The pelvic floor muscles (PFM) have long been recognized as vital for supporting the pelvic organs, for healthy sexual function and for ensuring urinary and bowel control. Additionally, the PFM contribute to core muscle stability and provide postural support. The PFM not only anatomically and functionally link the pelvic organs—the vagina, uterus, bladder and rectum—but also affect the independent function of each.

Exercises of the PFM are not a new concept, dating back over 6000 years ago to Chinese Taoism. The Yogis of ancient India practiced similar exercises, assuming the proper posture and performing rhythmic contractions of the anal sphincter (considered to be one of the superficial PFM). Hippocrates and Galen described PFM exercises in ancient Greece and Rome, respectively, where they were performed in the baths and gymnasiums and were thought to promote longevity as well as general health, sexual health and spiritual health.

For centuries thereafter, however, PFM exercises were thrust into the “dark.” Fast-forward to the 1930s when Margaret Morris, a British physical therapist, described PFM exercises as a means of preventing and treating urinary and bowel control issues. Then came the 1940s, when the seminal work of Dr. Arnold Kegel resulted in PFM exercises achieving the stature and acclaim that they deserved. Kegel’s legacy is the actual name that many use to refer to PFM exercises—“Kegels” or “Kegel exercises.” Kegel determined that a successful PFM program must include muscle education, feedback, resistance, and progressive intensity. He stressed the need for pelvic floor muscle training (PFMT) as opposed to casual exercises, emphasizing the importance of a diligently performed and dedicated routine.

Despite Kegel’s PFMT regimen proving effective for many female pelvic problems—including those of pelvic support, sexual function and urinary/bowel control—what is currently referred to as Kegel exercises bears little resemblance to what Kegel so brilliantly described in his classic series of medical articles sixty-five years ago. His PFMT regimen incorporated a critical focus and intensity that are unfortunately not upheld in most of today’s programs.

Sadly, easy-to-follow pelvic exercise programs or well-designed means of enabling PFMT are lacking. In the post-Kegel era, we have regressed to the Dark Ages with respect to PFMT. Today’s programs typically involve vague verbal instructions and perhaps a pamphlet suggesting a several month regimen of ten or so PFM contractions squeezing against no resistance, to be done several times daily during “down” times. These programs are typically static and do not offer more challenging exercises over time. Such Kegel “knockoffs” and watered-down, adulterated versions—even those publicized by esteemed medical institutions—lack in guidance, feedback and rigor, demand little time and effort and often ignore the benefit of resistance, thus accounting for their ineffectiveness. With women often unable to identify their PFM or properly perform the training, outcomes are less than favorable and the frustration level and high abandonment rate with these PFMT regimens are hardly surprising. Thus, PFMT remains an often ignored, neglected, misunderstood, under-respected and under-exploited resource.

The Challenge of Pelvic Floor Muscle Training (PFMT)
There are several obstacles to implementing PFMT: the PFM themselves, physicians who might try to take on administering the training, and patients.

The first challenge is that it is not an easy task to motivate people to exercise muscles that are not visible. Moreover, because the PFM are hidden muscles that are most often used subconsciously, teaching conscious engagement of them in order to develop muscle memory is difficult.
Secondly, many physicians have received little or no training on pelvic floor issues and those that have hardly have the time to adequately teach PFMT. Furthermore, most medical doctors are not particularly interested in this task, which can be burdensome, time-consuming and not reimbursed by medical insurance. The bottom line is do not expect to learn much about Kegels from your doctor.

Thirdly, patients—most of whom know nothing about these mysterious muscles—must be educated on the specifics of the PFM, the proper techniques of conditioning them and the practical application of the exercises to their specific issues. In our instant gratification world, many patients are not motivated or enthused about slow fixes and the investment of time and effort required of an exercise program—which lacks the sizzle and quick fix of pharmaceuticals or the operating room—so patient compliance and willingness to pursue the exercises are important and oftentimes limiting factors. Additionally, many women with pelvic issues are reluctant to seek help for a variety of reasons. These include embarrassment about the very personal nature of their problems, the misconception that their pelvic troubles are always an expected consequence of pregnancy or aging, a lack of awareness that help is available and the fear that surgery will be the only treatment option.

For years I managed these stumbling blocks by explaining PFM exercises as best as I could and handing patients written materials. I found this to be inadequate and ineffective, so I created a YouTube video to be used as a supplement to my office instruction and handout. Although more a general source of information about the PFM rather than a specific training regimen, this video was well received by my patients and many others, with hundreds of thousands of views to date. Its popularity informed me of the vital need and unmet demand for an effective means by which PFMT could be made easily accessible.

So, if one is so motivated to learn about their PFM and how to exercise them, how does one obtain information? Many navigate the Internet as a go-to source of enlightenment. However, the content on the Internet is poorly regulated, unfiltered, and is often lacking in quality, substantiated information. Many of the websites devoted to PFMT are promotional in nature. Most of the online PFMT guidance is far too basic and incomplete.

Additionally, there are a number of PFM applications (apps) available for download. Many are follow-along tutorials that provide a timer for doing PFM exercises and audio and visual cues for contracting and relaxing the PFM. Regrettably, they all have a bare minimum of in-depth content, medical focus and meaningful instruction, serving mainly as timing prompters. None provide the foundational knowledge upon which PFMT is based. The bottom line is that quality resources to improve pelvic floor health are sorely lacking in availability.

Physicians who want their patients to pursue PFMT but do not have the time nor the interest to teach them may consider referring them for pelvic floor physical therapy (PT). Physical therapists who specialize in pelvic floor issues deal with a wide range of pelvic floor dysfunctions ranging from PFM weakness to PFM tension (a condition in which the PFM are over-contracted, causing pelvic pain and sexual, urinary and bowel problems). Pelvic floor PT sessions can be a lifesaver for women who are incapable of mastering PFMT. There is compelling evidence that women do better with supervised PFMT regimens than they do without. I liken the pelvic floor physical therapist to a “personal trainer” for the PFM. The downside of PT is that it is time-consuming and expensive, with variable coverage depending upon the insurance carrier.

Many women are interested in pursuing PFMT, not necessarily under the guidance of a health professional such as a PT or MD, but more as part of an “exercise” routine as opposed to a “medical” program. What about “Do It Yourself” (DIY) programs? The first problem with DIY is in finding the proper plan and the second problem is seeing it through to reap meaningful results. The majority of those who try DIY Kegels cannot find a program that provides the foundational background and the means of isolating and exercising the PFM in a progressively more challenging fashion. It is the equivalent of giving someone a set of weights and expecting them to engage in a weight training program without the essential knowledge and principles of anatomy and function, a specific exercise routine and the supervision to go along with the equipment— which would most certainly doom them to failure.

This leads me to the purposes and objectives I have in writing this book. The consequences of weakened PFM are urinary and bowel control problems, dropped pelvic organs and sexual dysfunction, taboo issues that many women do not have much knowledge about nor consider topics appropriate for conversation. I wish to explore these “off-limit” subjects that are the final frontier of uncharted territory in women’s health. As the word doctor derives from the Latin docere (“to teach”), my intention is to engage and educate readers in order that they achieve pelvic health literacy, including an understanding of the pelvic consequences of pregnancy, labor, childbirth, menopause and lifestyle. My goal is to enhance the quality of life of women by showing them how to tap into the powers of their PFM and how to “snap, clench and squeeze” their way to a healthy, fit, firm and toned vagina and PFM. I aim to demystify the PFM—out of sight, out of mind, and often misunderstood—and make PFMT less intimidating and more accessible.

My ambition is to help deliver PFMT from the Dark Ages and contribute to the “pelvic revolution,” restoring PFMT to the classic sense established by Arnold Kegel—a “renaissance” to a new era of “pelvic enlightenment.” I introduce new age, next generation Kegels—progressive, home-based, tailored exercise programs consisting of strength and endurance training regimens that are designed and customized for the specific pelvic floor dysfunction at hand. My intent is to provide the means for women to master pelvic fitness and optimize pelvic support and sexual, urinary and bowel function, thereby empowering them from within.

Finally, because many women who are taught PFMT do not understand how to put their newfound knowledge and skills to real life use, my ultimate desire is to teach functional pelvic fitness—practical and actionable means of applying PFM proficiency to daily tasks and common everyday activities. There is no better time than the present to begin PFMT in order to prevent, delay or treat pelvic floor dysfunction, beneficial from bedroom to bathroom.

Be Well.

Dr. Andrew Siegel