Research estimates that nearly half of all adult women and 75 percent of women over 65 experience urinary incontinence—meaning they leak when they sneeze, laugh, or run. Yet, according to the Mayo Clinic, only 25 to 61 percent of people who experience the issue will discuss it with their doctor.
Experts aren’t exactly surprised by the lack of sharing. “The stigma surrounding incontinence means some women are reluctant to ask for help,” says Alyssa Dweck, M.D., an obstetrician-gynecologist practicing in New York, noting that the stigma-discomfort combo can keep women away from the sports they love. “It’s a shame.”
Pelvic floor dysfunction—and keeping those issues to yourself—doesn’t only affect women, either. “In fact, because we often think about pelvic floor issues as a woman’s issue, many men go years and years without proper diagnosis or treatment of pelvic floor dysfunction,” says Nora Arnold, P.T., D.P.T., pelvic health physical therapist at the Johns Hopkins Hospital’s physical medicine and rehabilitation department.
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While the shame around pelvic floor issues is real, it’s also true that some forms of exercise can make the problem worse. “Any activity that increases intra-abdominal pressure (including running and lifting) can cause leakage,” Dweck says. But pelvic floor exercises can help you deal with that leakage. This is especially true when you have a little better understanding of what pelvic floor health looks like and how you can improve it.
Causes of Weak Pelvic Floors and Urinary Incontinence
Dweck says there are three main risk factors at play when it comes to pelvic floor weakness: genetics, weight gain, and pregnancy/childbirth. The latter two risk factors come down to extra weight on the pelvic floor. “It’s not just the process of giving birth; women can also have a weak pelvic floor after having a C-section due to the weight of the baby during pregnancy,” Dweck says.
A weak pelvic floor mean less control of your pee because “muscles support the bladder, and as these muscles weaken, the bladder can mechanically bulge into the vagina,” explains Dweck. Activities such as exercising, laughing, and coughing may increase the pressure put on the bladder and, thus, pee leaks out.
A common misconception when it comes to pelvic floor health is that a tight muscle equals a strong muscle, says Arnold. But there is an ideal mid-length position of the pelvic floor muscles at rest (in other words, not an overly tight position) that allows for optimal strength.
To put it in perspective, she offers this example: “If you make a fist with your hand, as strong as you can with your wrist in a neutral position, it’s nice and strong. But if you bend your wrist to 90 degrees and then make a fist, it’s much weaker due to the muscles being in a shorter position prior to contracting. The same thing happens at the pelvic floor—a tight pelvic floor is a weak pelvic floor.”
While you might think your pelvic floor is weak because it’s difficult to contract the muscles, the issue is actually more overactivity and tightness, Arnold adds. “In these cases, lengthening is the main priority,” she says. “A tight pelvic floor is not a healthy one—and pelvic floor ‘tightness’ is definitely not the goal for optimal pelvic health, especially with running.”
The Benefits of Kegels, the Most Common Pelvic Floor Exercise
If you’re wondering why you’ve been hearing about kegels since that Sex and the City episode almost 20 years ago, it’s because Samantha was right: kegels offer an approachable way to strengthen the pelvic floor. “Kegels strengthen the muscles that hold your bladder inside,” Dweck says. “The stronger these muscles are, the more support for the bladder.”
There’s just one catch with kegels: They’re not for everyone, Arnold says. “For many people kegels can be harmful to pelvic health and increase pelvic floor symptoms,” she explains. “Kegels are a good way to connect with the pelvic floor and build coordination, but it’s not a functional exercise. Your ability to perform a kegel when lying on a treatment table or sitting in your car doesn’t directly impact or predict the ability of your pelvic floor to respond to the demands of functional movement, like running.”
Before you start doing kegels on your own—especially if you have incontinence or other pelvic floor problems—Arnold recommends seeing a pelvic floor therapist to make sure they should get added to your routine. This is particularly important because many people perform kegels the wrong way.
If you’re clear to add these to your routine, Arnold offers these form cues for doing a kegel correctly:
- Squeeze your pelvic floor like you’re holding back from passing gas
- Contract as if you’re stopping the flow of urine (but don’t actually do this while you’re actually peeing)
- Draw your pubic bone and tailbone toward one another
- Contract as if you are drawing your sit bones together
- Pull your pelvic floor up as if lifting your bladder towards your heart
An important thing to remember, Arnold says, is that you need to both squeeze and lift—people forget that second part. You also need to be able to fully relax the pelvic floor muscles between reps, and breathe through each contraction and relaxation.
“Likewise, it’s important to be able to isolate the pelvic floor from the surrounding structures,” Arnold adds. “Often, the hip, thigh, or breathing and core muscles contract with a kegel. This can indicate that the coordination of the pelvic floor isn’t optimal. In this case, work on a more gentle kegel and focus on only activating the muscles between the sit bones.”
You can also check to make sure you’re doing this pelvic floor exercise properly, hitting that activation, lift, and relaxation. “For people who have a penis, the base of penis will lift upward on a contraction and relax down towards toes on a relaxation,” Arnold says. “Likewise, those with vaginas can use a mirror to assess the perineum [that’s the area between the anus and vulva]—a drawing inward of the vaginal opening on contraction and a gentle opening and drop on relaxation. You can also use your hand over the perineum to feel if the pelvic floor lifts inward on a contraction and relaxes into your hand on the relaxation.”
Finally, Arnold suggests using kegels as coordination training and performing them in different positions like standing and sitting. “They can also be useful as an activation exercise or warmup prior to any strength training or physical activity to ensure optimal communication between the nervous system and the pelvic floor,” she adds.
Other Pelvic Floor Exercises to Add to Your Routine
While everyone will require different exercises to improve their pelvic health, a few tried-and-true pelvic floor exercises will also do these muscles some good. “The good news is that most of the cross training, strengthening, and functional movement you already do is strengthening your pelvic floor,” Arnold says.
When doing these exercises, you don’t have to consciously think about engaging your pelvic floor, Arnold explains. “Your pelvic floor should work without conscious effort when you move—so we need to train it that way, too. It’s also very important not to hold your breath with these exercises—that’s your body trying to make it easier for your core and pelvic floor,” she says. “As a runner, you need the pelvic floor to be fully functional with increased breath rate and volume.” Inhale as you lower into these movements, and exhale as you stand or press up.
Squat
Stand with feet just wider than shoulder-width apart, toes turned slightly out, and hands clasped in front of chest. Send hips back and down to lower to a squat. Drive through feet to stand back up. Repeat for 10-12 reps.
Push-Up
Start in a high plank position with wrists directly under shoulders, core and glutes engaged so body forms a straight line from head to heels. Bend elbows to lower chest to floor to perform a push-up. Repeat for 10-12 reps.
Glute Bridge
Lie faceup with knees bent, feet flat on floor, and arms resting at sides. Squeeze glutes and hamstrings to lift hips up off floor. Lower hips back to floor. Repeat for 10-12 reps.
Bird Dog
Start on all fours, shoulders over wrists and knees under hips. Keeping hips and shoulders square to the ground, extend right arm and left leg straight out, lifting to shoulder and hip height. Return back to all fours. Repeat on the other side. Continue alternating for 5 reps per side.
Why You Need More Than Strength Exercises for Your Pelvic Health
Strength is important for the pelvic floor, but as Arnold mentioned, you also need length and coordination. “Without normal resting length we cannot physiologically build strength, and without coordination any strength we do have may not be adequately recruited during functional activities,” she says. “It doesn’t matter how strong a muscle is if your body isn’t able to turn it on at the right time.”
The best way to focus on that lengthening and coordination is with diaphragmatic breathing, Arnold says. “As you inhale, your pelvic floor should relax and lengthen passively, just like the belly (or like a balloon filling with air). You can do this lying on your back, in child’s pose, happy baby, a deep squat, or reclined sitting,” she says. “In my opinion, diaphragmatic breathing is the number one tool in the pelvic health toolbox, and (unlike kegels) it’s safe for everyone to add to their routine.”
Because this type of deep belly breathing also trains coordination between the pelvic floor and diaphragm, it could improve breathing function, which also helps with running performance, Arnold adds.
Mallory Creveling, an ACE-certified personal trainer and RRCA-certified run coach, joined the Runner's World and Bicycling team in August 2021. She has more than a decade of experience covering fitness, health, and nutrition. As a freelance writer, her work appeared in Women's Health, Self, Men's Journal, Reader's Digest, and more. She has also held staff editorial positions at Family Circle and Shape magazines, as well as DailyBurn.com. A former New Yorker/Brooklynite, she's now based in Easton, PA.
