Kegels: Coochie Crossfit

Women, are you doing your Kegels? Are you doing them now, as reading the title of the post was a reminder for you to flex your vaginal biceps? Do you have a yoga practitioner who coaches you through pulling in and burning your inner fire? Do you remember to do them every time you're in an elevator, or at your place of worship, or drinking caffeine? Were you in an awesome midwifery and women's health student cohort like mine, where we would do them together every so often? Ah, how I miss those Kegel circles. But now I'm on to doing Kegels with women who are learning about them for the first time!The (awesome) Doula facilitator of last week's Centering group introduced everyone to Kegel exercises, and, girl, was that a surprise for some of those pregnant women. We all did a 10 second Kegel together, a few of them running out of breath or laughing halfway through. Later in the week I did Kegel exercises with two separate women during their GYN visits; one with reports of urinary leakage upon laughing or coughing (stress incontinence), and one who had a baby last year and feels "looser" during sex, which bothers her. We sat together and did Kegels during our visits. Neither of the individual women had heard about Kegels, and the Centering group really got a kick out of the facilitator describing them and encouraging everyone to do them.So what are these mystery exercises that women do? Is the woman sitting across from you on the bus doing them? What about your aunt? What about your financial advisor? What about that hot biker at the stop light? Probably not, actually, since it's difficult to remember to do them, and no one gives much credence to their importance. But let's work through this topic a bit and go from there. First, this fantastically descriptive video:Dr. Arnold Kegel, the man behind the movement (both physical and cultural), originally published the idea of pelvic muscle exercises to increase vaginal tone. The Wikipedia page on this topic has a wealth of information. I particularly find this picture useful in show the upwards motion of the muscles one hopes to achieve in the exercise. Interestingly (meaning I never knew this), penis-owners can also perform Kegels to their benefit, which has apparently been shown to decrease incidences of premature ejaculation and benign prostatic hyperplasia (BPH)'s impact on size and intensity of erections. Who knew. Back to the women. (Here is where I'll admit my frequent bias against men who have things to say about lady bits, so let's see what those presumably with lady bits have to say about Kegels nowadays.)Helen Varney, author of Varney's Midwifery, brings up Kegel exercises in all different parts of the book:

• 'Special Exercises for Pregnancy,' to strengthen and relax the muscles of the pelvic floor and birth canal.
• 'Making Exercise Recommendations' in the postpartum period, stating "if there are no complications with a vaginal birth, the new mother may begin to try to tighten her pelvic floor muscles within a few hours of birth. Regaining control of these muscles is a very significant contribution to well-being." Later, "The originator of the exercise reported that 20 to 40 hours of progressive resistance exercise, over two months time, was necessary to completely restore tone."
• 'Pelvic Floor' in common gynecological diagnoses, stating "Loss of pelvic floor integrity may be due to childbirth, the presence of abdominal or pelvic masses, previous surgical procedures or simply aging coupled with gravity."

Helen Varney, affectionately referred to as "Varney," is also poetic in describing midwives' fascination with this area, specifically related to pregnant women and birth:

"Midwives have always had a particular interest in the preservation of the integrity of the vagina and perineum during childbirth. The ability to allow for the safe birth of an infant in a manner that is nontraumatic to both the mother and the infant has long been a skill held in high esteem and meticulously taught in midwifery education. Although we now know that a birth that occurs in the absence of episiotomy incurs less long-term harm to the woman's pelvic floor and vaginal health, even the most nontraumatic birth may result in a degree of loss of muscle tone from pregnancy alone."

Kerri Schuiling and Frances Likis, in their book, Women's Gynecologic Health, a staple of nurse-midwife and women's health nurse practitioner education, discuss Kegel exercises in a surprisingly minimal way. Kegel's are only mentioned in the section on urinary incontinence, to help women already encountering issues with urinary leakage, and in conjunction with a separate exercise known as The Knack. There is no mention of pelvic muscle exercises as a preventive effort. The authors reference Sampselle et al.'s (1997) recommendations of "30 contractions of moderate to near maximum intensity each day; each contraction should be followed by at least 10 seconds of rest. Most women will notice improvement in strength and control within one month; although, three months or more may be needed to see full results." (I like the recommendation of 10 Kegels at a time, three times a day. I know it can be frustrating to not see results quickly, and even a month seems like a long time to see effect. So the woman last week with urinary incontinence, I recommended she come back in a week to see how it's going).Both resources stress the importance of ensuring that the woman is not bearing down in a Valsalva motion, like with squatting/weight lifting, which can cause you to push your pelvic floor out and down. Ensuring that a woman is not doing the opposite of the Kegel validates that she is using the correct muscles for the activity.Both of these books suggest describing it as the group of muscles you use to stop yourself from passing gas. In school, and recently on a feminist listserv email from undergrad, there was a long list of recommendations. These include: imagine picking up a pea with your vagina or sucking up a drink with a straw in your vagina; and using the same muscles that you use to stop peeing midstream. It's important to stress to not do Kegel's regularly while urinating, only the first time, because the routine practice of stopping while peeing can cause urinary retention and possibly lead to a urinary tract infection (UTI).As providers, what do we do to assess pelvic muscle strength, describe how to perform Kegels, and refer for further assessment if Kegel's aren't enough to provide the woman with relief?Helen Varney suggests that pelvic muscle assessment be done at every routine gynecological exam. Visually and manually, providers can determine if the woman is bearing down (incorrect) or flexing up (correct), if there is associated organ prolapse (bladder, uterus, or rectum bulging into the vagina), if the woman is starting out with enough vaginal tone to complete the exercise at all, or perform a Pyridium test to see if the woman is actually experiencing urinary incontinence or is having fluid such as sweat or vaginal secretions bothering her instead.For those women determined to have weakened vaginal tone, there are lots of options. Vaginal cones and weighted balls help women to experience the sensation of having something heavy to hold up, like an arm weight for your biceps, but a weight item for your vagina. Similarly, there are dildo-looking devices that one can insert vaginally, perform a Kegel, and then receive feedback on the amount of pressure one's exerting with each exercise. Lastly, stimulation or TENS-type devices provide current-based stimulation of the muscle, leading to contraction, leading to relaxation, and strength - like if you go to the chiropractor and get that dreamy current before the adjustment that makes your back muscles quiver and then you feel like a new person. It seems like most of the research concludes that devices are helpful, can provide feedback if the woman is performing her Kegels correctly, and can be a reminder and a tangible item correlated with the issue (like some providers do with prescribing antibiotics for viral infections). However, these conclusions reiterate the impact of the exercises themselves as a necessary starting point for anyone assessed to need improvements in their vaginal tone.And finally, in France, there is physical therapy. Women who birth in the French system are allotted 10 visits to a physical therapist to ensure proper strengthening of the perineal floor post-pushing. In this NY Times article, author Pamela Druckerman refers to her provider as a "Pilates instructor for the below-the-belt region," and concludes that perhaps it's helpful for the government (government healthcare, that is) to be in her crotch (for the benefit of vaginal physical therapy, anyway). Fascinating.What do I think about Kegels?

• They're important to do, but impossible to remember to do. My memory triggers at the following times: elevators, Starbucks, electronic health record charting, TV commercials. Oh, and meetings. Rarely do I actually remember to do my Kegels, however.
• They should be thought of as preventative work, strength building, rather than solely restorative once a woman experiences problems. Like abdominal crunches to save your back. Accordingly, I don't remember to do these, either.
• If you have sex, employing Kegels as a regular exercise will likely make it feel better, with stronger and tighter muscles for friction and more blood flow for sensation. Sometimes I also recommend women to practice Kegels during sex: if you grab around the fingers/penis/toy rather than pushing it out, then you're doing them right!
• If you are pregnant, the strength of the muscles and the blood flow from using them as an exercise will help with support during the birth and after. (Increased blood flow to tissues decreases risk of tearing during the birth). Some women might find Kegels difficult late in pregnancy, and I've heard midwives recommend women do 10 squats after going to the bathroom, each time, to encourage the blood flow to the perineum.
• If you weightlift, or work in a profession that requires heavy lifting, or are a mother/aunt/friend with a toddler, you might Valsalva often, which is the opposite work of Kegels, and might be even more benefited from Kegel exercises as preventive work. Like these hot chicks:

                                             I would only add, And do Kegel's!

• Lastly, anything women can do for themselves, covertly, openly, that makes them smile when they think about it, or that they can share with other women - typically I think that's a pretty good thing. If you can be at a boring staff meeting and smiling on the inside because you're doing Kegels and no one knows, I'm thrilled. I almost always smile at meetings.

For now, I'm just going to relax at the end of a long day, with my Kegel coozie, thanks to the UPenn midwife students at the ACNM meeting this past year, and breathe a sigh of relief that, perhaps, at least you might have flexed your vagina a few times while reading this. Let's all try and do some together... one, two three... Kegel!