Kegels.  When you bring up the subject of Kegel exercises around women, you get a chorus of answers:  some say they do 100 each day and have never had a day of incontinence in their life.  Others blush and say they know they “should” do them but they just don’t like them and conveniently forget to do them.  Still others (though not so many) say that they do hundreds each day and STILL experience incontinence.

I’m a student midwife, so I’m supposed to tell you to “do your Kegels”, right?  Not so fast….  with anything I think about recommending I first ask the question:  “How were we able to populate the earth before we knew about this?”  So, in this case, the question is:  Before we knew there was a pelvic floor and a Kegel exercise, how did the women who came before us have a significant number of pregnancies and births without their insides falling out?

They may have been stronger.  They were hunters and gatherers and they walked, lifted, carried, and squatted a lot more than we do.  They certainly didn’t sit at a computer, in the car, or in front of the TV for hours a day.  As a midwife who encourages mothers to follow their instincts, I would also argue that women pushed differently in labor long ago than most mothers do today, especially those giving birth in the hospital.  For a long time, we didn’t know what a cervix was, let alone how much you would have to dilate in order to be “allowed” to push.  Mothers from that time had to listen to their bodies and midwives listened to them too.  But what I found interesting (albeit annoying) was that I experienced incontinence after my second cesarean, and before I ever had a vaginal birth.  I hear a lot of women say that they will plan a cesarean section because they want to save their pelvic floor.  There are a few sources that agree with me when I say that the birth process may not be what causes incontinence.  In fact, “Studies that take a longer view find that most new problems with urinary and bowel incontinence that appear after birth lessen over time and disappear during the postpartum recovery period. Few women experience frequent or bothersome symptoms beyond a few months after giving birth, and any differences between women who had cesarean sections and women who had vaginal births seem to disappear by the time of menopause. Older women experience high rates of incontinence, but this appears to be due to other factors. For example, excess weight, smoking, and the development of certain diseases play a role. Women who have never been pregnant appear to experience high rates of urinary incontinence in later years.”  (1) For me, simply carrying my children for 9 months resulted in incontinence for a few months regardless of birth route.  I will say, though, that the incontinence I experienced after my vaginal birth was different.  It was as if there was a disconnection between my muscles and my brain.  One day I had that connection and the next day (after the birth) it was gone.  That would have made me think it was the BIRTH that did it, but it felt like it was more than that.  The only way I can describe it is to say that my brain disconnected from those muscles.  And now that I think about it, that kind of makes sense.  There is no other time in our lives outside of birth where we are required to release those muscles so completely.  I often talk about how my brain simply needed to “leave” the birth process and allow my body to do what it needed to do without logic, without thought.  But a few hours later, I needed to ask my brain to join the party again.  The Kegels helped me to make that connection again, but what baffled me the most was that is where the benefit ended.  I still had that little leak when I sneezed, that leak when I jumped on the trampoline with my girls, and that occasional panic that I couldn’t get to the bathroom in time.  More Kegels didn’t seem to make a difference.  One thing I noticed was that when I began running again, I found my incontinence decreased.  When I stopped the daily workouts, the leak would slowly return.  Get back to the gym, and it would nearly stop.  My number of Kegels each day didn’t really change.  That was what made me think that while Kegels have something to do with it, there was probably more to understand.

With this in mind, let’s look at the history of the Kegel exercise.

In 1948, Dr. Arnold Kegel, M.D., as Assistant Professor of Gynecology at the University of Southern California School of Medicine, wrote an article titled “A Nonsurgical Method of Increasing the Tone of Sphincters and their Supporting Structures”.  His article detailed his experience and his discovery.

For 18 years he had studied the physiology of the pelvic musculature.  During that time, he discovered that helping a woman identify the pelvic floor muscles, having her contract them around an inserted sensor he called a “Perineometer” and do so for over a period of time and days, he was able to improve stress incontinence dramatically.  (2)

By 1950 Kegel was able to boast a 93% cure rate for 300 unselected patients with stress incontinence in Los Angles. (3)  It is important to note that Dr. Kegel observed that many women were unable to successfully identify and isolate the pubococcygeus (PC) muscle in the beginning. His Perineometer was an important part of the therapy - it gave women direct feedback when they correctly performed the exercise.  If not given this feedback, he observed women using their abdominal and glueal muscles to incorrectly perform the exercise.  Instead, women inserted the sensor and then were alerted by a monitor to the proper contraction and release of the PC muscle. From the start, Kegels were taught using biofeedback. Today, most women are verbally taught how to contract and release the pelvic floor muscles.  Typically they are told to locate the muscle by stopping their urine mid-stream and then use the same movement during the exercises.  Kegel himself notes in his article:  “The examiner makes sure that while performing these movements the patient is actually contracting the pubococcygeus and not merely muscles around the orifices. It must be emphasized that woman with poor function of the pubococcygeus have all their lives compensated for this deficiency by depending for support upon the fasciae and the more superficial muscles.”  (2)  Research on the Kegel exercise reveals criticism that today’s recommendations are a far cry from the intent of Dr. Kegel.  Few, if any, women are using biofeedback and the success rates of his past work are not reflected today.

A new theory is presented by Katy Bowman, a biomechanical scientist, who comments on a number of topics on her blog “Katy Says”. (4)  Her theory is this:  “Nulliparous women and men are equally affected with PFD (pelvic floor disorder) so while child birth may accelerate pelvic floor (PF) weakening, it is not a primary cause of PFD. PFD is first caused by slack in the pelvic floor due to the fact that the sacrum is moving anterior, into the bowl of the pelvis. Because the PF muscles attach from the coccyx to the pubic bone, the closer these bony attachments get, the more slack in the PF (the PF becomes a hammock).A kegel attempts to strengthen the PF, but it really only continues to pull the sacrum inward promoting even more weakness, and more PF gripping. The muscles that balance out the anterior pull on the sacrum are the glutes. A lack of glutes (having no butt) is what makes this group so much more susceptible to PFD. Zero lumbar curvature (missing the little curve at the small of the back) is the most telling sign that the PF is beginning to weaken. Deep, regular squats (like we probably used to do when we were hunting and gathering) create the posterior pull on the sacrum.” (5)

She goes on to say, “One of the biggest misnomers is that tight muscles are "strong" and loose muscles are "weak." In actuality, the strongest muscle is one that is the perfect length.  The Kegel keeps making the PF tighter and tighter.  The muscle tissue in your PF is the same as the muscle tissue in your biceps. When you’re done working your biceps, you’d like your arm to go back to its original length, right? What if, when you were done doing your curls, your elbows stayed as bent as they were when your muscles were the TIGHTEST? If you equate strong with tight, then you’d have “strong,” contracted arms with bent elbows all the time. Tight muscles. Unusable arms.  That’s not what TONE is. Tone is having the MOST strength and the MOST length.”  (5)

In summary, a few Kegels a day, tightening the muscles “just enough” and relaxing them again (like we do with a bicep curl) is what she recommends, but she says the extreme amount of Kegels we are doing today are not giving us the balance we actually need for the pelvic floor:  “The short term benefits are masking the long term detriments. Instead of focusing on kegels, and add two to three squat sessions throughout the day. The glutes strengthen and as a result, they pull the sacrum back, stretching the pelvic floor from a hammock to a trampoline. Viola! You can still practice opening and closing your pelvic floor (using ‘Kegels’) in real-time situations, but you don't have to approach it like a weight-lifting session.”  (5)

These two theories might sound mutually exclusive, but when I put all of this information together, I feel that they resonate well.  In fact, the combination of the two is exactly what felt right for my body.  After childbirth, there was a disconnection from my brain to the pelvic floor muscles.  Kegel’s exercises helped me make that connection again, and made a huge difference in my incontinence in the immediate postpartum, but further results only came when I added strength to my gluteal muscles through exercise.  It makes sense - I found the balance my body needed.  If I go back to my original question wondering how we populated the earth if we didn’t know about Kegel exercises, what I come to is the fact that we were squatting more and we weren’t sitting for hours and hours or wearing high heels (which Bowman says exacerbates the unnatural position of the sacrum).

One thing we DO know is that, despite our knowledge about the pelvic floor muscles and Kegel exercises, we have more urinary incontinence than ever before.  At least one study showed that from 1988 to 1998 surgery for urinary incontinence increased by approximately 45%.  (6)  Maybe people are more inclined to get help than ever before.  Or MAYBE we simply don’t know the long-term effects of this exercise.  At least one book, written in 2007, that looks at the evidence regarding pelvic floor muscle therapy (PFMT) states “According to the results of the present review, PFMT after delivery is effective in reducing urinary incontinence in the immediate postpartum period.  However, the longer term effect is questionable.”  (7)  Maybe, since we aren’t using the biofeedback mechanism Dr. Kegel designed as an integral part of his therapy, we all are doing the exercise incorrectly 100 times a day.  Or maybe Katy Bowman is onto something.

Citations

(1)  Preventing Pelvic Floor Dysfunction available at:  http://www.childbirthconnection.org/article.asp?ck=10206 (Accessed 6/10/2010)

 (2)  1948, Dr. Arnold Kegel, M.D., as Assistant Professor of Gynecology at the University of Southern California School of Medicine, wrote an article titled “A Nonsurgical Method of Increasing the Tone of Sphincters and their Supporting Structures”

(3)  Perry J., Hullett L, The Bastardization Of Dr. Kegel's Exercises Memorial Hospital Continence Program:  This Paper Was Presented to Northeastern Gerontological Society, New Brunswick, New Jersey, May 20, 1988  (Accessed online 6/2010 at http://www.pelvictoner.co.uk/kegel_bastardization.htm)

(4)  http://www.katysays.com

(5)  Interview of Katy Bowman by Kara Thom, author of See Mom Run, available at: http://mamasweat.blogspot.com/2010/05/pelvic-floor-party-kegels-are-not.html  (accessed 6/9/2010)

(6)  Waetjen, L. Elaine MD et al: Stress Urinary Incontinence Surgery in the United States; Department of Obstetrics and Gynecology, University of California, Davis, Sacramento; and the Departments of Obstetrics, Gynecology and Reproductive Sciences and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.   July 17, 2002  available at http://journals.lww.com  (accessed 6/10/2010)

(7)  Evidence-Based Physical Therapy for the Pelvic Floor:  Bridging Science and Clinical Practice  By Kari Bo, Bary Berghmans, Siv Morkved, Marijke Van Kampen  Elsevier Ltd. 2007  p333 accessed online 6/9/2010 at http://books.google.com