The Kegel is not just for your grandma…

The Kegel is not just for your grandma. Or women with “loose vaginas.”  It is not a secret, so we need not whisper about it.  Oh, if I had a nickel for every time I’ve had an encounter like this…(yes, I’d have a lot of nickels).  I’m not sure where the shame or misconceptions about Kegels came from, but I know where they are going to end.  Kegels are an incredibly effective (when performed correctly) and underutilized therapy for a myriad of pelvic conditions in men, women, and children, and it’s about time we start using them as such.

What is a Kegel exercise?

“Kegels” or “kegel exercises” are a series of pelvic floor contractions named for the pelvic-pioneer who invented them, gynecologist Dr. Alan Kegel [1].  If you think of your pelvis as a bowl, the pelvic floor consists of the muscles that keep your pelvic organs from falling out (Thank goodness those are there!).  These muscles, including levator ani and coccygeus, also provide structure and support to the anus and urethra (in both sexes), and the vagina (in women).  These muscles of the pelvic floor are no different than the muscles we exercise at the gym; they can get just as “flabby” and “soft,” as unexercised skeletal muscle.  Thankfully they can similarly be strengthened, using our friend, the “Kegel.”

Why Kegels are good for Men, Women, and Children

By now you are probably wondering, Why should I do Kegels?  Can Kegels help me? The answer is likely, yes.  Even if you do not have issues now, pelvic floor exercise may help prevent future problems.  You can think of Kegels as a bit of insurance against some of the potential conditions listed below.

Pelvic floor exercises have been shown to improve the following conditions:

Erectile Dysfunction, Premature Ejaculation, Sexual Dysfunction

If you’re a man with these issues, I know what you’re thinking, A FREE tool to help with erectile dysfunction AND premature ejaculation?  Is it Christmas??

There are a few studies that show the effectiveness of pelvic floor exercises in treating these conditions.  In one study on erectile dysfunction (ED), after just three months of pelvic floor exercises, 40% of research participants had normal erectile functioning [2].  They essentially “cured” themselves of ED!  In the same study, 34.5% of the participants had a significant improvement in their ability to achieve and maintain an erection.  That’s a 75% success rate in treatment of erectile dysfunstion, with only a few months of exercises and no drugs or negative side effects.  Imagine being able to enjoy sexual activities without the concern of losing your vision or getting stuck with a painful, raging, four-hour erection!

But wait, there’s more!  In another study looking at the effects of pelvic floor exercise and premature ejaculation, researchers demonstrated a 61% success rate in completely alleviating this condition [3].  They put men with premature ejaculation problems through 15-20 sessions of pelvic floor exercises, and were able to cure it in well over half of the cases.  In fact, only 83% of the men in their study experienced premature ejaculation within the past five years, so it is likely that some of the men that didn’t “improve” weren’t actively having issues with it to begin with. It is possible that some men with premature ejaculation problems are unaware of the ability to contract the pelvic floor as a means to postpone ejaculation.  By simply teaching them this skill, they become capable of controlling their ejaculation!

Performing regular pelvic floor exercises can also increase the blood flow to the muscles and nerves involved in sexual arousal, which can increase arousal and vaginal lubrication.

 Voiding Issues in Children

Voiding problems in children can vary from frequent urinary tract infections, night and day wetting, to “dribbling” in underwear and urinary frequency.  One study sought to educate children about their pelvic floor muscles and to teach them how to contract and relax their pelvic muscles.  After one year of this education and treatment, over 50% of the girls were cured of their voiding issues, and the rest of the girls made some improvements in voiding patterns [4].  In other words, after one year of pelvic floor therapy, 100% of the girls were either cured or made improvements with their prior bathroom issues.  This is an incredible find and can give hope to the many parents and children struggling with these common conditions.

 Fecal Incontinence, Anal Incontinence, Anal Seepage

No, these are not the same as sharting, though I look forward to explaining the difference in a future blog post.  Fecal incontinence, anal incontinence, and anal seepage are all different, and can happen to men, women, and children. Fecal incontinence is the involuntary loss of liquid or solid stool from the anus, while anal incontinence is the involuntary loss of liquid, solid stool, or bowel gas.  Anal seepage can be either mucous and/or excess stool that leads to excess wiping or residual streaking in underwear (aka “racing stripes”).  Each of these conditions can be caused by a dysfunction in the anal sphincter, which is like the clamp that keeps your anus closed.  If this clamp that is responsible for keeping the gas and stool from coming out gets stretched too much (from anal sex, passing large stool, having a baby) or is not squeezing properly, it is easy to see how fecal material can escape.  Kegel exercises have been shown to strengthen and tighten the pelvic muscles to prevent anal seepage and incontinence from happening.

Stress Incontinence, Urge Incontinence, and Post-operative Prostatectomy

Though these problems are quite different, each can be helped by pelvic floor exercise.  Stress incontinence is the leaking of small amounts of urine when laughing, sneezing, coughing, running etc, and happens one third of all women at some point in their lives [1].  These activities put stress on the bladder, which is incapable of holding the urine when surrounded by a weak pelvic floor.   The weakness in the pelvic floor can be caused by a variety of things, such as: child birth, direct trauma to the pelvic muscles, age etc.  There is great evidence that suggests the effectiveness of Kegel exercises for stress incontinence.

With urge incontinence, you get a sudden urge to urinate, bladder spasm, and then leak small amounts of urine.  This is commonly caused by over active nerves to the bladder and can happen at any time…even when the bladder is practically empty!  Performing Kegel exercises send reflex signals to the bladder and will decrease the feeling of urgency.  Kegel exercises won’t prevent urge incontinence from happening, but they will help control an urge as it arises.

Incontinence and pain caused by prostatectomy has also been drastically improved by pelvic floor exercises in patients that regularly perform them[5].

Low Back Pain

In a study published in February of 2013, research demonstrated the effectiveness of pelvic floor exercises on the reduction of chronic low back pain.  They randomized two groups of people with back pain, treating one group with: traditional lumbar strengthening, short-wave diathermy, and ultrasonography; while treating the other group with pelvic floor exercises.  After 24 weeks, pain questionnaire scores pain severity were “significantly lower” in the pelvic floor exercise group than the traditional treatment group [6].  This study might make us want to rethink the ways we treat low back pain!

How do you do kegel exercises?

I have heard and experimented with a few different analogies, but the “correct one” always seems to be the one that works best for my patients.  Analogies and imagery seem to help, as the pelvic floor muscles can be hard for some people to activate.

Starting in the lying position is the easiest, as the pressure on the pelvic floor from the pelvic contents is at its least.  Men can do this standing, as a correctly performed Kegel will cause the testicles to rise and the base of the penis to slightly move up (towards the abs).  This will provide good visual feedback.

Try using the following strategies to contract your pelvic floor:

• imagine you are peeing on the toilet, and then try to stop the flow with your muscles.  Focus on this contraction and squeeze those muscles as hard as you can.  Try to not hold your breath.
• imagine you are sucking water through a straw with your anus or vagina
• imagine your vaginal or anal opening as an elevator.  Close the doors of the elevator, and then send it as high as it will go.

If none of these strategies work, try gloving up (or not, it’s up to you).  Insert a finger into your rectum or vagina (sorry guys, you only have one hole to choose from).  Perform the same contractions, attempting to squeeze your finger.  Sometimes the added proprioception works wonders in teaching people how to achieve the appropriate contraction.

It is important that after each strong contraction you release the contraction.  You can imagine that you are:

• taking the suction out of the straw
• sending the elevator to the basement (not just to the lobby- you really want to let those muscles go!)
• letting the bones that you sit on separate/spread apart

What are some common kegel mistakes?

Aside from squatting and deadlifting, Kegels are one of the most widely mis-performed exercises that people do.  I think this is because most doctors are either A. too busy to properly explain it or B. Are embarrassed to talk about it.  When I bring up Kegel exercises to patients, I often hear “yeah, yeah I know what they are,” only to find out that they have NO idea how to do them properly.  If you might be one of these people, I suggest you look at the mistakes below to avoid doing the exercises incorrectly.

• squeezing legs together, clenching butt cheeks, or sucking stomach in…You should not notice any movement in your lower or upper body.  If you notice your legs are moving, you are squeezing the wrong muscles.  You should be able to do these Kegels in church without anyone noticing!
• pushing out (like you’re trying to have a bowel movement)
• Sucking stomach in or only contracting abs
• not fully releasing each contraction (ie. sending the elevator to the basement)
• not holding the contraction for long enough
• holding breath
• Not sticking with them

How often should I do kegels?

Each of the above studies had slightly different parameters as to how often these exercises should be done.  For general strengthening, I follow the basic routine below.  Of course, exercise should be prescribed on an individual basis, as no two cases are alike.  Please consult your doctor (or me if I am your doctor!) before beginning a pelvic floor exercise regimen.

• Morning: 5-10 second holds, rest between each set of 10 (depends on how much time you need).  This is a total of 50 seconds of contracting as strongly and as correctly as you can.
• Lunch: 5-10 second holds, rest between each set of 10 (depends on how much time you need).  This is a total of 50 seconds of contracting as strongly and as correctly as you can.
• Evening:  5-10 second holds, rest between each set of 10 (depends on how much time you need).  This is a total of 50 seconds of contracting as strongly and as correctly as you can.
• When going from a seated to a standing position
• After going to the bathroom
• During any jumping movements
• Men can practice kegels during intercourse to postpone ejaculation

Should you use Ben wa balls or Kegelmaster (or other tools) when doing Kegels?

There have been claims that products like ben wa balls and the kegelmaster (see examples on the right) improve the effectiveness of pelvic floor exericses.  According to the research, which was done studying the kegelmaster, doing pelvic floor exercises alone were just as effective as with the instrument[7].  In other words, the Kegelmaster didn’t add any extra benefit.  If you think the added instrument will help you, don’t let me stop you!  Some people like having the feed back of an instrument.  Whether you decide to try the Kegelmaster, ben wa balls, anal beads, or decide to go au natural, I’ll just be ecstatic that you’re doing them!

References:

[1]Magon, Navneet et al.  “Stress urinary incontinence: What, when, why, and then what?”  Journal of Mid-Life Health.  Jul- Dec 2(2) (2011): 57-64.

[2]Dorey G, Speakman M, Feneley R, Swinkels A, Dunn C, Ewings P. “Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction.”  The British Journal of General Practice.  Nov. 54(508)(2004):819-25.

[3] La Pera G, Nicastro A.  “A new treatment for premature ejaculation: the rehabilitation of the pelvic floor.”  Journal of Sex and Marital Therapy.  22(1) (1996): 22-26.

[4]Wennergren H, Oberg B.  “Pelvic floor exercises for children: a method of treating dysfunctional voiding.”  British Journal of Urology.  Dec. 76(6)(1995):815.

[5] Bridgeman, B, Roberts, SG.  “The 4-3-2 method for Kegel exercises.”  The American Journal of Men’s Health.  March 4(1) (2010):75-76.

[6] Bi X, Zhao J, Zhao L, Liu Z, Zhang J, Sun D, Song L, Xia Y.  “Pelvic floor muscle exercise for chronic low back pain.”  The Journal of International Medical Research.  Feb 41(1) (2013):146-152.

[7]Kashanian M, Ali SS, Nazemi M, Bahasadri S.  “Evaluation of the effect of pelvic floor muscle training (PFMT or Kegel exercise) and assisted pelvic floor muscle training (APFMT) by a resistance device (Kegelmaster device) on the urinary incontinence in women: a randomized trial.”  European Journal of Obstetrics, Gynecology, and Reproductive Biology.  November 159 (1) (2011): 218-223. – See more at: http://cassiedc.com/1/previous/2.html#sthash.rSaYRKTb.dpuf