Dr. Kegel Cliffnotes

While Dr. Kegel's paper is very informative, it is also exhausting reading. Here's my layman's attempt at summarizing it:


A Nonsurgical Method of Increasing the Tone of Sphincters and their Supporting Structures

ARNOLD H. KEGEL, M.D., F.A.C.S.
Assistant Professor of Gynecology
University of Southern California School of Medicine
1948

 

Background

Through experience as a surgeon and research with cadavers, Dr. Kegel had noted that the pelvic muscles of women were often weak and thin from disuse. He theorized that just as we exercise other body parts to tone and improve the strength of weak muscles, surely there must be a way to repair these muscles that way as well-- instead of resorting to surgery, which was not effective long-term anyway.

He focused his attention on the pubococcygeus, nicknamed PG. He describes it as the most versatile muscle in the human body. It helps support all the pelvic organs, helps the muscles that control the openings, and is essential for maintaining the tone of the other pelvic muscles. The PG gives off countless fibers which interlock and insert themselves into the muscles of the urethra, middle third of the vagina and rectum.

When a patient's organs were in the right positions, the PG and its components would be found to be well developed. When the muscles were weak and thin, symptoms like uterine prolapse (uterus falling down), incontinence and sexual disfunction would occur. The next step is to test whether a patient can voluntarily contract various muscle groups. First he would have them retract and draw in the perineum (the diamond-shaped area corresponding to the outlet of the pelvis, containing the anus and vulva.) Next, the index finger is inserted to the middle third of the vagina (as above) and the patient is asked to squeeze it. A normal patient can immediately respond with a firm grip felt over a wide area. Others will state that they didn't know it was possible to contract those muscles. These patients will have the most weakened muscles.

Dr. Kegel would quantify this response using a device he developed called a Perineometer. It was inserted in the vagina and could measure the pressure exerted by contractions of the vaginal muscles. In a well developed vagina, a slight rise in pressure is detected when the device is inserted, without any patient effort. In weakened patients, this initial pressure is much lower. The pressure change caused by intentional contractions were then measured. Strong, immediate increases in pressure indicated a strong, well-developed PG. A weakened PG resulted in small or even imperceptible increases in pressure with attempted contraction.

Therapy

He points out that it is super important while doing these movements to make sure the patient is actually contracting the PG muscles and not just the muscles around the outer edges of the openings. He points out that women with poor PG function have compensated all their lives by depending on these external, surface muscles. So the goal is to focus more inward and upward, so that the inserted finger feels the contractions as these movements are made.
 

Most patients can learn pretty quickly to find these muscles, but some may require weeks of this practice. There is no point in further therapy until this can be done.

Diagnosis

A firm vaginal canal indicates that the fibers of the PG are well developed. Loss of tone and and prolapse of the vaginal walls indicates that the PG fibers are weak and thin. You can test the vaginal muscles by inserting an index finger into the vagina, up to about the second joint, so that you are feeling the middle third of the vagina. In a normal vagina, the canal is tight and the tissue resists from all directions. The walls naturally close around the finger. The walls feel firm and deeply attached to the surrounding tissue. On the other hand, if the middle of the vagina is roomy in all directions, regardless of whether the opening is wide or tight, and the walls offer little resistance to touch and feel thin and loose, this indicates that the PG fibers have weakened from lack of use. 

Education

The first step in therapy is to help the patient find and learn to activate the muscles. He found that 1/3 of patients could not contract their PG voluntarily on the first visit. He would use a process of pushing with a finger at different internal locations to prompt the patient to contract the correct muscles. He'd basically find a connected muscle that they could contract and then work from there towards the PG. This teaches the patient to find and feel these disused muscles. For continued practice, the patient is directed to squeeze the inserted finger, draw up and in the perineum, draw up the rectum as though checking a bowel movement and contract as though interrupting the flow of urine. 
 

Resistive Exercise

Dr. Kegel felt that patients were unlikely on their own to be able do continue to use the correct muscles without help and supervision. He also felt that without measurable results, they were likely to become discouraged and stop exercising. So he recommended his Perineometer for contraction practice at home. It provided resistance to the muscles that needed strengthening and provided measurable results. Patients were advices to use the device for 20 minutes, 3 times a day. They were also encouraged to do additional contractions without the device throughout the day. He found that 50% of patients would slip back into their old habit of using the external muscles, so he recommended weekly appointments for the first month to firmly establish proper technique. He found that most complaints of fatigue and aching muscles were due to improper technique. 

Results

Patients who dutifully did their exercises experienced the following changes: stronger and more sustained contractions, thicker muscles throughout the pelvic area, improved positioning of the pelvic organs, firmer and longer vaginal walls, and reduced uterus prolapse. Patients with urinary incontinence showed dramatic results. 212 patients with severe urinary stress incontinence were treated and 84% were able to establish good urinary control through the therapy. 

The widest application is for women with genital relaxation after childbirth since 30% of women complain of this condition. Previously, women had to just suffer through symptoms until after menopause when surgical intervention would be recommended. Dr. Kegel found that progress was a slower with these cases, probably because since their symptoms were less debilitating they are less motivated and more haphazard in their exercise. But patients who were diligent felt improvement after 2-4 weeks of exercise but exercises needed to be continued longer to build lasting, structural changes. 

Preventative use

Pelvic resistance exercise during pregnancy builds thicker, stronger muscles, resulting in easier postpardum repair and less postpardum relaxation.

Exercise is also recommended after any pelvic surgery to help return muscles to working condition.

 

Conclusion

I noticed this statement in his conclusion, "On the basis of therapeutic results achieved, it seems possible that other ill-defined complaints referable to the genital tract in women might profitably be studied from the standpoint of muscular dysfunction." 

 REFERENCES:
 Anson, Barry J. Atlas of Human Anotomy. Philadelphia: W.B. Saunders Company, 1950
 Bushnell, Lowell F.: Physiologic Prevention of Postpartal Relaxation of Genital Muscles. West. J. Surg., Obst & Gynec. 98: 66-67, February, 1950
 Counsellor, Virgil S.: Methods and Technics for Surgical Correction of Stress Incontinence, J.A.M.A.46: 27-30, May 3, 1951.
 Curtis, Arthur HJ., Anson, Barry J., and McVay, Chester B.: The Anatomy of the Pelvic and Urogenital Diaphragms in Relation to Urethrocele and Cystocele. Surg., Gynec. & Obst. 68: 161-166, February, 1939
 Jones, Edward Gomer: The Role of Active Exercise in Pelvic Muscle Physiology. West. J. Surg., Obst. & Gynec. 58: 1-10, January, 1990
 Kegel, Arnold H.: The Nonsurgical Treatment of Genital Relaxation, West, Med & Surg. 31: 213-216, May, 1948
 Kegel, Arnold H.: Progressive Resistance Exercise to the Functional Restoration of the Perineal Muscles. Am. J. Obst. & Gynec. 56: 238-248, August, 1948.
 Kegel, Arnold H.: The Physiologic Treatment of Poor Tone and Function of the Genital Muscles and of Urinary Stress Incontinence. West, J. Surg., Obst. & Gynec. 57: 527-535, November, 1949
 Kegel, Arnold H.: Active Exercise of the Pubococcygeus Muscle. Meigs, J.V., and Sturgis, S .H., editors: Progress in Gynecology, vol. II, New York: Grune & Stratton, 1930, pp. 778-792
 Kegel, Arnold H.: Physiologic Therapy for Urinary Stress Incontinence. To be published in J.A.M.A.
 Kegel, Arnold H., and Powell, Tracy O.: The Physiologic Treatment of Urinary Stress Incontinence. J. Urol 63: 808-813, May, 1990
 Read, Charles D.: The Treatment of Stress Incontinence of Urine. Meigs. J.V., and Sturgis, S.H., editors: Progress in Gynecology, vol II, New York: Grune & Stratton, 1950, 690-697
 Collins, Conrad G.: Chicago Med., Soc. Bull. 241-246, October 13, 1931

 Source: Arnold H. Kegel, MD, FACS. Stress Incontinence and Genital Relaxation. CIBA Clinical Symposia, Feb-Mar 1952, Vol. 4, No. 2, pages 35-52.

Am. J. Obst. & Gynec. Aug 1948. “Progressive Resistance Exercise in the Functional Restoration of the Perineal Muscles.” Dr. Arnold H. Kegel, MD FACS

Sources for the orginal content:
GyneFlex
Do the Kegel



 

Personal background - Female Urethral spasms and prolapsed uterus

To learn about our solution, read here background is below.


For any wanting more background on my symptoms and diagnosis of urethral spasms:
Nearly 15 years ago, not long after weaning my second child, I started finding myself in terrible pain every month with urinary tract infections. At least that's what it felt like--a feeling of urgency and painful cramping that pain killers wouldn't touch. I became a regular visitor to my primary care physician's office. Occasionally I would test fully positive for a urinary tract infection. More often, I would test positive for high white blood cell counts but negative for nitrates which would cause my physician to shake her head in confusion and sometimes give me antibiotics, sometimes not. Of course, going on antibiotics nearly every month also started leading to an endless merry-go-round of urinary tract infection, yeast infection, urinary tract, yeast infection and eventually a little bit of BV thrown in as well. And as so often seems to happen in the medical world, no matter how many times I came back to the doctor's office, the routine never changed. The doctor never seemed bothered by the repeated visits. She treated each one as a fresh occurrence independent of the others. Finally, after months and months of pain and frustration I came in armed with my list of how many times I'd been in, how many rounds of antibiotics I'd been on, etc. even though I knew all this information was in her charts and I demanded, " Why is this happening over and over?" and "Shouldn't we be trying to address the underlying cause?" Her answer was very illustrative of the limitations of our medical system. She explained that she wasn't trained to do that--to investigate and figure out medical mysteries. She said that primary care doctors are trained to treat symptoms and that's it. I was insistent that wasn't good enough and demanded she give me a referral to see a specialist. She wasn't too excited about doing so (thank you cost-saving insurance companies) but finally agreed.

In the mean time, I also went to my gynecologist's office for my annual well woman exam (more info about why this may be a waste) and to see if maybe there was something going on in that realm that was causing my discomfort. An earnest resident I talked to suggested that maybe I was dealing with Interstitial Cystitis and recommended I try eliminating various foods from my diet to see if that helped. As I researched IC, I didn't think it quite matched but it was closer anyway. And I greatly appreciated her at least trying to think outside the box. My actual gynecologist was less useful. She sent me in for a pelvic ultrasound, found nothing, and suggested they could try birth control pills or a hysterectomy and see if that helped. Umm, no thanks.

When I finally saw a urologist, he sent me in for a kidney x-ray and cystoscopy to eliminate possibilities. They were normal. He explained that I was having urethral spasms-- where the urethra thinks it is infected and acts accordingly. He said they had no idea why and no cure, but that it was fairly common in women my age. He gave me the helpful suggestion that if I got pregnant I might feel better during the pregnancy-- he'd noticed that was the case for at least one patient. Once again, no thank you. He put me on a couple medicines-- a low dose daily antibiotic and a muscle relaxant used to treat prostrate problems in men. Neither seemed to help much and I didn't like the side effects of the muscle relaxant (or the fact that it wasn't designed or tested for use with women) so I dropped that one but kept taking the antibiotic for a while. It didn't actually stop the symptoms, but it calmed my mind. When the pain would start, I wouldn't have to wonder and worry whether it was an actual infection that I needed to go get medicine for. Gradually I concluded that it was just as effective to only take it the days of the month I was feeling bad rather than every day. Eventually I moved and didn't bother finding a new urologist. I would just talk my primary care physician into low dose antibiotic prescriptions which I'd keep around for when I had flare ups.

And so it continued for the next decade plus. I learned that if I kept my stress down and got plenty of rest, I had fewer attacks. But they still would happen occasionally and I would just suffer through the pain. It wasn't until recently that we found something that worked. To learn about our solution, read on here.

What no one tells you about the dreaded pap smear

If you or your partner is promiscuous, this post is not for you. If you are in a long-term, completely monogamous relationship or celibate, read on.

For years I suffered through the annual torture of a pap smear. I was told that birth control pills upped my risk of cancer so I needed to be screened annually. I sort of looked at it as the price I had to pay-- I wanted the prescription so I had to take the test. Once I was off of birth control pills I no longer had to make the annual visit and the window between when I'd bother with a well woman exam kept spreading wider. I was feeling a bit guilty about not having a pap smear in a number of years, until we looked it up to see how often it was recommended... and then learned even more.

Honestly, I'm not even sure I knew which cancers a pap smear tested for-- just female part cancers. I'd just had it continually drummed in to me that it was a super important way to prevent cancer (and who doesn't want to prevent cancer, right?) The government said that I need this test. My insurance company said I need this test. I definitely didn't understand that it only tests for cervical cancer and I most certainly didn't know that a person had to had to be infected with HPV virus, a sexually transmitted disease, to get cervical cancer.  (According to the American Cancer Society "a woman must be infected with HPV in order to develop cervical cancer" link)

I have been happily married for 20+ years. My husband and I were both virgins when we married. I was aghast to find out I'd endured this uncomfortable test for a disease I had zero percent risk for! In this article it mentions a study of 13,000 nuns (not sexually active).  ZERO got cervical cancer.  Think about that next time someone quotes cancer risk statistics.  Zero in 13,000.  In another article clearly very pro testing for HPV it states, you can get HPV "unless you are both virgins and have never fooled around".  Love it when a very pro testing article makes the argument against testing for me :-)

Frankly it makes me angry. It comes down to the fact that doctors don't believe their patients' sexual history. They don't believe it is possible for someone to not sleep around and be married to someone who does not sleep around.  They don't take you seriously when you say that is the case. They do not create testing recommendations for a group they don't believe exists.  Or is it all about the money?

Pap smears are a huge industry. Think of how many tests the labs run and charge insurance for every year. Think how many annual exams are scheduled with gynecologists and family practitioners because of these recommended tests. Whatever the motivations, there is a bunch of unnecessary testing going on.

And some might say, better safe than sorry. What can it hurt to do too many tests?  You might say, well, if you really have no risk, your pap smear will always be negative. No worries. Unfortunately, pap smears are also wildly inaccurate--somewhere in the neighborhood of 70% accurate. So 30% of all pap smear readings are WRONG.  And due to our lawyer happy society if the results aren't clear they will error toward the conservative side, call the test irregular and order a cervical biopsy.

From Web MD link
"Paradoxically, increasing PAP smear sampling among low risk women actual increases your chance of getting a “false positive” one day. For example (DeMay, 2000), if you get a yearly PAP between the ages of 18 to 78, and one assumes a 5% incidence of false positives, you would have a 95% chance of getting a false positive report during that time."

From the NY times link
"In general, about 10% of Pap smears have abnormal results, but only about 0.1% of the women who have these results actually have cancer."

In other words, out of 100 women with abnormal pap smears 99 of them were scared out of their wits and likely had their cervix scarred because of an inaccurate pap test.

Biopsies are talked about as a simple test all the time, so I don't think many people register what they are. A biopsy equals cutting a decent sized chunk out of your cervix! To test for a disease which I would not have. So it is very possible that a person with no risk could have a false positive and have to undergo a cervical biopsy.  A biopsy which WILL cause scar tissue that will be there for life.  And can cause all kinds of side effects.  Not to mention the pain of the actual test.  All "just to be on the safe side"

Want to see what they do for a cevical biopsy.  Here is a video. VERY GRAPHIC.
Biopsy of Vaginal and Cervical Lesions   https://www.youtube.com/watch?v=1JgsW-HjtWs

Colposcopy Procedure (with biopsy)
At time 3:23 is when they take the biopsy.  https://www.youtube.com/watch?v=u7ld_JWH8tU

Biopsy is HIGHLY invasive "just to be safe" isn't good enough.


The other frightening aspect is the risk of cross-contamination. My husband and I both are HPV free. Zero risk there. I'm sure there are other patients that go to my gynecologist's office who have HPV. One sloppy moment-- cleaning equipment, changing gloves, etc.--and it could be transferred to me. Yes, it's not super common, but it does happen.  It is a risk.  Just like there is a risk of getting cancer. Having an exam and pap smear actually increases my risk of cervical cancer. But no doctor or nurse or goverment program will ever warn me of that!

Links to some articles about cross contamination.  Google and you'll find lots more.  Does unnecceary testing put people at risk?  Yes it does.

2010 in texas 70 speculums were not sterilized cross contaminating patients link
Discussion of several incidents link
Dangers of using reusable speculums link
Study finds HPV on spculums AFTER cleaning link

Another good article:
Top Five Reasons for Opting Out of Pap Tests link