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
Every physician as had occasion
to observe that six months after a well performed vaginal repair with
construction of a tight, long vaginal canal, the tissues, especially the
perineum, will again become thin and weak. It was this repeated observation
which first aroused the author's interest in the physiology of the pelvic
musculature.
Everyone agrees that suitable
exercises will improve the function and tone of weak stretched, atrophic
muscles. A point in fact is the correction of faulty posture. Why then would it
not be possible to restore through active exercise the normal anatomic
relationships of pelvic structures, since they depend so largely for their
support on various muscle groups?
In the study of this problem,
which we have carried out over a period of 18 years, we have become greatly
interested in one muscle, the functional importance of which has been largely
overlooked by anatomists, obstetricians, and gynecologists alike - the
pubococcygeus.
This muscle, when observed in
emaciated cadavers, is in such a state atrophy that it would seem to be capable
of little function. As in Figure I, the surgeon who operates from below
encounters only the more superficial muscles of the vulvar outlet and argental
diaphragm. This is true also of prophylactic episiotomy. Similarly, operations
from above rarely include the pubococcygeus. It is for these reasons that the
importance of this muscle has not been fully recognized.
Attention has been focused on the
pubococcygeus by the studies of Barry J. Anson with Curtis and McVay who, in
dissections of young female cadavers, demonstrated for the first time that the
pubococcygeus gives off innumerable fibers which interdigitate and insert
themselves into the intrinsic musculature of the proximal urethra, middle third
of the vagina and rectum.
Our own study in the dissecting
room, in surgery, and in animal experiments, as well as observations of the
effect of exercise in several thousand patients, has led us to conclude that
the pubococcygeus is the most versatile muscle in the entire human body. It
contributes to the support and sphincteric control of all pelvic viscera and is
essential for maintaining the tone of other pelvic muscles, both smooth and
striated.
After having been stretched over
a wider range than any other skeletal muscle, the pubococcygeus can regain
physiologic tension and, as we have demonstrated, it is able to recover its
function after many years of disuse and partial atrophy.
Palpation demonstrates that in a
normal pelvis with the viscera in their normal position, the pubococcygeus and
all of its components are well developed. However, when genital relaxation has
occurred, this muscle is found to be weak and atrophied.
Genital muscle relaxation, as
manifested by urinary stress incontinence, cystocele, or prolapse of the uterus
as well as certain types of lack of sexual appreciation, is always associated
with - even if not directly due to-dysfunction of the pubococcygeus. This fact
has been borne out by the success of non-surgical treatment of these
conditions, applying the general principles of muscle education and resistive
exercise to the pubococcygeus as the pivotal structure of the pelvic
musculature.
The fasciae are not discussed
here for the reason that, whether injured or intact, they depend upon their
muscular attachments for nourishment, viability, tone and tensile strength.
When grossly disrupted they remain a surgical problem.
Diagnosis
A firm vaginal canal, well closed
to a high level, indicates normal development of the interdigitating fibers of
the pubococcygeus. Loss of tone and prolapse of the vaginal walls, as is found
in genital relaxation, signify weakening and thinning of these minute
branchings.
The musculature of the middle
third of the vagina is readily palpated by means of the index finger introduced
up to about the second joint, or 3 to 5 cm beyond the introits.
In the normal vagina, the canal
is tight and the tissues offer a degree of resistance from all directions. The
walls close in around the finger as it is inserted, moved about, or withdrawn.
Upon palpation, the walls of the middle third of the normal vagina feel firm
throughout, and adjacent tissues give the impression of depth and good tone
because the terminal fibers of the pubococcygeus are well developed and are
attached to the intrinsic tissues of the vagina over a wide area.
In genital muscle relaxation on
the other hand, the findings are decidedly different. Whether the introitus is
gaping or tight, the vaginal canal in its middle third is short and roomy in
all directions. The walls offer little resistance to the palpating finger and
feel thin and loose, as if detached from the surrounding structures. The
tissues between the palpating finger and the symphysis or rami of the ospubis
are thin, tender, and of poor quality. From this it can be concluded that the
muscular structures in the perivaginal regions are atrophied, particularly the
terminal fibers of the pubococcygeus.
Vaginal examination as described
up to this point differs little from the usual technique practiced for the past
hundred years. The physical status of the perivaginal tissues has thus been
ascertained, but the cause of weakness and atrophy has not been determined. To
this end it is necessary to investigate the functional status of the supportive
and sphincteric muscles of the pelvic outlet, especially of the pubococcygeus.
The first step in the examination
for function is to observe whether by voluntary effort the patient is able to
retract, draw up, or draw in the perineum. Next, the index finger is introduced
into the middle third of the vagina, and the patient requested to contract upon
it. Normal patients will respond immediately, and a firm grip upon the finger
is felt over a wide area. Others, lacking awareness of function of the
pubococcygeus, will not respond to the instruction and will often state that
they did not know that it was possible to contract vaginal muscles. It is in
this group of patients that palpation demonstrates the atrophy of disuse.
The digital method of
ascertaining the presence of contractions of the perivaginal muscles should be
supplemented by the diagnostic use of the Perineometer. With this instrument,
strength of contractions in the middle third of the vagina as well as the width
of the contracting area can be measured and a progress chart of record kept to
follow the results of therapy.
The Perineometer is a simple,
pneumatic apparatus consisting of a vaginal resistance chamber connected with a
manometer calibrated from zero to 100 mm. Hg. The resistance chamber measures 2
cm. in diameter and 8 cm. in length and is formed by a cylindrical rubber
diaphragm stretched to a specific tension between two flanges on a metal stem.
The vaginal parts of the Perineometer conforms to the approximate dimensions of
the normal vagina and is so designed that pressure over a wide area will result
in higher readings than pressure of identical strength applied to a narrow
area. The vaginal chamber is compressible, without significant compensatory
expansion.
The specifications of this simple
apparatus were established after 18 years of experimentation with more than 30
different types of instruments. Only in rare cases, when the vagina has been
greatly shortened through surgical intervention or radium therapy, will it be
found necessary to reduce the size of the vaginal chamber of the instrument.
When the resistance chamber is
introduced, a slight rise on the scale of the manometer will be noted even
before the patient exerts any effort. This represents the static pressure which
in a normal vagina amounts to 15 to 20 mm. Hg. and indicates good muscle tone
and tissue resistance over a wide area.
In genital relaxation, muscle
tone is poor and tissue resistance is limited to a narrow area. Consequently,
in such cases the initial pressure is low, about 10 mm. Hg.
Contractions of a normally
developed pubococcygeus are registered by a prompt increase in manometric
reading to 20 mm. Hg. or more above the initial static pressure. Lack of
awareness of function and degrees of atrophy of the pubococcygeus are reflected
by a small or almost imperceptible increase in pressure, usually less than 5
mm. Hg. Intermediate readings may be obtained in patients having awareness of
function but only a narrow, poorly developed or partially atrophied
pubococcygeus muscle. In measuring function of the pubococcygeus, it must be
made certain that the patient is not using extraneous muscles, such as those of
the abdominal, gluteal, orintroital regions.
Therapy
Physiologic therapy of genital
muscle relaxation is divided into two phases or steps: (1) specific muscle
education and (2) resistive exercises of the pubococcygeus and its visceral
extensions.
Specific Muscle Education
The first and most important step
in therapy is muscle education. This is directed toward establishing adequate
awareness of function of the pubococcygeus, which is the pivot of all
supportive and sphincteric structures of the pelvis.
At the first office visit,
approximately one third of all patients will be unable to contract the
pubococcygeus voluntarily, or to only a questionable degree. When such is the
case, palpation is continued until the examiner finds among the contiguous
muscles, one which is under the patient's control. With this as a starting
point, contractions of the contiguous muscle are continued and varied until the
pubococcygeus itself is affected by such muscular movements.
The contractility of the
pubococcygeus can be determined most readily in its anterior portion, where the
fibers converge toward attachment to the os pubis, and posteriorly near the coccyx.
In order to demonstrate contractions near the pubis, the postero-inferior
margin of the symphysis is identified with the index finger, which is inserted
only to the second joint.
The tip of the finger is passed
laterally from the midline for about 0.5 to 1.0 cm. until the tendinous medial
margin of the pubococcygeus is encountered; the margin is then followed
downward for a short distance, approximately to the level of the urethra. At
this point, contractions of the pubococcygeus, if present, are felt as a
tensing of its medial margin, which may feel like a thin sheath, or it may be
as broad as thick as a finger.
The pubococcygeus is palpated for
function on both sides. Occasionally, unilateral impairment due to injury is
revealed. In identifying the pubococcygeus, it should be remembered that
congenital variations occur in its aponeurotic attachments.
Posterior contractions of the
pubococcygeus are identified by inserting the finger deeply into the vagina or
rectum. When palpating in the midline, the pubococcygeus can be felt near its
attachment to the coccyx. With the finger in contact with the muscle, the
patient is requested to contract it. Normally it will be noted that the
posterior portion of the muscle has the ability to rise upward for a distance
of 2 to 4 cm.
If there is lack of awareness of
function of the pubococcygeus, no such voluntary action can be elicited. The
patient is then requested to draw up or draw in the anus as though checking a
bowel movement. Pressure may also be applied with the tip of the finger to aid
the patient in identifying and contracting the pubococcygeus. If no response is
forthcoming, pressure is increased to the point of discomfort, and the patient
instructed to pull the muscle against the finger. In obstinate cases, reflex
contractions may be produced by pricking the skin lateral to the anus.
Repetition of any such action of the pubococcygeus for several minutes will
usually enable the patient to continue the same contractions through voluntary
effort. To make certain that the contractions elicited are those of the
pubococcygeus and not of the iliococcygeus, they are followed anteriorly until
they can be felt as tensing of the medial margins of the muscle at the level of
the urethra.
Under the guidance of the physician,
the patient who initially lacked awareness of function of the pubococcygeus has
at this point learned that the muscle can be contracted voluntarily.
Since therapeutic results can be
expected only from frequent repetition of active contractions of the
pubococcygeus, these efforts are now described in terms of muscular functions
of which the patient is cognizant.
With his finger on the medial
margin of the pubococcygeus at the level of the urethra, the physician
instructs the patient to (1) squeeze the vaginal muscles upon the palpating
finger; (2) draw up or draw in the perineum; (3) contract or draw up the rectum
as though checking a bowel movement; (4) contract as though interrupting the
flow of urine while voiding.
The examiner makes sure that while
performing these movements the patient is actually contracting the
pubococcygeus and not merely muscles around the orifices. It must be emphasized
that woman with poor function of the pubococcygeus have all their lives
compensated for this deficiency by depending for support upon the fasciae and
the more superficial muscles.
If the pubococcygeus is not
functioning the following will be observed:
The patient may be permitted to
repeat these superficial contractions temporarily, but she is urged to try to
transfer them to a higher level of the pelvic outlet, until contractions of the
pubococcygeus muscle are felt by the palpating finger.
Approximately 75 percent of
patients will respond after 10 to 20 minutes of instruction. In other
instances, considerable patience is required and the instructions must be
repeated at weekly intervals, occasionally over a period of many months, before
the patient learns to contract the pubococcygeus. In exceptional cases, the
attempt to establish awareness of function fails completely. This is usually
due to concomitant lesions of the central nervous system.
Establishment of awareness of
function of the pubococcygeus is essential. No clinical results from
physiologic therapy can be expected without activation of this muscle.
Resistive Exercises
Very few women who initially lack
awareness of function of the pubococcygeus will be able to continue correct
contractions of this muscle at home after instruction in the office. Since they
are unable to coordinate their muscles through the usual reflexes, it is
necessary to establish a connection between contractions of the pubococcygeus
and the sense of sight. Also, unless given an opportunity to repeat their
efforts under visual control, thereby noting any progress they may make,
patients are apt to become discouraged. A simple, direct, and reliable means to
overcome these difficulties is the Perineometer. The last phase of office
procedure is devoted to instructing the patient in the use of this apparatus.
In addition to visual control,
this instrument provides a means of contracting the perivaginal muscles against
resistance. Resistive exercises of this type have proved most effective in all
branches of muscle therapy for the correction of disuse atrophy and for
restoration of normal function. Resistive exercises are designed to strengthen
the pubococcygeus in all its components, especially the minute end-fibers
which, in genital relaxation, have undergone atrophy. This muscle is not
accessible to any other therapeutic measure, and its function is rarely
improved by surgical procedures.
With the vaginal chamber of the
Perineometer in place, the physician watches the manometer while the patient
repeats for several minutes those efforts of which had been found to result in
contractions of the pubococcygeus muscle. If the patient who had previously
lacked normal awareness of function uses the pubococcygeus, only irregular and
weak contractions can be expected. The indicator will show only a slight rise,
between 1 and 5 mm. Hg.
The patient herself watches the
manometer while continuing the same efforts. If contracting correctly, she is
instructed to continue the same exercises at home for 20 minutes three times
daily.
In addition to these exercises,
the patient is advised to repeat the same contractions without the apparatus
many times a day. The more frequently correct contractions are repeated, the
sooner will the muscular function be established as a reflex that does not
require any further voluntary effort.
About 50 percent of all patients
who start their exercises correctly will, during the first few weeks, lapse
back into the old habit of using extraneous muscles instead of the
pubococcygeus. Therefore, it is necessary to re-examine and re-instruct at
weekly intervals for one month, and thereafter as often as necessary to insure
correct use of the Perineometer. In this respect, a progress chart kept by the
patients is of great value.
Complaints of fatigue, aching
muscles of the back and abdomen, and nervous irritability following exercises
are usually due to unnecessary use of extraneous muscles.
OBJECTIVE EVIDENCE OF IMPROVEMENT
In patients who exercise
correctly and diligently, the following progressive changes will occur:
Therapy
Urinary Stress Incontinence
Muscle education and resistive
exercise with the Perineometer produce dramatic results in the treatment of
true urinary stress incontinence. This type of incontinence must be
distinguished from urge incontinence caused by various pathologic conditions
involving the upper urinary tract, such as infections, strictures of the
ureter, stones, diverticula, developmental anormalies, etc.; incontinence due
to fistulae; and spastic incontinence due to spinal cord changes following
injuries, poliomyelitis, multiple sclerosis, etc.
In simple urinary stress incontinence, control of the urinary outlet is partially lost