Kegel exercises

Definition

Kegel exercises (Kegels) are exercises designed to strengthen the muscles of the lower pelvic girdle, or pelvic floor—the pubococcygeal (PC) muscles. The PC muscles support the bladder, urethra, and urethral sphincter—the muscle group at the neck of the bladder that acts as a spigot for controlling urine flow into the urethra—and the vagina, uterus, and rectum. Anything that puts pressure on the abdomen can weaken or damage these pelvic muscles. Such conditions include pregnancy, childbirth, excess weight, hormonal changes, and aging. Kegel exercises enable the PC muscles to better withstand increases in intra-abdominal pressure (pressure inside the abdomen). They make the bladder, urethra, and vagina more resilient, and improve bladder control and sexual relations.

Thirteen to 20 million American women suffer from urinary incontinence, primarily stress urinary incontinence (SUI)—urine leakage while laughing, coughing, sneezing, standing up suddenly, or exercising. SUI occurs when intra-abdominal pressure increases and the urethral sphincter opens inappropriately. During pregnancy, the fetus puts pressure on the bladder and the sphincter may relax and leak. Postpartum incontinence may result from muscle and nerve damage during childbirth due to delivery of a large baby, prolonged labor, excessive pushing, a forceps delivery, or an episiotomy (an incision made during delivery to prevent tearing of maternal tissue). About 40% of American women suffer from incontinence after childbirth, and the incidence increases by about 12% following each birth. Childbirth also increases the risk for incontinence later in life. During menopause, as a result of lower levels of estrogen, women with SUI may have thinning of the lining of the outer urethra, a sensation of having to urinate often, and recurrent urinary tract infections (UTIs). Beginning Kegels in midlife can help prevent urinary incontinence later.

Origins

In the 1930s, Dr. Joshua W. Davies hypothesized that strengthening the PC muscles could improve bladder control by assisting the closure of the urethral sphincter. By 1948, Dr. Arnold M. Kegel, a Los Angeles-area obstetrician and gynecologist, was having his patients practice vaginal contractions in preparation for childbirth. That same year he invented the Kegel perineometer, or pelvic-muscle sensor, to help prevent urinary incontinence (leakage) following childbirth.

Kegel's perineometer was the first biofeedback machine designed for clinical use. Employing a vaginal sensor, an air-pressure balloon, and a tire gauge, it enabled patients to verify that they were performing Kegel's correctly and to monitor their progress. The patients continued their practice at home. Kegel published numerous papers on his work and claimed to have cured incontinence in 93% of 3,000 patients. He produced a documentary movie to teach the procedure to other physicians. However, his perineometer was never marketed effectively and there was a widespread misconception that Kegels could not be performed without it. In the 1970s, more sensitive electromyography (EMG) perineometers became available for those with severely debilitated pelvic muscles.

Benefits

Kegel exercises strengthen the PC muscles and increase blood flow and nerve supply to the pelvic region, promoting or resulting in:

  • increased pelvic support
  • restoration of vaginal muscle tone and improved vaginal health
  • protection from the physical stresses of childbirth
  • restoration of sexual function and improved sexual response and pleasure
  • increased vaginal-wall thickness and lubrication after menopause (cessation of menstruation)
  • prevention or reversal of urinary leakage and rectal incontinence
  • relief from pelvic pain or pain of vulvar vestibulitis (inflammation of the vaginal opening)

Description

Locating the PC muscles

The PC muscles can be felt by:

  • stopping and starting urine flow to identify the forward PCs
  • squeezing the vagina to identify the back of the PCs
  • squeezing around two fingers placed in the vagina
  • imagining sucking a marble up the vagina
  • preventing a bowel movement or the passing of gas by tightening the muscles around the anus

There is a pulling sensation when the correct muscles are contracted. Weaker and stronger contractions are practiced until the PC muscles can be squeezed at will.

Practicing Kegels

There are numerous suggestions for practicing Kegels, which include:

  • Contracting the PC muscles for three to 10 seconds and relaxing them three to 10 seconds for five to 15 repetitions, three to 12 times per day.
  • Contracting the PC muscles strongly for one second, then releasing for one second, 20 times, three times per day, speeding up the contractions until there is a fluttery sensation.
  • While emptying the bladder, stopping the urine flow at least three seconds, 10 times during each urination, which provides 60–80 contractions per day.

The complete exercise requires muscle contraction from back to front. It may take three to eight weeks for noticeable improvement. Once good muscle tone is achieved, Kegels may be performed just once a day.

The PC muscles can be exercised at almost any time—while lying down, sitting (in the car at a stop light, at work, etc.), squatting, standing, or walking—and varying the exercise position is said to be most effective. Sitting or standing adds weight to the exercise. It may be helpful to perform a Kegel squeeze before coughing, standing up, or lifting a heavy object. It may also be helpful to incorporate Kegels into a daily routine and keep a log. It is recommended that pregnant women practice Kegels regularly before, as well as after, childbirth.

Squeezing with two fingers in the vagina will confirm that only the vaginal muscles are contracting. Placing a hand on the lower abdomen is a reminder to keep the belly soft and relaxed, to refrain from tightening other muscles such as the stomach, buttocks, or leg muscles, or to hold the breath, all of which increase intra-abdominal pressure, working against the Kegels.

Vaginal cones

Kegels can be performed by the ancient Chinese technique of placing a weighted cone in the vagina and holding it in place up to 15 minutes twice a day. The practice is initiated using the heaviest cone that can be held easily for one minute. The cones weigh from 15–100 gm (0.04–0.3 lb). Brands include FemTone Weights, Kegel Weights, Kegel Kones, and Perineal Exerciser. Sequentially heavier cones are used until a maintenance program is established. This method automatically uses the correct muscles. Some of these products require a doctor's prescription.

Biofeedback devices and electrical stimulation

Nerve damage may prevent some people from performing Kegels properly. Vaginal or anal sensors and EMG perineometers with computerized visual or auditory feedback displays can measure the PC contraction. A handheld over-the-counter product (called the Myself pelvic muscle trainer) costs about $90. Another device can send mild electrical impulses to help locate the PC muscles.

With a vaginal sensor and biofeedback monitor, two 20-minute sessions per day for seven to nine months—with a specific goal such as holding 45-microvolts for 60 seconds—can relieve vulvar vestibular pain in the majority of women.

Insurance may not pay for EMG biofeedback therapy; however, Medicare will reimburse the patient if conventional Kegel exercises have failed.

Preparations

Training may be provided before initiating a Kegels routine.

Precautions

A temporary loss of muscle and nerve function following childbirth may make Kegels more difficult.

Kegel exercises do not work if abdominal, thigh, or buttock muscles are contracted. Furthermore, such contractions can increase pressure on the bladder, aggravating incontinence. Vaginal cones are not recommended in the presence of infection, neurological damage, diuretic medicines, or caffeine.

Side effects

There are no side effects to Kegel exercises.

Research & general acceptance

When performed properly and consistently, Kegels are usually helpful. The United States Agency for Health Care Policy and Research recommends that behavioral methods, including Kegels and biofeedback, be utilized to treat urinary incontinence before initiating drugs or surgery. Randomized controlled studies have shown that as many as 50–90% of women can reduce or overcome SUI with Kegels alone. However, reports of effectiveness vary since many people do not receive proper Kegel instruction. Consistent use of vaginal cones can improve or cure incontinence within four to six weeks in 70% of women.

The use of Kegels to improve urinary incontinence in men has not been extensively studied, although many clinicians report improvement. One study found that after the removal of a cancerous prostate, men who performed Kegels twice a day regained bladder control faster than those who did not do the exercises.

Training & certification

Patient training in Kegel exercises can be given by a knowledgeable healthcare provider.

Resources

BOOKS

Bladder Research Progress Review Group. Overcoming Bladder Disease: A Strategic Plan for Research. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, August 2002.

Hulme, Janet A. Beyond Kegels: Fabulous Four Exercises and More—To Prevent and Treat Incontinence. Missoula, MT: Phoenix, 2002.

Icon Health Publications. Kegel Exercises: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. Icon Health Publications, 2004.

National Kidney and Urologic Diseases Information Clearing-house. Exercising Your Pelvic Muscles. NIH Publication No. 02-4188. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, April 2002.

National Kidney and Urologic Diseases Information Clearing-house. Treatments for Urinary Incontinence in Woman. NIH Publication No. 03-5104. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, June 2003.

Northrup, Christiane. The Wisdom of Menopause. New York: Bantam, 2001.

PERIODICALS

Chiarelli, Pauline, and Jill Cockburn. "Promoting Urinary Continence in Women After Delivery: Randomized Controlled Trial." British Medical Journal 324, no. 7348 (May 25, 2002): 1241–4.

Perry, John D., and Leslie B. Talcott. "The Kegel Perineometer: Biofeedback Twenty Years Before Its Time." Proceedings of the 20th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback (March 17–22, 1989): 169–72.

Resnick, Neil M., and Derek J. Griffiths. "Expanding Treatment Options for Stress Urinary Incontinence in Women." Journal of the American Medical Association (JAMA) 290, no. 3 (July 16, 2003): 395–7.

Singla, A. "An Update on the Management of SUI." Contemporary Ob/Gyn 45, no. 1 (2000): 68–85.

ORGANIZATIONS

American Foundation for Urologic Disease, Inc. 1000 Corporate Boulevard, Suite 410, Linthicum, MD 21090. (800) 828-7866. (410) 689-3990. memberservices@nafc.org. <http://www.afud.org>.

Continence Restored, Inc. 407 Strawberry Hill Avenue, Stamford, CT 06902. (914) 493-1470.

National Association for Continence. P.O. Box 1019, Charleston, SC 292402-1019. 800-BLADDER. (843) 377-0900.

OTHER

Nerve Disease and Bladder Control. National Kidney and Uro-logic Diseases Information Clearinghouse. NIH Publication No. 03-4560. May 2003 [cited May 2, 2004]. <http://kidney.niddk.nih.gov/kudiseases/pubs/nervedisease/index.htm>.

Urinary Incontinence and Pelvic Muscle Rehabilitation Index. InContiNet. February 15, 2000 [cited May 2, 2004] <http:incontinent.com/articles/art_urin/index.htm>.

Urinary Incontinence in Men. National Kidney and Urologic Diseases Information Clearinghouse. NIH Publication No. 04-5280. March 2004 [cited May 2, 2004]. <http://niddk.nih.gov/kudiseases/pubs/uimen/index.htm>.

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