Posts Tagged ‘pelvic floor muscle training’

Integrating Kegels With Other Exercises

March 17, 2018

Andrew Siegel MD     3/17/2018

Initially, it is important to isolate the pelvic floor muscles (PFM) and exercise them while not actively contracting any other muscle groups. Once PFM mastery is achieved, PFM exercises can then be integrated into other exercise routines, workouts and daily activities.

No Muscle is an Island

In real life, muscles do not work in isolation, but rather as part of a team. The PFM are no exception, often contracting in conjunction with the other core muscles in a mutually supportive way, co-activating to maintain lumbar-pelvic stability, help prevent back pain and contribute to pelvic tone and strength.

The core muscles—including the PFM—stabilize the trunk when the limbs are active, enabling powerful limb movements. It is impossible to use arm and leg muscles effectively in any athletic endeavor without engaging a solid core as a “platform” from which to push off. Normally this happens without conscious effort; however, with focus and engagement, the core and PFM involvement can be optimized. The stronger the core platform, the more powerful the potential push off that platform will be, resulting in more forceful arm and leg movements. Thus, maximizing PFM strength has the benefit of optimizing limb power.  Core training that exercises the abdominal/lumbar/pelvic muscles as a unit improves the PFM response. Many Pilates and yoga exercises involve consciously contracting the PFM together with other core muscles during exercise routines.

Integrating PFMT with Other Exercises

Dynamic exercises in which complex body movements are coupled with core and PFM engagement provide optimal support and “lift” of the PFM, enhance non-core as well as core strength and heighten the mind-body connection. When walking, gently contract your PFM to engage them in the supportive role for which they were designed, which will also contribute to good posture. Consciously contract the PFM when standing up, climbing steps, doing squats and lunges, marching, skipping, jumping, jogging, and dancing.  When cycling, periodically get up out of the saddle and contract your PFM to get blood flowing to the compressed pelvic muscles and perineum.

Integrating PFMT with Weight Training: “Compensatory” Pelvic Contractions

Weight training and other forms of high impact exercise result in tremendous increases in abdominal pressure. This force is largely exerted downwards towards the pelvic floor, particularly when exercising in the standing position, when gravity comes into play, potentially harmful to the integrity of the PFM.  Engaging the PFM during such efforts will help counteract the downward forces exerted on the pelvic floor.  “Compensatory” PFM contractions, in which the PFM are contracted in proportion to the increased abdominal pressure, are effective in balancing out the forces exerted upon the pelvic floor.

Wishing you the best of health!

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

 

 

 

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Nuts and Bolts of Pelvic Floor Muscle Training: Part 4

March 3, 2018

Andrew Siegel MD   3/3/2018

There are few, if any, pelvic programs in existence targeted for specific pelvic floor dysfunctions, as what you will generally find is a “one-size-fits-all” approach.

What follows are focused pelvic training programs, each designed for the nuances of the specific pelvic dysfunction at hand.  I have designed a general program as well as programs for poor pelvic muscle endurance, stress urinary incontinence (SUI), overactive bladder (OAB), pelvic organ prolapse (POP)/vaginal laxity, sexual/orgasm issues, bowel incontinence and pelvic pain. These programs have been carefully crafted based on my specialized training in pelvic medicine and surgery, clinical experience, interactions with physical therapists, exercise/fitness experts, Pilates and yoga instructors, and most importantly, my patients.

 General PFMT Program

The general program is a balanced program that incorporates strength and endurance training.  It is intended for women who are found to have poor PFM strength or poor strength and endurance on the preliminary testing. It is also appropriate for women without specific pelvic issues who wish to pursue a PFM exercise program to make their PFM stronger, more durable and to help prevent the onset of pelvic floor issues.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each week try to step up the intensity of the PFM contractions and duration of the short contractions; allot equal time to relaxing phase as contracting phase; refer back to previous pages if you need a refresher on snaps, shorts and sustained.

 Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

 Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

 Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x3 = 1 set 

Week 5 and on: Advance to resistance training. However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue this as a “maintenance” program, consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

 PFMT for Poor PFM Endurance

This program is designed for those with satisfactory PFM strength (Oxford grades 3-5), but poor endurance. The number of contractions performed and contraction duration are gradually increased over the course of the training program as adaptation occurs.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; allot equal time to relaxing phase as contracting phase.

 Week 1: snaps x15; 2 second shorts x15; 6 second sustained x1 = 1 set 

 Week 2: snaps x25; 3 second shorts x20; 8 second sustained x2 = 1 set 

 Week 3: snaps x35; 4 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 5 second shorts x30; 10 second sustained x4 = 1 set 

 Week 5 and on: Advance to resistance training.  If you found yourself severely challenged by this non-resistance program or cannot/prefer not to use resistance (which requires the placement of a device in your vagina), you can continue this as a “maintenance” program consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for POP/Vaginal Laxity

Endurance training is especially relevant for those with POP and poor vaginal tone. Focusing on sustained contractions will benefit the slow twitch endurance PFM fibers that are the prime contributors to pelvic tone and support. 

 Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week, work on stepping up the intensity of the PFM contractions; allot equal time to relaxing phase as contracting phase.

 Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

 Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

 Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

 Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue using this as a “maintenance” program, which will consist of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for Sexual/Orgasm Issues

The PFM contract intensively at the time of climax with each contraction lasting about 0.8 of a second, about how long snaps last. A series of vigorous snaps is precisely the PFM contraction pattern experienced at the time of orgasm. If you have issues with achieving an orgasm or with orgasm intensity, this natural contraction pattern is replicated in this program, which focuses on high-intensity pulses of the PFM (snaps) that benefit the fast twitch explosive fibers.  Endurance training is also important for sexual function since sustained contractions benefit the slow twitch endurance PFM fibers that contribute to pelvic support and vaginal tone.    

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each week work on stepping up the intensity of the snap PFM contractions; allot equal time to relaxing phase as contracting phase.

Week 1: snaps x30; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x40; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x50; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x60; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advancing to the resistance training.  However, if you were severely challenged by this non-resistance program or cannot/prefer not to use resistance—which requires the placement of a device in your vagina—you can continue using this as a “maintenance” program, consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for SUI

Strength and power training are critical for managing SUI, with the power element (i.e., how rapidly you can maximally contract your PFM) vital in order to react quickly to SUI triggers.  Focusing on moderate intensity contractions that last for several seconds (shorts) will benefit SUI, as this type of PFM contraction deployed prior to and during any activity that induces the SUI will help prevent its occurrence.  Attention directed to these short contractions will allow earlier activation of the PFM with SUI triggers, as well as increased contraction strength and durability to counteract the sudden increase in abdominal pressure that induces SUI.  Effort applied to sustained contractions is equally important since the slow twitch endurance PFM fibers are prime contributors to pelvic tone and pelvic support of the urethra, which promote urinary continence.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week try to step up the PFM contraction intensity as well as the activation speed (how long it takes to get to peak intensity); allot equal time to relaxing phase as contracting phase.

Week 1: snaps x20; 5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x30; 5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x40; 5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x50; 5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue this as a “maintenance” program, which consists of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for OAB and Urinary/Bowel Incontinence

Focusing on high-intensity pulses of the PFM (snaps) will benefit the fast twitch explosive fibers that are critical for inhibiting urinary and bowel urgency/urgency incontinence. These snaps will generate increased PFM strength and power to enhance the inhibitory reflex between PFM and the bladder/bowel, permitting a speedy reaction to urgency and facilitating the means to counteract urinary and bowel urgency, frequency and incontinence. Of equal importance is endurance training of the slow twitch, fatigue-resistant fibers that contribute to baseline tone of the voluntary urinary and bowel sphincters.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week try to step up the intensity of the PFM contractions; allot equal time to relaxing phase as contracting phase.

Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot/prefer not to use resistance (which requires the placement of a device in your vagina), you can continue using this as a “maintenance” program, which will consist of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for Pelvic Pain Due to Tension Myalgia: “Reverse” PFMT

Focusing on the relaxing aspect of the PFM contraction/relaxation cycle is the key to “down-train” the PFM from their over-tensioned, knot-like state. Those with over-contracted and over-toned PFM will not benefit from the typical strengthening PFMT done for most PFM dysfunctions—and can actually worsen their condition—so the emphasis here is on the relaxation phase of the PFM. This is “reverse” PFMT, conscious unclenching of the PFM in which the PFM drop and slacken as opposed to rise and contract. Reverse PFMT strives to stretch, relax, lengthen and increase the flexibility of the PFM. 

“Reverse” Kegels can be a confusing and difficult concept, particularly because these exercises demand conscious relaxation of the PFM, which only occurs subconsciously in real life. Recall that the PFM have a baseline level of tone and that complete PFM relaxation only occurs at the time of urination, bowel movements, passing gas or childbirth. 

To make this easier to understand, think of a PFM contraction on a scale of 0-10, with 0 being complete relaxation and 10 being maximal contraction. I have arbitrarily chosen 2 as the baseline level of PFM tone.  In reverse Kegel exercises you strive to go from 2 to 0 as opposed to standard exercises in which the effort is to go from 2 to 10.  When you urinate, move your bowels or pass gas, the PFM relax to a level of 0, so this is the feeling that you should strive to replicate, while continuing to breathe regularly without straining or pushing.  A deep exhalation of air will facilitate PFM relaxation, as it does for other muscle groups.

Perform the following: A very gentle PFM contraction to initiate PFM engagement, followed by deep relaxation and release of the PFM lasting as long as the contraction; 3 sets; one-minute break between each set; do 3-4 times weekly.

Week 1: reverse snaps x20; reverse 2-5 shorts x15; reverse 10 second sustained x1 = 1 set 

Week 2: reverse snaps x30; reverse 2-5 shorts x20; reverse 10 second sustained x2 = 1 set 

Week 3: reverse snaps x40; reverse 2-5 shorts x25; reverse 10 second sustained x3 = 1 set 

Week 4: reverse snaps x50; reverse 2-5 shorts x30; reverse 10 second sustained x3 = 1 set 

Week 5 and on: There is no role for using resistance exercises for tension myalgia. Continue using this program as a “maintenance” program, consisting of the Week 4 regimen done twice weekly (as opposed to every other day). Make a concerted effort at keeping the PFM relaxed at all times, not just while pursuing the PFMT program.

…To be continued.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

The Nuts and Bolts of Pelvic Floor Muscle Training (PFMT): Part 3

February 17, 2018

Andrew Siegel MD   2/17/2018

What follows in this and the next few blog entries are pelvic training programs that I have crafted based on my specialized training in pelvic medicine and surgery; clinical experience; and interactions with physical therapists, exercise/fitness experts, Pilates instructors, yoga instructors and most importantly, my patients. Programs have been designed to treat areas of pelvic floor muscle weakness, e.g., if strength is the issue, emphasis on strength training is in order, whereas if  pelvic stamina is the issue, focus on endurance training is appropriate.

There are few, if any, pelvic programs in existence that are designed for specific pelvic floor dysfunctions, as what is generally out there is a “one-size-fits-all” approach.  I have created “tailored” PFMT exercise routines, customized for the particular pelvic health issue at hand, including stress urinary incontinence (SUI), overactive bladder (OAB), pelvic organ prolapse (POP), sexual/orgasm issues and pelvic pain.

Program Flexibility

These programs are not designed with the intent that they be rigidly adhered to, as they can be customized to make them work for you, recognizing that every woman and every pelvic floor is unique. You can modify the programs and experiment with all variables—intensity, power, contraction and relaxation duration, number of reps and number of sets, with the ultimate objective of challenging the pelvic muscles to make them stronger, better toned, firmer, more flexible and healthier.

Do what feels right and works for you, building to your maximal potential over time. If you feel fatigued before completing the number of reps recommended, do as many quality contractions as you can do.  If you cannot maintain contraction intensity for the duration recommended, do the best you can. Three sets per session are ideal, but if you find this too challenging, you can do two sets, or even just one. If you find that completing 3 sets becomes a simple task, you can do 4 or 5 sets as your PFM become stronger and more durable.

The 3 Types of Pelvic Floor Muscle Contractions

There are three basic types of PFM contractions based upon the duration and intensity of the contraction.  Three “S” words make these contractions easy to remember: Snaps, Shorts and Sustained.

Snaps are rapid, high intensity pulses of the PFM that take less than one second per cycle of contracting and relaxing. These are the type of PFM contractions that occur involuntarily at the time of sexual climax, so should be easy to understand and perform.

Shorts are slower, less intense squeezes of the PFM that can last anywhere from two to five seconds (with equal time allotted to the relaxing phase).

Sustained PFM contractions are less intense squeezes that last ten seconds or longer (with an equal time in the relaxing phase).  These are the type of PFM contractions that you use when you have a strong desire to urinate or move your bowels but do not have access to a bathroom and must apply effort to “hold it in.”

Warming Up

Before starting the PFMT program, I recommend a warm-up week to practice and become familiar with snaps, shorts and sustained contractions. Do not start the formal PFMT until you feel comfortable with all three contractions. Do the Oxford strength and endurance testing to obtain baseline values before you begin the warm-up week.

If your Oxford grade is 0-2, consider yourself to have weak PFM. If you cannot do more than 20 snaps, 15 shorts or one-10 second sustained contraction, consider your endurance poor. If your PFM strength is good, but your endurance is poor, use the program tailored for poor endurance. If you have a specific pelvic dysfunction that you would like to focus on improving, use the program tailored to that specific dysfunction. If you suffer with more than one pelvic floor dysfunction, e.g., both pelvic organ prolapse  and stress urinary incontinence, determine which issue is most compelling and disturbing to you and start with that specific program. If you feel that the problems are equal in degree, complete one program followed in succession by the other.

Warm-Up Week: Do as many good quality snaps as possible until you feel that you can no longer do them with full intensity.  Take a short break and then do as many good quality shorts until you feel that your efforts are diminishing.  Finally, do a sustained contraction for as long as you can until fatigue sets in. After a short break, repeat the sustained contraction.  Do this warm-up every other day for this preliminary week before proceeding with the programs.

…To be continued in 2 weeks.  Next week’s entry will take a break from PFM training to cover “When Sex Hurts and Pain Replaces Pleasure.”

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

The Nuts and Bolts of Pelvic Floor Muscle Training (PFMT): Part 2

February 10, 2018

Andrew Siegel MD    2/10/18

This is a continuation of last week’s entry.  Remember, PFMT is equally appropriate for males as well as females –both genders have these important muscles that can benefit from whipping them into shape.

3 screw icon square

 

The basic PFMT programs that follow are “low tech” exercises of the PFM without added resistance.  They can be thought of as PFMT 101, the goal of which is to provide the foundation for pelvic muscle proficiency. After mastery of basic PFMT, progression to the next phase of conditioning—resistance training—is in order.

PFMT is the essence of “functional fitness,” exercises that develop PFM strength, power, stamina and the skillset that can be used to improve and/or prevent specific pelvic functional impairments. PFMT regimens must be flexible and nuanced, designed and customized with particular functional needs in mind, i.e., issues of pelvic support, urinary control, sexual function, pain, etc., as opposed to a one-size-fits-all approach.  An additional consideration is baseline PFM strength and stamina.  After determining an area of weakness, focused effort should be applied to this deficit.

Time to Begin

You do not need to go to a gym, wear athletic clothing, have any special equipment, or dedicate a great deal of time to PFMT. It is vital to do properly performed, quality PFM contractions with the goal of slow and steady progress. Experiencing some aching and soreness as you begin is not uncommon.

If you are pursuing PFMT for specific pelvic issues, expect that it may take a number of weeks or more to see an improvement in your symptoms.  After you have noticed a beneficial effect, the exercise regimen must be maintained, because regression can occur if the pelvic muscles are not consistently exercised…”use it or lose it” applies here.

Basic PFMT exercises can be performed lying down, sitting upright in a comfortable chair with your back straight, or standing. It is best to begin lying down, to minimize gravity, which makes the exercises more challenging. Regardless of position, it is essential to maintain good form, posture and body alignment while doing PFMT. It is important to relax your abdomen, buttocks and thighs. Breathe slowly and do not hold your breath. Even though no muscle group works alone, by trying to isolate the PFM and focusing on squeezing only the PFM, you will make more rapid progress. You should not be grimacing, grunting or sweating, as PFMT is, in part, a meditative pursuit that employs awareness, focus, mindfulness and intention while performing deliberate contractions of the PFM.

Helpful metaphor: “Snap” describes a brief, vigorous, well-executed contraction of the PFM. With increasing PFM command, these pelvic muscles can be “snapped” like your fingers.

There are six variables with respect to PFM contractions:

  1. contraction intensity
  2. contraction duration
  3. relaxation duration
  4. power
  5. repetitions
  6. sets

Contraction intensity refers to the extent that the PFM are squeezed, ranging from a weak flick of the muscles to a robust and vigorous contraction. The contraction duration is the amount of time that the squeeze is sustained, ranging from a “snap”—a rapid pulsing of the PFM, to a “sustained hold”—a long duration contraction. The relaxation duration is the amount of time the PFM are unclenched until the next contraction is performed. Power is a measure of contraction strength and speed, the ability to rapidly achieve a full intensity contraction. Repetitions (reps) are the number of contractions performed in a single set (one unit of exercise).

It is relatively easy to intensively contract your PFM for a brief period, but difficult to maintain that intensity for a longer duration contraction. It is unlikely that you will be able to maintain the intensity of contraction of a sustained hold as you would for a snap.

The better PFMT regimens utilize a combination of snaps, few-second contractions and sustained duration contractions to reap the benefits of both strength and endurance training.

Fact: Short duration, high intensity contractions build strength and power, whereas longer duration, less intense contractions will build endurance, both vital elements of fit PFM.

Incremental change—the gradual and progressive increase in the intensity of contraction, duration of contraction, number of reps and number of sets performed—is the goal.  Performing the program 3-4 times weekly is desirable since recovery days are important for skeletal muscles.

PFMT is not an extreme program; nonetheless, it is by no means an undemanding program, and certainly requires effort and perseverance.  Depending on your level of baseline PFM fitness, you may find the exercises anywhere in the range from relatively easy to quite challenging. Your PFM are unique in terms of their shape, size and strength and consequently expectations regarding results will vary from individual to individual.

After a month or so, you should be on your way to achieving basic conditioning of the PFM. Reassessing the PFM by repeating the Oxford grading and the PFM endurance tests that you measured at baseline should demonstrate objective evidence of progress. More importantly, you should start noticing subjective improvement in many of the domains that PFM fitness can influence.  Once you have mastered non-resistance training, it is time to move on to resistance training, in which you squeeze your PFM against the opposing force of resistance in an effort to accelerate the PFMT.

If you are challenged by the non-resistance PFMT or cannot or prefer not to use resistance—which for women requires the placement of a device in your vagina and for men the ability to achieve a rigid erection—you can continue with the non-resistance training using it as a “maintenance” program.  PFM maintenance training typically requires continuing with the PFMT program, but performing it less frequently, twice weekly usually being sufficient.

To be continued next week…

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, Apple iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

The Nuts and Bolts of Pelvic Floor Muscle Training (PFMT): Part 1

February 3, 2018

Andrew Siegel MD  2/3/18

I received intensive exposure to surgical aspects of pelvic health at UCLA School of Medicine, where I spent a year training in pelvic medicine and reconstructive surgery following completion of my urology residency at University of Pennsylvania School of Medicine. This background, coupled with my passion for health, fitness and the benefits of exercise, led to my interest in PFMT as a means of optimizing pelvic health and to avoid, or at times facilitate, surgical management of pelvic floor dysfunctions.  Is it traditional for a pelvic surgeon to espouse non-surgical treatments?  Not at all, but after decades in the urology/gynecology “trenches,” I have concluded that PFMT is a vastly unexploited resource that offers significant benefits.

Photo below: Yours truly on left with Dr. Shlomo Raz (UCLA professor who is “father” of female urology) on right (1988)

shlomo and andy

 

“Strength training improves muscle vitality and function.” These seven words embody a key principle of exercise physiology that is applicable to the PFM.

Introduction

There is little to no consensus regarding the nuances and details of PFMT programs.  There is no agreement on the best position in which to do PFMT; the number of sets to perform; the number of repetitions per set; the intensity of PFM contractions; the duration of PFM contractions; the duration of PFM relaxation; and how often to do PFMT. The particulars of many PFMT routines are arbitrary at best. In fact, Campbell’s Urology—the premier textbook—concludes: “No PFMT regimen has been proven most effective and treatment should be based on the exercise physiology literature.”  

My goal is to take the arbitrary out of PFMT, providing thoughtfully designed, specifically tailored programs crafted in accordance with Dr. Arnold Kegel’s precepts, exercise physiology principles and practical concepts.

Dr. Kegel’s precepts are summarized as follows:

  • Muscle education
  • Feedback
  • Progressive intensity
  • Resistance

Exercise physiology principles as applied to PFMT include the following (note that there is some overlap with Dr. Kegel’s precepts and practical concepts):

  • Adaptation: The process by which muscle growth occurs in response to the demands placed upon the PFM, with adaptive change in proportion to the effort put into the exercises.
  • Progression: The necessity for more challenging exercises in order to continue the process of adaptive change that occurs as “new normal” levels of PFM fitness are established. This translates into slowly and gradually increasing contraction intensity, duration of contractions, number of PFM repetitions and number of sets.
  • Distinguishing strength, power and endurance training: Strength is the maximum amount of force that a muscle can exert; power is a measure of this strength factoring in speed, i.e., a measure of how quickly strength can be expressed. Endurance or stamina is the ability to sustain a PFM contraction for a prolonged time and the ability to perform multiple contractions before fatigue sets in. High intensity PFM contractions build muscle strength, whereas less intensive but more sustained contractions build endurance. Power is fostered by rapidly and explosively contracting the PFM.
  • “Use it or lose it”: The “plasticity” of the PFM—the adaptation in response to the specific demands placed on the muscles—requires continued training, at minimum a “maintenance” program after completion of a course of PFMT.
  • Full range of motion: The goal of PFMT is not only to increase strength, power and endurance, but also flexibility. This is accomplished by bringing the muscle through the full range of motion, which at one extreme is full contraction (muscle shortening), and at the other, complete relaxation (muscle lengthening). The exception to this is for muscles that are already over-tensioned, which need to be relaxed through muscle lengthening exercises.

Practical concepts encompass the following:

  • Initially training the PFM in positions that remove gravity from the picture, then advancing to positions that incorporate gravity.
  • Beginning with the simplest, easiest, briefest PFM contractions, then proceeding with the more challenging, longer duration contractions.
  • Slowly and gradually increasing exercise intensity and degree of difficulty.
  • Aligning the specific pelvic floor dysfunction with the appropriate training program that focuses on improving the area of weakness, since each pelvic floor dysfunction is associated with specific deficits in strength, power and/or endurance.

To be continued….

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

 

Stress Urinary Incontinence (SUI)—Gun and Bullet Analogy

November 18, 2017

Andrew Siegel MD   11/18/17

With all the violence and senseless shootings in the USA, I hate to even mention the words “guns” and “bullets,” but they do offer a convenient metaphor to better understand the concept of stress urinary incontinence

Stress urinary incontinence (SUI) is a spurt-like leakage of urine at the time of a sudden increase in abdominal pressure, such as occurs with sneezing, coughing, jumping, bending and exercising. It is particularly likely to occur when upright and active as opposed to when sitting or lying down, because of the effect of gravity and the particular anatomy of the bladder and urethra. It is common in women following vaginal childbirth, particularly after difficult and prolonged deliveries.  It also can occur in men, generally after prostate surgery for prostate cancer and sometimes after surgical procedures done for benign prostate enlargement. 7. SUIIllustration above by Ashley Halsey from The Kegel Fix

Although not a serious issue like heart disease, cancer, etc., SUI nonetheless can be debilitating, requiring the use of protective pads and often necessitating activity limitations and restrictions of fluid intake in an effort to help manage the problem. It  certainly can impair one’s quality of life.

The root cause of SUI is typically a combination of factors causing damage to the bladder neck and urethra or their support mechanisms.  In females, pelvic birth trauma as well as aging, weight gain, chronic straining and menopausal changes weaken the pelvic muscular and connective tissue support.  In males this can occur after radical prostatectomy, although fortunately with improved techniques and the robotic-assisted laparoscopic  approach, this happens much less frequently than it did in prior years.

An effective means of understanding SUI is to view a bladder x-ray (done in standing upright position) of a person without SUI and compare it to a woman or man with SUI.  The bladder x-ray is performed by instilling contrast into the urinary bladder via a small catheter inserted into the urethra.

A healthy bladder appears oval in shape because the bladder neck (situated at the junction of the bladder and urethra) is competent and closed at all times except when urinating, at which time it relaxes and opens to provide urine flow.  An x-ray of the bladder of a woman or man with SUI will appear oval except for the 6:00 position (the bladder neck) where a small triangle of contrast is present (representing contrast within the bladder neck).  This appears as a “funnel” or a “widow’s peak.” With coughing or straining, there is progressive funneling and leakage.

normal bladder

Above photo is normal oval shape of contrast-filled bladder of person without SUI

female sui relaxAbove photo is typical funneled shape of contrast-filled bladder of female with SUI

male suiAbove photo is typical funneled shape of contrast-filled bladder of male with SUI following a prostatectomy

female sui strainAbove photo shows progressive funneling and urinary leakage in female asked to cough, demonstrating SUI 

 

The presence of urine within the bladder neck region is analogous to a bullet loaded within the chamber of a gun.  Essentially the bladder is “loaded,” ready to fire at any time when there is a sudden increase in abdominal pressure, which creates a vector of force analogous to firing the gun.

What to do about SUI?

Conservative management options include pelvic floor muscle training to increase the strength and endurance of the muscles that contribute to bladder and urethra support and urinary sphincter control.  Surgical management includes sling procedures (tape-like material surgically implanted under the urethra) to provide sufficient support and compression.  Sling procedures are available to treat SUI in both women and men.  An alternative is urethral bulking agents, injections of materials to bulk up and help close the leaky urethra. On occasion, when the bladder neck is rendered incompetent  resulting in severe urinary incontinence, implantation of an artificial urinary sphincter may be required to cure or vastly improve the problem.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, Apple iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

 

 

Sex And The Female Pelvic Floor Muscles

July 15, 2017

Andrew Siegel MD   7/15/17

The vagina and clitoris are the stars of the show, but the pelvic floor muscles are the behind-the-scenes “powerhouse” of these structures. The relationship between the pelvic muscles and the female sexual organs is similar to that between the diaphragm muscle and the lungs, the lungs as dependent upon the diaphragm for their proper functioning as the vagina and clitoris are on the pelvic muscles for their proper functioning.  The bottom line is that keeping the pelvic muscles fit and vital will not only optimize sexual function and pleasure, but will also benefit urinary, bowel and pelvic support issues as well as help prevent their onset. 15606-illustrated-silhouette-of-a-beautiful-woman-or

Image above, public domain

Size Matters

While penis size is a matter of concern to many, why is vaginal size so much less of an issue?  The reason is that penises are external and visible and vaginas internal and hidden. The average erect penis is 6 inches in length and the average vagina 4 inches in depth, implying that the average man is more than ample for the average woman. The width of the average erect penis is 1.5 inches and the width of the average vaginal opening is virtually zero inches since the vagina is a potential space with the walls touching each other at rest. However, the vagina is a highly accommodative organ that can stretch, expand and adapt to the extent that 10 pound babies can be delivered vaginally (ouch!).

More important than size is the strength and tone of the vaginal and pelvic floor muscles. Possessing well-developed and fit vaginal and pelvic floor muscles is an asset in the bedroom, not only capable of maximizing your own pleasure, but also effective in optimally gripping and “milking” a penis to climax.  Additionally, when partner erectile dysfunction issues exist, strong pelvic floor muscles can help compensate as they can resurrect (great word!) a penis that is becoming flaccid back to full rigidity.

Female Sexuality

Sex is a basic human need and a powerful means of connecting and bonding, central to the intimacy of interpersonal relationships, contributing to wellbeing and quality of life. Healthy sexual functioning is a vital part of general, physical, mental, social and emotional health.

Female sexuality is a complex and dynamic process involving the interplay of anatomical, physiological, hormonal, psychological, emotional and cultural factors that impact desire, arousal, lubrication and climax. Although desire is biologically driven based upon internal hormonal environment, many psychological and emotional factors play into it as well. Arousal requires erotic and/or physical stimulation that results in increased pelvic blood flow, which causes genital engorgement, vaginal lubrication and vaginal anatomical changes that allow the vagina to accommodate an erect penis. The ability to climax depends on the occurrence of a sequence of physiological and emotional responses, culminating in involuntary rhythmic contractions of the pelvic floor muscles.

Sexual research conducted by Masters and Johnson demonstrated that the primary reaction to sexual stimulation is vaso-congestion (increased blood flow) and the secondary reaction is increased muscle tension.  Orgasm is the release from the state of vaso-congestion and muscle tension.

Pelvic Muscle Strength Matters

Strong and fit pelvic muscles optimize sexual function since they play a pivotal role in sexuality. These muscles are highly responsive to sexual stimulation, reacting by contracting and increasing blood flow to the pelvis, thus enhancing arousal.  They also contribute to sensation during intercourse and provide the ability to clench the vagina and firmly “grip” the penis. Upon clitoral stimulation, the pelvic muscles reflexively contract.  When the pelvic muscles are voluntarily engaged, pelvic blood flow and sexual response are further intensified.

The strength and durability of pelvic contractions are directly related to orgasmic potential since the pelvic muscles are the “motor” that drives sexual climax. During orgasm, the pelvic muscles contract involuntarily in a rhythmic fashion and provide the muscle power behind the physical aspect of an orgasm. Women capable of achieving “seismic” orgasms most often have very strong, toned, supple and flexible pelvic muscles. The take home message is that the pleasurable sensation that you perceive during sex is directly related to pelvic muscle function. Supple and pliable pelvic muscles with trampoline-like tone are capable of a “pulling up and in” action that puts bounce into your sex life…and that of your partner!

Factoid:  “Pompoir” is the Tamil, Indian term applied to extreme pelvic muscle control over the vagina. With both partners remaining still, the penis is stroked by rhythmic and rippling pulsations of the pelvic muscles. “Kabbazah” is a parallel South Asian term—translated as “holder”—used to describe a woman with such pelvic floor muscle proficiency.  

Pelvic Floor Dysfunction

As sexual function is optimized when the pelvic floor muscles are working properly, so sexual function can be compromised when the pelvic floor muscles are not working up to par (pelvic floor muscle “dysfunction”).  Weakened pelvic muscles can cause sexual dysfunction and vaginal laxity (looseness), undermining sensation for the female and her partner. On the other hand, overly-tensioned pelvic muscles can also compromise sexual function because sexual intercourse can be painful, if not impossible, when the pelvic muscles are too taut.

Vaginal childbirth is one of the key culprits in causing weakened and stretched pelvic muscles, leading to loss of vaginal tone, diminished sensation with sexual stimulation and impaired ability to tighten the vagina.

Pelvic organ prolapse—a form of pelvic floor dysfunction in which one or more of the pelvic organs fall into the vaginal space and at times beyond the vaginal opening—can reduce sexual gratification on a mechanical basis from vaginal laxity and uncomfortable or painful intercourse. The body image issues that result from vaginal laxity and pelvic prolapse are profound and may be the most important factors that diminish one’s sex life. As the pelvic floor loses strength and tone, there is often an accompanying loss of sexual confidence.

Urinary incontinence—a form of pelvic floor dysfunction in which there is urinary leakage with coughing, sneezing and physical activities (stress incontinence) or leakage associated with the strong urge to urinate (urgency incontinence or overactive bladder)—can also contribute to an unsatisfying sex life because of fears of leakage during intercourse, concerns about odor and not feeling clean, embarrassment about the need for pads, and a negative body image perception. This can adversely influence sex drive, arousal and ability to orgasm.

A healthy sexual response involves being “in the moment,” free of concerns and worries. Women with pelvic floor dysfunction are often distracted during sex, preoccupied with their lack of control over their problem as well as their perception of their vagina being “abnormal” and what consequences this might have on their partner’s sexual experience.

Pelvic Floor Training

Pelvic floor muscle training is the essence of “functional fitness,” a workout program that develops pelvic muscle strength, power and stamina. The goal is to improve and/or prevent specific pelvic functional impairments that may be sexual, urinary, bowel, or involve altered support of the pelvic organs.

Many women exercise regularly but often neglect these hidden–but vitally important muscles– that can be optimized to great benefit via the right exercise regimen.  The key is to find the proper program, and for this I refer you to your source for everything Kegel: The KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health.

Wishing you the best of health,

2014-04-23 20:16:29

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

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

 

No Erections Without A Solid Base

May 27, 2017

Andrew Siegel MD  5/27/2017  Happy Memorial Day Weekend!

A flagpole needs a solid base of support in order to stand tall and not be felled by the elements.  One that is poorly mounted will falter as soon as the wind picks up or other adverse circumstances surface.  This is analogous to a tree and its root system with no tree able to stand tall and bear the elements without a deep and powerful root system.  In both cases, the hidden, behind-the-scenes support system is equally important to the exposed product.

at20op_-03__topflight-telescoping-20ft-flagpole_1_1.jpg

Flagpole base

Exposed_mango_tree_roots

Exposed roots of a mango tree, by Aaron Escobar [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)%5D, via Wikimedia Commons

…And so it is with the penis. Like the flagpole and the tree that require a solid base of support, the penis also necessitates a sturdy foundation in order to be able to morph into a “proud soldier,” tall and erect in posture.  This foundation also enables the ability to maintain this rigid stability despite exposure to the “elements”– the substantial torquing and buckling forces the penis is subjected to at the time of sexual activity.

* Thank you to Paul Nelson–friend, colleague and president of the Erectile Dysfunction Foundation and launcher of FrankTalk.org–who came up with the clever  flagpole analogy.

What You See is Not What You Get

Half the penis is exposed and half is hidden.  The visible portion of the penis (pendulous penis) is the external half.  The internal half (infrapubic penis) lies under the surface and is known as the penile roots or in medical speak, the crura. Like the roots of a tree or the base of a flagpole responsible for foundational support, the roots of the penis stabilize and support the erect penis so that it stays rigid and skyward-angling with excellent “posture.”  Without functioning penile roots, the penis would remain limp, would dangle in accordance with gravity and have slouching posture at best.

4extintpenis

Illustration above by Christine Vecchione from “Male Pelvic Fitness: Optimizing Sexual & Urinary Health”

The penile roots are enveloped by two pelvic floor muscles, the BC (bulbocavernosus) and the IC (ischiocavernosus).  These rigidity muscles compress the roots of the penis, causing backflow of pressurized blood into the penis.  In a sexual situation, these muscles engage and contract, forcing blood within the roots of the penis into the external penis.  Not only is pressurized blood pushed into the external penis promoting rigidity, but also the contractions of these muscles causes the clamping of venous outflow—a tourniquet-like effect—that results in penile high blood pressure and full-fledged rigidity.  These muscles are also responsible for ejaculation—rhythmically compressing the urethra (urinary channel that runs through the penis) at the time of climax to cause the expulsion of semen.

Factoid: It is the BC and IC muscles that are responsible for the ability to lift one’s erect penis up and down (wag the penis) as they are contracted and relaxed.

00001Illustration above by Christine Vecchione from “Male Pelvic Fitness: Optimizing Sexual & Urinary Health”

The BC and the IC muscles together with the transverse perineal muscles and the levator muscles are collectively known as the pelvic floor muscles, a muscular hammock located between scrotum and anus  (“inner taint”). Although unseen and behind-the-scenes, hidden from view, these often unrecognized and misunderstood muscles have vital functions in addition to erection and ejaculation, including urinary and bowel control. As part of the core group of muscles, they affect posture, the lower back and the hips.

Take home message: The pelvic floor muscles are the rigidity muscles, necessary for transforming the stimulated penis that becomes plump into a rock-hard penis. When these muscles are not functioning optimally, one loses the potential for full rigidity.

Factoid: An erection—defined in hydraulic terms—is when the penile blood inflow is maximized while outflow is minimized, resulting in an inflated and rigid penis. The pressure in the penis at the time of an erection is sky-high (greater than 200 millimeters), the only organ in the body where high blood pressure is both acceptable and necessary for healthy functioning. This explains why blood pressure pills are the most common medications associated with erectile dysfunction.

Bottom Line: Neither flagpole, tree nor penis can be firmly supported without a solid foundation.  The penile roots and the pelvic floor muscles that surround them are the foundation.  Not only do these muscles support the deep roots of the penis, but they are also responsible for the high penile blood pressures responsible for erectile rigidity and are the motor power underlying ejaculation.  The IC muscle should be known as the “erector muscle” and the BC muscle the “ejaculator muscle.” Although not muscles of glamour, they are certainly muscles of “amour.”

Straddling the gamut of being vital for what may be considered the most pleasurable and refined of human pursuits—sex—they are equally integral to what may be considered the basest of human activities—bowel and bladder function.  These hidden muscles deserve serious respect and are capable of being intensified by training in order to improve and often prevent sexual, urinary and bowel issues. Why not consider exercising your erector and ejaculator muscles, as you do for so many other muscle groups in the body?

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  http://www.TheKegelFix.com

Co-creator of the PelvicRx male pelvic floor exercise program: http://www.PelvicRx.com

 

 

 

 

 

Rectoceles And Perineal Laxity: What You Need To Know

May 20, 2017

Andrew Siegel MD  5/20/17

recto copy

Image above: protrusion of the rectum into the floor of the vagina, a.k.a. rectocele (blue arrow); also note catheter in urethra (red arrow) and gaping vagina with scarring of tissues between vagina and anus, a.k.a. perineum (white arrow)

A rectocele is a specific type of pelvic organ prolapse in which the pelvic floor muscles and connective supporting tissue between the lower vaginal wall and rectum weaken, allowing protrusion of the rectum into the floor of the vagina and at times outside the vaginal opening. This not uncommonly follows vaginal childbirth, which places tremendous stresses on the tissues that provide to support of the pelvic organs. Other risk factors for the occurrence of a rectocele are chronic straining, menopause and weight gain.

Rectoceles are also known by the terms “dropped rectum,” “prolapsed rectum,” and “rectal hernia.” The most common symptom is an annoying vaginal bulge that worsens with assuming the upright position and being active and tends to improve with sitting, lying down and being sedentary. It is often quite noticeable when straining to move one’s bowels. It can give rise to bowel difficulties—most notably what is referred to as “obstructed defecation”—including constipation, incomplete bowel emptying, diarrhea and fecal incontinence. The prolapsed rectum often needs to be manipulated back into position in order to be able to effectively move one’s bowels. Rectoceles can also cause vaginal pressure, vaginal pain and painful sexual intercourse.

Relevant trivia: The word “rectum” derives from the Latin word meaning “straight,” because under normal circumstances the rectum is a straight chute, facilitating bowel movements. The presence of a rectocele causes kinking of the rectum to occur, destroying this anatomical arrangement and making bowel movements difficult without “splinting” the rectum (straightening it out) using one or more fingers placed in the vagina.

Often accompanying a rectocele is laxity of the perineal muscles, a condition in which the superficial pelvic floor muscles (those located in the region between the vagina and anus) become flabby. This causes a widened vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal angle. Women who are sexually active may complain of a loose or gaping vagina. This may lead to difficulty keeping a tampon in position without it falling out, the vagina filling with water while bathing, vaginal flatulence (the embarrassing passage of air) and sexual issues including difficulty retaining the penis with vaginal intercourse and difficulty achieving orgasm. Perineal laxity may result in the vagina “surrounding” the penis rather than firmly “squeezing” it during sexual intercourse, with the end result diminished pleasurable sensation for both partners. The perception of having a loose vagina and altered anatomy can lead to self-esteem and other psychological issues.

Relevant trivia: Under normal circumstances, sexual intercourse results in indirect clitoral stimulation. The clitoral shaft moves rhythmically with penile thrusting by virtue of penile traction on the inner vaginal lips, which join together to form the hood of the clitoris. However, if the vaginal opening is too wide to permit the penis to put enough traction on the inner vaginal lips, there will be limited clitoral stimulation and less satisfaction in the bedroom.

Management of Rectoceles

Rectoceles can be managed conservatively with pelvic floor exercises, behavioral modifications and consideration for using a pessary. Alternatively, surgical treatment, a.k.a. pelvic reconstruction, is often necessary for more extensive rectoceles or for those that do not respond to conservative measures.

Pelvic floor muscle training (PFMT) is useful under the circumstances of mild-moderate rectocele, for those who cannot or do not want to have surgery and for those whose minimal symptoms do not warrant more aggressive options. The goal of PFMT is to increase the strength, tone and endurance of the muscles that play a key role in the support of the rectum and perineum. Weak pelvic muscles can undoubtedly be strengthened; however, if there is connective tissue damage, pelvic training will not remedy the injury, but does serve to strengthen the muscles that can help compensate for the connective tissue impairment. If not completely cured with PFMT, the rectocele and perineal laxity can still be improved, and that might be sufficient.  Chapter 5 in The Kegel Fix book  (www.TheKegelFix.com) is devoted to a specific PFMT regimen for rectoceles and other forms of pelvic organ prolapse.  Note that if the pelvic floor muscles are torn or widely separated, PFMT will not be productive until surgical repair is performed.

Another component of conservative management is modification of activities that promote the rectocele (heavy lifting and high impact exercises), management of constipation and other circumstances that increase abdominal pressure, weight loss, smoking cessation and consideration for estrogen hormone replacement, since estrogen replacement can increase tissue integrity and suppleness.

A pessary is a mechanical device that is available in a variety of sizes and shapes and is inserted into the vagina where it acts as a “strut” to help provide pelvic support and keep the rectum in proper position. Pessaries need to be removed periodically in order to clean them. Some are designed to permit sexual intercourse.

Surgery is often necessary in the case of a symptomatic moderate-severe rectocele, particularly when quality of life has been significantly impacted. This type of surgery is most often done vaginally, typically on an outpatient basis. Both the rectocele and the perineal laxity are addressed.  The goal of surgery is restoration of normal anatomy with preservation of vaginal dimensions and improvement in symptoms with optimization of bowel and sexual function.  With improvement of anatomy, function often significantly improves, since function often follows form. Difficulties with evacuation, constipation, straining, incomplete emptying and fecal incontinence should improve, if not resolve. There should no longer be a need to splint the rectum and sexual function (for both patient and partner) should dramatically improve with the rebuilding of the perineum.

Marietta S pre-PP

Pre-operative photo–note gaping vulva, exposed vagina, rectocele and perineal laxity; (c) Michael P Goodman, MD. Used with permission

 

Mariette S 6 wk p.o. PP

Post-operative photo–note closed vulva, unexposed vagina and restored perineum after levatorplasty, vaginoplasty, perineorrhaphy and aesthetic perineoplasty; (c) Michael P Goodman, MD. Used with permission

 

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  http://www.TheKegelFix.com  

Much of the content of this entry was excerpted from Dr. Siegel’s The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health (Chapter 5. Pelvic Organ Prolapse)

12 STEPS TO OVERCOMING “OVER-ACTIVE” BLADDER (OAB)

May 6, 2017

Andrew Siegel MD  5/6/17 (my daughter’s 18th birthday!)

For most people, the urinary bladder is a cooperative and obedient organ, behaving and adhering to its master’s will, squeezing only when appropriate. However, some people have bladders that are unruly and disobedient, acting rashly and irrationally, squeezing at inappropriate times without their master’s permission. This condition is referred to as “overactive bladder” or OAB for short. This problem can occur in both women and men, although it is more common in females.

Picture1

“Gotta go,” the urinary urgency that is the hallmark of OAB

8. UUI

Image above (artist Ashley Halsey from “The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health”) illustrates a bladder contracting involuntarily, leading to urinary leakage

OAB (http://www.njurology.com/overactive-bladder/) is a common condition often due to one’s bladder contracting (squeezing) at any time without warning.  This involuntary bladder contraction can give rise to the symptoms of urgency, frequency (daytime and nighttime) and urgency incontinence. The key symptom of OAB is urinary urgency (a.k.a. “gotta go”), the sudden and compelling desire to urinate that is difficult to postpone.

Although OAB symptoms can occur without specific provocation, they may be triggered by exposure to running water, cold or rainy weather, hand-washing, entering the shower, positional changes such as arising from sitting, and getting nearer and nearer to a bathroom, particularly at the time of placing the key in the door to one’s home.

An evaluation includes a urinalysis (dipstick exam of the urine), a urine culture (test for urinary infection) if indicated, and determination of the post-void residual volume (amount of urine left in bladder immediately after emptying). A 24-hour voiding diary (record of urination documenting time and volume) is an extremely helpful tool.  Urodynamics (test of storage and emptying bladder functions), cystoscopy (visual inspection of inside of bladder), and renal and bladder ultrasound (imaging tests using sound waves) may also prove helpful.

The management of OAB is challenging, yet rewarding, and necessitates a partnership between patient and physician. Successful treatment requires a willing, informed and engaged patient with a positive attitude. Management options for OAB range from non-invasive strategies to pills to surgery. It is sensible to start with the simplest and least invasive means of treatment and progress accordingly to more aggressive and invasive treatments if there is not a satisfactory response to conservative measures.  Behavioral treatments are first-line: fluid management, bladder training, bladder control strategies, pelvic floor muscle training and lifestyle measures.  Behavioral therapies may be combined with medication(s), which are considered second-line treatment. Third-line treatments include neuromodulation (stimulating specific nerves to improve OAB symptoms) and Botox injections into the urinary bladder.

References that will help the process include the following:

Book: THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health www.TheKegelFix.com

Book: MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health www.MalePelvicFitness.com

DVD: Easy-to-use, follow-along, FDA-registered pelvic training program that includes a detailed instruction guide, an interactive DVD and digital access to the guided training routines: www.PelvicRx.com

12 Steps To Overcoming OAB

The goal of the 12 steps that follow is to re-establish control of the urinary bladder.  Providing that the recommendations are diligently adhered to, there can be significant improvement, if not resolution, of OAB symptoms.

  1. FLUID AND CAFFEINE MODERATION/MEDICATION ASSESSMENT  Symptoms of OAB will often not occur until a “critical” urinary volume is reached, and by limiting fluid intake, it will take a longer time to achieve this volume. Try to sensibly restrict your fluid intake in order to decrease the volume of urinary output. Caffeine (present in tea, coffee, colas, some energy drinks and chocolate) and alcohol increase urinary output and are urinary irritants, so it is best to limit intake of these beverages/foods.  Additionally, many foods—particularly fruits and vegetables—have hidden water content, so moderation applies here as well.  It is important to try to consume most of your fluid intake before 7:00 PM to improve nocturnal frequency. Diuretic medications (water pills) can contribute to OAB symptoms. It is worthwhile to check with your medical doctor to see if it is possible to change to an alternative, non-diuretic medication. This will not always be feasible, but if so, may substantially improve your symptoms.
  2. URGENCY INHIBITION Reacting to the first sense of urgency by running to the bathroom needs to be substituted with urgency inhibition techniques. Stop in your tracks, sit, relax and breathe deeply. Pulse your pelvic floor muscles rhythmically (see below) to deploy your own natural reflex to resist and suppress urgency.
  3. TIMED VOIDING (for incontinence) Urinating by the “clock” and not by your own sense of urgency will keep your bladder as empty as possible. By emptying the bladder before the critical volume is reached (at which urgency incontinence occurs), the incontinence can be controlled.  Voiding on a two-hour basis is usually effective, although the specific timetable has to be tailored to the individual in accordance with the voiding diary.  Such “preemptive” or “defensive” voiding is a very useful technique since purposeful urinary frequency is more desirable than incontinence.
  4. BLADDER RETRAINING (for urgency/frequency) This is imposing a gradually increasing interval between voids to establish a more normal pattern of urination. Relying on your own sense of urgency often does not give you accurate information about the status of your bladder fullness.  Urinating by the “clock” and not by your own sense of urgency will keep your voided volumes more appropriate. Voiding on a two-hour basis is usually effective as a starting point, although the specific timetable has to be tailored to the individual, based upon the voiding diary.  A gradual and progressive increase in the interval between voiding can be achieved by consciously delaying urinating.  A goal of an increase in the voiding interval by 15-30 minutes per week is desirable.  Eventually, a return to more acceptable voiding intervals is possible.  The urgency inhibiting techniques mentioned above are helpful with this process.
  5. BOWEL REGULARITY Avoidance of constipation is an important means of helping control OAB symptoms. Because of the proximity of the rectum and bladder, a full rectum can put pressure on the bladder, resulting in worsening of urgency, frequency and incontinence.
  6. PELVIC FLOOR MUSCLE TRAINING (PFMT)  *All patients need to understand the vital role of the pelvic floor muscles (PFM) in inhibiting urgency and frequency and preventing urge leakage.  PFMT voluntarily employs the PFM to help stimulate inhibitory reflexes between the pelvic floor muscles and the bladder.  Rhythmic pulsing of the PFM can inhibit an involuntary contraction once it starts and prevent an involuntary contraction before it even begins. Initially, one must develop an awareness of the presence, location, and nature of the PFM and then train these muscles to increase their strength and tone.  These are not the muscles of the abdominal wall, thighs or buttocks.  A simple means of recognizing the PFM for a female is to insert a finger inside her vagina and squeeze the PFM until the vagina tightens around her finger.  A simple means of identifying the PFM for either gender is to start urinating and when about half completed, to abruptly stop the stream. It is the PFM that allows one to do so. It is important to recognize the specific triggers that induce urgency, frequency or incontinence and prior to exposure to a trigger or at the time of the perceived urgency, rhythmic pulsing of the PFM–“snapping” the PFM several times–can either preempt the abnormal bladder contraction before it occurs or diminish or abort the bladder contraction after it begins.  Thus, by actively squeezing the PFM just before and during these trigger activities, the urgency can be diminished and the urgency incontinence can often be avoided.

oab

Schematic diagram above illustrates the relationship of the contractile state of the bladder muscle to the contractile state of the PFM. Note that a voluntary PFM contraction can turn off an involuntary bladder contraction (+ symbol denotes contraction; – symbol denotes relaxation)

7. LIFESTYLE MEASURES: HEALTHY WEIGHT, EXERCISE, TOBACCO CESSATION   The burden of excess pounds can worsen OAB issues by putting pressure on the urinary bladder. Even a modest weight loss may improve OAB symptoms.  Pursuing physical activities can help maintain general fitness and improve urinary control. Lower impact exercises–yoga, Pilates, cycling, swimming, etc.–can best help alleviate pressure on the urinary bladder by boosting core muscle strength and tone and improving posture and alignment. The chemical constituents of tobacco constrict blood vessels, impair blood flow, decrease tissue oxygenation and promote inflammation, compromising the bladder, urethra and PFM.  By eliminating tobacco, symptoms of OAB can be improved. 

8.  BLADDER RELAXANT MEDICATIONS A variety of medications are useful to suppress OAB symptoms. It may take several trials of different medications or combinations of medications to achieve optimal results. The medications include the following: Tolterodine (Detrol LA), Oxybutynin (Ditropan XL), Transdermal Oxybutynin (Oxytrol patch), Oxybutynin gel (Gelnique), Trospium (Sanctura), Solifenacin (Vesicare), Darifenacin (Enablex) and Fesoterodine (Toviaz).  The most common side effects are dry mouth and constipation.  These medications cannot be used in the presence of urinary or gastric retention or uncontrolled narrow-angle glaucoma.  The newest medication, Mirabegron (Myrbetriq), has a different mechanism of action and fewer side effects.

9.  BIOFEEDBACK This is an adjunct to PFMT in which electronic instrumentation is used to relay feedback information about your PFM contractions.  This can enhance awareness and strength of the PFM.

10.  BOTOX TREATMENT This is a simple office procedure in which Botox is injected directly into the bladder muscle, helping reduce OAB symptoms by relaxing those areas of the bladder into which it is injected. Botox injections generally will last for six to nine months and are covered by Medicare and most insurance companies.

11.  PERCUTANEOUS TIBIAL NERVE STIMULATION (PTNS) This is a minimally invasive form of neuromodulation in which a tiny acupuncture-style needle is inserted near the tibial nerve in the ankle and a hand-held stimulator generates electrical stimulation with the intent of improving OAB symptoms. This is done once weekly for 12 weeks.

12.  INTERSTIM This is a more invasive form of neuromodulation in which electrical impulses are used to stimulate and modulate sacral nerves in an effort to relieve the OAB symptoms. A battery-powered neuro-stimulator (bladder “pacemaker”) provides the mild electrical impulses that are carried by a small lead wire to stimulate the selected sacral nerves that affect bladder function.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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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.