squeeze on command.

A pelvic floor with normal or low resting tone that weakens further under stress is a candidate for strengthening work. A pelvic floor that is already tight at rest, that does not fully relax even when asked to, is a different problem entirely. For those patients, the first goal is relaxation and coordination, sometimes with pelvic floor physical therapy aimed at releasing tension rather than building it.

Giving a tight pelvic floor more strengthening work usually makes symptoms worse before anyone realizes the advice was wrong. I have had patients tell me they stopped doing their exercises because the pain got worse, then felt guilty for not keeping up with something that was never going to help them in the first place.

Why This Gets Missed so Often

Part of the reason this advice is given so broadly is that it is low risk and sounds proactive. Telling someone to do Kegels costs nothing, requires no referral, and feels like doing something useful. For a lot of women, it genuinely is useful. It just is not universal.

The other part is that a true pelvic floor assessment takes time that a general exam does not always allow. Checking resting tone, testing for coordination, and watching how the muscles behave under different conditions is not a five-minute addition to an annual visit. It requires a focused exam built for exactly that purpose.

What I Tell Patients Instead

If you have been doing pelvic floor exercises faithfully and your symptoms have not improved, or have gotten worse, that is information. It usually means the exercise was not matched to the actual problem, not that you did it wrong.

The standard advice is a reasonable starting point for a lot of people. It is not a diagnosis, and it should not be the only intervention offered to a patient with persistent symptoms. If months of Kegels have not helped, the next step is not more of the same. It is an exam that actually looks at what your pelvic floor is doing, so the plan can be built around what you need instead of around what works for someone else.