“Stress Incontinence and Genital Relaxation; A Nonsurgical Method of Increasing the Tone of Sphincters and their Supporting Structures” (1952), by Arnold Henry Kegel

In 1952, Arnold Henry Kegel published “Stress Incontinence and Genital Relaxation; A Nonsurgical Method of Increasing the Tone of Sphincters and their Supporting Structures” hereafter, “Nonsurgical Method,” in the journal Ciba Clinical Symposia. In the article, Kegel argues that the pubococcygeus muscle, a pelvic floor muscle that stretches from the pubic bone to the tailbone, is a crucial structure that provides control over specific sphincters and support for pelvic organs. When pelvic floor muscles, including the pubococcygeus, weaken or relax, prolapse of the uterus and urinary incontinence can result. Kagel argues that women can strengthen their pubococcygeus, and therefore avoid those conditions, through muscle education and resistive exercises, which as of 2025, some researchers call Kegel exercises. “Nonsurgical Method” was one of the first papers to provide an alternative to surgery for treating bladder and reproductive problems that are especially common in women who have given birth.

1. Background
2. Article Contents
3. Impacts

Background

At the time of publication, Kegel worked as an Assistant Professor of Gynecology at the University of Southern California School of Medicine, in Los Angeles, California. Gynecology is a medical specialty dealing with the female reproductive system. Prior to the publication, Kegel received his Doctor of Medicine degree from Loyola University School of Medicine, in Chicago, Illinois. Kegel studied the strength of the pelvic floor and how a weakened pelvic floor can result in disorders such as urinary incontinence and pelvic organ prolapse. Urinary incontinence is when a person can’t control the leakage of urine from their bladder. Pelvic organ prolapse is a condition in which the pelvic floor muscles cannot adequately support the pelvic organs, like the uterus for example, causing it to fall out of place. He also invented the perineometer, which is an instrument that people can use to measure the strength of voluntary contractions created through the pelvic floor muscles.

Before the publication of “Nonsurgical Method,” surgery was the primary treatment available for disorders caused by a weakened pelvic floor. For example, to treat pelvic organ prolapse, physicians often used a surgical procedure called total or partial colpocleisis. During the procedure, surgeons shorten the vaginal canal, which allows the patient to regain support and push pelvic organs back into place. Although the surgery is considered minimally invasive in comparison to other surgeries to treat pelvic organ prolapse, patients who get the surgery need to consider that they will not be able to have vaginal intercourse anymore. However, surgeons often waited to perform those procedures on women until they entered their menopausal years because the procedures could limit future sexual activity. Thus, many women in their childbearing years had no other option but to tolerate the discomforts or the side effects of the prolapse.

“Nonsurgical Method” is a description of Kegel’s findings from eighteen years of using exercises to strengthen the pubococcygeus as an alternative to surgical interventions. According to Kegel, surgical interventions did not always provide permanent solutions to disorders such as organ prolapse because once a patient has had surgery the muscles can weaken again and a prolapse can reoccur. Thus, he spent years studying the direct effect that the pelvic floor has in those disorders to find an alternate solution.

“Nonsurgical Method” builds on a previous study that Kegel published in 1948 called “Progressive Resistance Exercise in the Functional Restoration of the Perineal Muscles.” In that article, he discusses how childbirth can lead to injury of the vagina or perineal muscles, which are muscles that span between the genitals and the anus and are close to the pelvic floor. He discusses his findings that strengthening the pelvic floor muscles soon after damage occurs in those regions can actually result in improved recovery. He incorporates those ideas in his broader discussions in “Nonsurgical Method.”

Article Contents

Kegel organizes “Nonsurgical Method” into seven sections. In the first, untitled introductory section, Kegel notes the often poor results that doctors achieve through vaginal repair surgery and claims that muscle education and exercise can provide superior results. In the second section titled “Diagnosis,” Kegel explains that when a female experiences genital relaxation, the vaginal walls become comparatively thin and weak and that they struggle to contract the walls around an examiners finger. The third section titled “Therapy” has two subsections titled “Specific Muscle Education” and “Resistive Exercises.” In those subsections, Kegel explains that the first step of therapy is for the physician to teach the patient how to become aware of their pubococcygeus muscle, and that utilizing a perineometer to strengthen the pubococcygeus helps tone the muscles and allows the patient to see if they are performing the specific resistive exercises correctly. Next, in “Objective Evidence of Improvement,” Kegel explains that if patients exercise their pubococcygeus muscle correctly and consistently, their pubococcygeus and vaginal walls will progressively become stronger and previous health conditions such as pelvic organ prolapse can be improved. In the fifth section, also titled “Therapy,” there are two subsections titled “Urinary Incontinence” and “Genital Relaxation” where Kegel discusses that women with urinary incontinence and organ prolapse who utilized resistive exercises and the perineometer to strengthen their pubococcygeus muscle saw improvements in their conditions. In the sixth section, “Prophylactic Use,” Kegel reiterates that performing resistive exercises with or without a perineometer as a preventative measure during pregnancy or after surgery can be beneficial in the recovery of the pubococcygeus muscle. In the final section, “Conclusion,” Kegel states that the field of the physiologic therapy of the pelvic muscles is much larger than first suspected, and he calls for further research on how it could help other health conditions.

In the untitled introduction, Kegel argues for the importance of the pubococcygeus muscle due to its function in support of pelvic organs and controlling sphincters. He states that with the use of pelvic floor exercises, muscle atrophy can be prevented or reversed. Atrophy is where body tissue or organs thin out and decline in effectiveness due to the disuse or other heath conditions. He claims that every physician during his time must have observed that patients, months after a successful vaginal repair, will still end up with a weak and thin vaginal canal and perineum. Kegel states that his experience with such cases inspired his interest in the physiology of the pelvic muscles. He then argues that physicians had overlooked the pubococcygeus muscle, but he suspected that women could exercise their pubococcygeus muscle just like any other muscle and sought to understand how they could do so. Thus, based on previous research articles, observations of resistive exercises, animal experiments, and surgeries, Kegel claims that the pubococcygeus muscle is the most versatile muscle in the entire human body because it supports the pelvic organs and has a role in keeping the tone of the other pelvic muscles, allows for control of the sphincters in the pelvic area, such as the anus, and can regain physiologic tension and recover from partial atrophy. He ends the section by explaining that issues with the pubococcygeus can result in many health problems, such as urinary incontinence and prolapse and thus reeducation and exercise of the muscle can prove to be beneficial.

In the second section, titled “Diagnosis,” Kegel proposes that to diagnose someone with genital relaxation, a physician must perform a physical examination to assess the strength and development of the pubococcygeus muscle. The section starts out by explaining that a firm and closed vaginal canal signifies typical development of the pubococcygeus muscle. Kegel details that a loss of tone, prolapse of the vaginal walls, or weakening and thinning of the tissue indicates there is genital relaxation. He states that the first step in the examination is to determine the muscles, and whether the patient is able to retract or draw in the perineum to assess its functionality. Then, he articulates that the examiner should place their index finger just inside the vagina and ask the patient to contract on it. Kegel explains that in a functional vagina, when the patient contracts the examiner should feel restriction all around the finger. According to Kegel, in a female experiencing genital relaxation, the walls of the vaginal canal offer little resistance to the palpating finger and often feel thin and loose. According to Kegel, when asked to contract, sometimes the patient will not even know it is possible to contract the vaginal muscles. Those characteristics are signs that the pubococcygeus muscle have atrophied.

Continuing in “Diagnosis,” Kegel details the use a tool called a perineometer to measure the strength of the contractions in a more objective manner. The perineometer is a made of a small cylindrical apparatus, which Kegel refers to as the vaginal resistance chamber, that is connected to a box that displays the pressure, or strength of the muscle contraction. Kegel explains that the cylindrical apparatus is what is inserted into the vagina, and the physician can read the initial pressure that the vagina exerts on the resistance chamber. To measure the development of the pubococcygeus muscle, the physical will ask the patient to contract around the resistance chamber, and someone with typical development will have a higher pressure reading than their initial reading, and those without typical development will barely have a higher reading.

In the third section, “Therapy,” in the first subsection “Specific Muscle Education,” Kegel explains that the first step to treat genital muscle relaxation is to make the patient aware of the pubococcygeus muscles and then to teach them the steps to exercise the muscle. Kegel states that one third of patients are unable to contract their pubococcygeus muscles, thus physicians must teach their patients how to identify their pubococcygeus muscle because otherwise they would not know how to contract the correct muscles. If the patient is unable to contract the muscle voluntarily, the physician must further instruct the patient. After awareness is established, Kegel relays that to show patients how to properly exercise their pubococcygeus muscle, physicians should teach them how to perform four specific motions. The first involves squeezing the vaginal muscles upon a finger, if the patient is exercising with a physician. For the last three motions, Kegel describes that the patient contracts their rectum as though preventing a bowel movement, draws in the perineum, and contracts their vagina as though interrupting the flow of urine. He explains that if the pubococcygeus muscle is not functioning properly, no actual retraction would occur and instead the physician may observe twitching of the urethra, anus, or the muscles of the buttocks would tighten. Kegel ends the subsection by stating that seventy-five percent of patients learn to contract the pubococcygeus muscle after only ten to twenty minutes of instruction, but no actual improvement can be made if the patient is unable to contract the correct muscle.

In the second subsection, “Resistive Exercises,” Kegel explains that patients may face challenges when continuing to exercise their pubococcygeus muscle on their own, but using perineometers can help patients overcome those challenges. Kegel explains that for some patients, it is difficult to continue performing their exercises correctly as it is hard to measure the progress by themselves. Thus, Kegel suggests using a perineometers and adds that a portion of the pelvic floor therapy should be devoted to learning how to use it. He also relays that the instrument will allow the patient to practice contractions against resistance further strengthening the pubococcygeus muscle. The physician will work with the patient until they are contracting around the perineometer correctly, and then the patient can continue the exercises at home, three times daily, for twenty minutes. Kegel also include that they should do the same contractions without the perineometer multiple times a day. Kegel states that about fifty percent of patients who start their exercises correctly end up using the wrong muscles again within the first few weeks. As a result, Kegel claims that it is valuable for the physician to ensure that the patient is contracting the correct muscles as often as needed, and thus utilizing the perineometer correctly.

In the next section, “Objective Evidence of Improvement,” Kegel writes a list of changes and improvements female will face, such as improving organ prolapse and increasing muscle tone of the pelvic floor and vagina, if females perform the exercises correctly. In addition to helping patients become aware of the function of their pubococcygeus muscle, correctly performing resistance exercises causes the pubococcygeus muscle contractions to be stronger, and the perineometer readings to increase. He also adds that it may cause females to feel muscular contractions in areas not previously stimulated. Kegel states that the vaginal wall will become both tighter and firmer, allowing for patients to use better fitting forms of contraception, and the tone and texture of the tissues of the pelvic floor will improve. Kegel ends the list by explaining that the exercises will improve various types of organ prolapse and a patient may be able to stop using supportive devices for the prolapse.

The fifth section, titled “Therapy,” has two subsections, the first one being titled “Urinary Stress Incontinence,” where Kegel discusses that women with forms of urinary incontinence have experienced dramatic improvements after doing resistive exercises. Kegel emphasizes the two types of urinary stress incontinence, simple urinary stress incontinence and severe urinary stress incontinence, that are able to improve after consistent pubococcygeus muscle exercises. Simple urinary stress incontinence can result in urinary leakage when coughing, sneezing, laughing, or any other pressures on the bladder. Kegel states that more than 700 cases of simple urinary incontinence experienced complete relief after pelvic floor therapy. In severe urinary stress incontinence, individuals experience an either intermediate or a constant leakage of urine because they no longer have the reflexes that help them to control the flow of their urine. Kegel states that he observed that among 212 females with severe urinary stress incontinence eighty four percent of them regained what Kegel calls good urinary control. For some females it took two months of exercise for improvement, while for others there was no improvement after a year. Kegel explains that outside factors may have caused some the lack of improvement such as complications of surgery or advanced diabetes.

In the second subsection of “Therapy” titled “Genital Relaxation,” Kegel explains that more women experience genital relaxation, but it can be treated by strengthening the pubococcygeus muscles. Kegel explains that genital relaxation can occur during menopausal years, which is typically during the mid-forties to the mid-fifties, or the years when a woman is still able to give birth. He adds that the widest form of application for the perineometer is to treat cases of genital relaxation. He states that overall, females exercising their pubococcygeus muscles saw less improvement in their genital relaxation than with urinary stress incontinence, but many more women experience genital relaxation. Kegel states that restoring pubococcygeus muscle function and structure alleviates genital relaxation symptoms. Kegel states that after two to four weeks of constant exercise, patients already feel improved in terms of symptoms, but they must continue exercise to strengthen the muscles and to continue feeling relief. Even though the exercises were less effective for individuals with genital relaxation, patients described less discomfort and more strength in the pelvic and lower back region.

In “Prophylactic Use,” Kegel describes in two subsections titled “Obstetrics” and “Postoperative” that conducting resistive exercises during pregnancy or after surgery of the pelvic area can lessen the risk of the pelvic relaxation. In the first subsection Kegel discusses findings in a study published in 1950 that determined the usefulness of the exercises during pregnancy. The study found that about thirty percent of pregnant women have a weak perineum and weak contractions of the pubococcygeus. However, Kegel explains that through exercise, the pregnant individual’s muscles became stronger, their contractions after pregnancy remained stronger, and as a result postpartum recovery became easier. Additionally, Kegel explains that prevalence of genital relaxation was significantly reduced during the early postpartum period. In the second subsection, Kegel emphasizes that to restore use of the pubococcygeus muscle after a surgery, physiological therapy must be done to achieve that.

Finally, in his “Conclusion,” Kegel restates that the exercises or therapies done to strengthen the pubococcygeus muscle were successful, and further research is necessary to determine whether such therapies can address other health concerns. Based on his research, Kegel explains that it could be beneficial to study other complaints related to the certain organs of the female reproductive system to determine whether muscular dysfunction causes it. For example, he states that researchers have found that restoring the function of the pubococcygeus muscle could improve sexual function, or one’s ability to become sexually aroused and experience orgasm. Kegel ends the paper by emphasizing that pelvic floor therapy is a much larger field than researchers and physicians first suspected.

Impacts

According to Google Scholar, “Nonsurgical Methods” has been cited 235 times as of 2025. Since Kegel wrote “Nonsurgical Methods” in 1952, more research on the pubococcygeus muscle has shown its role in the pelvic floor. For example, researchers have studied the role of the pubococcygeus muscle in sexual function, urinary incontinence, organ prolapse, and many more conditions. In 1979, Benjamin Graber and Georgia Kline-Graber, a nurse-physician team published an article titled “Female Orgasm: Role of Pubococcygeus Muscle.” In it, Graber and Kline-Graber examined the physiological state of the pubococcygeus muscle in a group of 281 women. The data showed that the strength of pubococcygeus muscle strength played an important role in the strength of the female orgasm, thus lending further support to Kegel’s ideas.

Researchers have also established that females are not the only ones who benefit from strengthening their pelvic floors; males may also benefit. Improving the strength of their pubococcygeus muscle can help males with issues such as improving urinary or fecal incontinence or managing prostate pain and swelling. The prostate is an organ that is a part of the male reproductive system. In terms of sexual function, researchers have noted that strengthening the pelvic floor through exercise can help with sexual dysfunctions such as erectile dysfunction, which is the difficulty in getting or maintaining an erection, and premature ejaculation, which is when an individual ejaculates before they wanted to.

Between the time of publication in 1952 and 2025, strengthening the pelvic floor muscles, specifically the pubococcygeus muscle, has become a more widespread and well-known form of therapy. As of 2025, there is a branch of physical therapy specifically dedicated to strengthening the pelvic floor muscles. Pelvic floor physical therapy is a treatment that is specialized to include technologies or exercises that can strengthen the muscles and also relieve symptoms of pain and discomfort. Technologies may include tools or methods such as laser therapy or electrical stimulation which helps the muscles to contract and thus strengthen the pelvic floor.

“Nonsurgical Methods” and publications that followed have given more insight into the pubococcygeus muscle and its relationship to disorders such as urinary incontinence, organ prolapse, and sexual function. Such research has led to better non-surgical methods to improve pubococcygeus muscle strength and thereby treat or prevent common pelvic problems that women experience following childbirth.

Sources

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3. Graber, Benjamin, and Georgia Kline-Graber. “Female Orgasm: Role of Pubococcygeus Muscle.” The Journal of Clinical Psychiatry 40 (1979): 348–51.
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