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Dr Arnold Kegel
Kegel exercises were originally developed by Dr. Arnold Kegel in
1948 as a method of controlling incontinence in women following
childbirth. Dr. Kegel is a californian gynecologist, famous also
for his Kegel Perineometer used for measuring vaginal pressure.
The text of Dr Kegel's original article follows
A Nonsurgical Method of Increasing the Tone of Sphincters and
their Supporting Structures
Arnold H. Kegel, M.D., F.A.C.S.
Assistant Professor of Gynecology University of Southern California
School of Medicine
Every physician has had occasion to observe that six months after
a well performed vaginal repair with construction of a tight, long
vaginal canal, the tissues, especially the perineum, will again
become thin and weak. It was this repeated observation which first
aroused the author's interest in the physiology of the pelvic musculature.
Everyone agrees that suitable exercises will improve the function
and tone of weak stretched, atrophic muscles. A point in fact is
the correction of faulty posture. Why then would it not be possible
to restore through active exercise the normal anatomic relationships
of pelvic structures, since they depend so largely for their support
on various muscle groups?
In the study of this problem, which we have carried out over a
period of 18 years, we have become greatly interested in one muscle,
the functional importance of which has been largely overlooked by
anatomists, obstetricians, and gynecologists alike - the pubococcygeus.
This muscle, when observed in emaciated cadavers, is in such a state
atrophy that it would seem to be capable of little function.
The surgeon who operates from below encounters only the more superficial
muscles of the vulvar outlet and argental diaphragm. This is true
also of prophylactic episiotomy. Similarly, operations from above
rarely include the pubococcygeus. It is for these reasons that the
importance of this muscle has not been fully recognized.
Attention has been focused on the pubococcygeus by the studies
of Barry J. Anson with Curtis and McVay who, in dissections of young
female cadavers, demonstrated for the first time that the pubococcygeus
gives off innumerable fibers which interdigitate and insert themselves
into the intrinsic musculature of the proximal urethra, middle third
of the vagina and rectum.
Our own study in the dissecting room, in surgery, and in animal
experiments, as well as observations of the effect of exercise in
several thousand patients, has led us to conclude that the pubococcygeus
is the most versatile muscle in the entire human body. It contributes
to the support and sphincteric control of all pelvic viscera and
is essential for maintaining the tone of other pelvic muscles, both
smooth and striated.
After having been stretched over a wider range than any other skeletal
muscle, the pubococcygeus can regain physiologic tension and, as
we have demonstrated, it is able to recover its function after many
years of disuse and partial atrophy.
Palpation demonstrates that in a normal pelvis with the viscera
in their normal position, the pubococcygeus and all of its components
are well developed. However, when genital relaxation has occurred,
this muscle is found to be weak and atrophied.
Genital muscle relaxation, as manifested by urinary stress incontinence,
cystocele, or prolapse of the uterus as well as certain types of
lack of sexual appreciation, is always associated with - even if
not directly due to-dysfunction of the pubococcygeus. This fact
has been borne out by the success of non-surgical treatment of these
conditions, applying the general principles of muscle education
and resistive exercise to the pubococcygeus as the pivotal structure
of the pelvic musculature.
The fasciae are not discussed here for the reason that, whether
injured or intact, they depend upon their muscular attachments for
nourishment, viability, tone and tensile strength. When grossly
disrupted they remain a surgical problem.
A firm vaginal canal, well closed to a high level, indicates normal
development of the interdigitating fibers of the pubococcygeus.
Loss of tone and prolapse of the vaginal walls, as is found in genital
relaxation, signify weakening and thinning of these minute branchings.
The musculature of the middle third of the vagina is readily palpated
by means of the index finger introduced up to about the second joint,
or 3 to 5 cm beyond the introits.
In the normal vagina, the canal is tight and the tissues offer
a degree of resistance from all directions. The walls close in around
the finger as it is inserted, moved about, or withdrawn. Upon palpation,
the walls of the middle third of the normal vagina feel firm throughout,
and adjacent tissues give the impression of depth and good tone
because the terminal fibers of the pubococcygeus are well developed
and are attached to the intrinsic tissues of the vagina over a wide
In genital muscle relaxation on the other hand, the findings are
decidedly different. Whether the introitus is gaping or tight, the
vaginal canal in its middle third is short and roomy in all directions.
The walls offer little resistance to the palpating finger and feel
thin and loose, as if detached from the surrounding structures.
The tissues between the palpating finger and the symphysis or rami
of the ospubis are thin, tender, and of poor quality. From this
it can be concluded that the muscular structures in the perivaginal
regions are atrophied, particularly the terminal fibers of the pubococcygeus.
Vaginal examination as described up to this point differs little
from the usual technique practiced for the past hundred years. The
physical status of the perivaginal tissues has thus been ascertained,
but the cause of weakness and atrophy has not been determined. To
this end it is necessary to investigate the functional status of
the supportive and sphincteric muscles of the pelvic outlet, especially
of the pubococcygeus.
The first step in the examination for function is to observe whether
by voluntary effort the patient is able to retract, draw up, or
draw in the perineum. Next, the index finger is introduced into
the middle third of the vagina, and the patient requested to contract
upon it. Normal patients will respond immediately, and a firm grip
upon the finger is felt over a wide area. Others, lacking awareness
of function of the pubococcygeus, will not respond to the instruction
and will often state that they did not know that it was possible
to contract vaginal muscles. It is in this group of patients that
palpation demonstrates the atrophy of disuse.
The digital method of ascertaining the presence of contractions
of the perivaginal muscles should be supplemented by the diagnostic
use of the Perineometer. With this instrument, strength of contractions
in the middle third of the vagina as well as the width of the contracting
area can be measured and a progress chart of record kept to follow
the results of therapy.
The Perineometer is a simple, pneumatic apparatus consisting of
a vaginal resistance chamber connected with a manometer calibrated
from zero to 100 mm. Hg. The resistance chamber measures 2 cm. in
diameter and 8 cm. in length and is formed by a cylindrical rubber
diaphragm stretched to a specific tension between two flanges on
a metal stem. The vaginal parts of the Perineometer conforms to
the approximate dimensions of the normal vagina and is so designed
that pressure over a wide area will result in higher readings than
pressure of identical strength applied to a narrow area. The vaginal
chamber is compressible, without significant compensatory expansion.
The specifications of this simple apparatus were established after
18 years of experimentation with more than 30 different types of
instruments. Only in rare cases, when the vagina has been greatly
shortened through surgical intervention or radium therapy, will
it be found necessary to reduce the size of the vaginal chamber
of the instrument.
When the resistance chamber is introduced, a slight rise on the
scale of the manometer will be noted even before the patient exerts
any effort. This represents the static pressure which in a normal
vagina amounts to 15 to 20 mm. Hg. and indicates good muscle tone
and tissue resistance over a wide area.
In genital relaxation, muscle tone is poor and tissue resistance
is limited to a narrow area. Consequently, in such cases the initial
pressure is low, about 10 mm. Hg.
Contractions of a normally developed pubococcygeus are registered
by a prompt increase in manometric reading to 20 mm. Hg. or more
above the initial static pressure. Lack of awareness of function
and degrees of atrophy of the pubococcygeus are reflected by a small
or almost imperceptible increase in pressure, usually less than
5 mm. Hg. Intermediate readings may be obtained in patients having
awareness of function but only a narrow, poorly developed or partially
atrophied pubococcygeus muscle. In measuring function of the pubococcygeus,
it must be made certain that the patient is not using extraneous
muscles, such as those of the abdominal, gluteal, orintroital regions.
Physiologic therapy of genital muscle relaxation is divided into
two phases or steps: (1) specific muscle education and (2) resistive
exercises of the pubococcygeus and its visceral extensions.
Specific Muscle Education
The first and most important step in therapy is muscle education.
This is directed toward establishing adequate awareness of function
of the pubococcygeus, which is the pivot of all supportive and sphincteric
structures of the pelvis.
At the first office visit, approximately one third of all patients
will be unable to contract the pubococcygeus voluntarily, or to
only a questionable degree. When such is the case, palpation is
continued until the examiner finds among the contiguous muscles,
one which is under the patient's control. With this as a starting
point, contractions of the contiguous muscle are continued and varied
until the pubococcygeus itself is affected by such muscular movements.
The contractility of the pubococcygeus can be determined most readily
in its anterior portion, where the fibers converge toward attachment
to the os pubis, and posteriorly near the coccyx. In order to demonstrate
contractions near the pubis, the postero-inferior margin of the
symphysis is identified with the index finger, which is inserted
only to the second joint.
The tip of the finger is passed laterally from the midline for
about 0.5 to 1.0 cm. until the tendinous medial margin of the pubococcygeus
is encountered; the margin is then followed downward for a short
distance, approximately to the level of the urethra. At this point,
contractions of the pubococcygeus, if present, are felt as a tensing
of its medial margin, which may feel like a thin sheath, or it may
be as broad as thick as a finger.
The pubococcygeus is palpated for function on both sides. Occasionally,
unilateral impairment due to injury is revealed. In identifying
the pubococcygeus, it should be remembered that congenital variations
occur in its aponeurotic attachments.
Posterior contractions of the pubococcygeus are identified by inserting
the finger deeply into the vagina or rectum. When palpating in the
midline, the pubococcygeus can be felt near its attachment to the
coccyx. With the finger in contact with the muscle, the patient
is requested to contract it. Normally it will be noted that the
posterior portion of the muscle has the ability to rise upward for
a distance of 2 to 4 cm.
If there is lack of awareness of function of the pubococcygeus,
no such voluntary action can be elicited. The patient is then requested
to draw up or draw in the anus as though checking a bowel movement.
Pressure may also be applied with the tip of the finger to aid the
patient in identifying and contracting the pubococcygeus. If no
response is forthcoming, pressure is increased to the point of discomfort,
and the patient instructed to pull the muscle against the finger.
In obstinate cases, reflex contractions may be produced by pricking
the skin lateral to the anus. Repetition of any such action of the
pubococcygeus for several minutes will usually enable the patient
to continue the same contractions through voluntary effort. To make
certain that the contractions elicited are those of the pubococcygeus
and not of the iliococcygeus, they are followed anteriorly until
they can be felt as tensing of the medial margins of the muscle
at the level of the urethra.
Under the guidance of the physician, the patient who initially lacked
awareness of function of the pubococcygeus has at this point learned
that the muscle can be contracted voluntarily.
Since therapeutic results can be expected only from frequent repetition
of active contractions of the pubococcygeus, these efforts are now
described in terms of muscular functions of which the patient is
\With his finger on the medial margin of the pubococcygeus at the
level of the urethra, the physician instructs the patient to (1)
squeeze the vaginal muscles upon the palpating finger; (2) draw
up or draw in the perineum; (3) contract or draw up the rectum as
though checking a bowel movement; (4) contract as though interrupting
the flow of urine while voiding.
The examiner makes sure that while performing these movements the
patient is actually contracting the pubococcygeus and not merely
muscles around the orifices. It must be emphasized that woman with
poor function of the pubococcygeus have all their lives compensated
for this deficiency by depending for support upon the fasciae and
the more superficial muscles.
If the pubococcygeus is not functioning the following will be observed:
When an effort is made to draw up or draw in the perineum, no actual
retraction occurs. Instead there is a tightening of the gluteal
muscles together with sphincteric action which is confined to the
introital group of muscles, including the bulbocavernosus, the transverse
perinei, and the superficial pillars of the levator ani.
In the effort to contract as though to stop the flow of urine,
only a slight twitching of the meatus of the urethra is observed,
without retraction of the urethra itself or of the vaginal tissues
overlying it. These shallow, superficial contractions are in themselves
of no value in the prevention and treatment of genital relaxation
and urinary stress incontinence. When contracting as though to check
a bowel movement, the action is limited to puckering of the anus,
and no retraction of the anus is observed.
The patient may be permitted to repeat these superficial contractions
temporarily, but she is urged to try to transfer them to a higher
level of the pelvic outlet, until contractions of the pubococcygeus
muscle are felt by the palpating finger. Approximately 75 percent
of patients will respond after 10 to 20 minutes of instruction.
In other instances, considerable patience is required and the instructions
must be repeated at weekly intervals, occasionally over a period
of many months, before the patient learns to contract the pubococcygeus.
In exceptional cases, the attempt to establish awareness of function
fails completely. This is usually due to concomitant lesions of
the central nervous system.
Establishment of awareness of function of the pubococcygeus is essential.
No clinical results from physiologic therapy can be expected without
activation of this muscle.
Very few women who initially lack awareness of function of the pubococcygeus
will be able to continue correct contractions of this muscle at
home after instruction in the office. Since they are unable to coordinate
their muscles through the usual reflexes, it is necessary to establish
a connection between contractions of the pubococcygeus and the sense
of sight. Also, unless given an opportunity to repeat their efforts
under visual control, thereby noting any progress they may make,
patients are apt to become discouraged. A simple, direct, and reliable
means to overcome these difficulties is the Perineometer. The last
phase of office procedure is devoted to instructing the patient
in the use of this apparatus.
In addition to visual control, this instrument provides a means
of contracting the perivaginal muscles against resistance. Resistive
exercises of this type have proved most effective in all branches
of muscle therapy for the correction of disuse atrophy and for restoration
of normal function. Resistive exercises are designed to strengthen
the pubococcygeus in all its components, especially the minute end-fibers
which, in genital relaxation, have undergone atrophy. This muscle
is not accessible to any other therapeutic measure, and its function
is rarely improved by surgical procedures.
With the vaginal chamber of the Perineometer in place, the physician
watches the manometer while the patient repeats for several minutes
those efforts of which had been found to result in contractions
of the pubococcygeus muscle. If the patient who had previously lacked
normal awareness of function uses the pubococcygeus, only irregular
and weak contractions can be expected. The indicator will show only
a slight rise, between 1 and 5 mm. Hg.
The patient herself watches the manometer while continuing the
same efforts. If contracting correctly, she is instructed to continue
the same exercises at home for 20 minutes three times daily. In
addition to these exercises, the patient is advised to repeat the
same contractions without the apparatus many times a day. The more
frequently correct contractions are repeated, the sooner will the
muscular function be established as a reflex that does not require
any further voluntary effort.
About 50 percent of all patients who start their exercises correctly
will, during the first few weeks, lapse back into the old habit
of using extraneous muscles instead of the pubococcygeus. Therefore,
it is necessary to re-examine and re-instruct at weekly intervals
for one month, and thereafter as often as necessary to insure correct
use of the Perineometer. In this respect, a progress chart kept
by the patients is of great value.
Complaints of fatigue, aching muscles of the back and abdomen,
and nervous irritability following exercises are usually due to
unnecessary use of extraneous muscles.
Objective Evidence of Improvement
In patients who exercise correctly and diligently, the following
progressive changes will occur:
- Establishment of awareness of function of the pubococcygeus.
- Slight, gradual increase in initial manometric readings from
a level of 1 to5mm. Hg. to as high as 20 to 40 mm.Hg. or more.
- Muscular contractions can be felt in areas where none could
be demonstrated before, especially in the anterior and lateral
quadrants of the vaginal wall.
- Contractions of the pubococcygeus which at first were weak and
irregular became strong and sustained.
- Improvement in tone and texture of all musculofascial tissues
of the pelvic floor and outlet takes place.
- Increased bulk of the pubococcygeus and its visceral extensions
- Changes occur in the position of the perineum, introitus, urethra,
bladder, neck, and uterus in relation to an ideal line drawn between
the os pubis and coccyx.
- The vaginal canal becomes tighter and longer.
- The vaginal walls, which formerly were flaccid, improve in tone
- Bulging of the anterior vaginal wall (often diagnosed as moderate
cystocele) becomes less pronounced.
- Prolapsus of a freely movable uterus, when present, with cervix
presenting near the level of the introitus is usually improved,
and in some instances the cervix has ascended to as high as 5
to 7 cm. above the introitus.
- Supportive pessaries, worn for as long as ten or more years,
can usually be discarded without return of discomfort.
- Patients can be fitted with smaller contraceptive diaphragms,
whereas diaphragms of larger size formerly slipped out of place.
Urinary Stress Incontinence
Muscle education and resistive exercise with the Perineometer produce
dramatic results in the treatment of true urinary stress incontinence.
This type of incontinence must be distinguished from urge incontinence
caused by various pathologic conditions involving the upper urinary
tract, such as infections, strictures of the ureter, stones, diverticula,
developmental anormalies, etc.; incontinence due to fistulae; and
spastic incontinence due to spinal cord changes following injuries,
poliomyelitis, multiple sclerosis, etc.
In simple urinary stress incontinence, control of the urinary outlet
is partially lost with coughing, sneezing, laughing, or other sudden
strains. In the past, women tolerated this annoying and embarrassing
condition with all its undesirable psychological effects because
it was felt that the conditions did not warrant surgical intervention.
With physiologic therapy, complete relief from simple urinary stress
incontinence has been consistently obtained in a series of over
700 cases of this type.
As some degree of awareness of function is initially present, the
response to muscle education is prompt. Symptoms usually show improvement
within two weeks after starting resistive exercises using the Perineometer.
Lasting relief, however, depends on firms establishment of muscle
reflexes and strengthening of muscular structures.
In severe urinary stress incontinence, dribbling is constant or
intermittent. Patients with this degree of incontinence have ceased
to make an effort to control the flow of urine, depending on pads
and tampons. The normal reflexes of urination have been practically
In these cases, because the pubococcygeus has been little used for
many years, the muscle is atrophied. Often there is a history of
so-called "bladder weakness" dating from childhood, aggravated
by childbirth, severe illness, injury, menopause, senile changes,
or pelvic surgery. Cases of this type have in the past been treated
by surgical intervention, often with disappointing results.
The first step of physiologic therapy, muscle education, must be
carried out meticulously and with great patience in this group.
It is often necessary to repeat instructions at weekly intervals
for many months.
Since these patients are trying to contract muscles which they probably
have never before in their lives used voluntarily, they are likely
to employ those of the abdominal and gluteal regions. It is therefore
necessary to re-instruct patients carefully during weekly office
visits and, at the same time, prevent them from becoming discouraged
in their efforts.
As awareness of function and strength of the atrophied visceral
end-fibers of the pubococcygeus returns, Perineometer readings will
increase slightly and gradually. Approximately two months of diligent
exercise is required before improvement of symptoms is noted. In
a few cases satisfactory relief was not attained until after a year
of concentrated effort.
Severe urinary stress incontinence has been treated by physiologic
therapy in a series of 212 patients, the majority of whom had previously
undergone one or more unsuccessful surgical interventions to relieve
incontinence. Good urinary control was established in 84 percent
of this group.
These patients were able to discontinue the use of pads and have
remained continent under normal circumstances. Recurrences have
occurred after debilitating illnesses, prolonged spells of coughing,
etc., but these could usually be controlled by resumption of resistive
exercises for a few weeks.
While all cases of simple urinary stress incontinence were relieved,
only partial relief or failure occurred in 16 percent of patients
with severe urinary stress incontinence. These failures could be
traced to local or general complications. Local conditions included
marked shortening and scaring of the anterior vaginal wall due to
previous surgical procedures or radium therapy. In three instances,
however, good results were obtained following surgical release of
restricting fibrous bands. Also, it appears that exercises of the
pubococcygeus cannot succeed where the connections between this
muscle and bladder neck and proximal urethra have been severed.
Among the general conditions accounting for failures are neurologic
changes, mental deficiency, senility and advanced diabetes.
When urinary stress incontinence coincides with a large cystocele,
the incontinence is first relieved by active exercises and the cystocele
corrected later through surgical repair.
Additional Measures in the Treatment of Urinary Stress Incontinence:
Patients suffering from urinary incontinence usually have formed
the habit of restricting fluid intake. In order to increase use
of the bladder outlet, they are advised to drink at least 8 to 10
glasses of water a day and to interrupt the flow of urine several
times while voiding. If successful, the contractions which resulted
in interrupting the stream should be remembered and immediately
duplicated during exercises with the Perineometer. The use of vaginal
tampons and pessaries which exert pressure upon the bladder neck
to control the urine is discontinued, since they interfere with
the urinary reflex and contribute to atrophy of the pubococcygeus.
For the same reason perineal pads to absorb the urine are reduced
in size and eliminated as quickly as possible.
The widest field of application of Perineometer exercises is in
the treatment of genital relaxation during the childbearing and
early menopausal years. While the results obtained are less dramatic
than in the treatment of urinary stress incontinence, many more
women (over 30 percent) complain of this annoying condition.
In the past, no conservative treatment has been available. Women
in their child-bearing and most active years, therefore, had to
endure discomforts and pelvic fatigue due to genital relaxation,
usually described by the patient as bearing down, fullness, or "falling-out"
sensations, until surgical intervention became advisable after the
This type of genital relaxation is recognized clinically by marked
roominess of the middle third of the vagina and the presence of
some degree of cysto-urethrocele, uterine prolapse, rectocele, and
bulging or lax perineum. It has been found that these conditions
are associated with poor function of the pubococcygeus, and that
when function of this muscle is restored, complaints are often relieved
and the clinical findings ameliorated.
Functional and structural improvement of the pubococcygeus has
been demonstrated to have indirect influence on the support of the
uterus. It has been observed that with increasing tone of the pubococcygeus
the smooth muscle diaphragm, which is the chief support of the uterus,
becomes strengthened - again demonstrating the pivotal importance
of the pubococcygeus muscle.
Subjectively, patients describe relief of their complaints as feeling
stronger in the pelvic, groin, and lower back regions and report
that they are able to be on their feet for long periods of time
and do their housework without having to lie down at frequent intervals.
Since the discomforts of genital relaxation are not as incapacitating
as those in urinary stress incontinence, women in this category
are apt to be haphazard in their exercises. It is, therefore, common
experience that it takes longer before definite and enduring results
are obtained. Diligent patients usually begin to notice symptomatic
relief after 2 to 4 weeks of resistive exercises. Structural changes
are, at this time, too slight to be palpable. In order to be of
lasting benefit, exercises must be continued until improvement in
tone and strength of the muscle can be clinically demonstrated.
After the beneficial effect of resistive exercises on atrophy of
the pubococcygeus muscle had been satisfactorily established, it
was logical to prescribe Perineometer exercises before major degrees
of pelvic relaxation had occurred.
The usefulness of these exercises during pregnancy has been extensively
investigated by Bushnell. His experience, which now includes more
than 500 patients, indicates that about 30 percent of all pregnant
women have a weak, thin perineum and poor contractions of the pubococcygeus.
By exercises with and without the Perineometer, the muscles become
stronger, thicker, and firmer. Postpartum repair is facilitated,
and fewer sutures are required. As soon as the effect of anesthesia
has worn off, these patients are able to perform strong contractions
of the perivaginal muscles, especially at the level of the middle
third of the vagina. Pain and edema are less frequently observed.
The incidence of early postpartrum relaxation of genital muscles
was greatly reduced. One would expect that in later years urinary
stress incontinence, cystocele, urethrocele, uterine prolapse, and
malposition of the uterus will develop less frequently in these
patients. However, no definite statement to this effect can be made
until after additional years of observation.
Taken as a group, young expectant mothers are most diligent in their
exercises of the pubococcygeus muscle. Their cooperation is easily
obtained once they understand the relationship of a strong pelvic
musculature to sexual appreciation and the avoidance of later so-called
The value of postoperative exercises for restoration of normal function
has been firmly established in all other plastic and orthopedic
procedures for repair of neuromusculofascial-tendinous structures.
Physiologic therapy of the pubococcygeus permits application of
the same principle to surgical reconstruction of the tissues of
the pelvic outlet.
Because of the great friability of the muscles, the surgery of the
pelvic repair is limited to anatomic approximation of the fasciae.
Whatever reconstruction of the muscles can possibly be achieved
is incidental to repair of the fasciae.
Restitution of muscular function, essential to maintenance of the
surgical result, can only be obtained by the subsidiary technique
of active exercises of the pubococcygeus. Thus, these exercises
are indicated following perineorrhaphy and in anterior repair to
improve elastic support of the bladder, including all types of surgical
procedures for the correction of urinary stress incontinence. As
Collins has pointed out: "It is a good idea in all cases that
have been operated on for prolapse of the vagina vault or uterus,
or in every postpartal woman to teach them how to contract the vaginal
musculature and let them use this as a prophylactic measure."
Experience with muscle education and resistive exercises of the
pubococcygeus has proved gratifying whenever these procedures have
been applied to conditions due to, or connected with, impaired function
of the pelvic musculature. On the basis of therapeutic results achieved,
it seems possible that other ill-defined complaints referable to
the genital tract in women might profitably be studied from the
standpoint of muscular dysfunction. For instance, it has been found
that dysfunction of the pubococcygeus exists in many women complaining
of lack of vaginal feeling during coitus and that in these cases
sexual appreciation can be increased by restoring function of the
pubococcygeus. The field of physiologic therapy of the pelvic muscles
is thus much wider than at first suspected.
In the present paper, only the essential points of diagnosis and
therapy of genital muscle relaxation have been presented.
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Bushnell, Lowell F.: Physiologic Prevention of Postpartal Relaxation
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To be published in J.A.M.A.
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