Pelvic Muscle Contraction After Verbal Instruction

Can patients successfully perform a pelvic muscle contraction following verbal instruction? This question was asked by Bump and colleagues in the often-cited research article published in 1991. Urethral pressure profiles were assessed in forty-seven women at rest and during a pelvic muscle contraction following brief, standardized verbal instruction. In the article, the authors found that nearly half of the women performed with "an ideal effort" leading to urethral closure without a Valsalva effort. 25% of the women, unfortunately, demonstrated an effort at muscular contraction that could promote incontinence. The authors' conclusion is that simple verbal or written instruction is not the best approach for a patient engaging in a pelvic floor muscle training program.

The limitations of the above study (small number of subjects, arbitrary definition of "effective Kegel," and inability to predict patient outcomes based on urethral profile) are made very clear throughout the article, yet how do we see this apply to our patient population? How often do we complete a perineal observation during an examination and identify that the patient is not generating any perineal movement, demonstrating a bearing down maneuver rather than a shortening, protective contraction, or creating such force through the abdomen that even a well-contracted pelvic floor would struggle against the strain from above? The value of the Bump study reminds us that not all patients respond positively to verbal or written instruction only.

What about men? A recent study aimed to assess the ability of 52 healthy men (mean age of 22.6 years with a standard deviation of 4.42 years) to complete a pelvic muscle contraction in standing or crook lying following brief, standardized instruction. Real-time transabdominal ultrasound was used to measure bladder base elevation. 6 participants were unable to contract the pelvic floor muscles in either position, 17 were unable to contract the muscles in crook lying, and 14 could not contract the muscles in standing. While many of the men we instruct in pelvic muscle rehabilitation strategies are significantly older than the men in this study, the major point matches that of the Bump article: it is not safe to assume that a patient (even a young, healthy patient) can contract the pelvic floor muscles following verbal instruction. The authors suggest that transabdominal ultrasound may be a useful clinical tool for measuring bladder base elevation and therefore pelvic muscle activity.

To be fair, more people in general need to be educated about the pelvic floor muscles;we can likely agree that the lack of awareness and discussion about the roles the PFM play in daily life leads to persisting dysfunction. There are people within the population who can activate the pelvic muscles appropriately with verbal instruction, and for this portion of the population, verbal or written instruction may be better than no instruction. Group education in community or institutional settings may benefit patients who are unwilling, unable or uninterested in acquiring a referral to a pelvic rehab provider. But for the group of patients who is either not contracting the muscles or bearing down rather than lifting, the consequences of doing pelvic muscle strengthening incorrectly may be significant. Do we need to change how we are instructing the patient verbally? Should we offer assessment of pelvic muscle contraction ability in varied positions? Must we include other functional applications of the coordinating muscles such as the respiratory diaphragm? At this time, there is not one answer. If we can ask the questions, read the research, and participate in our own way to the research, or at a minimum, apply these questions to clinical care, we may find the best answer for each individual patient.

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