Journal of Obstetrics and Gynaecology, 2014; Early Online: 1–4
© 2014 Informa UK, Ltd.
ISSN 0144-3615 print/ISSN 1364-6893 online
DOI: 10.3109/01443615.2014.960831
Effect of home-based Kegel exercises on quality of life in women with
stress and mixed urinary incontinence
S. Cavkaytar, M. K. Kokanali, H. O. Topcu, O. S. Aksakal & M. Doğanay
Department of Obstetrics and Gynecology, Dr Zekai Tahir Burak Women’s Health Research and Education Hospital, Ankara, Turkey­
The aim of this study was to assess the effects of home-based
Kegel exercises in women with stress and mixed urinary
incontinence. A total of 90 women with urodynamically proven
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urinary stress (SUI) and mixed (MUI) incontinence awaiting
anti-incontinence surgery were recruited in the urogynaecology
clinic of Ankara Zekai Tahir Burak Women’s Health Research
and Education Hospital. Of these, 18 women were excluded
due to low compliance and the remaining 72 were divided into
two groups according to urodynamic diagnosis (SUI group,
n  38; MUI group, n  34). Age, BMI, menopausal status and
medical history of the women were recorded. The women
took Kegel exercise, consisting of 10 sets of contractions/
day; each set included 10 repetitions, for at least 8 weeks. To
For personal use only.
evaluate the pelvic floor muscle strength, the modified Oxford
grading system was used before and after Kegel exercising.
The Incontinence Impact Questionnaire (IIQ-7); Urogenital
Distress Inventory (UDI-6) and the Patient Global Impression of
Improvement (PGI-I) questions were compared before and after
8 weeks of Kegel exercising. The age, BMI, gravidity, menopausal
status, macrosomic fetus history, hypertension and asthma were
similar between the groups. There were statistically significant
lower scores in both IIQ-7 and UDI-6 before and after Kegel
exercises within each group (p  0.001). The mean change of
the IIQ-7 and UDI-6 score was statistically significantly higher in
the SUI group than in the MUI group (p  0.023 and p  0.003,
respectively). Results of the Oxford scale were also statistically
significantly higher after Kegel exercises within each group
(p   0.001). In total, 68.4% of the women in the SUI group and
41.2% of the women in the MUI group reported improvements
which were statistically significant (p  0.02). We conclude that
home-based Kegel exercises, with no supervision, have been
found effective in women with SUI and MUI. The improvement
was more prominent in women with SUI.
Keywords: Home-based Kegel, mixed urinary incontinence,
quality of life, stress urinary incontinence
Introduction
Urinary incontinence (UI) is an important health and social
problem among women, with a prevalence of 25–45% (Milsom
et  al. 2013). Differences in definition, ethnicity and under-
reporting due to embarrassment would probably affect its
prevalence. In Turkey, UI prevalence in women is in the range
9.6–63.8% (Ekin et al. 2004; Cetinel et al. 2007).
Correspondence: S. Cavkaytar, Gurpınar sok. No: 4, 8 Cebeci, Cankaya, Ankara, Turkey. E-mail: sabri.cavkaytar@gmail.com
Stress urinary incontinence (SUI) is involuntary urine
leakage upon physical exertion, such as coughing or laugh-
ing (Haylen et  al. 2010), and its prevalence varies at 10–39%
(Dumoulin et  al. 2014). Mixed urinary incontinence (MUI) is
urine leakage with a combination of SUI and detrusor overac-
tivity and has a prevalence of 7.5–25% (Dumoulin et  al. 2014).
Thus, SUI and MUI constitutes nearly two-thirds of the women
with urinary incontinence.
Dr Arnold Kegel first reported successful outcomes in women
with SUI symptoms using pelvic floor muscle exercises, in 1948.
Since 1948, several physiotherapy methods have been used
(biofeedback, electrostimulation, vaginal cones, vaginal ball,
individual or group therapy) in the treatment of UI, with dif-
ferent success rates (Janssen et  al. 2001; Parkkinen et  al. 2004;
Konstantinidou et  al. 2007; Kashanian et  al. 2011). In a recent
review, pelvic floor muscle training (PMFT) has been found to
improve UI symptoms in all types of incontinence (Dumoulin
et  al. 2014). In the literature, most PMFT programmes have
been performed under regular control of a physiotherapist in
physiotherapy centres, which may not be cost-effective and is
time-consuming (Janssen et al. 2001; Konstantinidou et al. 2007;
Kashanian et al. 2011). Also, there is no study that compares the
effects of home-based Kegel exercises on SUI and MUI groups
separately.
In this study, we aimed to assess the effects of simple
home-based Kegel exercises in women who were on an anti-
incontinence operation list and had to delay the operation due to
various factors.
Materials and methods
A total of 90 women with urodynamically proven urinary stress
and mixed incontinence awaiting anti-incontinence surgery were
recruited in the urogynaecology clinic of Ankara Zekai Tahir
Burak Women’s Health Research and Education Hospital, between
April 2013 and March 2014. All the women had some reasons to
delay the surgery and none of them had performed pelvic floor
exercises before. All women gave written informed consent and the
study was approved by the Ethics Committee of the hospital.
Exclusion criteria were anti-incontinence or pelvic organ
prolapse surgery history, active urinary tract or vaginal infection,
pregnancy, post-void residual volume  100 ml, pelvic organ
prolapse  Grade 2, presence of comorbidities that affect the
lower urinary tract, such as neurological disease, diabetes
mellitus, psychiatric disease or renal failure.
 2  S. Cavkaytar et al.

Inclusion criteria were: urodynamically proven stress or Table I. Demographic characteristics of women according to groups.
mixed incontinence; age  18 years; positive stress test (urine SUI (n  38) MUI (n  34)
leakage with coughing when the bladder is 300 ml filled with
saline); and willing to participate to the study. Demographic n (%) n (%) p value
features of the women, such as: age; body mass index (BMI); Age (years) (mean  SD) 49.6  8.1 48.9  8.8 NS
gravidity; menopause status; macrosomic fetus history ( 4,000 BMI (kg/m2) (mean  SD) 30.6  4.4 31.7  4.5 NS
g); current smoking status; presence of hypertension and Gravidity (median, range) 4 (1–9) 4 (1–8) NS
asthma were recorded. Menopause 15 39.5 19 55.9 NS
Incontinence symptoms were evaluated by the validated Macrosomic fetus history 13 34.2 9 26.5 NS
forms of Incontinence Impact Questionnaire (IIQ-7) and the Current smoking 1 2.6 10 29.4 0.002
Urogenital Distress Inventory (UDI-6) in the Turkish population HT 9 23.7 6 17.6 NS
Asthma 2 5.3 1 2.9 NS
(Cam et al. 2007). The women’ self-assessment of their condition
was considered very important, according to the recommenda-
tions of the International Consultation on Incontinence and
was asked via the Patient Global Impression of Improvement The demographic characteristics of the women are presented
(PGI-I) question: Has your condition improved over the past in Table I. The age, BMI and gravidity of the women in each group
8 weeks? – which has a yes or no answer. were similar and there was no significant difference in the meno-
Kegel exercise was taught, as described by Kegel (1948) and pausal status, macrosomic fetus history, hypertension and asthma
also by stopping urination in the toilet, as described by Gosling between the groups (Table I). Current smokers were statistically
(1979) and it was confirmed that the women learned to use the significantly higher in the MUI group when compared with the
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correct muscles. The exercise programme consisted of 10 sets of
contractions per day and each set included 10 repetitions. The
women were told to continue Kegel exercises for at least 8 weeks,
since this period is necessary to strengthen the pelvic muscles.
The strength of the pelvic floor muscles (PFM) was assessed by
the same physician (SC) by using the modified Oxford digital
assessment (Laycock 1994). After bladder emptying, the two distal
phalanges of the index and the middle finger were inserted into
the introitus vagina and the women were asked to squeeze and
For personal use only.
SUI group (p  0.002).
When we compared the scores of IIQ-7 and UDI-6 before
and after Kegel exercises, there was statistically significant lower
scores in both IIQ-7 and UDI-6 within each group (p   0.001)
(Table II).
There was also a statistically significant improvement in pelvic
floor muscle strength in the Oxford scale after Kegel exercises
within each group (p   0.001) (Table II).
The mean change of the IIQ-7 and UDI-6 score was statisti-

lift their pelvic floor muscle. The contraction was graded accord-
ing to the modified Oxford grading system: 0 (no contraction);
1 (flicker); 2 (weak); 3 (moderate); 4 (good); 5 (strong) (Laycock
1994). At 10 days after teaching how to contract the pelvic floor
muscles, the women were evaluated as to whether they could
contract the correct muscles. The PFM assessment, UDI-6, IIQ-7
and PGI-I were performed 2 months after the Kegel exercises. The
PGI-I question (see above) was the primary outcome measure of
our study.
Data were stored and analysed using the SPSS version 13.0
(SPSS, Chicago, IL). Normality was tested by the Kolmogorov–
Smirnov test. The independent samples t-test and the Mann–
Whitney U test were used for comparison of continuous variables
according to normal distribution. The c2-test was used for com-
parison of categorical variables. The Wilcoxon signed-rank test
was used to compare the differences of non-parametric continu-
ous variables before and after treatment. A value of p  0.05 was
considered significant.
Results
Of the 90 women, 18 (8 in the SUI group; 10 in the MUI group)
who did not come to control, or could not perform Kegel exercises
regularly, were excluded from the study. The remaining
72 women formed the study group (SUI group, n  38; MUI
group, n  34).
cally significantly higher in the SUI group than in the MUI group
(p  0.023 and p  0.003, respectively) (Table III).
When the Oxford scale change was compared, there was no
significant difference between the groups (p  0.724) (Table III).
In SUI group, 68.4% of the women reported improvement
8 weeks after Kegel exercises, while 41.2% of the women reported
improvement in the MUI group, which was statistically signifi-
cant (p  0.02) (Table III).
Discussion
In our study, simple home-based Kegel exercises have been found
effective in the short-term treatment of women with SUI and
MUI. Although there was improvement in both groups of urinary
incontinence, women in the SUI group showed more improve-
ment on the quality-of-life (QoL) questionnaire and in PGI-I,
than in women with MUI (Table III). In vaginal assessment of
the pelvic floor muscles of women, by using the Oxford scale,
pelvic floor muscle strength increased significantly in both
groups. There was no significant difference in Oxford scale change
between the groups.
Recently, Dumoulin et  al. (2014) reported that PMFT was
found to improve UI symptoms in all types of incontinence.
Since Kegel exercises were found to be effective in the treatment
of SUI in women in 1948, various types of PMFT have been
proposed in UI treatment, such as biofeedback, electrostimulation,

Table II. Changes in QoL forms and vaginal assessment of pelvic floor muscles (Oxford scale).

SUI MUI

Before Kegel After Kegel p value Before Kegel After Kegel p value
IIQ-7 (mean  SD) 63.1  21 41.2  13  0.001 62.8  21 47.6  22  0.001
UDI-6 (mean  SD) 68.6  17 42.5  16  0.001 66.3  20 53.2  18  0.001
Oxford scale (median, range) 2 (1–4) 3 (2–4)  0.001 2 (1–3) 3 (2–4)  0.001
 Effect of home-based Kegel exercises on quality of life in women with stress and mixed urinary incontinence  3
Table III. Comparison of the mean changes of QoL forms, Oxford scale
and PGI-I.
SUI (n  38) MUI (n  34)
Median Range Median Range p value
IIQ-7 change 24 0–48 9 0–76 0.023
UDI-6 change 27 0–62 11 0–45 0.003
Oxford scale change 21 23–0 21 22–0 0.724
PGI-I (n, %) 26 (68.4) 14 (41.2) 0.02
vaginal cones, vaginal ball (Janssen et  al. 2001; Parkkinen et al.
2004; Konstantinidou et al. 2007; Kashanian et al. 2011). But low
patient compliance, high costs and regular control necessity, have
been the major concerns about the PMFT programmes. Simple
home-based Kegel exercises thus might be an alternative choice
to supervised PMFT (Janssen et  al. 2001). In the Netherlands,
individual and group PMFT have been found equally effective
in the improvement of UI in 530 women for at least 9 months
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(Janssen et al. 2001). Kashanian et al. (2011) reported improvement
of UI in 85 women who were on Kegel exercises or assisted Kegel
exercise treatment, but they found no difference between the two
methods. In Finland, 33 women with SUI were followed-up for
5 years; home-based PMFT with vaginal ball was found equally
effective with supervised PMFT with vaginal ball at the end of
the 5th year (Parkkinen et  al. 2004). However, Konstantinidou
et al. (2007) reported better results under intensive PMFT when
compared with home-based PMFT in 30 women with SUI. In a
study from Turkey, 34 women with SUI or MUI were randomised
For personal use only.
into a PMFT and a control group; increased pelvic floor muscle
strength and higher QoL scores were reported in the PMFT
group (Sar and Khorshid 2009). Similar to Parkkinen et al. (2004)
and Janssen et  al. (2001), we found significant improvement in
SUI and MUI women after Kegel exercises, even if performed at
home under no supervision.
Our primary aim was to investigate the women’s self-
assessment of their condition (PGI-I question) in SUI and MUI
groups. At 8 weeks after Kegel exercises, 68.4% of the women
reported improvement in SUI group, whereas 41.2% of the women
reported improvement in MUI group (p  0.02) (Table III). Thus,
women with SUI improved much more than women with MUI
by home-based Kegel exercises.
To reveal the effects of Kegel exercises on the QoL of the
women, validated questionnaires UDI-6 and IIQ-7 were used in
this study (Cam et  al. 2007). In both groups, IIQ-7 and UDI-6
scores decreased significantly after Kegel exercises (Table II).
When we compared the mean change of the IIQ-7 and UDI-6
scores between the groups, the improvement in QoL was statisti-
cally significantly higher in the SUI group than in the MUI group
(p  0.023 and p  0.003, respectively) (Table III). Sar et al. (2009)
and Fan et  al. (2013) reported improvement in QoL in women
with SUI and MUI, similar to our results but we have found more
improvement in the SUI group.
Pelvic floor muscle tone and maximal strength have been
found to be worse in women with SUI and MUI than in conti-
nent women (Morin et al. 2004; Verelst and Leivseth 2004). The
increase in pelvic floor muscle strength supports the urethra,
which prevents urine leakage under physical exertion (DeLancey
1988) and also might inhibit detrusor muscle contraction in
urge incontinence (Godec et al. 1975). Vaginal digital palpation
and intravaginal pressure measurements were reported to have
good correlations in the PFM assessment (Hahn et  al. 1996;
Kerschan-Schindl et  al. 2002). The modified Oxford grading
system is widely used, is quick and does not require any instru-
ments in PFM assessment (Morin et al. 2004). In our study, there
was also statistically significant improvement in pelvic floor
muscle strength in the Oxford scale after Kegel exercises within
each group (p  0.001) (Table II). But the improvement in the
Oxford scale was similar in both groups, indicating that the PFM
strength increase was similar (p  0.724) (Table III). Thus, the
differences in QoL in both groups might not be only due to pelvic
floor muscle strength. Since good correlation between vaginal
digital palpation and pressure measurements has been reported,
such as in our study and others (Hahn et  al. 1996; Kerschan-
Schindl et al. 2002; Morin et al. 2004), the Oxford scale can be
used widely in clinical practice.
Confounding factors, such as age, BMI, gravidity and meno-
pausal status that can affect UI, were similar in both groups,
which increases the strength of our study. Urodynamically proven
pre-treatment diagnosis of the women is another important
advantage of our study.
The compliance of the women were evaluated by self-
reporting. Also there was no control group in this study to elimi-
nate the placebo effect and the examination of PFM strength by
the same examiner who knew the study protocol might have
caused bias in the final assessment of PFM strength. These might
be accepted as the limitations of our study.
As a result, home-based Kegel exercises under no supervi-
sion have been found effective in women with SUI and MUI but
give much improvement in women with SUI. Home-based Kegel
exercises can be used widely in clinical practice due to low costs,
high patient compliance and good efficacy, but large prospective
randomised clinical trials that investigate long-term effects of
home-based Kegel exercises are necessary.­­­
Declaration of interest:  The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the paper.
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