Search almost any male pelvic floor symptom and you'll be told to do Kegels. Pelvic pain, dribbling, erection problems, finishing too fast: Kegels. So plenty of men start squeezing before anyone has examined them, and some of them get worse.
One of the most common things I hear at a first visit is some version of "I started doing Kegels and the pain went up." That isn't bad luck. Kegels train a contraction. If your problem is a pelvic floor that can't let go, more squeezing works against you.
Two problems with opposite fixes
The International Continence Society uses two terms for this (Messelink et al., 2005). An overactive pelvic floor doesn't relax when it should, and may even tighten at moments it should let go, like when you pee or have a bowel movement. An underactive pelvic floor can't contract well enough when it needs to.
"Tight" and "weak" are the everyday words for the same idea. Both get called pelvic floor dysfunction, and they need close to opposite approaches.
One wrinkle: tight doesn't mean strong. A muscle that never fully relaxes often can't produce a good contraction either, because it's starting from partway clenched. So a man can test as weak and still need to learn to relax before strengthening does him any good.
What a tight pelvic floor tends to look like
Pain in the perineum, penis, testicles, rectum or tailbone
Pain that's worse after sitting
A slow start to urination, a weak or stop-start stream, or feeling like you didn't fully empty
Straining with bowel movements, or feeling like you didn't finish
Pain during or after ejaculation
A penis that feels semi-firm, shrunken or numb at rest (more on that in hard flaccid vs. erectile dysfunction)
Symptoms that flare with stress
What a weak pelvic floor tends to look like
Leaking when you cough, sneeze, lift or stand up, most often after prostate surgery
Dribbling after you've finished peeing and zipped up
Trouble holding gas
In some men, erections that don't hold as well as they used to
Why a symptom list won't settle it
The two lists overlap more than they look. Urinary frequency shows up with both. So do erection problems. Even dribbling can come from either side: a pelvic floor that doesn't relax while you pee can leave urine behind that leaks out later.
That's why I examine before deciding anything. An internal exam tells me your resting tension, whether you can contract on purpose, and the part most men don't expect: whether you can let go afterward. Plenty of men can squeeze hard. Fewer can fully release.
Where Kegels do help
Kegels have good evidence behind them for the right problem. They're a standard part of recovering bladder control after prostate surgery. In a 1997 randomized trial, men with dribbling after urination who did pelvic floor exercises for 12 weeks lost less urine than men who only got counseling (Paterson et al.). A review of randomized trials in men also found that strengthening helped erectile function (Dorey, 2005).
What those studies have in common is a pelvic floor that needed more strength. For one that's already stuck on, the first job is different: bringing the tension down with manual therapy, learning to drop and relax the muscles on purpose, and changing habits that keep them braced, like holding urine or clenching through the day. Strength work may come later, once the muscles can let go.
If Kegels have made your symptoms worse, stop doing them until someone has actually examined you.
Find out which one you have
I treat men's pelvic floor conditions exclusively at Pelvic Lab, and sorting out tight from weak is a central part of the evaluation. If you're not sure which side you're on, a short call can help you decide whether an evaluation makes sense.
Book a free 15-minute call with Dr. Weber or schedule a full evaluation.
Pelvic Lab is located in the Flatiron District of Manhattan at 16 Madison Square West.
Dr. Joshua Weber, PT, DPT, is the owner of Pelvic Lab in Manhattan. This article is educational and is not a substitute for an individualized medical or physical therapy evaluation.
