Kegel Exercises and Bladder Training

Pelvic floor (Kegel) exercises and bladder training are often recommended as the first-line approach for treating most forms of urinary incontinence. They can help to substantially improve symptoms in many patients, including elderly people who have had the problem for years. Kegel exercises may be especially helpful for women in their 40s and 50s who suffer from stress incontinence.

Kegel exercises are designed to strengthen the muscles of the pelvic floor that support the bladder and close the sphincters.  The figure below shows these pelvic floor muscles wrapping around the urethra.

Dr. Kegel first developed these exercises to assist women before and after childbirth, but they are very useful in helping to improve continence for both men and women.

The general approach for learning and practicing Kegel exercises is as follows:

• Since the muscles are sometimes difficult to isolate, initial visits with a pelvic floor physical therapists may be indicated.  Old methods of isolating these muscles involved contracting the muscles in the pelvic area during urination with intention of slowing or stopping the flow of urine. We do not encourage this however, as it can sometimes lead to voiding dysfunction. Women can detect these muscles by inserting a finger inside the vagina. When the vaginal walls tighten, the pelvic muscles are being correctly contracted. Patients should place their hands on their abdomen, thighs and buttocks to make sure there is no movement in these areas while exercising.
• An alternate approach is to isolate the muscles used in Kegel contractions by sensing then squeezing and lifting the muscles in the rectum that are used in passing gas. (Again, women should contract the vaginal muscles as well.)
• The first method is used for strengthening the pelvic floor muscles. The patient slowly contracts and lifts the muscles and holds for 5 seconds, then releases them. There is a rest of 10 seconds between contractions.
• The second method is simply a quick contraction and release. The object of this exercise is to learn to shut off the urine flow rapidly.
• In general, patients should perform 5-15 contractions, three to five times daily.

Some notes of caution:

• Once learned, Kegel exercises should not be performed while urinating.
• In women, incorrect or overly vigorous exercises may cause vaginal muscles to tighten excessively, resulting in pain during sexual intercourse.
• Overexercise can tire muscles and cause more leakage.
• Incontinence will return to its original severity if these exercises are discontinued.
• It may be several months before the patient sees significant improvement.

Bladder training involves a specific and graduated schedule for increasing the time between urinations:

• Patients start by planning short intervals between urinations, then gradually progressing with a goal of voiding every 3-4 hours.
• If the urge to urinate arises between scheduled voidings, patients should remain in place until the urge subsides. At the time, the patient moves slowly to a bathroom.

 This system uses a set of weights to improve pelvic floor muscle control:

• The typical set includes five cones of graduated weights ranging from 20 grams (less than 1 ounce) to 65 grams (slightly over 2 ounces).
• Starting with the lightest, the woman places the cone in her vagina while standing and attempts to prevent the cone from falling out. The muscles used to hold the cone are the same ones needed to improve continence.

As with standard Kegel exercises, frequent repetition is required, but most women will eventually be able to use the heavier weights and build up the ability to prevent stress and urge incontinence.

Typically used for pelvic organ prolapse, vaginal pessaries are devices inserted into the vagina that support the inside of the vaginal walls, but may also support the urethra, thus providing better continence. Pessaries come in various shapes and sizes and must be fitted by a health professional to be effective.

Women who are unable to learn Kegel muscle contraction and release with verbal instructions may be helped with the use of biofeedback:

• Biofeedback uses a vaginal or rectal probe inserted by the patient that relays information to monitoring equipment so that the patient can actually “see” their contraction.
• The patient isolates the pelvic floor and bladder muscles and performs Kegel exercises.
• The monitor emits auditory or visual signals that indicate how strongly the patient is contracting the proper pelvic floor muscles and how effectively the bladder muscles are being released.
• The apparatus is designed for both in office and home use.

As with any Kegel exercise regimen, biofeedback must be used for several months before it is effective. Biofeedback that teaches control of pelvic muscles may also be helpful for children who have daytime wetting, frequent urinary tract infections, or both.