Currently, there is a lot of information about pelvic floor muscle exercises commonly known as Kegel exercises. They are often recommended to all people who are struggling with stress urinary incontinence and lowering of the pelvic organs. And all would be well if each of us did not have a different tension/tone of the pelvic floor muscles resulting from different reasons. But let us start from the beginning. The pelvis is the base of our body, and within it, like a hammock, are muscles that, along with fascia, ligaments, nerves, blood and lymph vessels, and organs, make up the “pelvic floor” mentioned above (1).

The pelvic floor has several important functions in women (2):

• It holds the abdominal and pelvic organs in the correct position and supports their functions by contracting and relaxing the muscles.
• It generates pressure in the abdomen in cooperation with the respiratory diaphragm, which means, among other things, that it counteracts the forces generated, for example, when lifting objects, laughing, sneezing or coughing.
• Closes and opens the lumen of the urethra and anus for proper urinary and bowel continence or defecation.
• Is involved in sexual function and activity.
• Along with the respiratory diaphragm and abdominal muscles, it is involved in maintaining posture in various movement situations.
• It is active during pregnancy and childbirth.

Three theoretical mechanisms underlie the effectiveness of individual pelvic floor training:

1. The first and most important mechanism is “pelvic floor strengthening,” which refers to increasing the cross-sectional area of the levator ani muscle that supports the overlying urethra. The mechanism of action consists of repeated contractions to increase the strength of the levator ani. The names of programs that use this theoretical mechanism are (usually) “Kegel exercises” or pelvic floor muscle training (PFMT).
2. The second mechanism is “maximum timing awareness” and refers to increased conscious control of the pressure that closes the urethra when you sneeze, laugh or cough. This mechanism targets the striated muscles of the urethra, is used as the initial identification of the muscles that facilitate urine leakage so that the predicted timing of pelvic floor muscle contraction can occur at that particular time, and has been called the PFMT program “cracking maneuver,” “stress strategy,” and “crotch closure” muscle contraction in response to an impending stressful situation (laughing, coughing, sneezing) Timely emphasizes the ability to recognize when the pelvic floor muscles should contract in everyday situations.
3. The third mechanism is “core muscle strengthening.” This mechanism assumes that contraction of the deep abdominal muscles causes reflex contraction of the pelvic floor muscles. The “strengthening of the core muscles” targets the transverse abdominal (TrA) muscles. PFMT programs based on this theoretical mechanism are commonly referred to as trunk muscle training, which includes the pelvic floor muscles (3).

The gold standard for the conservative treatment of urinary incontinence and genital prolapse, the effectiveness of which has been sufficiently scientifically proven, is guided pelvic floor training. This is a comprehensive physical therapy intervention that includes patient education, specific pelvic floor muscle exercises to increase reactivity, strength, endurance, efficiency, and relaxation, and breathing, movement, and postural training. The exercises are essentially aimed at improving pelvic floor function in response to, for example, rapidly increasing intra-abdominal pressure, lowering of the reproductive organs, or sphincter dysfunction. The conclusions of a recent review of the literature are as follows: PFMT resulted in a reduction in urine loss in women with stress urinary incontinence regardless of the protocol used in the study. However, an exercise program should last 6-12 weeks, with >3 sessions per week and session duration of <45 minutes to see results. It should be remembered that the purpose of urogynecological physiotherapy varies according to the clinical condition of the patient and the stage of the disease (4).

Authors of various publications agree that for exercises to be effective, patients must be trained in proper contraction and relaxation of the pelvic floor muscles before beginning specific, individualized pelvic floor training (see the article “How to properly recognize and perform pelvic floor contraction”). In addition, supplementing individual home training with group training is more effective than home training alone, and group training is not inferior to individual training if patients receive thorough instruction and appropriate assessment and feedback on their ability to perform PFM contractions correctly. The PFMT group is cost-effective and can include information about health (physioprophylaxis), physical fitness, and general fitness and breathing exercises. It can also be a powerful motivator for women to increase their level of physical activity, making it easier to begin and continue more advanced exercise programs (5).

Martyna Kasper-Jędrzejewska

References:

1. DeLancey JOL. The anatomy of the pelvic floor. Curr Opin Obstet Gynecol. sierpień 1994;6(4):313–6.
2. Vieira GF, Saltiel F, Miranda-Gazzola APG, Kirkwood RN, Figueiredo EM. Pelvic floor muscle function in women with and without urinary incontinence: are strength and endurance the only relevant functions? a cross-sectional study. Physiotherapy [Internet]. 19 grudzień 2019 [cytowane 4 marzec 2020]; Dostępne na: http://www.sciencedirect.com/science/article/pii/S0031940619301300
3. Sheng Y, Carpenter JS, Ashton-Miller JA, Miller JM. Mechanisms of pelvic floor muscle training for managing urinary incontinence in women: a scoping review. BMC Womens Health. 13 maj 2022;22:161.
4. García-Sánchez E, Ávila-Gandía V, López-Román J, Martínez-Rodríguez A, Rubio-Arias JÁ. What Pelvic Floor Muscle Training Load is Optimal in Minimizing Urine Loss in Women with Stress Urinary Incontinence? A Systematic Review and Meta-Analysis. Int J Environ Res Public Health [Internet]. listopad 2019 [cytowane 18 listopad 2020];16(22). Dostępne na: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887794/
5. Paiva LL, Ferla L, Darski C, Catarino BM, Ramos JGL. Pelvic floor muscle training in groups versus individual or home treatment of women with urinary incontinence: systematic review and meta-analysis. Int Urogynecology J. 1 marzec 2017;28(3):351–9.