Dr. Kegel's Exercises
The medical establishment is as polarized about the value of Kegel's Exercises as this country ever was over "Vietnam" or "McCarthyism". On the one hand "patient advocates", such as nurses and physical therapists, insist that (l) anyone can learn to do them, (2) everyone should learn to do them, and (3) they each know the one "correct" way to teach them. On the other hand, most urologists and gynecologists only politely smile at the mention of Kegel's legacy, knowing full well that, sooner or later, almost every incontinent person will eventually submit to a surgical procedure or urological medication.
Explication of this paradoxical conflict is of considerable interest to gerontologists, since Arnold Kegel, M.D., originally proposed his exercises as an alternative to needless and ineffective surgery2, which he perceived in his own practice and those of his colleagues. He correctly anticipated several contemporary medical trends, including (l) cost containment, (2) the self-help movement, (3) women's rights, (4) the value of isometric exercise and (5) biofeedback technology. Like cartoonist Jules Pfiffer's youthful anti-Vietnam activist, his primary mistake was "pre-mature morality".
In popular literature, Kegel's exercises are most frequently described as those which have to do with the "stopping and starting the flow of urine". As a simple means of pubococcygeus muscle identification, this test is educational-but only for those who already have strong muscles. It was never intended to be the "instructional tool" that it has become in women's magazines. Indeed, Elizabeth Noble even warns against this practice, which often leads only to "anxiety, stress and loss of control"3. Failing to interrupt the stream, many women conclude that their own muscles are already beyond self-help, and readily submit to the surgeon's confident invitation. And the surgeon becomes more firmly convinced of the futility of Kegel's exercise when one after another patient claims that they "tried them" but "they didn't work." Since the patient is now incontinent, that is obviously true.
It is the thesis of this paper that the bastardization of Dr. Kegel's exercises-the unintentional but thoroughly understandable emancipation of the exercises from their historical parentage-has led to a state of confusion among both professionals and laypersons alike. This confusion is epitomized in the title of a recent paper by Burgio, Robinson & Engel: "The Role of Biofeedback in Kegel Exercise Training for Stress Urinary Incontinence"4 But the title is quite misleading. Rather than investigate the role of biofeedback in Dr. Kegel's exercise, the authors present a controlled experiment in which exercises are prescribed with and without biofeedback. A false dichotomy is drawn between "Kegel Exercises", by which the researchers mean merely verbal instruction without biofeedback, and "Biofeedback", by which was meant verbal instruction in pelvic muscle exercise with concomitant direct visual feedback of that muscle activity. Naturally the instruction-with-biofeedback condition proved considerably more effective than instruction-without-biofeedback. This should surprise no one, since this model of research has been replicated many times in the literature about biofeedback in general. For example, countless studies have shown that various forms of relaxation training (for stress management, for example) are significantly better when physiological feedback of muscle states and peripheral temperature augments mere verbal instruction.
What is distressing about this NIA research is not that it proves the superiority of biofeedback, but that it validates the bastardization of Dr. Kegel's exercises by hypothesizing therapeutic efficacy to an emaciated version of them. This is an illegitimate distortion of historical scientific research. Most researchers know that Kegel's claims were based on exhaustive clinical records of patients seen at the Perineometer Research Institute at UCLA. (The actual number of patients seen is often under-reported by scholars who may have read only one or two of Kegel's earlier papers. For example, Taylor and Henderson remark that Kegel did his research "on small groups of women"5 But in his 1956 film and later papers, Kegel refers clearly to "several thousand women"-hardly a small group!)
Moreover, we cannot be impressed by sophomoric complaints that Kegel's sample was "not scientific" because he did not validate his exercises with controlled experiments. Chi Squared is only one form of statistic. In cases where we already know the success rates for of untreated populations and of alternative therapies (such as surgery), it is only necessary to show that the new treatment improves significantly upon the previous options. If the data are unclear, a "t-test" can be employed. But a statistical test is quite unnecessary with the unmistakable data generated in Kegel's clinic.
Kegel clearly stated that there were three steps to his method.
"The first step is external observation, with the patient in the lithotomy position."6 Kegel first observed the patient's ability to visibly draw up the perineal structures.
"The second step is vaginal examination, performed gently with one finger."7 The digital exam served a double purpose: first, it enabled the physician to assess the development of the puboccocygeus muscle at various depths, and second, it enabled the physician to verify that the patient was able to identify the correct muscle and contract it. Thus identification of the muscle, and not its exercise, was the purpose of Kegel's digital exam.
The third stage follows quickly: "after [only] 5 to 10 correct contractions the Perineometer is inserted, and both physician and patient watch the manometer to note the results of her efforts"8 (emphasis added). In several articles, the insertion of the Perineometer biofeedback device marks the beginning of the third and primary step in Dr. Kegel's exercise program.
It is important to observe that Kegel defined his exercises "operationally", rather than "formally". That is, rather than specify "how to do the exercises", he specified what would be measured if they were done correctly with his device in place. He invented and used the world's first biofeedback instrument, the perineometer, to objectively assess pelvic muscle strength, both in the office, and in daily at-home use by the patient.
Kegel's own reliance on his perineometer is clearly documented in all of his writings. For example:
"Patients vary greatly in their ability to contract the vaginal muscles. Many, especially those with marked relaxation of the pelvic floor, are unable to register even a few millimeters of pressure on their initial attempts. Gradually, after practice, and as the muscles become stronger through exercise, the pressure which can be exerted increases and frequently reaches 60 to 80 or more millimeters of mercury.9
"The perineometer is employed to measure strength of contractions. Normally, a slight increase of 1-5 mm Hg will be registered at first visits, provided the exercises have been carried out correctly.... If at the second or third visit the patient does not report some slight relief of symptoms, the reason is immediately investigated.... The physician need not depend on the patient's word alone, for lack of diligence betrays itself by rapid fatigue, as revealed by lower Perineometer readings after only 3 or 4 contractions.10
Kegel often stressed the "resistive device" function of his vaginal probe in anticipation of isometric exercises. But he was also aware of what later came to be called "behavioral principles" when he wrote: "A woman who is able to observe the slow but steady day-by-day progress on the manometer will be encouraged to keep up the good work."11 B. F. Skinner couldn't have said it better.
Kegel did mention the interruption of the urinary stream, but not at all in the context which his less-than-faithful followers have. Urinary interruption was not proposed as a means of locating the muscle, but as one of many daily opportunities to practice exercising it in the advanced stages of therapy.
Recently two nursing professors (Dougherty and Wells) have independently tried to promote the digital examination itself as a subjective measure of pubococcygeus strength. But Kegel himself-while making it the second step in his program-was acutely aware of its limitations. "The strength of the puboccocygeus muscle can be roughly estimated by digital palpation," he said, "or more accurately measured with the Perineometer"12. Admittedly his numerical scale was, by today's standards, itself a bit rough. The quotation continues: "Contractions of 5 mm Hg or less denote pronounced weakness of the perivaginal muscles, readings of 20-50 mm Hg indicate good development of the musculature, while intermediate values suggest borderline conditions."
Contemporary forms of perineometry, based on electronic sensors and computerized instruments, permit considerably finer precision in recording and averaging muscle data than was possible in Kegel's day. This has led Taylor and Henderson13, for example, to delineate "10.85 microvolts" (EMG reading on the Personal PerineometerЄ) as "the mean reading at which our subjects were dry", and 12 microvolts as the absolute level for urinary control. Modern perineometry is also considerably more sensitive than the manometric system employed by Kegel. EMG instruments are capable of detecting muscle action potentials far below the level necessary for an actual contraction of muscle fibers to occur (i.e., below "trace"). In other words, today's EMG perineometers are capable of confirming the patient's identification of the PC muscle at far lower levels than even Dr. Kegel's experienced fingers could palpate. While the digital examination may retain some value in the physician's initial assessment of the muscle's development, it is probably no longer the best means of helping the patient identify the muscle.
Kegel routinely prescribed a therapeutic regimen of a full hour a day of practice with his Perineometer device in the vagina. No where does he mention the duration of a single contraction, but he states that "twenty minutes, three times a day, or for a total of 300 contractions daily". Sixty minutes times 60 seconds equals 3600 seconds, divided by 300 repetitions allows for 12 second cycles. In his drawings of "pressure over time" he sketches symmetrical sine waves, and he remarks that in the final, healthy stage contractions become "prolonged"14, so we can conclude by simple arithmetic that he envisioned six-second contractions.
The role of the Kegel Perineometer as a "home trainer" with quantifiable biofeedback signals was quite clear to Kegel. "While the patient is exercising regularly, she is encouraged to attempt to increase the pressure 1 to 2 mm of mercury daily, and to keep a record of the maximum contraction of which she is capable at each exercise period."15 More recent disciples have made the use of the Perineometer home trainer either optiona116, or dispensed with it all together. Recently Wells explained that the federally-funded Ann Arbor program decided against the use of home trainers because they feared "sexual arousal" among their patients.17 Kegel disagreed:
"The physician's explanation of the therapy need not and should not be made in an apologetic attitude. The method is presented to the patient in a factual manner, stressing the necessity for restoration of dormant muscle function. The objection that sexual stimulation may be brought about through exercises with the perineometer is sometimes intimated by physicians, but has no basis in fact in normal women. As long as no unsound associations are suggested the patient will appreciate the simplicity and practicability of the therapy."18
[In our own experience with over 100 incontinent patients, less than two percent have even commented on sexual connotations of the (EMG) perineometer sensor, and none have objected to the daily use of the "home trainer" biofeedback device.]
By 1950 Kegel was able to boast a 93% cure rate for 300 unselected patients with stress incontinence in Los Angles, and claimed that other physicians using his device were 91% successful. Beginning in 1948, "on the strength of these favorable results urinary stress incontinence in women is no longer routinely treated by surgical intervention at...LA County General Hospital."19 But the promise of Kegel's exercises has yet to be fulfilled.
Some origins of Kegel's demise are self-evident. Among surgeons at least, the goal of eliminating surgery is no more popular in 1988 than it was in 1948. Judged by, for example, the Proceedings of the International Continence Society over the past few years, the profession is committed to finding new and better surgical techniques; not fewer surgical opportunities. It bears noting also, that while Kegel himself was a surgeon, the contemporary advocates of his exercises are almost exclusively drawn from the ancillary medical professions.
Unfortunately, history found it easier to transmit Kegel's words than his device. The latter was marketed for many years by Kegel and his wife, who assembled the components-literally-on their kitchen table. Mrs. Kegel diligently continued the practice for three more years following his death in 1976, but she finally retired in 1979. The gradual decline of the device may be reflected in its inappropriately stable price: from 1947 to 1979, it always sold for the same $39.95 at which it was first introduced. Lacking ordinary commercial incentives, the medical equipment industry lost interest in the perineometer. Lacking his perineometer, medical personnel were forced to improvise on his methods. The results of trying to teach Kegel's exercise without his measuring device have been less than impressive. Fortunately there is now a movement to restore biofeedback to its rightful place as an integral part of Dr. Kegel's exercises, and thus restore full credit to one of America's greatest pioneering physicians.