pelvic floor muscle rehabilation

pelvic floor muscle rehabilation

Four Phases of Pelvic Muscle Exercise

Dr. Kegel described four phases in the performance of the exercises:

1. Awareness of the function and co-ordination of the PFM muscle.
   For older adults and persons whose pelvic muscle is severely relaxed, this may take several weeks.
2. Gains over muscle identification, control and strength.
   Muscle strength is the maximal force that can be generated by the PFM. Although the PRM is not flexible, the muscle must adapt to different or changing requirements so the PFM must have contractibility and build force quickly when contracting.
3. Firming, thickening, broadening and bulking of the muscles to increase muscle endurance.
   Muscle endurance is a performance characteristic of the ability of the PFM to execute repeated contractions to an initial level of strength often called a "submaximum" contraction.
4. Improvements of the symptoms indicate that the muscles are strengthening, especially as the ability to feel the muscle contract and relax increases.
   The ability to contract the muscle during the time of leakage (when coughing, sneezing, laughing, on the way to the bathroom) prevents urine loss. At this point some people feel that their incontinence is so improved that regular exercising is no longer needed.

How to Identify the Pelvic Floor Muscle

Individuals have a difficult time identifying and isolating this muscle. Without sufficient information, many men and women may mistakenly bear down or exercise ineffectively. Specifically, women should "draw in" and "lift up" the perivaginal and rectal/anal sphincter muscles. Men should just draw in or tighten the rectal sphincter. Once the person is able to identify the muscle, he or she is instructed to perform a series of "quick flicks" or 2-second contractions followed by sustained (endurance contractions) contractions of 5 seconds and longer as part of a daily exercise regimen. At least 10 seconds of relaxation is recommended between contractions. The individual should aim for a high level of concentrated effort with each pelvic muscle contraction, as greater contraction intensity is associated with improvement in pelvic muscle strength. (Bo et al, 1990; Dougherty et al, 1993)

How Often to Do the Pelvic Muscle Exercises

Individuals are instructed to do the pelvic muscle exercises three times daily and, optimally, to perform the exercises in 3 positions -- lying, sitting and standing. A minimum of 50-60 PMEs per day is recommended. A gradual increase in number of contractions over a period of PME practice has been shown to increase muscle strength significantly and decrease urine loss. The person should be instructed to contract the muscle at the time of the UI episode. (Miller, Ashton-Miller, Delancey, 1996) Contracting it before sneezing, coughing, lifting, standing or swinging a golf club can prevent stress UI from occurring. The muscle also can be contracted when he or she feels a strong urge to void. Results may not occur until after 6-8 weeks of exercise, and optimal results usually take longer.

A large body of medical research has demonstrated the efficacy of behavioral intervention that includes PMEs. The 1996 Guideline on Urinary Incontinence in Adults (Fantl, Newman, Colling, et al, 1996) outlined research showing that PME's are indicated for persons with stress incontinence and can reduce urgency and prevent urge UI. Pelvic floor re-education has proven to be effective in women with sphincter deficiency and detrusor instability. More recent research has supported this claim (AWHONN, 2000a, b; Sampselle, Miller et.al., 1998; Wyman, Fantl et.al., 1998, Burgio, Locher, et.al., 1998; Holtedahl, et.al., 1998; Sampselle, et.al., 2000; Sampselle, et.al., 1998). Burgio, et.al. (1998) reported a mean 80.7% reduction of incontinence in her research of older women with urge UI. Long term studies have demonstrated that improvement persists over time. (Bo, Talseth, 1996)

Practice of PME's in primiparas (women who have given birth to one child) results in fewer UI symptoms during late pregnancy and the postpartum period. (Sampselle, et al, 1998) Behavioral modifications, pelvic muscle rehabilitation and bladder retraining programs have successfully decreased UI in homebound elders. (McDowell, Engberg, et al., 1999 Flynn, et al, 1994) A study of men with urinary incontinence following radical prostate surgery showed that 88% of the treatment group achieved continence in 3 months compared to 56% of the control group. (Van Kampen, et.al, 2000) In addition, a more recent study (Burgio, Locher, Goode, 2000) examined the effects of combining behavioral treatment and drug treatment for urge UI in ambulatory women. The subjects' reduction of incontinence went from a mean 57.5% with behavioral therapy to a mean 88.5% overall reduction with combined behavioral and drug (anticholinergic) treatment. The majority of the PME research used some type of device to teach and train the PFM.

In general, both men and women may experience improvements in continence from a Kegel exercise program.