Saturday, April 28, 2007

Sexercise

(c) 2007 Urogynics PLLC, all rights reserved





Dr. Arnold Kegel's Legacy
How many times have you read an article in a magazine about exercising the love muscles? Or heard a pregnant woman talk about Kegel exercises? Or wondered what those mail order gadgets are in the back end of those catalogues for self-health?
What are these exercises, how can you know you are doing them correctly and who came up with this idea anyway?
The love muscle, called the levator ani (as in “elevator”) muscle is an important part of the structure of the human body. When you look at a human skeleton, the pelvic bones form a circle with the spine attached from above and the legs below. The levator ani (aka pelvic or Kegel) love muscles form a sheet from one side of the pelvis to the other, attaching to the pelvic bones all around, and actually hold the body’s organs in place so that it all doesn’t fall down to the knees. This muscle group is not only sexy, it is, literally, a muscle none of us can live without.



The Levator Ani Muscle; Dr. Kegel's Holy Grail
Through the center of this muscle sheet pass a woman’s rectum, vagina and urethra. This anatomic proximity is why Kegel exercises help women with incontinence problems. Once you learn them, the benefits last a long time and might even keep you out of the operating room. In one study of Kegels and urinary incontinence, 66% of the women maintained "favourable effects" over a 10 year span. But you don’t have to have a leaky bladder to benefit from the sexy side effects…
These exercises were first introduced by Dr. Arnold Kegel in 1948, in a series of research papers that showed improved bladder and bowel control in women without resorting surgery. At the time it was a radical notion, but now these exercises are the cornerstone of incontinence therapy.



Dr. Kegel also advocated the teaching of pelvic muscle contractions to women of all ages whether they have incontinence problems or not. Somehow this part of his message was lost over the years, and only women who are pregnant or who suffer extreme pelvic floor disorders such as dropped bladder or urinary incontinence are taught these common sense exercises.
Keeping this muscle strong is great for getting back to normal after child birth so that the vaginal area rebounds back into pre-pregnancy shape. Research indicates that orgasm is may be easier to achieve and more intense when this muscle is worked-out regularly, even for women who have never been pregnant. We believe, although there is no definitive medical data, that keeping the pelvic muscles in shape will prevent problems with vaginal laxity, dropped bladder, and incontinence if a woman makes them a lifelong habit. Think of Kegel exercises as “the dental floss of pelvic health.”

While many women have natural control of this muscle group, and do the exercises properly on their own, research tells us that up to 30% of women will do the exercise incorrectly or not at all after reading simple illustrated instructions. This incorrect performance is due to the fact that the muscle is deep inside your body and contracts isometrically. Since you cannot see what you are doing, you must have a high level of internal body awareness to do them properly. Looking at your vulva in the mirror, the vaginal opening will pull back toward the tailbone and in toward the navel when the pelvic floor is contracting. Or, when you are urinating, if you contract the muscles midstream, you may slow or stop the flow. But many women with weak muscles will not see much movement in the mirror, or may not be able to slow or stop the urine stream at all, even if they are doing the exercises correctly, and will be discouraged if they try these self-check maneuvers, and possibly assume they are not doing the right thing. So if you want to make sure you Kegel correctly, ask for a pelvic muscle check at your next gynecologic checkup.




Below is a quick test of coordination, strength and endurance of this muscle group that your doctor can use to score your "Kegel Capacity" during a routine Gynecology checkup.




5 Second Pelvic Muscle Test




This test takes place during the gynecology exam after the Pap smear. Pressure generated around the examining fingers is rated for duration of maximal contraction effort and the degree to which the muscle contraction rotates the fingers toward the pubic symphysis. Detailed 5 second pelvic score directions for clinicians are below the reference list for this posting.

Pelvic Floor Biofeedback
As with any other fitness regimen, you can work on your own, or you can work with a personal trainer. Biofeedback is the personal trainer of pelvic muscle fitness. Tampon sized sensors inside the vagina rest on the muscles and register muscle activity, registering on a monitor screen as you work and relax the muscles.


Office-Based Pelvic Floor Biofeedback Unit

There are two types of muscle fibers in the levator muscles, fast twitch and slow twitch. Fast twitch fibers keep you dry when you cough or sneeze, and contract rhythmically during orgasm. Slow twitch fibers maintain bladder control and pelvic support during activities of daily living, and help you "hold it" when you are on line for the bathroom. Biofeedback training programs work both types of fibers so that your pelvic muscles work to their fullest potential.


Today's computer-based biofeedback regimens reflect the vision of Dr. Kegel's original work, which included the premier of the modern world's first pelvic floor biofeedback system, the "perineometer".

Dr. Kegel's Perineometer







In the spirit of Arnold Kegel's original vision, home perineometers abound, available to any woman with an interest in feminine fitness.


The Gadgets:
There are many Kegel Exercise devices available without a doctor's prescription. Some of the Kegel exercise units have clinical research data verifying that they enhance pelvic exercise programs, others have none, relying on design, testimonials and common sense to recommend their use. All of them provide rudimentary biofeedback. As your muscles gain strength, you will be able to move to the heavier cone, or will see more concentric rings on the screen, or will squeeze to a higher pressure on the gauge.

Cones are the most time-tested of the group, with data over the past 20 years proving utility as adjunctive tools in Kegel exercise programs. The lightest is the easiest to retain, and the heaviest is the most challenging. For women with vaginal laxity and moderate to severe pelvic organ prolapse, these cones can be difficult to work with, slipping out even if you do the contractions properly.

At the other end of the spectrum is this ("Myself") device that mimics in-office biofeedback by showing your effort on a hand-held screen, with concentric rings lighting up to the degree that the muscles contract so that stronger contractions show more rings. These and many other Kegel exercisers show you how you are doing and motivate you to exercise regularly. Your clinician will help you choose the one best suited to your personal goals.


If you are very weak...

In some women, the levator ani muscles are thin and weak to a degree that makes even in-office biofeedback difficult. These atrophied muscles can be made to exercise with gentle, painless electrical stimulation, or "E-stim". E-stim units are hand-held and easy to use, either as an adjunct to pelvic floor biofeedback, or on your own at home in 15-30 minute daily treatments. So even if you are literally "too weak to move", there is a therapy for you.
(www.empi.com)

Bladder Control...Sex...what about Pelvic Organ Prolapse?

There is plenty of data showing that Kegels are good for bladder control and a few studies that show Kegels will give you a stronger orgasm, but none shedding light on whether or not Kegels will hold your pelvic organs in place nor even how best to do Kegels. The newest device, Colpexin, is the only one with clinical research showing that it actually reduces prolapse in addition to increasing pelvic muscle fitness.



Colpexin is worn for 16 weeks, during which time it tones and stimulates the levator ani muscles. At the end of the 16 week pre-clinical trial, 81% of the women had measurably lesser prolapse on examination by the doctor, 63% had stronger, more fit levator muscles, and 92-100% were happy with their results, reporting better vaginal muscle fitness and bladder control, stating they would recommend Colpexin to a friend. Colpexin is fitted to your individual muscle strength at the doctor's office. (www.colpexin.com)

Other than the single study on the Colpexin device, we are not sure if Kegel exercises prevent or treat pelvic organ prolapse (dropped bladder, vaginal laxity, uterine prolapse). No other device or Kegel exercise technique has been tested for prolapse treatment. When it comes to Kegels and prolapse, one can only apply a healthy dose of common sense; it is probably very helpful to keep your levator ani muscles in good shape with Kegel exercises. If you have moderate prolapse, Kegels make pessary use more successful. On the other hand, if you have severe prolapse, it is unlikely that Kegels will do much to pull your parts back into position, any more than sit-ups would be likely to help a large groin or belly-button hernia.

Kegel Exercise: The Dental Floss of Feminine Fitness
Keeping pelvic muscles strong and bulked with exercise is a very large pound of prevention within the reach of all women of all ages, even if the muscles are thin and weak. Check your pelvic muscle score at your next gynecologic check-up. Or consult a physical therapist, urogynecologist or female urologist in your community; these clinicians are used to checking this muscle group and often have biofeedback equipment that can measure exactly how strong and coordinated you are. Exercise on your own, sign up for pelvic floor biofeedback, use a Kegel exercise device, or gently bring the muscles back to life with electrical stimulation.
Keeping your levator ani muscles in good working order with Kegel exercise is smart for your health and good for your sex life. Stay in shape from the inside out!

References:
1. Romanzi L, Polaneczky M, Glazer HI. Simple test of pelvic muscle contraction during pelvic examination: correlation to surface electromyography. Neurourol Urodyn 1999; 18:603-12.
2. Kegel AH. The physiological treatment of stress incontinence of the urine in women. Gynecol Prat. 1960;11:539-60.
3. Kegel AH. Early genital relaxation; new technic of diagnosis and nonsurgical treatment.Obstet Gynecol. 1956 Nov;8(5):545-50.
4. Kegel AH. Stress incontinence of urine in women; physiologic treatment.J Int Coll Surg. 1956 Apr;25(4 Part 1):487-99.
5. Kegel AH. Sexual functions of the pubococcygeus muscle.West J Surg Obstet Gynecol. 1952 Oct;60(10):521-4.
6. Kegel AH. Stress incontinence and genital relaxation; a nonsurgical method of increasing the tone of sphincters and their supporting structures.Clin Symp. 1952 Feb-Mar;4(2):35-51.
7. Jones EG, Kegel AH. Treatment of urinary stress incontinence with results in 117 patients treated by active exercise of pubococcygeal.Surg Gynecol Obstet. 1952 Feb;94(2):179-88.
8. Kegel AH. Physiologic therapy for urinary stress incontinence.J Am Med Assoc. 1951 Jul 7;146(10):915-7.
9. Kegel AH, Powell TO. The physiologic treatment of urinary stress incontinence.J Urol. 1950 May;63(5):808-14.
10. Kegel AH. The physiologic treatment of poor tone and function of the genital muscles and of urinary stress incontinence.West J Surg Obstet Gynecol. 1949 Nov;57(11):527-35.
11. Cammu H, Van Nylen M, Amy JJ. A 10 year follow-up after Kegel pelvic floor muscle exercisese for genuine stress incontinence.
12. Cammu H, Van Nylen M. Pelvic floor muscle exercises: 5 years later. Urology. 1995 Jan;45(1):113-7.
13. Morkved S, Bo K. Effect of postpartum pelvic floor muscle training in prevention and treatment of urinary incontinence: a one-year follow up. BJOG. 2000 Aug;107(8):1022-8.
14. Bo K, Talseth T. Long-term effect o pelvic floor muscle exercise 5 years after cessation of organized training. Obstet Gynecol 1996 Feb;87(2):261-5.
15. Bo K. Can pelvic floor muscle training prevent and treat pelvic organ prolapse? Acta Obstet Gynecol Scand. 2006;85(3):263-8.
16. Harvey MA. Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. J Obstet Gynaecol Can. 2003Jun;25(6):451-3.
17 Rosenbaum TY. Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabiitation in treatment: a literature review. J Sex Med. 2007Jan;4(1):4-13.
18. Bo K, Talseth T, Vinsnes A. Randomized controlled trial on the effect of pelvic floor muscle training on quality of life and sexual problems in genuine stress incontinent women. Acta Obstet Gynecol Scand 2000Jul;79(7):598-6-3.
19. Beji NK, Yalcin O, Erkan HA. The effect of elvic floor training on sexual function of treated patients. Int Urogynecol J Pelvic Floor Dysfunct 2003 Oct;14(4):234-8.
20. Wein AJ. Weighted vaginal cones for urinary incontinence. J Urol 2003 Sep;17(3):1045-6.
21. Herbison P, Plevnik S, Mantle J. Weighted vaginal cones for urinary incontinence. Cochrane Database Syst Rev. 2002;(1):CD002114.

22. Goode PS, Burgio KL, Locher JL, ROth DL, Umlauf MG, Varner RE, Lloyd LK. Effect of behavioral training with or without pelvic floor electrical stiumlation on stress incontinence in women: a randomized controlled trial. JAMA 2003Jul16;290(3):345-52.

23. Dannecker C, Wolf V, Raab R, Hepp H, Anthuber C. EMG-biofeedback assisted pelvic floor muscle training is an effective therapy of stress urinary or mixed incontinence: a 7-year experience with 390 patients. Arch Gynecol Obstet 2005 Dec;273(2):93-7.

Pelvic Muscle Rating Scale: Instructions for Clinicians

done at time of bimanual pelvic examination

Rating scale parameters:
· Pressure:


o weak – a flicker-like contraction which generates minimal or no resistance to digital retraction
o moderate – a contraction which generates definite but unsustainable resistance to digital apposition
o strong – a contraction which generates sustained resistance to digital apposition


· Duration:

baseline tone of the resting pelvic floor is assessed prior to the contraction. As the patient tightens the pelvis floor in a maximal effort, the amount of time the contraction takes, from initiation to return to baseline tone, is recorded as none, <1,>5 seconds.

· Displacement:

when examining the pelvis bimanually, the examiner’s fingertips are in apposition to the anterior vaginal wall. With active contraction of the pelvic floor, the entire vault is elevated caudad and rotated anteriorly. Given the position of the examiner’s fingers, it is reasonable to grade the degree of rotation of the anterior vaginal wall only when assessing displacement.
o slight anterior displacement of the anterior wall will elevate and/or rotate the distal portion of the examiner’s fingers only
o whole anterior displacement elevates and rotates the full length of the examiner’s fingers without causing the fingers to override each other
o gripped displacement will elevate and rotate the examiner’s fingers and cause the fingers to override.

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