Posts Tagged ‘pelvic relaxation’

Even More About Pelvic Prolapse: Diagnosis & Treatment

October 29, 2016

Andrew Siegel MD 10/29/2016

Note: This is the final entry in a 3-part series about pelvic organ prolapse.

 How is POP diagnosed and evaluated?

The diagnosis of POP can usually be made by listening to the patient’s narrative: The typical complaint is “Doc, I’ve got a bulge coming out of my vagina when I stand up or strain and at times I need to push it back in.”

After listening to the patient’s history of the problem, the next step is a pelvic examination in stirrups.  However, the problem with an exam in this position is that this is NOT the position in which POP typically manifests itself, since POP is a problem that is provoked by standing and exertion. For this reason, the exam must be performed with the patient straining forcefully enough to demonstrate the POP at its fullest extent.

A pelvic examination involves observation, a speculum exam, passage of a small catheter into the bladder and a digital exam. Each region of potential prolapse through the vagina—roof, apex, and floor—must be examined independently.

box

A useful analogy is to think of the vagina as an open box (see above), with the vaginal lips represented by the open flaps of the box.  A cystocele (bladder prolapse) occurs when there is weakness of the roof of the box, a rectocele (rectal prolapse) when there is weakness of the floor of the box, and uterine prolapse or enterocele (intestinal prolapse) when there is weakness of the deep inner wall of the box.

Inspection will determine tissue health and the presence of a vaginal bulge with straining. After menopause, typical changes include thinning of the vaginal skin, redness, irritation, etc. The ridges and folds within the vagina that are typical in younger women tend to disappear after menopause.

Useful analogy: The normal vulva is shut like a closed clam. POP often causes the vaginal lips to gape like an open clam.

Since the vagina has top and bottom walls and since the bulge-like appearance of POP of the bladder or rectum look virtually identical—like a red rubber ball—it is imperative to use a speculum to sort out which organ is prolapsing and determine its extent. A one-bladed speculum is used to pull down the bottom wall of the vagina to observe the top wall for the presence of urethral hypermobility and cystocele, and likewise, to pull up the top wall to inspect for the presence of rectocele and perineal laxity. To examine for uterine prolapse and enterocele, both top and bottom walls must be pulled up and down, respectively, using two single-blade specula. Once the speculum is placed, the patient is asked to strain vigorously and comparisons are made between the extent of POP resting and straining, since prolapse is dynamic and will change with position and activity.

 

exam-relaxed

Image above shows vaginal exam at rest (mild prolapse)

exam-minor-strain

Image above shows vaginal exam with straining (moderate prolapse)

exam-full-streain

Image above shows vaginal exam with more straining (more severe prolapse)

After the patient has emptied her bladder, a small catheter (a narrow hollow tube) is passed into the bladder to determine how much urine remains in the bladder, to submit a urine culture in the event that urinalysis suggests a urinary 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 (hypermobility) is a sign of loss of urethral support, which often causes stress urinary incontinence (leakage with cough, strain and exercise).

Finally, a digital examination is performed to assess vaginal tone and pelvic muscle strength. A bimanual exam (combined internal and external exam in which the pelvic organs are felt between vaginal and external examining fingers) is done to check for the presence of pelvic masses. On pelvic exam it is usually fairly obvious whether or not a woman has had vaginal deliveries. With exception, the pelvic support and tone of the vagina in a woman who has not delivered vaginally can usually be described as “high and tight,” whereas support in a woman who has had multiple vaginal deliveries is generally “lower and looser.”

Depending upon circumstances, tests to further evaluate POP 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 or pelvic MRI).

cystogram-normal

Image above is x-ray of bladder showing oval-shaped well-supported normal bladder.

cd-cystocele

                    Image above is x-ray of bladder showing tennis-racquet shaped bladder,                          which is high-grade cystocele.

How is POP treated?

First off, it is important to know that POP is a common condition and does not always need to be treated, particularly when it is minor and not causing symptoms that affect one’s quality of life.

There are three general options of managing POP: conservative; pessary and surgery (pelvic reconstruction).

Conservative treatment options for POP include pelvic floor muscle training Kegel); modification of activities that promote the POP (heavy lifting and high impact exercises); management of constipation and other circumstances that increase abdominal pressure; weight loss; smoking cessation; and consideration for hormone replacement since estrogen replacement can increase tissue integrity and suppleness.

A pessary is a mechanical device available in a variety of sizes and shapes that is inserted into the vagina where it acts as “strut” to help provide pelvic support.

512px-pessaries

Image above is an assortment of pessaries (Thank you Wikipedia, public domain)

The side effects of a pessary are vaginal infection and discharge, the inability to retain the pessary in proper position and stress urinary incontinence caused by the “unmasking” of the incontinence that occurs when the prolapsed bladder is splinted back into position by the pessary. Pessaries need to be removed periodically in order to clean them. Some are designed to permit sexual intercourse.

Studies comparing the use of pessaries with pelvic floor training in managing women with advanced POP have shown that both can significantly improve symptoms; however, pelvic floor muscle training has been shown to be more effective, specifically for bladder POP.

PFM Training (PFMT)

PFMT is useful under the circumstances of mild-moderate POP, 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 pelvic muscles that play a key role in the support of the pelvic organs. Weak pelvic muscles can be strengthened; however, if POP is due to connective tissue damage, PFMT will not remedy the injury, but will strengthen the pelvic muscles that can help compensate for the connective tissue impairment. PFMT is most effective in women with lesser degrees of POP and chances are that if your POP is moderate-severe, PFMT will be less effective. However, if not cured, the POP can still be improved, and that might be sufficient for you.

Numerous scientific studies have demonstrated the benefits of PFMT for POP, including improved pelvic muscle strength, pelvic support and a reduction in the severity and symptoms of POP. Improvements in pelvic support via PFMT are most notable with bladder POP as opposed to rectal or uterine POP. PFMT is also capable of preventing POP from developing when applied to a healthy female population without POP.

In symptomatic advanced POP, surgery is often necessary, particularly when quality of life has been significantly impacted. There are a number of considerations that go into the decision-making process regarding the specifics of the surgical procedure (pelvic reconstruction) to improve/cure the problem. These factors include which organ or organs are prolapsed; the extent and severity of the POP; the desire to have children in the future; the desire to be sexually active; age; and, if the POP involves a cystocele, the specific type of cystocele (since there are different approaches depending on the type). Surgery to repair POP can be performed vaginally or abdominally (open, laparoscopic or robotic), and can be done with or without mesh (synthetic netting or other biological materials used to reinforce the repair). The goal of surgery is restoration of normal anatomy with preservation of vaginal length, width and axis and improvement in symptoms with optimization of bladder, bowel and sexual function.

More than 300,000 surgical procedures for repair of POP are performed annually in the United States. An estimated 10-20% of women will undergo an operation for POP over the course of their lifetime.

Dr. Arnold Kegel—the gynecologist responsible for popularizing pelvic floor exercises—believed that surgical procedures for female incontinence and pelvic relaxation are facilitated by pre-operative and post-operative pelvic floor exercises. Like cardiac rehabilitation after cardiac surgery and physical rehabilitation after orthopedic procedures, PFMT after pelvic reconstruction surgery can help minimize recurrences. Pre-operative PFMT—as advocated by Kegel—can sometimes improve pelvic support to an extent such that surgery will not be necessary. At the very least, proficiency of the PFM learned pre-operatively (before surgical incisions are made and pelvic anatomy is altered) will make the process of post-operative rehabilitation that much easier.

Useful resource: Sherrie Palm is an advocate, champion and crusader for women’s pelvic health who has made great strides with respect to POP awareness, guidance and support. She is founder and director of the Association for Pelvic Organ Prolapse Support and author of “Pelvic Organ Prolapse: The Silent Epidemic.” Visit PelvicOrganProlapseSupport.org.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.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. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. 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 and 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.

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

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.  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.

 

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More About Pelvic Organ Prolapse (POP)

October 22, 2016

Andrew Siegel MD 10/22/2016

This is the second entry in a three-part series about pelvic organ prolapse.  It is important to understand that the issue in POP is NOT with the pelvic organ per se, but with the support of that organ. POP is not the problem, but the result of the problem. The prolapsed organ is merely an “innocent passenger” in the POP process.

How Much Of A Vaginal Bulge Can POP Cause?

The extent of prolapse can vary from minimal to severe and can vary over the course of a day, depending on position and activity level.  POP is more pronounced with with standing (vs. sitting or lying down) and with physical activities (vs. sedentary).

The simplest system for grading POP severity uses a scale of 1-4:

grade 1 (slight POP); grade 2 (POP to vaginal opening with straining); grade 3 (POP beyond vaginal opening with straining); grade 4 (POP beyond vaginal opening at all times).

Which Organs Does POP Affect?

POP can involve one or more of the pelvic organs including the following: urethra (urethral hypermobility); bladder (cystocele); rectum (rectocele); uterus (uterine prolapse); intestines (enterocele); the vagina itself (vaginal vault prolapse); and the perineum (perineal laxity).

Urethra

The healthy, well-supported urethra has a “backboard” or “hammock” of support tissue that lies beneath it. With a sudden increase in abdominal pressure, the urethra is pushed downwards, but because of the backboard’s presence, the urethra gets pinched closed between the abdominal pressure above and the hammock below, allowing urinary control.

When the support structures of the urethra are weakened, a sudden increase in abdominal pressure (from a cough, sneeze, jump or other physical exertion) will push the urethra down and out of its normal position, a condition known as urethral hypermobility. With no effective “backboard” of support tissue under the urethra, stress urinary incontinence will often occur.

sui

Urethral hyper-mobility causing stress urinary incontinence (the gush of urine) when this patient was asked to cough.

Bladder

Descent of the bladder through a weakness in its supporting tissues gives rise to a cystocele, a.k.a. “dropped bladder,” “prolapsed bladder,” or “bladder hernia.”

A cystocele typically causes one or more of the following symptoms: a bulge or lump protruding into or even outside the vagina; the need for pushing the cystocele back in in order to urinate; obstructive urinary symptoms (a slow, weak stream that stops and starts and incomplete bladder emptying) due to the prolapsed bladder causing urethral kinking; urinary symptoms (frequent and urgent urinating); and vaginal pain and/or painful intercourse.

untitled

Cystocele

Rectum

Descent of the rectum through a weakness in its supporting tissues gives rise to a rectocele, a.k.a. “dropped rectum,” “prolapsed rectum,” or “rectal hernia.” The rectum protrudes into the floor of the vagina. A rectocele typically causes one or more of the following symptoms: a bulge or lump protruding into the vagina, especially noticeable during bowel movements; a kink of the normally straight rectum causing difficulty with bowel movements and the need for vaginal “splinting” (straightening the kink with one’s fingers) to empty the bowels; incomplete emptying of the rectum; fecal incontinence; and vaginal pain and/or painful intercourse.

rectocele

Rectocele with perineal laxity

Perineum

Often accompanying a rectocele is perineal muscle laxity, a condition in which the superficial pelvic floor muscles (those located in the region between the vagina and anus) become flabby. Weakness in these muscles can cause the following anatomical changes: a widened and loose vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal orientation such that the vagina assumes a more upwards orientation as opposed to its normal downwards angulation towards the sacral bones.

Women with vaginal laxity who are sexually active may complain of a loose or gaping vagina, making intercourse less satisfying for themselves and their partners. This may lead to difficulty achieving orgasm, difficulty retaining tampons, difficulty accommodating and retaining the penis with vaginal intercourse, the vagina filling with water while bathing and vaginal flatulence (passing air through the vagina). The perception of having a loose vagina can often lead to low self-esteem.

Small Intestine

The peritoneum is a thin sac that contains the abdominal organs, including the small intestine. Descent of the peritoneal contents through a weakness in the supporting tissues at the innermost part of the vagina (the apex of the vagina) gives rise to an enterocele, a.k.a. “dropped small intestine,” “small intestine prolapse,” or “small intestine hernia.”

An enterocele typically causes one or more of the following symptoms: a bulge or lump protruding through the vagina, intestinal cramping due to small intestine trapped within the enterocele, and vaginal pressure/pain and/or painful intercourse.

enterocele

Enterocele

Uterus

Descent of the uterus and cervix because of weakness of their supporting structures results in uterine prolapse, a.k.a. “dropped uterus,” “prolapsed uterus,” or “uterine hernia.” Normally, the cervix is situated deeply in the vagina. As uterine prolapse progresses, the extent of descent into the vaginal canal will increase.

Uterine POP typically causes one or more of the following symptoms: a bulge or lump protruding from the vagina; difficulty urinating; the need to manually push back the uterus in order to urinate; urinary urgency and frequency; urinary incontinence; kidney obstruction because of the descent of the bladder and ureters (tubes that drain urine from the kidneys to the bladder) that are dragged down with the uterus, creating a kink of the ureters; vaginal pain with sitting and walking; painful intercourse; and spotting and/or bloody vaginal discharge from the externalized uterus, which becomes subject to trauma and abrasions from being out of position. The most extreme form of uterine POP is uterine “procidentia,” a situation in which the uterus is exteriorized at all times and, because of external exposure, has a tendency for ulceration and bleeding.

 

uterus

Uterine prolapse

ulcerated-procidentia

Severe uterine prolapse (procidentia) with ulcerative inflammation surrounding cervix

Vagina

The most advanced stage of POP occurs when the support structures of the vagina are weakened to such an extent that the vaginal canal itself turns inside out. Vault prolapse, a.k.a. “dropped vaginal vault,” “prolapsed vaginal vault,”or “vaginal vault hernia,” is rarely an isolated event, but often occurs coincident with other forms of POP and most often is a consequence of hysterectomy. If the vagina is likened to an internal “sock,” vaginal vault prolapse is a condition in which the sock is turned inside out. When I explain vaginal vault prolapse to patients, I demonstrate it by turning a front pocket of my pants inside out.

To be continued…

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.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. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. 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 and 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.

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

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.  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.

 

What’s That Bulge Coming Out Of My Vagina?

October 15, 2016

Andrew Siegel MD   10/15/2016

untitled

Photo above: typical appearance of  a vaginal bulge (in this case a dropped bladder)

“The thought was delivered just after my newborn’s placenta: A sneaking suspicion that things were not quite the same down there, and they might never be again…my daughter had finished using my vagina as a giant elastic waterslide.”

-Alissa Walker, Gizmodo.com, April 2, 2015

Between A Rock And A Hard Place

The bony pelvis provides the infrastructure to support the pelvic organs and to allow childbirth. Adequate “closure” is needed for pelvic organ support, yet sufficient “opening” is necessary to permit vaginal delivery. The female pelvis evolved as a compromise between these two important, but opposing functions.

The pelvic floor muscles (PFM) divide the abdominal and pelvic cavities above from the perineum below, forming an important structural support system that keeps the pelvic organs in place. Many physical activities result in significant increases in abdominal pressure, the force of which is largely exerted downwards towards the pelvic floor, especially when upright. This pelvic floor “loading” puts the PFM at particular risk for damage with the potential for pelvic organ prolapse, a.k.a. pelvic relaxation or pelvic organ hernia.

Pelvic Organ Prolapse (POP)

POP is a common condition in which there is weakness of the PFM and other connective tissues that provide pelvic support, allowing the pelvic organs to move from their normal positions into the space of the vaginal canal and, at its most severe degree, outside the vaginal opening. It is a situation in which the pelvic organs go wayward, literally “popping” out of place. POP often causes a bulge outside the vaginal opening, appearing like a man’s scrotum…little wonder why most women are disturbed by this condition.

Two-thirds of women who have delivered children have anatomical evidence of POP (although most are not symptomatic) and 10-20% will need to undergo a corrective surgical procedure. POP is not life threatening, but can be a distressing and disruptive problem that negatively impacts quality of life. Despite how common an issue it is, many women are reluctant to seek help because they are too embarrassed to discuss it with anyone or have the misconception that there are no treatment options available or fear that surgery will be the only solution.

POP may involve any of the pelvic organs including those of the urinary, intestinal and gynecological tracts. The bladder is the organ that is most commonly involved in POP. POP can vary from minimal descent—causing few, if any, symptoms—to major descent—in which one or more of the pelvic organs prolapse outside the vagina at all times, causing significant symptoms. The degree of descent varies with position and activity level, increasing with the upright position and exertion and decreasing with lying down and resting, as is the case for any hernia.

POP can give rise to a variety of symptoms, depending on which organ is involved and the extent of the prolapse. The most common complaints are the following: a vaginal bulge or lump, the perception that one’s insides are falling outside, and vaginal “pressure.” Because POP often causes vaginal looseness in addition to one or more organs falling into the space of the vaginal canal, sexual complaints are common, including painful intercourse, altered sexual feeling and difficulty achieving orgasm as well as less partner satisfaction.

When one’s bladder or rectum descends into the vaginal space, there can be an obstruction to the passage of urine or stool, respectively. This often requires placing one or more fingers in the vagina to manually push back the prolapsed organ. Doing so will straighten the “kink” in order to facilitate emptying one’s bladder or bowels. Pushing (and holding in place) a prolapsed organ back into position with one’s finger(s) is called “splinting.”

Why Do I Have A Bulge Coming Out Of My Vagina?

POP results from a combination of factors including multiple pregnancies and vaginal deliveries (especially deliveries of large babies), menopause, hysterectomy, aging and weight gain. Additionally, conditions that give rise to chronic increases in abdominal pressure contribute to POP. These include chronic constipation, asthma, bronchitis and emphysema (chronic wheezing and coughing), seasonal allergies (chronic sneezing), high-impact sports, and repetitive heavy lifting, whether work-associated or due to weight training. Other causes are genetic predispositions to POP and connective tissue disorders.

Childbirth is one of the most traumatic events that the female body experiences and vaginal delivery is the single most important factor in the development of POP. Passage of the large human head through the female pelvis causes intense mechanical pressure and tissue trauma (stretching, tearing, compression and crushing) to the PFM and PFM nerve supply. This results in separation or weakness of connective tissue attachments and alterations and damage to the integrity of the pelvis. POP that occurs because of a difficult vaginal delivery may not manifest until decades later. It is unusual for women who have not had children or who have delivered by elective caesarian section to develop significant POP.

To be continued…

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.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. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. 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 and 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.

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

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.  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.

 

 

10 Myths About Kegel Exercises: What You Need to Know

November 14, 2014

Andrew Siegel, M.D.

 

shutterstock_orange gu tract closeup

 

shutterstock_femalebluepelvic

 

Myth: Kegels are just for the ladies.

Truth: Au contraire…men have essentially the same pelvic floor muscles as do women and can derive similar benefits to sexual, urinary, and bowel health.

 

Myth: The best way to do Kegels is to stop the flow of urine.

Truth: If you can stop your stream, it is indeed proof that you are contracting the proper set of muscles. However, this is just a means of feedback to reinforce that you are employing the right muscles, but the bathroom should not be your Kegel muscle gymnasium.

 

Myth: You should do Kegel exercises as often as possible.

Truth: Pelvic floor muscle exercises strengthen and tone the pelvic floor muscles and like other muscle-strengthening routines, should not be performed every day. Pelvic exercises should be done in accordance with an intelligently designed plan of progressively more difficult and challenging exercises that require rest periods in order for optimal muscle growth and response.

 

Myth: You can and should do Kegels anywhere (while stopped in your car at a red light, waiting in line at the check out, while watching television, etc.)

Truth: Exercises of the pelvic floor muscles, like any other form of exercise, demand gravitas, focus, and isolation of the muscle group at hand. Until you are able to master the exercise regimen, it is best that the exercises be performed in an appropriate venue, free of distraction, which allows single-minded focus and concentration. This is not to say that once you achieve mastery of the exercises and a fit pelvic floor that you cannot integrate the exercises into the activities of daily living.

 

Myth: Holding the pelvic floor muscles tight all the time is desirable.

Truth: Not a good idea…the pelvic floor muscles have natural tone to them and when you are not actively engaging and exercising them, they should be left to their own natural state. There exists a condition—tension myalgia of the pelvic floor muscles—in which there is spasticity, tightness and pain due to excessive tension of these muscles. Pelvic floor training in this circumstance must be done with caution in order to avoid aggravating the pain, but maximal muscle contraction can induce maximal muscle relaxation, a meditative state between muscle contractions.

 

Myth: Focusing on your core is enough to ensure pelvic floor muscle fitness.

Truth: The pelvic floor muscles do form the floor of the “core” group of muscles and get some workout whenever the core muscles are exercised. However, for maximum benefit, specific focus needs to be made on the pelvic floor muscles. In Pilates and yoga, there is an emphasis on the core group of muscles and a collateral benefit to the pelvic floor muscles, but this is not enough to achieve the full potential fitness of a regimen that focuses exclusively on the pelvic muscles.

 

Myth: Kegel exercises do not help.

Truth: Au contraire…pelvic floor muscles have proven to help a variety of pelvic maladies in each gender. In females, pelvic floor muscle training can help urinary and bowel incontinence, pelvic relaxation, and sexual dysfunction. In males, pelvic floor muscle training can help incontinence (stress incontinence that follows prostate surgery, overactive bladder, and post void dribbling), erectile dysfunction, premature ejaculation and other forms of ejaculatory dysfunction as well as help bowel incontinence and tension myalgia of the pelvic floor.

 

Myth: Kegels are only helpful after a problem surfaces.

Truth: No, no, no. As in any exercise regimen, the best option is to be proactive and not reactive in order to maintain muscle mass and strength in order to prevent problems from arising before they have an opportunity to do so. Pelvic floor muscle training done during pregnancy can help prevent pelvic issues from arising in females and pelvic muscle training in males can likewise help prevent the onset of a variety of sexual and urinary maladies. There is no better time than the present to start pelvic exercises to delay or prevent symptoms.

 

Myth: You can stop doing Kegels once your muscles strengthen.

Truth: No, “use it or lose it” applies here as it does in any muscle-training regimen. Muscles adapt positively to the stresses and resistances placed upon them and so they adapt negatively to a lack of stresses and resistances. “Disuse atrophy” is a possibility with all muscles, including the pelvic floor muscles.

 

Myth: It is easy to learn how to isolate and exercise the pelvic floor muscles.

Truth: No, not the case at all. Studies have shown that over 70% of women who think they are doing pelvic floor muscle exercises properly are actually contracting other muscles, typically the rectus, the gluteal muscles, and the adductor muscles of the thigh. One of the greatest challenges is that there have been no well-designed, easy-to-follow pelvic muscle training programs…UNTIL NOW! The Private Gym Company was established after recognizing that there was an unmet need for a means by which a pelvic floor muscle-training program could be made accessible and available in the home setting. This comprehensive, interactive, follow-along exercise program is available on DVD…PrivateGym.com.

 

Myth: Kegels can adversely affect your sex life.

Truth: Absolutely not… In both genders, pelvic floor muscle training has been found to improve sexual function. The pelvic floor muscles play a critical role in both female and male sexuality, supporting clitoral and penile erections as well as ejaculation in males and orgasm in both genders.

 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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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: http://www.MalePelvicFitness.com

Private Gym: http://www.PrivateGym.com – now available on Amazon

30 Interesting Kegel Facts

November 8, 2014

Kegel Facts

Andrew Siegel MD (11/8/14)

shutterstock_femalebluepelvic

 

  • Arnold Kegel (1894-1981) was a gynecologist who taught at the University of Southern California School of Medicine. He was singularly responsible in the late 1940s for popularizing pelvic floor exercises in women in order to improve their sexual and urinary health, particularly after childbirth. His legacy is the pelvic floor exercises that bear his name, known as “Kegels.”
  • Arnold Kegel invented a resistance device called the perineometer that was placed in the vagina to measure the strength of pelvic floor muscle contractions.
  • Arnold Kegel did not invent pelvic floor exercises, but popularized them in women. Pelvic floor muscle exercises have actually been known for thousands of years, Hippocrates and Galen having described them in ancient Greece and Rome, respectively, where they were performed in the baths and gymnasiums.
  • Kegel exercises are often used in women for stress incontinence (leakage with exercise, sneezing, coughing, etc.) and pelvic relaxation (weakening of the support tissues of the vagina causing dropped bladder, dropped uterus, dropped rectum, etc.).
  • Arnold Kegel wrote four classic articles: The Non-surgical Treatment of Genital Relaxation; Progressive Resistance Exercise in the Functional Restoration of the Perineal Muscles; Sexual Functions of the Pubococcygeus Muscle; The Physiologic Treatment of Poor Tone and Function of the Genital Muscles and of Urinary Stress Incontinence.
  • Kegel wrote: “Muscles that have lost tone, texture and function can be restored to use by active exercise against progressive resistance since muscles increase in strength in direct proportion to the demands placed upon them.”
  • Kegel believed that at least thirty hours of exercise is necessary to obtain maximal development of the pelvic floor muscles.
  • Kegel believed that surgical procedures for female incontinence and pelvic relaxation are facilitated by pre-operative and post-operative pelvic floor muscle exercises.
  • Kegel believed that well-developed pelvic muscles in females are associated with few sexual complaints and that “sexual feeling in the vagina is closely related to muscle tone and can be improved through muscle education and resistive exercise.” Following restoration of pelvic floor muscle function in women with incontinence or pelvic relaxation, he noted many patients with “more sexual feeling.”
  • Kegel believed that impaired function of the genital muscles is rarely observed in tail-wagging animals, suggesting that with constant movement of the tail, the pelvic floor muscles are activated sufficiently to maintain tone or to restore function following injury.
  • The pelvic floor muscles form the floor of the all-important core group of muscles.
  • The pelvic floor muscles are involved in 3 “S” functions: support of the pelvic organs; sphincter control of the bladder and the bowel; and sexual
  • Men have virtually the same pelvic floor muscles as do women with one minor variation: in men the bulbocavernosus muscle is a single muscle vs. in women it has a left and right component as it splits around the vagina.
  • Men can derive similar benefits from Kegel exercises in terms of improving their sexual and urinary health as do women.
  • Kegel exercises can improve urinary control in men, ranging from stress urinary incontinence that follows prostate surgery, to overactive bladder, to post-void dribbling.
  • Kegel exercises can improve sexual function in men, enhancing erections and ejaculation.
  • If the pelvic floor muscles are weak and not contracting properly, incontinence and sexual dysfunction can result. If they are hyper-contractile, spastic and tense, they can cause tension myalgia of the pelvic floor muscles, a.k.a. a “headache in the pelvis,” which often negatively affects sexual, urinary and bowel function.
  • The pelvic floor muscles contract rhythmically at the time of climax in both sexes. These muscles are the motor of ejaculation, responsible for the forcible ejaculation of semen at sexual climax. Kegel exercises can optimize ejaculatory volume, force and intensity.
  • The pelvic floor muscles have an important role during erections, activating and engaging to help maintain penile rigidity and a skyward angling erection. They are responsible for the transformation from a tumescent (softly swollen) penis to a rigid (rock-hard) penis. They exert external pressure on the roots of the penis, elevating blood pressure within the penis so that it is well above systolic blood pressure, creating a “hypertensive” penis and bone-like rigidity.
  • The Kegel muscles are located in the perineum, the area between the vagina and anus in a woman and between the scrotum and anus in a man.
  • The Kegel muscles are not the thigh muscles (adductors), abdominal muscles (rectus), or buttock muscles (gluteals).
  • You know you are doing Kegel exercises properly when you see the base of the penis retract inwards towards the pubic bone and the testicles rise up as you contract your Kegel muscles.
  • You know you are doing Kegel exercises properly when you can make your erect penis lift up as you contract your Kegel muscles.
  • You know you are doing Kegel exercises properly when you can interrupt your urinary stream as you contract your Kegel muscles.
  • The 1909 Gray’s Anatomy referred to one of the male Kegel muscles as the erector penis and another as the ejaculator urine, emphasizing the important role these muscles play in erections, ejaculation, and the ability to push out urine.
  • The pelvic floor muscles are 70% slow-twitch fibers, meaning fatigue-resistant and capable of endurance to maintain constant muscle tone (e.g., sphincter function), and 30% fast-twitch fibers, capable of active contraction (e.g., for ejaculation).
  • Kegel exercises are safe and non-invasive and should be considered a first-line approach for a variety of pelvic issues, as fit muscles are critical to healthy pelvic functioning.
  • The pelvic floor muscles are hidden from view and are a far cry from the external glamour muscles of the body. However, they deserve serious respect because, although not muscles with “mirror appeal,” they are responsible for powerful and beneficial functions, particularly so when intensified by training. Although the PFM are not muscles of glamour, they are our muscles of “amour.”
  • The Kegel muscles—as with other muscles in the body—are subject to the forces of adaptation. Unused as intended, they can suffer from “disuse atrophy.” Used appropriately as designed by nature, they can remain in a healthy structural and functional state. When targeted exercise is applied to them, particularly against the forces of resistance, their structure and function, as that of any other skeletal muscle, can be enhanced. Kegel exercises are an important component of Pilates and yoga.
  • As Kegel popularized pelvic floor muscle exercises in females in the late 1940’s, so Siegel (rhymes with Kegel) popularized pelvic floor muscle exercises in males in 2014, with a review article in the Gold Journal of Urology entitled: Pelvic Floor Muscle Training in Men: Practical Applications, a book entitled: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, and his work co-creating the Private Gym male pelvic floor exercise DVD and resistance program.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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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: http://www.MalePelvicFitness.com

Private Gym: http://www.PrivateGym.com – now available on Amazon

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