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Diane Newman: So pelvic floor muscles I review on the anatomy and physiology presentation. So please listen to that prior to this so you understand what the pelvic floor and where it is. Sometimes patients come to me with a gym bag and think that they're going to have to get on the floor to do exercises. We say they're pelvic floor muscles because they're in the floor of the pelvis. But basically you exercise and you train and you rehab these muscles. And the goal is to increase urethral resistance, which means you're going to increase the support of the urinary sphincter, the external sphincter, and you're going to improve bladder control through the active use of the pelvic floor. The components of pelvic floor muscle exercises are you want to isolate the muscle, very difficult. Almost all the patients I see are not isolating the correct muscle, even though they say they're doing it.

It's an internal muscle. It takes time to really identify and isolate it. You want to be able to contract and relax it. You want to be able to use the muscle during active exercise, like during an incontinent episode or prior to the episode. So we'll talk about that and that's a stress strategy.

So I start with showing patients, and by this picture you can see that this is the pelvic floor sideways, and I actually have these boards of this muscle, teaching boards, in my office, in my exam room where I teach patients and I show them where the pelvic floor muscles are and in relation to the bladder, the urethra, the uterus, the rectum, the prostate. And so they understand what they're to do. You have to have the patient do these. Pelvic floor muscle training is a part of a whole constellation of behavioral training.

The patient has to do it. If they're not motivated and if they don't comply, they will not be successful. This is not like a pill that you take and you get better. That's the difference, with behavioral you have to have a motivated patient, have to have a patient that's willing to follow your instructions. So that is sometimes a very big negative, as some people do not want to do that. But that's really important that they understand, with behavioral conservative treatments I will teach them everything I know, but they are the ones that must do it. No one can do it for them.

And the concept, of course, with the pelvic floor muscle is that if it's not strong, it's not supportive, you leak urine. So let's go a really quick review of voiding. So basically you've got the bladder muscle, which is like the tank. You've got the urethra, short in women, long in men. You have the valve there, the external sphincter, that's the important one, that's the voluntary one. The pelvic floor muscle hugs it. This sphincter has static tone, which means at rest it's contracted because that pelvic floor muscle keeps it tight. If you have weakness in the pelvic floor muscle, if it's been traumatized, it's not as tight. And when you go and cough, laugh, and sneeze, you may leak a little or a lot depending on the severity of the trauma or the damage to it or the weakness of the pelvic floor muscle.

Or if you have a bladder, contractive, overactive bladder that's pushing the urine out and it's not tight, you will have an overactive bladder or urgency incontinence. So the pelvic floor plays really a role in all this. Or you can have a too tight pelvic floor, so that whenever ... Because whenever the bladder's contracting it doesn't relax and then you can have urinary retention. So basically it's really important to understand what strong pelvic floor muscles do.

I explain to patients that the pelvic floor muscle is a voluntary muscle. It's a skeletal muscle like your thigh. And what's important to tell them is that it has two types of fibers, short and long, fast twitch muscle fibers and slow. So we teach them quick pelvic flow muscle contractions, two second holds, quick ones, or a slow, long five or 10 seconds. So that's important that they understand. So really the fast twitch muscle fibers build strength. I tell them that's what a basketball player uses, his fast twitch muscle fibers, when he goes to hit the basket. The slow fibers build bulk when you're going to bulk up a muscle. So it's important that you review that for them prior to beginning the training.

Now, what is the assessment that you can do? And with a digital exam and then with my biofeedback, which is another presentation in this series, is that it can be a normal pelvic floor muscle. What that means is that it can voluntarily, it contracts and relaxes, that's normal. You can have an underactive where the pelvic floor muscle does not contract at all. It's extremely weak for whatever reason and it does not contract. So it's really weak and hypotonic. You can also have overactivity, where the muscle just spasms, it doesn't relax well enough. And then that can occur as a non-relaxing, so it doesn't relax with voiding or defecation. Or you can have a mix, underactive and overactive qualities of the pelvic floor muscle.

Now, these exercises used to be called Kegel exercises, but I want to stress to you that that was after Dr. Arnold Kegel, who in the 1940s was an obstetrician/gynecologist in southern California. He did some really wonderful research, randomized controlled trials that were published in major journals. He talked about the relaxed vagina of women, and he said that if they did an isometric contraction of the pelvic floor muscle he noticed that their incontinence went away and they developed improved strength of the muscle, and that became a Kegel. He then went on to in the '50s describe the fact that if you strengthen your pelvic floor, your orgasms improved, women's orgasms improved, or they had better sex, that type of thing. And a lot of his research then I think was taboo then because of the sexual connotation with the exercise.

He mostly mentions the isometric long holds contraction, ten second holds. Mostly every patient who comes to me says they do Kegels and they don't work. And when I put them on the biofeedback, which is another presentation, I find out that they don't really isolate that muscle. So I tell them that we've really, and we have, we've expanded Kegels to super Kegels or muscle physiology. We've added a lot of the physical therapy information to how you rehab weak muscles to pelvic floor muscle exercises. So they are different, I tell patients that. The other really important thing about the Kegel is that most patients are not tightening the correct muscle, like I said. And what happened with Dr. Kegel is he really had a structured service, as far as with a nurse who really did intensive therapy, like I say, what I do in my practice.

And what happened is now in practice for the last 30 years is, patients are given a handout, "Oh, just tighten down there." They're given instructions. And again, most patients can't isolate. They need to be shown what the muscle is. So most people think what they're doing is a Kegel, but a Kegel is not a butt squeeze. It's not a thigh squeeze. So it's not a thigh master. It's not an exercise that tones the abs, stomach, thighs, or your butt. You should not hold your breath because the muscle's not in your chest. I remember one patient who I was working with and I told them to contract, they had no idea where the muscle was. You don't only perform it lying down, you should perform it in any position. It should not be painful. If it causes pain, there's something else going on. In practice, really simple handout is not adequate and the research shows that really 30% perform a pelvic floor muscle contraction incorrectly.

So really the most important is that before you teach these, that you want to have a pelvic or rectal exam to assess the muscle before you give any instructions, especially if the muscle's hypertonic. Because if you don't find that out, doing these may cause more pain and you don't want that to happen. And the other thing that I stress to my patients, I tell them I do not want them to do these exercises during urination, while they pee. The stopping and starting the streaming urine, I know that's in a lot of the literature, especially in books that professionals have written to teach patients how to do pelvic floor muscle exercises. I don't teach that. It sounds intuitive that if you're contracting the muscle when you urinate, it should stop the stream of urine. But I don't want anybody doing this while voiding. There's a small study where actually women who stopped and started the stream of urine while urinating reflux back up into the kidney. So I don't want that. I want this to be a planned exercise that you do, as you do any type of exercise program.

So what do I tell them? In my examination I say, "Contract your muscles around my finger. Try to pull in. Without tensing the muscles of your legs or buttocks or stomach, try to think you're preventing passing gas." That's always, I have them do more of the posterior muscle. Remember, the pelvic floor muscle goes from the front to the back, it's muscle so there's many layers. There's more layers posteriorly in the back part around the rectal sphincter because stool is heavier than urine. So that sphincter support has to be tighter so that we don't lose stool or have fecal incontinence. So what I do is, they should feel a tightening around the rectum. As patients start to contract more posteriorly, they will start to feel it up front and they'll start to feel, maybe men will feel their scrotum or their penis move or women will start to feel their vagina lifting up.

I do not teach from the front, because I find when patients try to tighten anteriorly the pelvic floor muscle, they actually tighten their stomach. And that I think is counterproductive because it puts pressure on the pelvic floor. For men, again, imagine moving the penis up and down without moving any part of your body. This is some things you could say. For women, you should feel your vagina and rectum pull in and up. Now, this is a really neat presentation of the pelvic floor and I want you to see this. This is an MRI and it shows, I did this in one of my research studies, and it shows the uterus, the bladder. So let's listen.

See, pulling in as she contracts her pelvic floor. Now it's compressing up against the pubic bone. So that's really a visual that shows you exactly what's going on. That's a female, of course. And this is what you see as far as this, I have surface electrodes, and this is externally after my exam. And then I put the external surface electrodes around the introitus at 9:00 and 3:00, and I'm going to be doing biofeedback on her. And that's another presentation that you can view. And you can see, when she contracts her pelvic floor, the pulling upward and in the vaginal introitus.

So how to do the exercises, here are the steps. Step one, I tell them to go to the bathroom and urinate, then find a quiet room, sit and relax, wear loose pants or skirt so they're not tight around the stomach, so they're comfortable, is what that's about. To find the right muscle, imagine being in an elevator and feeling the need to pass gas. What most people do is squeeze the rectum, this is the pelvic muscle. And then I tell them what they should feel, the man, the penis will move up and down. Women, tighten the pelvic muscle, they'll feel a lifting sensation they feel around the opening of the vagina. Pulling in of the rectum will be felt.

Step four is that one exercise is tightening and relaxing. So there's two types of exercises. The fast twitch, which is two-second quick contraction, and then the longer holds. And depending on what type of strength they have, I may start with three-second long holds, five, to build to 10. Again, especially in my men post prostatectomy, they'll come and say, "Oh Diane, I've been doing these, I've been holding it for 10." But when I show them on the biofeedback, it falls away after three or four seconds. I may want them to start with just five-second long holds. And then how do I have them do it? I have them do it as far as three times a day in three positions, sitting, standing, and lying down. And again, they put their hand on their stomach. If their stomach's moving as they contract the pelvic floor, they're actually using several muscles. If they're lifting, they're using their butts. So I give them key areas to try to trigger, what are they doing correctly? Again, they should feel internally, nothing else should move.

And then I give them a home program. And my home program is basically a prescription as far as when to do the exercises and what positions. Now, what should they not do? They should not clench their teeth, hold their breath, clench their fists, tighten facial muscles, lift their butt, bear down, or wiggle their toes. And believe me, I've had people do all of those things. And what I tell them is that an effective program may take eight to 12 weeks to improve, but basically it depends on how often they do it and how often they comply. So if they do it consistently, if they do how I instruct them, then they should improve. But it will take time. So again, certain patients may not want to do this. They want a quick change, the quick fix, I say. That's not the case with these. These do take time. It's like building any weak muscle.

Now, there's something called the stress strategy. So as they improve they'll say to me or even themselves, they'll say, "Well, I'm not doing them as much, Diane, I'm better." Or they'll say, "Do I have to do these the rest of my life?" No. I teach them to incorporate the contraction into their life. And that's called the knack of doing something, or the squeeze trick, or a stress strategy. So the concept of this is that they can track the pelvic floor prior to the event that triggers the incontinence. So if they cough and they leak, tighten the pelvic floor before they cough. If they go from sitting to standing, tighten the pelvic floor as they go to stand up and throughout the standing, bending over. If they keep forcing themselves to do that, it becomes a reflex.

The pelvic floor muscle knows when it feels pressure from above. And that's what happens when we do those types of movements or activities or events. The pelvic floor muscle will contract, it puts pressure so the pelvic floor muscle knows that it's to contract. This works. And patients will sometimes start doing this before you even tell them that. So that's a stress strategy. So you want it to become automatic like a reflex. And then this is my prescription. So I give them actually a paper that is called the exercise prescription. Patients are used to getting prescriptions, and I tell them exactly what they want to do. And you can see this is pretty aggressive. Exercises lying, sitting, and standing twice a day, both short and quick exercises. And again, it's about 120 exercises for every day.

I get asked a lot, "How many should they do a day, Diane, how many exercises per day?" There's not a lot of good data on that. Some of my men want to do double this, and I tell them you don't want to fatigue the muscle, so this is enough. This is very aggressive. You don't want to do too much. So you need to really work with them as far as what they should do. Here's the evidence. So these are effective. This is from the International Consultation on Incontinence. They grade the evidence, the research showing the effectiveness. A is your top, and as you can see, pelvic floor muscle training, A rating, should be first line conservative therapy for women. Supervised, and I think the second one here is very important, that a clinician who knows what they're doing. So hopefully if you're a clinician watching this, you're going to know what you're doing. These series of presentations will help you learn behavioral conservative treatment, how to teach pelvic floor muscle exercises.

The most intensive program that has a trained professional does the best. And in older women, there's some initial data that it can prevent incontinence. In post prostatectomy, you have a lot more research showing that it's effective in men. Actually in men it's been shown that if they start an aggressive program taught by a person who's knowledgeable, they become continent quicker after the surgery. And also, we have quite a bit of evidence in childbearing women showing that it is effective, that they should be offered supervised training in the antipartum, and then again afterwards. So it should be first line treatment.

So you have the evidence there. So don't let anybody tell you what you're doing doesn't work. It works. We have research on this. The problem is there's not a lot of clinicians that know exactly how to train patients on this and there's not a lot of women that come forward and really do this. And that's really a real problem, I think, in this field. But really these do work. So thank you very much for listening. That's the end of my presentation on pelvic floor muscle training with the stress strategy. Hopefully you're going to be able to go back to your practice and teach this. And if you're someone who has urinary symptoms, you're going to be able to do these. So good luck.