Posts Tagged ‘Kegels’

Leaking Havoc: Diagnosing And Treating Female Stress Urinary Incontinence

March 4, 2017

Andrew Siegel, MD  3/4/17

This is the completion of a blog entry uploaded last week entitled “Leaking Havoc: Female Stress Incontinence.”

How is Stress Urinary Incontinence (SUI) diagnosed and evaluated?

Listening carefully to the patient is usually sufficient to make the diagnosis of SUI, the typical complaint being: “Doc, I leak urine when I sneeze, cough and exercise.”

After hearing the details of the patient’s problem, the next step is a pelvic examination. The issue with an exam with legs-up-in-stirrups is that this is NOT the position in which SUI typically occurs, since SUI is usually provoked by standing, exertion and physical activities. For this reason, the exam must be performed using straining or coughing forcefully enough to demonstrate the SUI.

The pelvic examination is done after the patient empties her bladder. The exam involves observation, passage of a small catheter (a narrow hollow tube) into the bladder, a speculum exam and a digital exam.

Inspection determines tissue health and the presence of urethral movement with straining. After menopause, typical changes include thinning of the vaginal skin, redness, irritation, etc. The ridges and folds within the vagina that are present in younger women (rugae) tend to disappear.

A small catheter is passed into the bladder to determine how much urine remains, to obtain a urine culture in the event that urinalysis suggests infection and to determine urethral angulation. With the catheter in place, the angle that the urethra makes with the horizontal is measured. The catheter is typically parallel with the horizontal at rest. The patient is asked to strain and the angulation is again measured, recording the change in urethral angulation that occurs between resting and straining. Urethral angulation with straining (hyper-mobility) is a sign of loss of urethral support, which often is seen with SUI. The vagina is carefully inspected for other manifestations of pelvic organ prolapse (dropped bladder, rectum, uterus) that can accompany the SUI.

urethra-rest

                                     Image above: female urethra (woman in stirrups)–note that urethra points straight ahead, like the barrel of a rifle

urethra-strain

                             Image above: female urethra (woman in stirrups)– because of urethral hyper-mobility the urethra leaks at the moment she is asked to strain or cough

Finally, a digital examination is performed to assess vaginal tone and pelvic muscle strength (rated on a scale from 0-5). A bimanual exam (combined internal and external exam in which the pelvic organs are felt between internal and external examining fingers) checks for the presence of pelvic masses.

Depending on circumstances, tests to further evaluate SUI may be used, including an endoscopic inspection of the lining of the bladder and urethra (cystoscopy), sophisticated functional tests of bladder storage and emptying (urodynamics) and, on occasion, imaging tests (bladder fluoroscopy).                   

How is SUI managed?

There are a variety of treatment options for SUI, ranging from non-invasive strategies to surgery. There are no effective medications for SUI. If there is not an adequate response to first-line, non-invasive, conservative measures, surgery becomes an appropriate consideration. However, it is always sensible to initially use a conservative approach that is cost-effective, natural, uses few resources and is free from side effects.

Kegel Exercises for SUI

Kegels have emerged from obscure to mainstream…In fact the 2017 Oscar “swag bag” included a pelvic floor device called “The Elvie,” reviewed in my book THE KEGEL FIX.

 

one-sheet-poster

Combating SUI demands contracting one’s pelvic floor muscles (PFMs) strongly, rapidly and ultimately, reflexively. The goal of Kegels, a.k.a. pelvic floor muscle training (PFMT) is to increase PFM strength, power, endurance and coordination to improve urethral support and closure.

Who Knew? PFMT has the potential to improve or cure SUI in those who suffer with the problem and prevent it in those who do not have it.

The cough reflex is an automatic contraction of the PFMs above and beyond their resting tone when one coughs. This squeezes the urethra shut to help prevent leakage. This is nature’s way of protection against incontinence with a sudden increase in abdominal pressure, a defense against cough-related SUI. An extension of this principle is to exercise the PFMs to amplify strength and power to allow earlier activation and more robust contraction.

PFMT increases PFM bulk and thickness, reducing the number of SUI episodes. Additionally, PFMT improves urethral support at rest and with straining, diminishing the urethral hyper-mobility that is characteristic of SUI. It also permits earlier activation of the PFMs when coughing, more rapid repeated PFM contractions and more durable PFM contractions between coughs.

Who Knew? PFMT can cure or considerably improve 60-70% of women who suffer with SUI. The benefits persist for many years, as long as the exercises are adhered to on an ongoing basis. PFMT is equally effective for pre-menopausal and post-menopausal women with SUI.

Who Knew? PFMT is most effective in women with mild or mild-moderate SUI. Chances are that if the SUI is moderate-severe, PFMT will be less effective. However, if not cured, the SUI can be improved, and that might be sufficient.

Once the PFMs are conditioned via PFMT, it is vital to apply the improved conditioning on a practical basis. The cough reflex can be replicated—voluntarily—when one is in situations other than actual coughing that induce SUI. In order to do so, one needs to be attentive to the triggers that provoke the SUI. By actively contracting the PFMs immediately prior to the trigger exposure, the SUI can be improved or prevented. For example, if changing position from sitting to standing results in SUI, consciously performing a brisk PFM contraction—an intense contraction for 2-5 seconds prior to and during transitioning from sitting to standing—should “clamp the urethra” and help control the problem. Such bracing of the PFMs can be a highly effective means of managing SUI and when practiced diligently can become automatic (a reflex behavior).

More Non-Invasive Strategies to Improve SUI

Manage the condition that provokes the SUI: Since discrete triggers often provoke SUI (e.g., when asthma causes wheezing, seasonal allergies cause sneezing, or when tobacco use, bronchitis, sinusitis, or post-nasal drip cause coughing), by managing the underlying condition, the SUI can be avoided.

Moderate fluid intake: With a sudden increase in abdominal pressure, there will tend to be more SUI when there are larger volumes in the bladder (although SUI can occur even immediately after urinating). Since there is a direct relationship between fluid intake and urine production, any moderation in fluid intake will decrease the volume of urine in the bladder and potentially improve the SUI. The key is to find the right balance to diminish the SUI, yet avoid dehydration. Since caffeinated beverages and alcohol increase urine volume, it is best to limit exposure (caffeine is present in coffee, tea, cola and even chocolate has a caffeine-like ingredient).

Urinate regularly: Based on the premise that there tends to be more SUI when there are greater volumes in the bladder, by emptying the bladder more frequently, SUI can be better controlled. Urinating on a two-hour basis is usually effective, although the specific timetable needs to be individually tailored. Voluntary urinary frequency is more desirable than involuntary SUI. An extension of this principle is to empty one’s bladder immediately before any activity that is likely to induce the SUI.

Maintain a healthy weight: Extra pounds can worsen SUI by increasing abdominal pressure and placing a greater load on the pelvic floor and bladder. Even a modest weight loss may improve SUI.

Who Knew? Bearing the burden of unnecessary pounds adversely affects many body parts. As much as obesity puts a great strain on the knees that support the body’s weight, so it does on the PFM.

Exercise: Being physically active can go a long way towards maintaining general fitness and helping improve SUI. In general, exercises that emphasize the core muscles—particularly Pilates and yoga—are most helpful for SUI. Unfortunately, and ironically, it is exercise that often provokes SUI.

Tobacco cessation: Tobacco causes bronchial irritation and coughing that provoke SUI. Additionally, chemical constituents of tobacco constrict blood vessels, impair blood flow, decrease tissue oxygenation and promote inflammation, negatively affecting function of the bladder, urethra and PFMs. By eliminating tobacco, SUI can be significantly improved.

Maintain bowel regularity: Achieving bowel regularity may improve SUI and prevent it from progressing. A rectum full of stool can adversely affect urinary control by putting internal pressure on the bladder and urethra. Additionally, chronic straining with bowel movements—similar in many ways to being in “labor” every day—can have a cumulative effect in weakening PFMs and can be a key factor in the development of SUI. To promote healthy bowel function, exercise daily and increase fiber intake by eating whole grains, fruits and vegetables.

The tampon trick: If SUI occurs under very predictable circumstances—e.g., during tennis, golf or jogging—a strategically placed tampon can be a friend. The tampon is not used for absorption purposes, but to support the urethra. By positioning the tampon in the vagina directly under the urethra, it acts as a space-occupying backboard. The tampon does not need to be positioned as deeply as it would be for menstruation, but just within the vagina. This may allow one to pursue activities without the need for a pad. Poise has come out with “Impressa,” a tampon available in three sizes designed specifically for SUI. It is placed via an applicator and can be worn for up to eight hours. In Australia and the UK, “Contiform,” a self-inserted, foldable intra-vaginal device that is shaped like a hollow tampon, is often used to help manage SUI.

Surgical Management of SUI: Mid-urethral sling

sling

Image above is of a mid-urethral sling in place under the urethra to provide the support necessary to cure/substantially improve the stress urinary incontinence

If conservative measures fail to sufficiently improve SUI, there are solutions. A relatively simple outpatient procedure—the mid-urethral sling—is the implantation of a synthetic tape between the urethra and vagina to recreate the “backboard” of urethral support that is defective. This creates a “hammock” to provide support and to allow compression and pinching of the urethra with any activity that increases abdominal pressure.

The sling procedure is performed via a small vaginal incision. The permanent material used for the sling is polypropylene tape, the same material as used by general surgeons to repair groin hernias. Mid-urethral refers to the placement of the sling beneath the mid-urethra, the channel that leads from the bladder to the urinary opening. Sling refers to the configuration created when the tape is firmly anchored to the soft tissues of the pelvis after being placed underneath the urethra. The sling procedure has a 85-90% cure rate for SUI.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health. Much of the content of this entry was excerpted from this book.  The book was written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.

10 Ways To Know That You Are Doing Your Man Kegel Exercises Properly

July 19, 2014

Andrew Siegel, MD   Blog # 163

6813

There has been a great deal of hubbub on the topic of pelvic floor exercises for men this past week, with the publication of a review article in the Gold Journal of Urology reviewing the benefits of pelvic floor muscle training in males:

http://www.ncbi.nlm.nih.gov/pubmed/24821468

and with Tuesday’s New York Times article entitled Pelvic Exercises For Men, Too.

http://well.blogs.nytimes.com/2014/07/14/pelvic-exercises-for-men-too/?_php=true&_type=blogs&_r=0

and with the launch this week of the first comprehensive, interactive, follow-along exercise program that helps men strengthen the muscles that support sexual and urinary health www.PrivateGym.com.

The story was carried in the NY Daily News

http://www.nydailynews.com/life-style/health/men-kegels-new-device-article-1.1869335

as well as the San Francisco Chronicle, the Atlanta Journal Constitution, the Tampa Bay Times and many other media outlets, including Live With Kelly and Michael and Doctor Radio.

There has been some misinformation regarding the proper technique of pelvic floor muscle exercises, and I would like to set the record straight. On one of the radio shows I listened to, it was stated that kegel exercises are akin to “pushing down, grunting and doing the Valsalva maneuver (medical term for pushing and straining).”  The truth of the matter is that kegel exercises involve pulling in and up without grunting, just the opposite of straining. One strains to move their bowels, whereas when one kegels they accomplish the opposite—tightening up the sphincters to NOT move their bowels; in fact, doing kegels is a means of suppressing bowel as well as urinary urgency.

In the 1940’s, gynecologist Dr. Arnold Kegel popularized pelvic floor muscle exercises for females—particularly for women who had recently given birth—in order to improve urinary and sexual health. But Kegel exercises are NOT just for the ladies. Men have the same pelvic floor muscles as do women and they are equally vital for sexual and urinary health. The pelvic floor muscles form the floor of the all-important “core” group of muscles and contribute strongly to men’s ability to have control of their bladders and colons and are play a crucial role in erections and ejaculation. The pelvic floor muscles are what allow the blood pressure in the penis at the time of erection to be sky high—way above systolic blood pressure—allowing for bone-like rigidity. These muscles are also the “motor” of ejaculation.

Doing Kegel exercises properly is fundamental to reaping the benefits derived from getting your pelvic floor muscles in tip-top shape. So how do you know if you are contracting the pelvic floor muscles properly?

  1. You know you are doing your Man Kegels properly when you see the base of your penis retract inwards towards the pubic bone as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you see the testicles rise up towards the groin as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you place your index and middle fingers in the midline between the scrotum and anus and contract your pelvic floor muscles and you feel the contractions of the bulbocavernosus muscle near the scrotum and the pubococcygeus muscle towards the anus.
  1. You know you are doing your Man Kegels properly when you can pucker your anus (not the gluteal muscles) as you contract your pelvic floor muscles. As you do so, you feel the anus tighten and pull up and in.
  1. You know you are doing your Man Kegels properly when you get the same feeling as you do when you are ejaculating as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you touch your erect penis and feel the erectile cylinders surge with blood as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you can make the penis lift up as you contract your pelvic floor muscles when you are in the standing position.
  1. You know you are doing your Man Kegels properly if you can stop your urinary stream completely when you contract your pelvic floor muscles.
  2. You know you are doing your Man Kegels properly if you can push out the last few drops of urine that remain after completing urination when you contract your pelvic floor muscles
  3. You know you are doing your Man Kegels properly ifafter doing a pelvic floor muscle training regimen you start noticing improvements in erectile rigidity and durability as well as better quality ejaculations, ejaculatory control and improvement in urinary control.

Andrew Siegel, M.D.

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

www.healthdoc13.wordpress.com

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook, Kobo); paperback now available:

www.MalePelvicFitness.com

Private Gym website where pelvic floor instructional DVD and resistance training equipment are now available:

www.PrivateGym.com

 

 

 

Pelvic Floor Muscle Exercises: Becoming the Master of Your Pelvic Domain

February 12, 2014

Andrew Siegel, M.D.  Blog # 59

I have had numerous requests to reblog this, so based upon popular demand, here it is…

The pelvic floor muscles (PFM)—popularized by Dr. Arnold Kegel—are key muscles that are essential to the health and well being of both women and men.  These muscles do not get a great deal of respect, as do the glamour muscles of the body including the pectorals, biceps and triceps; however, they should garner such respect because, although hidden from view, they are responsible for some very powerful and beneficial functions, particularly when trained.

The PFM compose the floor of our “core” muscles.  Our core is a cylinder of muscles of our torso that function as an internal corset.  They surround the inner surface of the abdomen, providing stability.  These muscles are referred to in Pilates as the “powerhouse”; Tony Horton, guru of the P90x exercises series, uses the term “cage.”  The major muscle groups in this core are the following: in the front the transversus abdominis and rectus abdominis; on the sides the obliques; in the back the erector spinae; the roof is the diaphragm; the base are the PFM.  These muscles stabilize the torso during dynamic movements and provide the wherewithal for body functions including childbirth; coughing; blowing our noses; equalizing the pressure in our ears when we are exposed to a change in air pressure as when we travel on airplanes; passing gas; moving our bowels; etc.

Core strength provides us with good posture, balance, support of the back and stabilization and alignment of the spine, ribs and pelvis. The core muscles are a “missing link” when it comes to fitness, often neglected at the expense of the limb muscles.   Tremendous core strength is evident in dancers, swimmers, and practitioners of yoga, Pilates and martial arts.  The core stabilizes the trunk while the limbs are active, enabling us to put great effort into limb movements—it is impossible to use the arms and legs effectively in any athletic endeavor without a solid core to act as a platform to push off.   An example of static core function is standing upright in gale force winds—the core helps stabilize the body so that the winds do not cause a loss of balance or posture. An example of dynamic core function is running up flight of stairs, resisting gravity while maintaining balance and posture.

POP QUIZ (answer below): CAN YOU NAME AN ANIMAL THAT HAS TREMENDOUS CORE STRENGTH?

The PFM form the base of the pelvis and represent the floor of the core muscles.  They provide support to the urinary, genital and intestinal tracts.  There are openings within the PFM that allow the urethra, vagina, and rectum to pass through the pelvis to their external openings.  There are two layers of muscles: the deep layer is the levator ani (literally, “lift the anus”) and coccygeus muscle.   The levator ani consists of the iliococcygeus, pubococcygeus, and puborectalis.  The superficial layer is the perineal muscles. These consist of the transverse perineal muscles, the bulbocavernosus and ischiocavernous muscles, and anal sphincter muscle.

The PFM have a resting muscle tone and can be voluntarily and involuntarily contracted and relaxed.  A voluntary contraction of the PFM will enable interruption of the urinary stream and tightening of the vagina and anus.  An involuntary (reflex) contraction of the PFM occurs, for example, at the time of a cough to help prevent urinary leakage.  Voluntary relaxation of the PFM occurs during childbirth when a female voluntarily increases the abdominal pressure at the same time the PFM are relaxed.

The PFM have three main functions: supportive, sphincter, and sexual. Supportive refers to their important role in securing our pelvic organs in proper position. Sphincter function allows us to interrupt our urinary stream, tense the vagina, and pucker the anus and rectum upon contraction of the PFM.  In terms of female sexual function, the PFM tightens the vagina, helps maintain and support engorgement and erection of the clitoris, and contracts rhythmically at the time of orgasm.  With respect to male sexual function, the PFM helps maintain penile erection and contracts rhythmically at the time of orgasm, facilitating ejaculation by propelling semen through urethra.

In men, the bulbocavernosus muscle surrounds the inner urethra. During urination, contraction of this muscle expels the last drops of urine; at the time of ejaculation, this muscle is responsible for expelling semen by strong rhythmic contractions.  In women, the bulbocavernosus muscle is divided into halves that extend from the clitoris to the perineum and covers the erectile tissue that is part of the clitoris.  The ischiocavernosus muscle stabilizes the erect penis or clitoris, retarding return of blood to help maintain engorgement.

The PFM can get weakened with aging, obesity, pregnancy, chronic increases in abdominal pressure (due to straining with bowel movements, chronic cough, etc.), and a sedentary lifestyle. 

The strength of the PFM can be assessed by inserting an examining finger in the vagina or rectum, after which the patient is asked to contract their PFM. The Oxford grading scale is used, with a scale ranging from 0-5:

0—complete lack of response

1—minor fluttering

2—weak muscle activity without a circular contraction or inward and upward     movement

3—a moderate contraction with inner and upward movement

4/5—a strong contraction and significant inner and upward movement

PFM exercises are used to improve urinary urgency, urinary incontinence, pelvic relaxation, and sexual function. The initial course of action is to achieve awareness of the presence, location, and nature of these muscles.  The PFMs are not the muscles of the abdomen, thighs or buttocks, but are the saddle of muscles that run from the pubic bone in front to the tailbone in back. To gain awareness of the PFM, interrupt your urinary stream and be cognizant of the muscles that allow you to do so.  Alternatively, a female can place a finger inside the vagina and try to tighten the muscles so that they cinch down around the finger. When contracting the PFMs, the feeling will be of your “seat” moving in an inner and upward direction, the very opposite feeling of bearing down to move your bowels.  A helpful image is movement of the pubic bone and tailbone towards each other. Another helpful mental picture is thinking of the PFMs as an elevator—when PFMs are engaged, the elevator rises to the first floor from the ground floor; with continuing training, you can get to the second floor.

Once full awareness of the PFM is attained, they can be exercised to increase their strength and tone.  The good news is that you do not need to go to a gym, wear any special athletic clothing, or dedicate a great deal of time to this.  As a test, perform as many contractions of your PFM as possible, with the objective of a few second contraction followed by a few second relaxation, doing as many repetitions until fatigue occurs.  The goal is to gradually increase the length of time of contraction of the PFMs and the number of repetitions performed. Working your way up to 3 sets of up to 25 repetitions, 5 seconds duration of contraction/5 seconds relaxation, is ideal.  These exercises can be done anywhere, at any time, and in any position—lying down, sitting, or standing.  Down time—traffic lights, standing in check-out lines, during commercials while watching television, etc.—are all good times to integrate the PFM exercises.  Expect some soreness as the target muscles will be overloaded at first, as in any strength-training regimen.  It may take 6-12 weeks to notice a meaningful difference, and the exercises must be maintained because a “use it or lose it” phenomenon will occur if the muscles are not exercised consistently, just as it will for any exercise.

With respect to incontinence and urgency, recognize what the specific triggers are that induce the symptoms.   Once there is a clear understanding of what brings on the urgency or incontinence, immediately prior to or at the time of exposure to the trigger, rhythmically and powerfully contract the PFM—“snapping” or “pulsing” the pelvic floor muscles repeatedly—this can often be a means of pre-empting or terminating both urgency and leakage.   This benefit capitalizes on a reflex that involves the PFMs and the bladder muscle—when the bladder muscle contracts, the PFM relaxes and when the PFM contracts, the bladder muscle relaxes. So, in order to relax a contracting bladder (overactive bladder), snap the PFM a few times and the bladder contraction dissipates.  Stress incontinence can improve as well, because of increased resistance to the outflow of urine that occurs as a result of increased PFM tone and strength.

By improving the strength and conditioning of the PFM, one may expect to reap numerous benefits. Urinary control will improve, whether the problem is stress incontinence, urgency, or urgency incontinence. Post-void dribbling (leaking small amounts of urine after completing the act of voiding) will also be aided. Furthermore, improvement or prevention of bowel control issues will accrue.  Some improvement in pelvic organ prolapse may result, and PFM exercises can certainly help stabilize the situation to help prevent worsening.  PFM toning can also improve sexual performance in both genders.  When a female masters her pelvic floor, she acquires the ability to “snap” the vagina like a shutter of a camera, potentially improving sexual function for herself and her partner.  Similarly, when a man becomes adept at PFM exercises, erectile rigidity and durability as well as ejaculatory control and function can improve. For both sexes, PFM mastery can improve the intensity and quality of orgasms. In terms of quality of life, PFM exercises are really as important—if not more so—than the typical resistance exercises that one does in a gym.

ANSWER TO QUESTION: Can you name an animal that has tremendous core strength?

Dolphins—essentially all core with rudimentary limbs.

Much more info on this subject will be available with the April1, 2014 release of my new book: Male Pelvic Fitness: Optimizing Sexual and Urinary Health www.MalePelvicFitness.com

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Pelvic Floor Muscle Exercises: Becoming the Master of Your Pelvic Domain

May 18, 2012


Andrew Siegel, M.D.  Blog # 59

The pelvic floor muscles (PFM)—first described by Dr. Arnold Kegel—are key muscles that are essential to the health and well being of both women and men.  These muscles do not get a great deal of respect, as do the glamour muscles of the body including the pectorals, biceps and triceps. The PFM should garner such respect because, although hidden from view, they are responsible for some very powerful and beneficial functions, particularly when trained.

The PFM compose the floor of our “core” muscles.  Our core is a cylinder of muscles of our torso that function as an internal corset.  They surround the inner surface of the abdomen, providing stability.  These muscles are referred to in Pilates as the “powerhouse”; Tony Horton, guru of the P90x exercises series, uses the term “cage.”  The major muscle groups in this core are the following: in the front the transversus abdominis and rectus abdominis; on the sides the obliques; in the back the erector spinae; the roof is the diaphragm; the base are the PFM.  These muscles stabilize the torso during dynamic movements and provide the wherewithal for body functions including childbirth; coughing; blowing our noses; equalizing the pressure in our ears when we are exposed to a change in air pressure as when we travel on airplanes; passing gas; moving our bowels; etc.  If you want to be able to expectorate like Gaston in Beauty and the Beast, you need a good core!

 

Core strength provides us with good posture, balance, support of the back and stabilization and alignment of the spine, ribs and pelvis. The core muscles are a “missing link” when it comes to fitness, often neglected at the expense of the limb muscles.   Tremendous core strength is evident in dancers, swimmers, and practitioners of yoga, Pilates and martial arts.  The core stabilizes the trunk while the limbs are active, enabling us to put great effort into limb movements—it is impossible to use the arms and legs effectively in any athletic endeavor without a solid core to act as a platform to push off.   An example of static core function is standing upright in gale force winds—the core helps stabilize the body so that the winds do not cause a loss of balance or posture. An example of dynamic core function is running up flight of stairs, resisting gravity while maintaining balance and posture.

POP QUIZ (answer below): CAN YOU NAME AN ANIMAL THAT HAS TREMENDOUS CORE STRENGTH?

The PFM form the base of the pelvis and represent the floor of the core muscles.  They provide support to the urinary, genital and intestinal tracts.  There are openings within the PFM that allow the urethra, vagina, and rectum to pass through the pelvis to their external openings.  There are two layers of muscles: the deep layer is the levator ani (literally, “lift the anus”) and coccygeus muscle.   The levator ani consists of the iliococcygeus, pubococcygeus, and puborectalis.  The superficial layer is the perineal muscles. These consist of the transverse perineal muscles, the bulbocavernosus and ischiocavernous muscles, and anal sphincter muscle.

 

The PFM have a resting muscle tone and can be voluntarily and involuntarily contracted and relaxed.  A voluntary contraction of the PFM will enable interruption of the urinary stream and tightening of the vagina and anus.  An involuntary (reflex) contraction of the PFM occurs, for example, at the time of a cough to help prevent urinary leakage.  Voluntary relaxation of the PFM occurs during childbirth when a female voluntarily increases the abdominal pressure at the same time the PFM are relaxed.

The PFM have three main functions: supportive, sphincter, and sexual. Supportive refers to their important role in securing our pelvic organs in proper position. Sphincter function allows us to interrupt our urinary stream, tense the vagina, and pucker the anus and rectum upon contraction of the PFM.  In terms of female sexual function, the PFM tightens the vagina, helps maintain and support engorgement and erection of the clitoris, and contracts rhythmically at the time of orgasm.  With respect to male sexual function, the PFM helps maintain penile erection and contracts rhythmically at the time of orgasm, facilitating ejaculation by propelling semen through urethra.

In men, the bulbocavernosus muscle surrounds the inner urethra. During urination, contraction of this muscle expels the last drops of urine; at the time of ejaculation, this muscle is responsible for expelling semen by strong rhythmic contractions.  In women, the bulbocavernosus muscle is divided into halves that extend from the clitoris to the perineum and covers the erectile tissue that is part of the clitoris.  The ischiocavernosus muscle stabilizes the erect penis or clitoris, retarding return of blood to help maintain engorgement.

The PFM can get weakened with aging, obesity, pregnancy, chronic increases in abdominal pressure (due to straining with bowel movements, chronic cough, etc.), and a sedentary lifestyle.

In women suffering with urinary incontinence or pelvic relaxation, the strength of the PFM can be assessed by inserting an examining finger in the vagina, after which the patient is asked to contract her PFM tightly.  (A similar assessment can be performed by placing a finger in the rectum, after which the patient is asked to contract the PFM.)

The Oxford grading scale is used, with a scale ranging from 0-5:

0—complete lack of response

1—minor fluttering

2—weak muscle activity without a circular contraction or inward and upward     movement

3—a moderate contraction with inner and upward movement

4/5—a strong contraction and significant inner and upward movement

PFM exercises are used to improve urinary urgency, urinary incontinence, pelvic relaxation, and sexual function. The initial course of action is to achieve awareness of the presence, location, and nature of these muscles.  The PFMs are not the muscles of the abdomen, thighs or buttocks, but are the saddle of muscles that run from the pubic bone in front to the tailbone in back. To gain awareness of the PFM, interrupt your urinary stream and be cognizant of the muscles that allow you to do so.  Alternatively, a female can place a finger inside the vagina and try to tighten the muscles so that they cinch down around the finger. When contracting the PFMs, the feeling will be of your “seat” moving in an inner and upward direction, the very opposite feeling of bearing down to move your bowels.  A helpful image is movement of the pubic bone and tailbone towards each other. Another helpful mental picture is thinking of the PFMs as an elevator—when PFMs are engaged, the elevator rises to the first floor from the ground floor; with continuing training, you can get to the second floor.

Once full awareness of the PFM is attained, they can be exercised to increase their strength and tone.  The good news is that you do not need to go to a gym, wear any special athletic clothing, or dedicate a great deal of time to this.  As a test, perform as many contractions of your PFM as possible, with the objective of a few second contraction followed by a few second relaxation, doing as many repetitions until fatigue occurs.  The goal is to gradually increase the length of time of contraction of the PFMs and the number of repetitions performed. Working your way up to 3 sets of up to 25 repetitions, 5 seconds duration of contraction/5 seconds relaxation, is ideal.  These exercises can be done anywhere, at any time, and in any position—lying down, sitting, or standing.  Down time—traffic lights, standing in check-out lines, during commercials while watching television, etc.—are all good times to integrate the PFM exercises.  Expect some soreness as the target muscles will be overloaded at first, as in any strength-training regimen.  It may take 6-12 weeks to notice a meaningful difference, and the exercises must be maintained because a “use it or lose it” phenomenon will occur if the muscles are not exercised consistently, just as it will for any exercise.

With respect to incontinence and urgency, recognize what the specific triggers are that induce the symptoms.   Once there is a clear understanding of what brings on the urgency or incontinence, immediately prior to or at the time of exposure to the trigger, rhythmically and powerfully contract the PFM—“snapping” or “pulsing” the pelvic floor muscles repeatedly—this can often be a means of pre-empting or terminating both urgency and leakage.   This benefit capitalizes on a reflex that involves the PFMs and the bladder muscle—when the bladder muscle contracts, the PFM relaxes and when the PFM contracts, the bladder muscle relaxes. So, in order to relax a contracting bladder (overactive bladder), snap the PFM a few times and the bladder contraction dissipates.  Stress incontinence can improve as well, because of increased resistance to the outflow of urine that occurs as a result of increased PFM tone and strength.

By improving the strength and conditioning of the PFM, one may expect to reap numerous benefits. Urinary control will improve, whether the problem is stress incontinence, urgency, or urgency incontinence. Post-void dribbling (leaking small amounts of urine after completing the act of voiding) will also be aided. Furthermore, improvement or prevention of bowel control issues will accrue.  Some improvement in pelvic organ prolapse may result, and PFM exercises can certainly help stabilize the situation to help prevent worsening.  PFM toning can also improve sexual performance in both genders.  When a female masters her pelvic floor, she acquires the ability to “snap” the vagina like a shutter of a camera, potentially improving sexual function for herself and her partner.  Similarly, when a man becomes adept at PFM exercises, erectile rigidity and durability as well as ejaculatory control and function can improve. For both sexes, PFM mastery can improve the intensity and quality of orgasms. In terms of quality of life, PFM exercises are really as important—if not more so—than the typical resistance exercises that one does in a gym.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

Available on Amazon Kindle

ANSWER TO QUESTION: Can you name an animal that has tremendous core strength?

Dolphins—essentially all core with rudimentary limbs.

To access my video on PFM exercises:  http://www.youtube.com/watch?v=5IbliBiRzOw