In the late '40s and early '5Os Arnold Kegel1"4 and EG Jones5 did research on small groups of women with simple urinary stress incontinence; Kegel invented and used a perineometer for measurement of muscle strength and for biofeedback. The published reports of success led to great interest in "Kegel Exercises" for a limited time. The changing healthcare industry and the advent of hospitalization insurance seems to have contributed to a decreasing emphasis on self-care practices. Today, the rising cost of health care is, in turn, promoting a swing back to programs of prevention and self-care. National interest in health prevention and self-maintenance has also increased.
Incontinence is often cited as the major reason for nursing home admissions,6·7 and it is estimated that 20% of women over 55 suffer from simple urinary stress incontinence.7·8 In addition, it is known from client interviews that incontinence leads to social isolation in the attempt to avoid embarrassing incidents.
The report of the incidence of incontinence may be underestimated since many women believe that "losing urine" when intraabdominal pressure is suddenly increased (eg, when sneezing, coughing, laughing, lifting) is the normal result of childbearing or age. Thus, many women resort to wearing perineal pads or diapers and do not seek medical or surgical interventions.
The American College of Obstetrics and Gynecology cite a 50% to 60% cure rate for a period of six months to one year after surgical intervention.9 Kegel4 cites much higher success rates (86%) in very small samples. Jones's5 studies corroborate Kegel's findings.
The pubococcygeal muscle, which forms the main support of the pelvic floor, surrounds all the outlets of the pelvis: the urethra, vagina, and rectum. The pubococcygeus is stretched during childbirth, sometimes damaged, and is known to weaken, along with other muscles in postmenopausal women.
It has been assumed, in all studies related to pubococcygeal muscle strength and incontinence, that the contractile ability of the muscle high in the vagina is an accurate guide to its overall strength. This study also makes this assumption.
Purpose and Design
A pilot study, preliminary to a much larger study, was constructed to examine the effects of biofeedback on pubococcygeal muscle strength and simple urinary stress incontinence in postmenopausal women. The major function of this study was to obtain information that would improve the major study.
The pilot study was conducted using a pretest-posttest control group design with a randomly assigned, self-selected sample of twelve females. All subjects were 55 or older (actual age range, 55-79) and were currently experiencing simple urinary stress incontinence. For the purposes of this study, simple urinary stress incontinence was defined as the unintentional loss of urine during activities that involve sudden increase of intraabdominal pressure. One study criterion was met if the subject affirmed urine loss in one or more listed activities, such as sneezing, coughing, laughing, lifting, and participating in exercise programs.
Other study criteria that the participants were required to meet were that they be noninsitutionalized, capable of self-care, able to speak English, and capable of transporting themselves to the clinic on the university campus. Participants also had to have no known neurogenic or neuromuscular disorders, including such diseases as diabetes, multiple sclerosis, Parkinson's, and stroke, and no symptoms indicating urinary tract infection. Subjects had to make all nine, weekly visits to be included in the study data. No medications were given as a part of the study. Clients' health histories indicated that they were not taking any medication for urological disorders.
Each client was seen by researchers individually. The initial visit lasted about l'/2 hours and involved an extensive health history, instructions in the correct method of doing Kegel exercises, measurement of pubococcygeal strength using an electromyographic (EMG) device called the Personal Perineometer™ , and a Self- Assessment of Continence (SAC) developed specifically for this study. After the initial intake, subjects returned for 30-minute individual appointments with a researcher for eight, weekly visits. All subjects completed a SAC at each visit, and all but the control group were measured weekly for pubococcygeal muscle strength and allotted ten minutes of private use of the perineometer as a biofeedback device.
Instruments - Researchers provided each subject with a take-home teaching guide that featured a cross section of the female pelvis with a Personal Perineometer™ sensor in place in the vagina (see Figure 1). The teaching plan also contained an outline of the material discussed with each subject (ie, what the Kegel muscle is; the importance of the muscle; and how to do Kegel exercises).
In addition, researchers discussed and discouraged some common practices of incontinent women including:
1 . Restricting fluids. Not only is this a poor health practice, but it results in the concentration of urine. This assures that when urine is lost it will have a stronger odor.
2. Going to the bathroom frequently to keep the bladder empty. The bladder, like the stomach, is a hollow organ and thus somewhat dependent on internal stress to maintain the size. Frequent emptying does nothing to increase pubococcygeal muscle strength and causes the bladder to shrink in size just as the stomach does during periods of fasting. The end result is a small bladder that still leaks urine. Under normal circumstances a person should be able to go two hours between voidings.
Kegel's perineometer is no longer available. It was a simple pneumatic device that used a cone-shaped diaphragm for vaginal placement, and pubococcygeal muscle contractions were registered on an aneroid gauge similar to those used on a sphygmomanometer. The Personal Perineometer™ is an electronic instrument that registers the strength of contractions on a series of lights arranged in a circle and numbered from 1 to 20 microvolts. As the muscle tightens around the sensor, the microvolt readings on the circular, lighted gauge rises. Mechanical reliability of the instrument is established by the manufacturer. When a known amount of pressure is applied to the sensor, a reliable reading in microvolts is registered on the face of the Personal Perineometer™. The vaginal insert is made of denture material and contains three silver sensors. It is easily sterilized in Cydex-7™. The vaginal sensor is self-inserted and can be used without disrobing or exposure. The Personal Perineometer™ was used in this study as a simple biofeedback mechanism.
The Self-Assessment of Continence was a paper-and-pencil instrument developed by the researchers, designed to arrive at a quantitative assessment of the client's perception of the severity of her incontinence. Scoring was weighted to give increasingly higher scores to coping behaviors cited in the literature as socially isolating. The reliability was established on a test-retest of 51 women. Content validity was established by submitting the items to three judges with research expertise. The format was changed and items were clarified for the final structure (see Figure 2).
The literature is rife with various instructions on how to do Kegel exercises. Even Kegel did not use the same protocol twice in his reports of studies. This study utilized information from other programs that concentrate on building muscle strength and endurance. In other words, the exercises were to be done 100 times, once a day rather than a fewer number of repetitions, several times a day.
Subjects were assisted in identifying the correct muscle to contract by the following instructions:
The muscle can be felt with your finger about 3A of the way up in the vagina. When contracted you can feel it best along the side of the vaginal wall and it will feel about the size of a pencil. It is the same muscle that you use when you need to urinate and there is no opportunity. The muscle strength can be checked by spreading the knees apart while voiding and stopping the stream of urine. A muscle with good strength should be able to do this readily in the female.
Subjects were then instructed to contract this muscle, hold it to a count of ten and relax. They were instructed to repeat this exercise 100 times a day for the rest of their lives. Subjects received weekly diary sheets on which to record the number of exercises daily, the incidents of wetting, and the circumstances. Subjects also received nonelectronic hand calculators to enable them to count 100 exercises while repeatedly counting to 10.
Demographic data concerning age, weight, parity, previous pelvic repair surgery, multiple or difficult births were collected in the health history for later analysis.
Study Groups - One control group and three experimental groups were used. AU groups were taught Kegel exercises. The control group was measured for muscle strength at entry and exit only. At weekly appointments, they completed the SAC and discussed any problems they were having with researchers. They turned in their diary sheets and received new ones. No biofeedback was administered to this group.
Experimental Group 1 was provided wim Personal Perineometers ™ for biofeedback use at home during their daily exercise sessions. They, and all experimental groups, engaged in all the control group activities and were measured weekly.
SELF-ASSESSMENT OF CONTINENCE SAMPLE QUESTIONS
One of the criticisms of Kegel's work and subsequent studies is the question of the value of the sensor in the vagina as a muscle resistive device. In response to this criticism, Experimental Group 2 was given vaginal sensors detached from the machine to be used as a resistive device during daily practice sessions.
Experimental Group 3 was not provided with home devices for daily practice. They received weekly biofeedback in the clinic setting, as did all of the experimental groups.
Attrition - The total number of subjects admitted to the study was 13. One person continued in the program, but her data was excluded from the study because a heart attack necessitated that she miss a weekly clinic visit. The study was conducted during the winter in Kansas, and most clients lived at least 15 miles from the clinic. Since this study population often lives on fixed income, the Easter Seals Society provided travel reimbursement for subjects at 20 cents per mile up to 20 miles per visit. Subjects' opinions regarding acceptance of this reimbursement varied, and those who objected were encouraged to return it to the society as a donation. Special parking was arranged through the university.
Results and Discussion
Graphically, as perineometer scores increased, SAC scores decreased. This indicates that as pubococcygeal strength increased, the incidences of, and concerns regarding, urine loss decreased (see Figure 3).
There was a 100% continence rate in Experimental Group 1 using daily biofeedback at home during Kegel exercises. Overall, the continence level achieved by the control group was 67%, as was the rate obtained by the experimental groups as a whole. All subjects improved in muscle strength. All SAC scores showed improvement, but sometimes a small decline due to heavy weighting in the area of concern about incidents was seen. This result suggests that, although subjects were wetting themselves less often, their concerns remained high. Due to the small number in the study, any inferences to the general population would be misleading.
As indicated at the outset, the purpose of the study was not to draw any conclusions about incontinence, pelvic floor exercise, or biofeedback but to improve a larger study. The following outcomes of that inquiry were identified:
1. Subjects were easy to recruit, and interest in the study was expressed by young and old alike. Many subjects had to be told they were "too young" and were later recruited into a separate comparison group under other funding.
2. Kegel exercises increased pubococcygeal strength in older women which, in turn, seemed to decrease incidents of urine loss.
3. The SAC needed to be reorganized and the scoring system simplified. Older subjects found it difficult to use computer scoring sheets and researchers found scoring time consuming.
4. There was a need for written instructions regarding recharging of home-use instruments.
5. A new data collection sheet was developed early in the study. What appeared useful prior to seeing clients was not always useful in practice.
6. The length of the study needed to be extended. Some clients were dry for a week or two, then had incidents, and finally reported dry in the eighth week. A more accurate evaluation could be achieved in three months. Useful information could be gained by bringing subjects back at six months and one year.
7. Practice before coming to clinic seemed to lower perineometer scores. Subjects were advised to practice on clinic day, in the clinic only.
8. K-Y Jelly®, although recommended by the manufacturer, seemed to interfere with EMG impulse conduction. Those women who needed a lubricant to insert the sensor were advised to use water only.
9. This particular group of women was highly motivated and not embarrassed to discuss their problem frankly.
10. Blood pressures were taken at the beginning and end of the clinic visit. This was instituted as a side issue and resulted in two subjects being referred to their physician. In this age group, blood pressure readings appeared to be a good practice that should be continued.
11. The Risonai Perineometer™ has been little used for incontinence research and no suggested "dry" readings exist. We found the mean reading at which our subjects were dry to be 10.85. Those women whose readings were 12 and above had no further incidents after that reading was attained.
PERINEOMETER MICROVOLT READING: REPORTED CONTINENCE
Previous pelvic surgery was not a deterrent to entering this study. Several subjects had histories of previous repair, and one subject had had three previous surgical interventions for simple urinary stress incontinence.
It appears to the researchers, in light of the improvement of all 12 women, that although further conclusive research is needed, Kegel exercises are a valuable self-care practice presurgically, postsurgically, or in lieu of surgery. The major hurdles in effective use of Kegel exercises include:
1. Teaching the exercises correctly. Many texts contain false or misleading information (eg, contract the buttocks).
2. Assisting the client in identifying the correct muscle to contract. When done correctly, no observer should be able to detect that one is practicing Kegel's exercises.
3. Allowing enough time for the exercise sessions. Even in a nondatacollecting setting, teaching these exercises would consume at least 30 minutes of the practitioner's time. In the average office setting, the time factor is usually prohibitive and nonreimbursable .
It is the subjective observation of the researchers that the biofeedback device is useful in early identification of the correct muscle and a motivating factor in increasing the strength of the contractions. Since most women do not know they have a pubococcygeal muscle, identifying and contracting it is not always an easy task. Women using the device only in the clinical setting frequently remarked on how much harder they could contract when concentrating on the "lights. " Thus, the perineometer might have value as a time-saving device in the clinical situation.
Finally, it must be pointed out that diminishing frequency of embarrassing incidents is both a type of biofeedback and a motivating factor among already incontinent women. A much larger study is necessary to determine the value of the instrumentation as a teaching tool.
The small size (N = 12) and low cost (less than $3,000) of this study indicates that it would lend itself readily to replication. Not only would data be of value to individual researchers, but its compilation would add strength to the results as the number of subjects increases.
- 1. Kegel AH: Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol 1948; 56(2):238-248.
- 2. Kegel AH: The physiologic treatment of poor tone and function of the genital muscles of urinary stress incontinence. The Western Journal of Surgery, Obstetrics, and Gynecology 1949; 57(November):527-535.
- 3. Kegel AH, Powell TO: The physiologic treatment of urinary stress incontinence. J Urol 1950; 53(May):808-813.
- 4. Kegel AH: Stress incontinence of urine in women: Physiologic treatment. The Journal of International College of Surgeons 1956; 25(April):487-489.
- 5. Jones EG: The role of active exercise in pelvic muscle physiology. The Western Journal of Surgery, Obstetrics, and Gynecology 1950; 56(l):238-248.
- 6. Specht J, Cordes A: Genitourinary problems, In Carnevali D, Patrick M (eds): Nursing Management for the Elderly. Philadelphia, JB Lippincott, 1979.
- 7. Wells T: Pelvic Floor Exercises for Stress Urinary Incontinence. GSA paper, San Antonio, 1984.
- 8. Katterman L: Incontinence comes out of the water closet. Aging 1985; (350):28, 30.
- 9. Witty DL: Managing incontinence in women. Patient Care, 1977; (September):120-122, 127-133, 137-141.
- Special thanks are extended to Dr John Perry of Biotechnologies, Ine for loaning the sensors and arranging instrument rental, and for the many supportive phone calls; to Dr Martha Shawver, chair of the WSU Nursing Department for support and funding; and to Dr Francine Nichols and Dr Cramer Reed for support, guidance, and advice.
SELF-ASSESSMENT OF CONTINENCE SAMPLE QUESTIONS