Pelvic floor exercises were first described by an American gynecologist, Arnold Kegel, in 1948. This form of therapy appears to be the most cost-effective form of conservative treatment, in part because patients can do them themselves at home. However, for the exercises to be effective, patients must learn to properly tense and relax the pelvic floor muscles. In the initial phase of learning, contraction of the pelvic floor muscles should be performed in what is called isolation, i.e., the muscles of the adductors of the thighs, abdominals, gluteals, or back extensors should remain relaxed. Bø (1) points out that the lack of ability to perform the so-called isolated contraction, i.e. without the participation of its synergists, can obscure the awareness of this muscle group and its strength, which in turn translates into a lower effectiveness of the proposed exercises. According to other authors, the order in which the different muscle groups are activated during contraction of the pelvic floor muscles correlates with the symptoms of urinary incontinence. The results of studies on the effectiveness of pelvic floor exercises vary depending on whether patients exercise their pelvic floor muscles, after identifying them, how they exercise, and even how involved they are in their performance. Several studies show that about 30% of women surveyed are unable to perform an isolated contraction of the pelvic floor muscles without prior written or verbal instruction. In women with pelvic floor dysfunction, this figure even increases to about 70%. Other conclusions can be drawn from studies (2) that healthy women and women with mild pelvic floor dysfunction correctly contract the pelvic floor muscles after verbal instruction, suggesting that prophylactic exercises can be performed without contact, e.g., with a physical therapist. Thus, it appears that verbal and/or nonverbal instructions are important for some women, especially when respiratory arrest or abdominal muscle contraction occurs while attempting to contract the pelvic floor muscles. Both of these activities increase intra-abdominal pressure, which lowers the pelvic floor without improving its strength and coordination. In addition, it may be important to use supportive techniques when learning to voluntarily contract the pelvic floor muscles, as exercises alone may not produce the expected results.

The therapeutic program for pelvic floor exercises is based on the concepts of motor learning and can be divided into different phases:

1. Phase 1: Understanding: Patients need to understand where the pelvic floor muscles are located and what their functions are (3).
2. Phase 2: Search “Where is my pelvic floor?”. Patients need time to apply this understanding to their bodies and often need feedback and improvement in depth perception. Considering the balance and postural problems and the insufficient activation time of the pelvic floor muscles in women with stress urinary incontinence, improving proprioception seems to play an essential role in motor control. However, further research is needed in this area (4).
3. Phase 3: Learning (automation). Patients must learn to properly tense and relax the pelvic floor muscles. At this point, feedback from the physical therapist is advisable (5).
4. Phase 4: Control. Most patients still need to work on performing controlled and coordinated contractions and recruiting as many motor units as possible during each contraction (6).

Learn to contract and relax the pelvic floor muscles:

Starting position of the patient: lying on the back, lower limbs flexed at the hip and knee joints.

Therapist: give the verbal instruction “contract the muscles around the therapist’s electrode/finger that are inside your body as hard as you can (as if to stop the urine stream), and then relax completely” (7). When it is not possible to use a vaginal electrode or palpation, according to Ami and Dar (8), verbal instruction in the form of “tighten the sphincter muscles around the anus” activates the pelvic floor muscles the most. These activities should be an isolated contraction: Keep the hamstrings, abdominals, gluteal adductors, or dorsiflexors relaxed.

HOW TO LONG SHOULD THE EXERCISE PROGRAM LAST?

According to a systematic review (9), the shortest duration of an exercise program proposed by some researchers is 6 weeks, and the greatest changes are observed with short exercise sessions (10-45 minutes) and a frequency of 3/7 days per week (10).

Martyna Kasper-Jędrzejewska

References:

1. Bø K. Physiotherapy management of urinary incontinence in females. J Physiother. 2020;66(3):147–54.
2. Henderson JW, Wang S, Egger MJ, Masters M, Nygaard I. Can women correctly contract their pelvic floor muscles without formal instruction? Female Pelvic Med Reconstr Surg. 2013;19(1):8–12.
3. Yoshida M, Murayama R, Hotta K, Higuchi Y, Sanada H. Differences in motor learning of pelvic floor muscle contraction between women with and without stress urinary incontinence: Evaluation by transabdominal ultrasonography. Neurourol Urodyn. 2017;36(1):98–103.
4. Kharaji G, Nikjooy A, Amiri A, Sanjari MA. Proprioception in stress urinary incontinence: A narrative review. Med J Islam Repub Iran. 25 czerwiec 2019;33:60.
5. de Azevedo Ferreira L, Fitz FF, Gimenez MM, Matias MMP, Bortolini MAT, Castro RA. The role of vaginal palpation in motor learning of the pelvic floor muscles for women with stress urinary incontinence: study protocol for a randomized controlled trial. Trials. 31 lipiec 2020;21(1):693.
6. de Azevedo Ferreira L, Fitz FF, Gimenez MM, Matias MMP, Bortolini MAT, Castro RA. The role of vaginal palpation in motor learning of the pelvic floor muscles for women with stress urinary incontinence: study protocol for a randomized controlled trial. Trials. 31 lipiec 2020;21(1):693.
7. Mateus-Vasconcelos ECL, Brito LGO, Driusso P, Silva TD, Antônio FI, Ferreira CHJ. Effects of three interventions in facilitating voluntary pelvic floor muscle contraction in women: a randomized controlled trial. Braz J Phys Ther. 2018;22(5):391–9.
8. Ami NB, Dar G. What is the most effective verbal instruction for correctly contracting the pelvic floor muscles? Neurourol Urodyn. 2018;37(8):2904–10.
9. Dumoulin C, Cacciari LP, Hay‐Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev [Internet]. 4 październik 2018 [cytowane 6 kwiecień 2020];2018(10). Dostępne na: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516955/
10. Bo K, Fernandes ACNL, Duarte TB, Brito LGO, Ferreira CHJ. Is pelvic floor muscle training effective for symptoms of overactive bladder in women? A systematic review. Physiotherapy. 2020;106:65–76.