The 'Pee Symphony:' Why No Kegels on the Toilet
Urination requires the bladder, spinal cord and pelvic floor muscles to seamlessly coordinate; the act is like a symphony with each section playing in perfect harmony. The conductor orchestrates the timing between various neurological loops to play the exquisite peice, “Blissful Urination.” Some common toileting habits confuse the orchestral sequence, however, and can lead to dysfunction. Hovering & straining to urinate, going to the bathroom 'just in case,' and practicing 'kegels' by stopping the flow of urine, are like an electrical guitar playing out of time with the symphony...it confuses the entire piece and eventually the production will fall apart. Let’s examine in more detail why practicing pelvic floor muscle contractions on the toilet can confuse urination and lead to bladder dysfunction.
'KEGELS' DURING URINATION
Have you ever been told to strengthen your pelvic floor muscles by stopping the flow of urine? This 'old-school' recommendation has been passed on through the generations. Most pelvic floor therapist's opinion of doing pelvic floor exercises on the toilet is a resounding NO!! It makes sense to try a kegel during urination as tightening the pelvic floor closes the door to the urethra and coordinating a contraction can be hard for some people to feel but, let’s examine why this may not be the best advice ever.
THE INVERSE RELATIONSHIP OF THE BLADDER & PELVIC FLOOR:
There is an intricate relationship between your pelvic floor and bladder muscles. Simply put, when your pelvic floor muscles are turned on the bladder relaxes to fill, and when your bladder muscle is turned on the pelvic floor muscles let go to release urine. During bladder filling, your pelvic floor muscles turn on just a little to keep the doors of the urethra shut; this keeps you continent & prevents leakage (think of a valve closing over a faucet to keep water in). On the flip side, when your bladder fills it will stretch. Eventually, the feeling of urgency will reach a crescendo and you will plan to find a bathroom. When you reach the toilet, the micturition reflex for urination kicks in reversing the storage phase. Now, the bladder muscle contracts and the pelvic floor muscles relax to open the doors of the urethra (you open the valve on the faucet to flow).
NEUROLOGICAL LOOPS & COORDINATION:
Neurologically speaking, a LOT is happening between the brain and spinal cord to make urination happen. Physiologically we have circuits called 'Bradley's Loops' that activate in order to maintain continence and allow for urination. There are 4 of them.
- Bradley's Loop 1 is all about concious awareness. You decide in the frontal lobe of your brain, “I need to go to the bathroom” and plan your next steps. It allows you to switch between bladder filling and voiding states.
- Bradley's Loop 2 coordinates bladder and sphincter contraction and relaxation (when one is on the other is off).
- Bradley's Loop 3 causes the sphincters of your pelvic floor to relax while your bladder muscle contracts to push urine out.
- Bradley’s loop 4 reverses urination for bladder filling: the pelvic floor turns on to maintain continence while to bladder relaxes to fill.
TOILET KEGELS & NEUROLOGICAL CONFUSION:
But, WAIT! “Whu oh! What’s this?! Pelvic floor muscle contractions?! You’ve got to be kidding me!” the conductor say, ”abort mission urination!" By doing a pelvic floor contraction during urination you performed a concious over-ride of the micturition reflex. This isn't going to mess up the interplay of the neurological loops if you do it just one time, but if you make a habit of it you may begin to notice the following:
- difficulty starting the flow of urine
- slow or light stream
- feeling like you haven’t completed urinated
- urinary tract infections
Many women have practiced performing kegels on the toilet to ensure they are doing a pelvic floor muscle contraction properly. If you feel that not doing a kegel on the toilet is taking away your method of confirmation here are some other suggestions for working on coordination:
- you can insert a finger into the vagina and feel the pelvic floor squeeze around your finger
- watch the pelvic floor lift in a mirror
- sit on a towel for proprioceptive feedback
I hope this helps! Please post any questions or comments below!
- Article written by Susannah Haarmann, PT, WCS, CLT
Susannah is a board-certified Women's Clinical Specialist by the American Physical Therapy Association. She is a private practice owner in Asheville, North Carolina, teaches nationally in pelvic health and internationally in breast oncology rehabilitation. Susannah is an advocate of conservative treatment for pelvic health conditions and writes handouts for practitioners to improve patient literacy
If you found this article helpful and want to learn more about other toilet habits that cause neurological confusion you may find the following blogs helpful:
If you are a pelvic practitioner, you may find the following patient education handouts helpful in your practice: