Alexander Foundation for Women's Health
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Alexandar Foundation

The Controversy over Kegels

Are women doing them correctly?

Beverly Whipple, PhD, RN, FAAN and Talli Yehuda Rosenbaum

June, 2004

Kegel exercises, which develop the muscles of the pelvic floor, are the gift that keeps on giving at every stage of a woman's life. [1]

Kegels are useful in preparation for and recovery from childbirth. They prevent prolapse of the bladder and uterus. They control incontinence and are instrumental in relieving cramps and alleviating pelvic pain during intercourse. They can even enhance orgasm. The problem is most women don't start doing these exercises soon enough. And those who do often have difficulty isolating the right muscles.

In this article, we'll explore recent research on the benefits of Kegel exercises and the added effectiveness of biofeedback.

The importance of the PC muscle

Kegels are contractions of the pubococcygeus (PC) muscle in the pelvic floor. This muscle stretches from the pubic bone to the coccyx. An interesting evolutionary sidelight: Cats, dogs, and horses use this muscle to wag their tails.

However, many women are unaware of this portion of their anatomy, and take the PC muscle for granted until they develop problems.

Strain during childbirth takes its toll on the PC muscle, and so does age and gravity. Further, many women develop bad habits while exercising that place undue stress on the pelvic floor. It's important to avoid bearing down or pushing these muscles out while lifting weights or practicing aerobics at the gym. High-impact activities like running or jumping take their toll on this portion of the anatomy. Women should also avoid excessive straining during bowel movements.

What can Kegels do?

Kegel exercises work well to relieve stress-related incontinence, an increasing concern for women in mid-life and beyond. Stress incontinence is the leakage that occurs due to a cough, giggle, or sneeze. Reports show that Kegel exercises can produce a 50 percent to 90 percent cure rate for mild to moderate stress incontinence and can provide a non-invasive alternative to surgery.

Younger women may also suffer from incontinence after childbearing. In addition, researchers have found that Kegel exercises help relax the uterus and, thereby, reduce cramping during delivery, as well as cramping during the menses. [2]

Finally, Kegel exercises contribute to a woman's sexual enjoyment. In his early research on incontinence, California gynecologist Dr. Arnold Kegel discovered that a well-toned PC muscle also helped women achieve orgasms much more easily. With Kegel contractions, the vagina becomes more sensitive, and the improved muscle tone helps a woman achieve a more frequent and more satisfying orgasm.

Researchers now associate stress incontinence with weak pelvic floor muscles, diminished arousal, and impaired orgasm. These findings are linked to decreased clitoral and genital blood flow on Doppler ultrasound tests, to diminished genital neurosensitivity as measured by Medoc Quantitative Genital Sensory Analysis, and to poor resting tone and contraction strength in the pelvic floor, as quantified by vaginal manometry and electromyography. [3]

Put in simpler terms, these exercises can help reverse the aging process in the sexual organs. The lining of the vagina and urethra deteriorate over time, but Kegel exercises keep the blood flowing to this area. More blood and fitter muscles keep the vaginal area younger and more robust.

Kegels are also prescribed for patients complaining of anorgasmia (inability to orgasm). A study by Graber and Kline-Graber also shows positive correlation between a toned PC muscle and a woman's sexual response. The stronger the PC contractions, researchers note, the more likely the woman is have an orgasm from vaginal stimulation. [4]

Finally, Kegels can reduce tenderness and pain at the entrance to the vagina, a condition known as vulvar vestibulitis [5] that interferes with sexual activity. After practicing Kegels with biofeedback daily for 16 weeks, 22 of 28 VV patients were able to resume intercourse. Dr. Esperanza McKay of the Pain and Health Management Center in Houston, Texas, reported similar results at a conference on vulvovaginal diseases in August 2003, sponsored by Baylor College of Medicine. [6] (Both studies relied in EMG biofeedback, which monitors the amplitude of the contraction and muscle stability. There is no data on the effectiveness of Kegels alone on superficial vaginal pain.)

Getting Kegels right

For years, clinicians have been telling women this is the muscle they flex when they stop their urine flow mid-stream.

This may seem evident to women with a healthy PC muscle, but it's not to those who are already experiencing incontinence. These patients may assume that their muscle no longer works and sign up for expensive surgery for leaky bladder. Yet often they can regain control of the PC muscle with the aid of biofeedback.

In the 1940s, Dr. Kegel noted that many women were unable to successfully identify and isolate the PC muscle. So he invented a vaginal sensor that shows women how to correctly do these exercises. Women reclined in a chair fully clothed, inserted the sensor, then were alerted by a monitor to the proper contraction and release of the PC muscle. From the start, Kegels were taught using biofeedback. A host of studies since then show that patients benefit far more from this approach than from verbal instruction alone. [7]

How does a woman know if she's in dire need of Kegels? Any form of incontinence is a clue that these muscles might be weakening and in need of immediate attention. Clinicians may also prescribe Kegels if the patient has a cystocele (prolapse of the bladder) or rectocele (a bulge in the front wall of the rectum that protrudes into the vagina). Further indications include vulvar vestibulitis or pain or tenderness at the entrance to the vagina. [8]

Physicians can also check the objective strength of pelvic floor muscles, their resilience, and resting tone with Pelvic Floor Sensory EMG, a non-invasive test.

A guide to Kegel exercises

A good resource for women and clincians is the web site www.Incontinet.com, which contains detailed diagrams of pelvic floor muscles, Dr. Kegel's three-step digital exam, information about biofeedback, and other patient aids.

Once a woman has identified the PC muscle with the help of a nurse, midwife, pelvic floor therapist, or gynecologist, she can start with three simple Kegel exercises. Here are the directions:

  • Squeeze the PC muscle for 10 seconds, and then relax it for 10 seconds. Stop after 10 repetitions. Do this routine three times spaced out over a 24-hour period.

    If you can't hold the contraction for 10 seconds, start out slowly with just 2 to 3 seconds doing only 3 to 5 contractions. The muscle will get stronger the more you do the exercise.

  • The second Kegel is called the "flutter." Squeeze the same muscle, but this time, contract and relax it as quickly as you can. Do this 10 times at three different times during the day. Eventually, you will be able to achieve the "flutter" more rapidly.

  • The third exercise is subtle. Imagine that you are sucking a tampon up into your vagina. The goal should be to hold and release this contraction the same number of times as you did the first exercise.

You may not be able to hold any of these contractions for the entire 10 seconds; do as much as you can at first and build up gradually to 20-repetition sets.

Never hold your breath as you do these exercises. Inhale deeply through your nose, and exhale through your mouth. As you exhale, concentrate on the contractions, pulling the pelvic floor muscle up and in. Scoop your naval toward the spine. Then inhale as you release.

The most important thing is to avoid bearing down as if you trying to expel a tampon from the vagina or were straining with a bowel movement.

Make sure you are not contracting the buttocks or inner thighs.

For years, women have been told not to contract the abdominals while doing Kegels, yet it is fine to co-contract the lower or transverse abdominals by pulling the navel in toward the spine, a motion used in several yoga postures and in Pilates exercise.

As with any other skill, the most important thing is practice. If you can successfully identify the PC muscles, you can do these isometric exercises anywhere: You can pick up the phone, stop for a red light, or address a crowd, and no one will guess you're working on your pelvic muscles.

If you need more help identifying the PC muscle or have conditions that require a controlled approach, ask for a referral to a pelvic-floor therapist. A health care practitioner may also provide you with a biofeedback device that tells if you're contracting the right muscle and applying the right degree of pressure.

Finally, patient aids like the Kegel Exerciser provide resistance to the PC muscle and give it a more thorough workout.

Notes

1 Burgio et al., 1986.

2 Henderson 1983; Perry and Whipple 1981; Perry and Whipple in Graber, 1982.

3 Salonia et al., 2004.

4 Graber and Kline-Graber, 1979.

5 Glazer et al., 1995.

6 McKay et al., 1995.

7 Bo et al., 2000; Morkved et al., 2002.

8 Glazer et al., 1995.

This article is for educational purposes only and is not intended as a substitute for medical advice. Please consult with a clinician to review any current symptoms and address your medical concerns.

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