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Author   Judith Florendo, PT
Column   A Healthy Balance
Issue   Fall 2008
Vol/No   Vol 26 No 3
Title   Kegels De-Mystified for Women

Pelvic Floor Muscle Exercises, or PFMEs, are often called “Kegels,” and frequently recommended to women who have urinary or fecal incontinence or pelvic organ prolapse and men preparing for or recovering from prostate cancer surgery. Research reveals that these exercises are performed incorrectly nearly 50% of the time. As a physical therapist working with individuals with pelvic floor muscle weakness, it is fairly common to hear women say, “I don’t know why my doctor sent me to you, I’ve done Kegels in the past and they don’t work.” On the surface, they seem easy enough, but why don’t they “work”? What accounts for the reported failure rate?

To start with, most women are unable to locate the targeted pelvic floor muscles. Unlike your biceps or quadriceps muscles, you cannot see the PFM contract. Nor can you easily place a hand over the muscles to feel the contraction. A good starting point is to think about stopping the flow of urine midstream or imagine you are trying to hold back gas. Contrary to some sources, it is not a good idea to interrupt the urine flow midstream and do pelvic floor muscle exercises while voiding on the toilet. It is permissible to do this as a test only on occasion, but not as a daily exercise. The normal brain/bladder reflexes that coordinate voiding are disrupted and other bladder problems can result.

Additionally, it is helpful to use a mirror to visualize the perineum. When correctly executed, a pelvic floor muscle contraction can be seen to draw the perineum, including the anus, inward. Conversely, if one sees a bulging of the perineum it is likely there is a pushing or bearing down occurring indicating poor technique. Inserting your finger into the vagina and contracting around it is excellent self-biofeedback. Besides feeling a constriction around your finger, you should also feel your finger being pulled up. You can also insert a tampon, pull lightly on the string, contract the muscles, and feel the upwards tug on the string.

Once the proper technique has been mastered, determining an exercise progression is next. A general rule of thumb is that if one can stop the flow of urine completely, you should be able to do pelvic floor muscle exercises in an upright position, either sitting or standing. If you cannot do this, or just barely do it, you might want to do your exercises in a horizontal position, such as reclined, semi-reclined, or in a side-lying position. This decreases the effects of gravity and weight of your organs on the pelvic floor, thereby making it easier than doing them in the upright positions. This is often a source of error when it comes to doing effective PFMEs. Your starting point should be in the horizontal position if you are just beginning. Afterwards, progress to an upright position as your muscles become stronger and you are more successful at slowing or stopping the flow of urine (remember – only stop urine flow once every few weeks or once a month).

And finally, how many repetitions, how long do you hold the contraction, and how many times a day do you do the exercises? Because the PFMs are made up of two different muscle fiber types, you may need to do both short and long holds of the muscle contraction. For instance, you might do “quick flicks,” which are simply contracting the muscles and releasing the contraction immediately, and then perhaps “long holds,” which are maintaining the contraction for 5-10 seconds. Women who try the self-biofeedback method of inserting a finger into the vagina should be able to feel if they are able to hold the contraction for several seconds. You will also be able to count how many repetitions you can do well, with good technique, before your muscles fatigue. In general, you can work up to 40-50 repetitions by day’s end, divided

between the “quick flicks” and the “long holds.” Depending on how many you can do well with your initial “test” and self-biofeedback, you might only be able to do 5-10 repetitions at a time, or perhaps a couple of sets of 10 each day. In the latter case, you would then have two shorter exercise sessions in your day to reach 40-50 repetitions. Wait several seconds between repetitions.

A few additional pointers:

• Avoid holding your breath while doing the “long holds”

• Do not substitute other muscles like the buttock or thigh muscles

• Do not bulge the abdominal muscles while contracting the PF

Although PFMEs can appear to be “no-brainer” –type exercises, they really aren’t. Initially, it is important to learn the technique correctly, in order to make a brain-muscle connection. In this motor relearning phase the exercises should not be done “mindlessly.” After practicing carefully with attention to technique, the exercises can be performed eventually more spontaneously.

Occasionally it may take working with a pelvic floor physical therapist to help you figure out if you’re doing the exercises correctly, as well as to set up and progress your exercise program to achieve your goals for continence. Evaluation of the pelvic floor muscles usually involves direct assessment via a digital examination of the vagina or rectum. Other external measures are instrumented biofeedback and/or rehabilitative ultrasound imaging. To find a women’s health therapist in your area, contact the American Physical Therapy Association’s Section on Women’s Health: www.womenshealthapta.org.

ABOUT THE AUTHOR

Judith Florendo is a physical therapist in private practice in Chicago at Florendo Physical Therapy, PC (www.florendophysicaltherapy.com), specializing in treating women and men with a variety of core and pelvic floor problems. She welcomes your questions and comments at: judith@florendopt.com.