pelvic floor muscle rehabilation

by Diane K. Newman, RNC, MSN, CRNP, FAAN

Both men and women can benefit from a consistently practiced Kegel exercise program.

In the late 1940's, Dr. Arnold Kegel, an obstetrician/ gynecologist in California, outlined a comprehensive program of progressive contractions of the pelvic floor muscles (PFMs), specifically the levator ani muscle, which is under voluntary control. Dr Kegel's program, which later became known as Kegel exercises, was designed specifically for young women who were experiencing stress urinary incontinence (UI), defined as involuntary urine leakage when coughing, laughing, sneezing or with physical exertion. He offered a medical service, under the direct supervision of a trained nurse, which included biofeedback technology.

These exercises became known as Kegel exercises and were taught mostly to pregnant women during childbirth classes. Although many women attempted to practice these exercises, most did not find them helpful, and prior to the 1990s, the medical profession did not appear to embrace their effectiveness. 

Effects of Pelvic Muscle Exercises (PMEs)

The actual effects of pelvic muscle exercises (PME's) on the bladder and pelvic muscles are not completely understood but there may be a relationship between changes in various measures of pelvic floor strength, such as anal or rectal sphincter strength or increased urethral closure pressure, and resistance, all of which prevent urine leakage. These exercises have become known as pelvic muscle exercises (PMEs) or pelvic floor muscle training (PFMT.) Research starting in the 1980s and continuing in the present has shown them to decrease urine leakage in women and men with stress and urge UI and with overactive bladder symptoms of urinary urgency and frequency. 

PMEs increase support to the urethral sphincter and detrusor (bladder) muscle, thereby preventing stress, urge and mixed UI, and are most appropriate in persons:

• who do not have cognitive impairments,
• are motivated to comply with the program and
• have a pelvic floor that is neurologically intact.

The goal of pelvic muscle training is to isolate the pelvic floor muscle, specifically the levator ani. The PFMs comprise a striated, skeletal muscle group, that is under voluntary control and is important in maintaining urinary and fecal continence as well as in providing support to the pelvic organs (bladder, rectum and, in women, the uterus. See Figures 1 & 2.)

Pelvic Muscle Exercises for Two Types of Muscle Fibers

PMEs consist of repeated, high intensity pelvic floor muscle contractions. The PFM has two types of muscle fibers -- Type I or slow twitch muscle fibers and Type II, fast twitch muscle fibers. 

At least 80% of the levator ani muscle is composed of Type 1 muscle fibers. These fibers produce less force on contraction and assist in improving muscle endurance by generating a slower, more sustained but less  intense contraction. Over time, the continuous, though lower intensity contraction of these muscle fibers maintains a general level of muscle support. Type I muscle fibers are also fatigue resistant. Exercising these muscle fibers is usually referred to as long holds or contractions. 

The second group is Type II or fast twitch fibers, which aid in strong and forceful muscle contractions. These fibers come into play during sudden increases in intra-abdominal pressure by contributing to urethral closure. By exercising these fibers, pelvic muscle strength will increase. These are referred to as short contractions or "quick flicks". 

As these Type II fibers fatigue easily, persons are taught to perform a small number of this type of exercise. Muscle inactivity, aging and nerve damage can contribute to a decrease in the proportion of Type II fibers. The functional demands on the fibers of the pelvic muscle include sustaining force over time especially during increases in intra-abdominal pressure, developing force quickly, and contracting and relaxing voluntarily. During voiding, the person must relax the PFM to open the external urethral sphincter to allow voiding. When these muscles do not function properly, both urinary and bowel incontinence, and in women, pelvic organ prolapse may occur.

Four Phases of Pelvic Muscle Exercise

Dr. Kegel described four phases in the performance of the exercises:

1. Awareness of the function and co-ordination of the PFM muscle.
   For older adults and persons whose pelvic muscle is severely relaxed, this may take several weeks.
2. Gains over muscle identification, control and strength.
   Muscle strength is the maximal force that can be generated by the PFM. Although the PRM is not flexible, the muscle must adapt to different or changing requirements so the PFM must have contractibility and build force quickly when contracting.
3. Firming, thickening, broadening and bulking of the muscles to increase muscle endurance.
   Muscle endurance is a performance characteristic of the ability of the PFM to execute repeated contractions to an initial level of strength often called a "submaximum" contraction.
4. Improvements of the symptoms indicate that the muscles are strengthening, especially as the ability to feel the muscle contract and relax increases.
   The ability to contract the muscle during the time of leakage (when coughing, sneezing, laughing, on the way to the bathroom) prevents urine loss. At this point some people feel that their incontinence is so improved that regular exercising is no longer needed.

How to Identify the Pelvic Floor Muscle

Individuals have a difficult time identifying and isolating this muscle. Without sufficient information, many men and women may mistakenly bear down or exercise ineffectively. Specifically, women should "draw in" and "lift up" the perivaginal and rectal/anal sphincter muscles. Men should just draw in or tighten the rectal sphincter. Once the person is able to identify the muscle, he or she is instructed to perform a series of "quick flicks" or 2-second contractions followed by sustained (endurance contractions) contractions of 5 seconds and longer as part of a daily exercise regimen. At least 10 seconds of relaxation is recommended between contractions. The individual should aim for a high level of concentrated effort with each pelvic muscle contraction, as greater contraction intensity is associated with improvement in pelvic muscle strength. (Bo et al, 1990; Dougherty et al, 1993) 

How Often to Do the Pelvic Muscle Exercises

Individuals are instructed to do the pelvic muscle exercises three times daily and, optimally, to perform the exercises in 3 positions -- lying, sitting and standing. A minimum of 50-60 PMEs per day is recommended. A gradual increase in number of contractions over a period of PME practice has been shown to increase muscle strength significantly and decrease urine loss. The person should be instructed to contract the muscle at the time of the UI episode. (Miller, Ashton-Miller, Delancey, 1996) Contracting it before sneezing, coughing, lifting, standing or swinging a golf club can prevent stress UI from occurring. The muscle also can be contracted when he or she feels a strong urge to void. Results may not occur until after 6-8 weeks of exercise, and optimal results usually take longer. 

A large body of medical research has demonstrated the efficacy of behavioral intervention that includes PMEs. The 1996 Guideline on Urinary Incontinence in Adults (Fantl, Newman, Colling, et al, 1996) outlined research showing that PME's are indicated for persons with stress incontinence and can reduce urgency and prevent urge UI. Pelvic floor re-education has proven to be effective in women with sphincter deficiency and detrusor instability. More recent research has supported this claim (AWHONN, 2000a, b; Sampselle, Miller et.al., 1998; Wyman, Fantl et.al., 1998, Burgio, Locher, et.al., 1998; Holtedahl, et.al., 1998; Sampselle, et.al., 2000; Sampselle, et.al., 1998). Burgio, et.al. (1998) reported a mean 80.7% reduction of incontinence in her research of older women with urge UI. Long term studies have demonstrated that improvement persists over time. (Bo, Talseth, 1996) 

Practice of PME's in primiparas (women who have given birth to one child) results in fewer UI symptoms during late pregnancy and the postpartum period. (Sampselle, et al, 1998) Behavioral modifications, pelvic muscle rehabilitation and bladder retraining programs have successfully decreased UI in homebound elders. (McDowell, Engberg, et al., 1999 Flynn, et al, 1994) A study of men with urinary incontinence following radical prostate surgery showed that 88% of the treatment group achieved continence in 3 months compared to 56% of the control group. (Van Kampen, et.al, 2000) In addition, a more recent study (Burgio, Locher, Goode, 2000) examined the effects of combining behavioral treatment and drug treatment for urge UI in ambulatory women. The subjects' reduction of incontinence went from a mean 57.5% with behavioral therapy to a mean 88.5% overall reduction with combined behavioral and drug (anticholinergic) treatment. The majority of the PME research used some type of device to teach and train the PFM. 

In general, both men and women may experience improvements in continence from a Kegel exercise program.

 See also:

• Vaginal Weights
• Frequently Asked Questions About Vaginal Weights

References

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), (2000a) Evidence-based Clinical Practice Guideline, Continence for Women., Washington D.C.

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), (2000b) Quick Care Guide, Continence for Women., Washington D.C.

Bo K, Talseth, T.  (1996) Long-term effect of pelvic floor muscle exercise 5 years after cessation of  organized training. Obstet Gyncol; 87:261-65.

Boyington, AR, Dougherty, MC (2000) Pelvic muscle exercise effect on pelvic muscle performance in women.  Int Urogynecol J. 11:212-218.

Burgio, K.L., Locher, JL., Goode, PS, (2000) Combined behavioral and drug therapy for urge incontinence in older women. JAGS.; 48:370-374.

Dougherty MC, Dwyer JW, Pendergast JF, Tomlinson BU, Boyington AR, Vogel WB, Duncan RP, Coward RT, Cox, CL. (1998) Community-based nursing: continence care for older rural women. Nursing Outlook 46(5): 233-244.

Holtedahl, K, Verelst, M., Schieflow, A (1998) A population based, randomized, controlled trial of conservative treatment of urinary incontinence in women.  Acta Obstet Gynecol Scan, 46:870-4.

McDowell BJ, Engberg S, Weber E, Brodak I, Engberg R. (1994) Successful treatment using behavioral interventions of urinary incontinence in homebound older adults. Geriatric Nursing 15(6):303-307.

McDowell BJ, Engberg S, Sereika S, Donovan N, Jubeck ME, Weber E, Engberg R. (1999) Effectiveness of behavioral therapy to treat incontinence in homebound older adults. JAGS 47(3):309-318.

Newman, DK.  (2000) New Technology for Women for Stress Incontinence. Contemporary OB/GYN: April 15:69-70,74-75, 79-83.

Newman, D.K. (2000) Continence for Women: Research-Based Practice, Association of Women’s Health, Obstetric and Neonatal Nurses, Washington, D.C.

Newman, D.K. (1999). 2^nd Edition  The Urinary Incontinence Sourcebook, Los Angeles: California; Lowell House.

Sampselle, CM, Miller, JM, Mims, BL, Delancey, JOL et al. (1998) Effect of Pelvic muscle exercise on transient incontinence during pregnancy and after birth. Obstet & Gynecol;91(3):406-412.

Sampselle, CM, Wyman, J, Thomas, KK, Newman, DK, et al.  (2000) Continence for Women: Evaluation of AWHONN’s Third Research Utilization Project. JOGNN: January:29(1):9-17.

Sampselle, CM, Wyman, Thomas, KK, Newman, DK, et al.  (2000) Continence for Women: a test of AWHONN’s evidence-based protocol in clinical practice. JOGNN., January:29(1):18-26.

Van Kampen, M, DeWeerdt, W, Van Poppel, H, De Ridder, D, Feys, H., Baert, L.  (2000) Effect of pelvic floor reeducation on duration and degree of incontinence after radical prostatectomy: a randomized controlled trial. Lancet, 355:98-102.

Posted: April 2003
Updated February 2009 

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