"To Kegel, or NOT to Kegel..."

That is the question.

In 1948 Dr. Andrew Kegel noted that the “passage of the fetal head through the vagina during delivery is inevitably attended by muscle injury.” In other words, delivering babies is hard on the pelvic floor muscles. At the time, Dr. Kegel was convinced that having babies caused the lack of muscle tone that led to incontinence. Then he realized that women often became incontinent, even if they never had babies. So what’s going on here?

Well, the theory I like best has to do with cultural norms. We, like most western, industrial nations, use toilets; and sit in chairs when eating; and sit in chairs while working; and socializing. We are a sitting culture. Squatting cultures have very little problems with female incontinence. In pre-WWII Japan, the condition was very rare. Now, as our toileting and sitting habits have been widely adopted by Japanese society, the rate of incontinence there is equal to our own. Interesting, huh? The pelvic floor muscles activate in rising from a full squat, so they are naturally exercised in these cultures just by normal activities of daily living. Since I don’t think our end of the world is going to give up toilets – face it, I’m not even going to give up mine – then we have to come up with another way to keep these muscles strong and healthy.

Dr. Kegel studied the muscle integrity of thousands of women. He developed a system of strengthening these muscles that was three-fold:

• Isolate. Find the muscle, contract it- and try not to let the rest of the body kick in. He had women isolate the muscle by inserting a finger into the vagina, and squeezing around it.


• Resistance. He felt having something to contract against was important. A finger, a penis, a perinometer.


• Feedback. This is where the perinometer comes in. He developed this device so that the women could see how much she was contracting. A pneumatic device (kind of like a partially filled balloon) was inserted into the vagina. As the women contracted the muscles, the pressure in the balloon would make the gauge on the end move. It was the same sort of dial they use on the end of a blood pressure cuff. The woman got instant feedback as to the strength of her contractions.

This probably does not sound a thing like the instructions you were given in your doctor’s office, or the last women’s magazine you read. Mainstream civilization kept the concepts of Dr. Kegel alive, but we lost a lot in translation over the years.

There are many products on the market that provide resistance and feed back: The PMTx, which is very similar to Dr. Kegel's device; MySelf is more high tech, and has an easy to read screen, but; I’m cautious about giving this to my patients with pelvic floor dysfunction, because you lose the visual feedback during the relaxation phase, and the contract/relax timing is cued by the device, so if I want you to relax for longer than you contract, you have to really think about it.

There are lots of products out there that give resistance, without feedback. Vaginal cone weights are common (the link is just one of many examples). I never give these unless the patient is critically weak, and I have evaluated her on EMG (electromyogram) and I am positive that there are no coordination or spasm issues with the pelvic floor. There are also some pretty scary devices out there; some of them show up on the Google ads on this blog. Did I mention that I don’t screen or condone the banner ads that show up here?

So – what about pelvic floor patients? Should they do Kegels (the modified, common ones that every body teaches now), or not? The answer is: maybe.

Before I give strengthening exercise of any kind, I make sure that the person has good control of the muscle. You should be able to isolate the muscle, contract it, and most importantly, relax it. This is true of just about any muscle in the body, not just the pelvic floor muscles (PFM). I use a lot of EMG (biofeedback) training with my patients. It is a very good visual and audio system for learning the difference between a relaxed PFM and a tight one. If the person does not have good control while hooked up to the machine, I will not recommend a series of activities that involve regular contraction of the PFM for a home program. When I am absolutely positive that my patient can tell when her PFM is tight, and can consciously get it to relax and stay relaxed, then we are ready for some strengthening activity. Even at this point I am very cautious. Most of my patients are given programs that include relaxation times that are twice as long as the contraction phase. Even when they don’t present with a pelvic floor dysfunction, I want to make sure they are relaxing appropriately.

The average woman in our society needs to be doing strengthening activities with her pelvic floor muscles. The populations I treat are the exceptions to the rule: people with tight, spasmodic, or uncoordinated muscles; because of this I tend to error on the side of caution. As with any exercise program, before jumping into it, if you feel that you have any problems or medical issues that could be affected by your activities, consult your physician or physical therapist.