Comparison of self-reported ability to perform Kegel’s exercise pre- and post-coital penetration in postpartum women

ABSTRACT

We compared the self-reported ability to perform Kegel’s exercises pre- and post-coital penetration in postpartum women. A cross-sectional design. Twenty-seven postpartum women with mild urinary incontinence were recruited. Measures included perceived strength of pelvic floor muscle contraction (Strength of Contraction [SOC] scale] and ease of performing Kegel’s exercises (Ease of Performance [EOP] scale). These measures as well as information on attaining orgasm were collected in one session, pre- and post-coital penetration. Findings showed that both measures (SOC and EOP) varied significantly (p < 0.001) pre- and post-coital penetration, with decreasing values post-coitus. Additionally, the outcomes of both measures showed no significant differences (p < 0.05) between women who reached orgasm and those who did not. Self-reported ability to perform Kegel’s exercise immediately after coital penetration is reported to affect the appropriateness of its performance and effective outcomes. Thus, women should be discouraged from performing Kegel’s exercises immediately post-coitus.

KEYWORDS:

• Kegel’s exercise
• coital penetration
• ease of performance
• perceived strength of contraction
• orgasm

1. Introduction

Pelvic floor dysfunctions (PFD) refer to a broad range of clinical scenarios, including lower urinary tract, excretory and defecation disorders, such as urinary and anal incontinence, overactive bladder, pelvic floor dyssynergia, and pelvic organ prolapse, as well as sexual disorders [1, 2]. With advancing age and parity, women tend to suffer from at least one PFD disorder [3]. These disorders can be as a result of changes in pelvic floor muscle integrity which occurs due to the different stages of experiences in a woman’s life, such as spontaneous vaginal delivery (SVD), pregnancy, postpartum and menopause [4]. Damage to pelvic floor muscles (PFMs) which play an important role in pelvic organ support and continence control [5] is the major cause of PFDs and other related conditions [6]. PFDs and their resultant complications generally have negative effects on quality of life, including mental, sexual and physical health [7]. These conditions are particularly embarrassing and distressing with significant medical, social and economic implications [8].

Amongst several treatment options available for the management of PFDs [9,10], physical therapy is regarded as the first line of therapeutic intervention as evidenced by the diagnostic and therapeutic algorithms developed by a panel of experts and based on scientific evidence [11,12]. The most predominant physical therapy modality utilized for this purpose is PFMs exercises, commonly referred to Kegel’s exercises. The first description of PFMs exercises was created and published in 1948 by Kegel for the management of PFDs. According to descriptions in literature, Kegel’s exercises rely on conscious contraction and relaxation of the PFMs [13]. When performed correctly, this exercise helps to strengthen the muscles that support the bladder and urethra and hold the pelvic organs in place [14]. Kegel’s or exercises would result in improved sexual function that causes increase in vaginal blood flow and subsequent genital sensation, and it would result in improved arousal, orgasm and libido [15], as well as prevent postpartum PFDs and sexual dysfunction [11]. Although the efficacy of some of the Kegel’s exercise techniques are being questioned for their ability to recruit the PFMs [16], this exercises is still the most common type of PFM training and a non-invasive treatment method, as compared to other methods including the use of vaginal cones, balls and electrical stimulation. It is also the most cost-effective treatment and differs from other therapies in that patients can perform them by themselves anytime, anywhere while doing other work without regular hospital visits. Usually, the prescription of these exercises are such that they can be performed at anytime of the day, in various starting positions [17]. Particularly, several studies have reported positive outcomes of Kegel’s exercises on the functioning of the PFMs [18,19]. They have also been shown to increase libido and orgasm experiences during sexual intercourse [20]. Regarding the impact of Kegel’s exercise on postpartum incontinence, several studies [21,22]; also have reported positive outcomes.

Awareness of Kegel’s exercises is constantly created among women across various stages of the reproductive cycle in most climes. Several studies have reported compliances with performance of these exercises [18,23], while others have shown otherwise [24,25]. In Nigeria, common barriers of Kegel’s exercise practices include forgetting, being too tired, and being too busy [26]. Anecdotally, we have observed that most postpartum mothers who report to the clinics attest that they forget to practice their Kegel’s exercises duly. Even with the reminders of alarm clocks or some prompts (the cry of a baby, boiling kettle, traffic light), they may not be physically or mentally ready to perform these exercises at such points in time. Surprisingly, majority of these women have reported that their best reminders of Kegel’s exercise are the immediate periods after sexual intercourse. In undocumented interviews, these women have elucidated that sexual activities remind them of the need to work on their PFMs to enhance sexual functions in the postpartum period and beyond.

We hypothesized the possibilities of inappropriate practices and negative outcomes of Kegel’s exercises when performed immediately after sexual intercourse, considering that the activities associated with sexual intercourse (particularly coital penetration) result in some levels of physical stress to the PFMs. For instance, the repeated thrust of the penis into the vagina tends to stretch the vaginal tissues with indirect impact on the surrounding PFMs. In an attempt to increase vagina-penile contact with a resultant increased satisfaction for both parties, some women have also reported to attempt ‘gripping the penis’ with the vaginal walls during intercourse, an activity we also envisage to result in fatigue of the surrounding PFMs. In addition, the process of orgasm may further result in temporary fatigue in the pelvic floor muscles after sexual intercourse as it involves rhythmic contraction of pelvic floor muscles. Orgasm is also associated with a discharge of accumulated erotic tension,(McIntosh, [27]), resulting in general body relaxation and/or sedation afterwards. Bearing these in mind, we are uncertain of the effectiveness of Kegel’s exercise performance immediately after intercourse as majority of our postpartum clients reported. Kegel’s exercises require voluntary isolation and concentric contraction of the PFMs to increase their strength with sustained contractions to improve their endurance. Preadventure of these muscles are temporarily fatigued post-coital penetration, how possible will it be to contract them and sustain contractions effectively? To clarify these uncertainties, this study was designed to compare self-reported abilities (strength of PFMs contraction and ease-of-performance) to perform Kegel’s exercise pre- and post-coital penetration in postpartum women. We further explored the influence of orgasm experiences on the two aforementioned parameters of assessment.

2. Methods

2.1. Design

This study utilized a cross-sectional observational study to ascertain self-reported ability to perform Kegel’s exercise pre- and post-coital penetration in postpartum women.

2.2. Participants

A preliminary power analysis showed that a sample size of 20 participants will be needed for the paired sample t-test at degree of freedom (dfb) = 1, to achieve 80% (0.80) power with a large effect size of 0.80 at an alpha level of 0.05 [28]). However, a sample size of 38 purposively selected postpartum women (18–35 years) was recruited for this study in order to control for participant attrition, and 27 were successfully followed up.

Sexually active women, up to 16 weeks postpartum with recent vaginal deliveries who had available sex partners as at the time of this study and reported of mild-to-moderate urinary incontinence (ICIQ score <11) [29] were included in this study. On the other hand, those who reported recent genitourinary surgery, malignancy in the pelvic region, neurological defects affecting sensation at the perineal region, chronic urinary incontinence, pelvic organ prolapse, sexual dysfunctions, dyspaerunia, vaginismus, and anorgasmia were excluded from this study.

2.3. Study instrument

Variables measured included ease-of-performance of Kegel’s exercise and determination of self-reported strength of pelvic muscle contraction pre- and post-coital penetration respectively. A researchers-developed structured ease-of-performance scale was used to assess the ease with which participants performed Kegel’s exercises pre- and post-coital penetration. This tool has one item and utilized the Likert scale of measurement system in which the participants were asked to grade their ease-of-performance of Kegel’s exercise on a scale of 1 to 7 where 1 denoted ‘not easy at all’ and 7 representing ‘extremely easy’.

The second measurement tool, the contraction grading scale developed by the researchers for this study, was used to subjectively assess the self-reported strength of the participants’ PFM contractions during Kegel’s exercises. This scale also have one-item and utilized a Likert-scale grading system, ranging from 1 to 5 (1 = ‘very weak contraction’; 5 = ‘very strong contraction’). The contents of both measurement tools were validated by experts and found to be easily interpreted by postpartum women.

2.4. Study procedure

Ethical approval for this study was first obtained from the College of Medicine Research Ethic Committee (COMREC), University of Nigeria, Enugu Campus. Participants for this study were then recruited from the post-natal clinics of two tertiary health-care institutions in Enugu State, Nigeria. The objectives and procedures of this study were explained to the volunteers on which basis their written informed consent was sought and obtained. Subsequently, their biodata, and other relevant maternal information were obtained. Their anthropometric characteristics (body weight, standing height and body mass index) were also assessed.

The participants then went through a habituation process where they were educated on correct performance of Kegel’s exercise, using verbal and visual instructions (using pre-recorded videos). For uniformity purposes, they were all taught to initiate the exercise with the imagination of ‘holding back urine flow at the sound of a fire alarm’ [16]. On the average, the consecutive 2–3 days post participant recruitment was delegated to training on for Kegel’s exercise performance with well-monitored home programmes. Finally, participants were asked to perform Kegel’s exercises any time before and not more than 5 min immediately after coital penetration with their spouses. On both occasions, they subjectively graded their perceived ease-of-performance and strength of contraction using the aforementioned structured numerical scales. They were also asked to provide information on their orgasm experience for each intercourse session. All data were collected within April to June 2021.

2.5. Data analysis

Descriptive statistics of mean and standard deviation was used to summarize data. Normality was determined by the Kolmogorov–Smirnov test, and inferential Statistics of paired samples t-test was used to determine differences between pre- and post-coital Kegel’s Exercise outcomes.

To ascertain the role of orgasm in Kegel’s Exercise performance outcomes, participants were grouped into two categories, based on their orgasm attainment during the specific coital penetrations considered in this study. Independent samples t-test was then used to determine the statistical differences for each of the Kegel’s Exercise ease-of-performance and perceived strength of contraction between the two groups.

Alpha level was set at P < 0.05. The data analysis was done with Statistical Package for Social Sciences (SPSS) software (version 21).

3. Results

Out of total 38 postpartum women recruited for our study, only 27 successfully completed this study. Their socio-demographic characteristics are summarized in Table 1. From this table, the mean age, height, body weight and body mass index of the participants are 28.5 ± 3.0 years, 1.6 ± 2.0 m, 75.5 ± 13.8 kg and 28.3 ± 5.5 kg/m², respectively.

Table 1. Socio-demographic characteristics of participants (n = 27).

Variables	Mean± Standard Deviation	Minimum Value	Maximum Value
Age (years)	28.5 ± 3.0	23.0	35.0
Height (m)	1.6 ± 2.0	1.2	1.8
Body weight (kg)	75.5 ± 13.8	55.7	101.2
Body mass index (kg/m^2)	28.3 ± 5.5	19.0	37.7

Table 2 shows the frequency distribution of the participants’ general characteristics. Majority of the women were primigravida (55.6%), primiparous (66.7%) and were within 7–12 months postpartum duration (29.8%). A greater percentage of them (77.8%) had tears and episiotomy during their last childbirth but were completely healed up. Most (92.6%) of the participants had no history of urinary incontinence, while only 7.4% leaked urine mildly. Majority of the women had never practiced Kegel’s exercises (55.6%) and/or other post-natal exercises (74.1%) at any point in their lives.

Table 2. Frequency distribution of participants’ obstetrics characteristics (n = 27).

Variable	Frequency	Percentage
Gravity
1 Pregnancy (primi-gravida)	15	55.6
>1 Pregnancy (multi-gravida)	12	44.4
Parity
1 Childbirth (primiparous)	18	66.7
>1 Childbirth (multiparous)	9	33.3
Postpartum duration (months)
0–6	7	25.9
7–12	8	29.8
13–18	5	18.5
>18	7	25.9
History of tears or episiotomy during the last childbirth
Yes	2	77.8
No	6	22.2
History of urinary incontinence
Yes	2	7.4
No	25	92.6
Frequency of urine leakage (n = 2)
Very often	1	50.0
Rarely	1	50.0
Previous practice of Kegel exercise
Yes	12	44.4
No	15	55.6
Practice of post-natal exercise
Yes	7	25.9
No	20	74.1

In Table 3, the comparisons of participants’ self-reported strength of contraction and ease – of-performance of Kegel’s exercise were reported. The results showed that there were statistically significant differences (p < 0.001) between the pre- and post-values of all the studied parameters, with lesser values of strength of contraction (2.56 ± 0.712) and ease-of-performance (4.04 ± 1.594) recorded after sexual intercourse.

Table 3. Comparisons of self-reported strength of contraction and self-perceived ease of participation among postpartum women.

Variable	Pre	Post	t-Value	p-Value
Self-reported strength of contraction	3.44±o.870	2.56 ± 0.712	4.993	0.000*
Self-perceived ease of participation	5.32 ± 1.145	4.04 ± 1.594	5.018	0.000*

Note: Key: * Indicates significance at p < 0.05.

Furthermore, comparisons of the mean differences (post minus pre values) in strength of contraction and ease of performance of Kegel’s exercises between participants who attained orgasm and those who were unable to are presented on Table 4. From the results, there were no significant differences [strength of contraction (p = 0.775); ease of performance (p = 0.236)] in both parameters across the two groups.

Table 4. Between-group comparisons of mean differences in strength of contraction and ease of performance of Kegel’s exercises among the participants, based on orgasm attainment during sexual intercourse.

Variable	Group 1 (orgasm) n = 10	Group 2 (No orgasm) n = 17	t-Value	p-Value
Mean difference in strength of contraction	−1.200 ± 0.423	−1.13 ± 0.640	0.289	0.775
Mean difference in ease of performance	−0.800 ± 0.63246	−1.47 ± 1.642	1.218	0.236

Note: Key: Mean difference= Post minus pre intercourse value.

4. Discussion

This study was aimed at ascertaining self-reported abilities to perform Kegel’s exercises pre- and post-coital penetration in postpartum women. In this study, perceived strength of contraction, ease of performance and pre- and post-coital penetration were assessed. The result showed that the women reported ease of performance of Kegel’s exercises and the perceived strength of contraction reduced after coital penetration. This implies that prior to coital penetration, they perceived that the performance of Kegel’s exercise was easier with stronger contractions experienced from the PFMs, as compared to minutes after sexual intercourse. Our proposed hypothesis of reduced Kegel’s ability after coital penetration was not disconfirmed. There are possible physical and hormonal factors that may be responsible for these observed changes.

Coital penetration involves physical contact and pressure within the vaginal walls and its surrounding muscles, considering that structurally and functionally, some of the pelvic muscles are closely related to the vagina and they work as a functional unit [30,31]. The bulbospongiosus muscle lies on its lateral wall while the transverse (deep and superficial) perineal muscle lies posteriorly. These muscles support the structure of the vagina and in conjunction with other pelvic floor muscles (PFM), partake in the rhythmic contractions in the perineal region during orgasm. It is possible that the thrusting movement of the penis during sexual intercourse will lead to intermittent stretching of these muscles which may affect their contractile abilities. Kelleher and Cardozo [32] posited that penetrative intercourse in humans is associated with considerable displacement of the female pelvic anatomy.

The other suggested physical factor is the fatigued state of the pelvic floor muscles after orgasm. Sequel to the rhythmic contractions encountered during orgasm or arousal stages of sexual activity, the PFMs may also be in transient states of fatigue post-coital penetration. Considering that, these muscles are the primary muscles that are contracted during Kegel’s exercises; any compromise on their integrity will possibly affect their functional activities. Post-orgasm, the resolution phase of sexual activity is characterized by generalized muscle relaxation to reverse the process that built up during the excitement stage [33]. If orgasm is reached, resolution phase may last 10–15 minutes and be accompanied by a feeling of serenity and relaxation [34]. An ancient study [35] also reported that during orgasm, there is an increased intra-abdominal pressure, which is directly transmitted to the vaginal wall, adding to its mechanical load. Such increased mechanical load has been associated with a stretch on the vaginal and its surrounding tissues [36] which may further compromise the functional activities of the PFMs. Although this study showed no statistical differences in the post-coital abilities of Kegel’s exercise performance between women who reached orgasm and those who did not, there is still a need to investigate further the role of orgasm on the functional abilities of the PFMs.

On the other hand, hormonal factors may be responsible for the observed differences in Kegel’s exercise performance pre- and post-coital penetration. Sexual stimulation and orgasm result in the secretion of some hormones, including oxytocin (love hormone) and prostaglandin (as released by the woman and introduced by the male semen) [37–39]. These hormones result in cervical dilation and relaxation (cervical ripening) which may be associated with inhibited activities of the surrounding PFMs. Another hormone, relaxin, which is known for its effects in the relaxation and inhibition of the muscles and ligaments of the pelvis, is also introduced into the female system via the male semen during coital penetration [40,41]. In addition, some other hormones, including oxytocin, dopamine and serotonin which result in generalized sedation, decreased muscle performance and fatigue are also released within the female body during sexual activities [42]. Are there possibilities that the influences of these hormones may be responsible for the decreased abilities of the PFMs post-coital penetration? If possible, they are most likely contributing factors of decreased Kegel’s abilities after penile penetration.

In summary, this novel study has provided some empirical evidences to support our instructions to women regarding the discouraging of Kegel’s exercise performance post-coital penetration. We suggest further emphasis on this aspect of maternal health education and Kegel’s exercise prescription. However, the outcome measures utilized in this study are purely subjective with reliance on self-reported data, which may have influenced the study findings to a certain extent. Despite the literacy level of the participants, it is still possible that the comprehension of instructions will vary amongst them. Therefore, objective measures of assessment, including palpations [43] and electromyography may be most suitable for the assessment of pelvic floor muscle functional activities during Kegel’s exercise pre- and post-coital penetration in future studies to confirm the outcomes of this preliminary study. Also, a larger and heterogenous sample may also provide more generalizable findings across different categories of women.

5. Implications for practice

This study provides empirical evidence on the comparison of self-reported ability to perform Kegel’s exercise pre- and post-coital penetration in postpartum women. This evidence will undoubtedly guide physiotherapists and other related health professionals on instructions given to women during the prescription of Kegel’s exercises. It recommends that for effective performance and outcomes of Kegel’s exercise, its practice immediately after coital penetration should be discouraged among postpartum women.

6. Conclusion

The ease of performance and perceived strength of the PFMs during Kegel’s exercises was reported to reduce after sexual activities involving coital penetration in postpartum women. As a result, it is recommended that for effective performance and outcomes of Kegel’s exercise, its practice immediately after coital penetration should be discouraged among postpartum women.

Authors’ contribution

CPO: protocol development, manuscript writing and editing, and data analysis; GTN and SSE: literature review, and data collection; AUE and UE: project development, and data collection; AEM, SSE and SCC: literature review, manuscript writing and editing. All authors read and approved the final manuscript.

Informed consent

All participants provided written and oral informed consent and the study was conducted according to the Declaration of Helsinki.

Ethical considerations

All experimental protocols were approved by the University of Nigeria Health Research Ethics Committee (NHREC/05/01/200BB-FWA00002458-1RB00002323) and conducted according to the Declaration of Helsinki.

Guarantor

CP Ojukwu

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

No external funding was obtained for this study.