Strengthening the Pelvic Floor: to reduce incontinence and improve sexual functioning

Urinary incontinence is a widespread problem that affects seventy-five percent of women over 65, and 43% of women aged 50-64. Eighty percent of women who have incontinence are mothers, so it appears to be related to having babies. These are not just numbers, but a reality that many women face. I became interested in incontinence because, as a sex therapist, I know about the value of Kegel exercises for strengthening the pelvic floor. They enhance sexual function across the board in women - desire, arousal, lubrication, and orgasm, and they reduce sexual pain and vaginal laxity. In men, Kegels enhance erection, endurance, and orgasm, and relieve pain.

Kegels can prevent urinary incontinence, prolapse of pelvic organs, and the need for some hysterectomies and bladder surgeries that can have devastating consequences. Also, individuals can avoid having to take medications for incontinence, which can have side effects of dry mouth, constipation, and dizziness.

Kegel exercises involve contracting and relaxing the pelvic floor muscles, which are the muscles that support the uterus, bladder, and rectum. They can be done anywhere, anytime, and are a key part of pelvic floor physical therapy. However, many people find it difficult to follow through on Kegel exercises. They require concentration, and it is hard to remember to do them. When the pelvic floor is weak, it feels like they have no effect, so many women give up. 

In France, where there is a relative openness to sex, every woman who gives birth has the option of receiving 20 pelvic floor physical therapy sessions, at government expense, starting about a month after delivery. During a housecall, a nurse inserts her gloved fingers into the woman’s vagina to make sure the woman is doing Kegel exercises correctly. Many women do not do them right. They push down instead of pulling up. They also do not breathe properly. They should exhale during the exertion part of the exercise (the pulling up) and inhale during the relaxation portion (letting go).

Physical therapists in France and the United States use biofeedback to monitor the strength of contractions and electrical stimulation to induce stronger contractions than women can do independently. Biofeedback monitors muscle activity, helping women learn to control their pelvic floor muscles. Electrical stimulation delivers a small electrical current to the pelvic floor muscles, causing them to contract without effort. These devices are available for purchase in the United States but are not covered by insurance.

Several new, non-invasive electrical or energy-based devices can help strengthen the pelvic floor, reduce incontinence, and provide sexual benefits. 

These devices are considered integrative primarily because the practitioners who recommend them have an integrative orientation. They are not yet standard of care; they may have been FDA-approved for other indications but are considered experimental for sexual problems and urinary incontinence and are used off-label for these purposes. Questions of efficacy and safety remain about many of them, and most treatments are expensive and not covered by insurance. Several of these treatments are listed below.