Sitting on the toilet!! Actually sitting, skin to porcelain. No more hovering! Even in public restrooms. I know, it’s going to be a tough paradigm shift since this issue is ubiquitous; one study, done in the UK, surveyed 528 women at a gynecology clinic and found that 85% reported that they crouched over public toilets while urinating. 12% said that they used a paper toilet seat cover and 2% reported that they sat all the way down1. Only 2%! So, I decided to make a point to ask every woman that I’ve seen recently in my office what their preference is regarding toilet seats.The answer: overwhelmingly in favor of squatting over the pot (especially when in public).

This week, my goal is to try to dispel some of the myths about public toilet seats and try to convince you, the readers, that sitting on the toilet is more important to urinary/bowel function and health than the germs you might find hanging out on the john.

 

First, let me back up and explain how our urinary and bowel systems work from a musculoskeletal standpoint. A typical urinary system works like this: liquid waste (urine) that has already been filtered by the kidneys, empties into the bladder. As the bladder fills, it stretches to accommodate the extra volume. Once it starts getting somewhat close to full, (about 300 cc or about 1 ¼ cup) it sends a message to the brain, which then sends a message to the pelvic floor muscles to say “Hey, we need to pee, let’s get to an appropriate place (in this case we are going to call ‘that place’ the toilet).” We get to the toilet, we sit, our brain tells our pelvic floor muscles and the urinary sphincters to relax and we empty our bladder. In an adult with typical or “normal” urinary function, we expect close to full emptying of the urine in the bladder.

 

The bowel system works similarly: The colon fills with solid waste, it moves by peristalsis through the ascending, transverse, and descending colon. Once it arrives in the rectum, a signal is sent to the brain, that says it’s time to go. We get to a toilet, we sit, the sphincters relax, we empty. Voila.

 

Hovering over a toilet seat can become seriously problematic, especially if it is a habit that you have been practicing for many years. Even if all of the events leading up to voiding may be normal,when we hover, we are engaging so many muscle groups to support us in that position! Think about doing a squat and holding it for 45 seconds. Better yet-try it. If you do, you can feel the core engage, as well as the quadriceps, hamstrings, gluteals, and pelvic floor muscles. They are all on! So the mechanisms to empty the bladder/bowel engage, but the sphincters CANNOT fully relax here. It becomes an uphill battle.

 

The sphincters cannot fully relax, which means that the bladder and/or rectum could not fully empty, meaning that now we are getting a backup of residual waste left in the body. If this becomes a regular occurrence we can begin to see issues arise within the bowel/bladder systems. We can begin to see increased risk for bladder stones, infections, hesitancy, urgency and frequency, constipation, prolapse, and incontinence.  

 

In the same study that I mentioned above, the researchers found that there was a 21% decrease in average urine flow rate and a 149% increase in residual urine volume in women that voided in a crouching position. They went on to conclude that women found with any abnormal bladder voiding/retention symptoms may benefit from being encouraged to sit comfortably on the toilet whenever possible1.

 

Still not convinced? Ok let me try a different route. In 2014, an article came out in the journal of Applied and Environmental Microbiology. In this study researchers found that “while enteric bacteria would be dispersed rapidly due to toilet flushing, they would not survive long, as most are not good competitors in cold, dry, oxygen-rich environments.”2 In other words, although germs are present in and on all toilets, they don’t last long. In an interview for The Huffington Post, Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center commented, “toilet seats are not a vehicle for the transmission of any infectious agents — you won’t catch anything.”3

 

Intact skin is generally thought of as an effective germ barrier, and the skin of the buttocks and legs is relatively thick. If you have very thin or cracked skin on the buttock or thigh, or have any open wounds in that area consider wiping the seat down. The American Society for Microbiology (ASM) published a study which found that after a porcelain surface had been wiped one time with either water, liquid soap, or an antibacterial wipe,* the amount of germs was decreased 10,000 times. A second wipe further reduced any remaining germs 1,000 times.4

 

A study published by the Public Library of Science swabbed flushers, door latches, faucet handles, and towel dispensers and found they are as dirty as, or dirtier, than the toilet seats themselves.5 In fact, many other places far from toilets are colonized by microbes. The main culprits include kitchen sponges, playground equipment, gym mats, and computer keyboards.5 And don’t get me started on your cell phone; cell phones carry 10 times more bacteria than most toilet seats, according to Charles Gerba, a microbiologist at the University of Arizona.6

 

Have I totally freaked you out? Don’t worry! Germs ARE everywhere. But if your immune system is healthy, and if you adopt simple hygienic measures like hand washing, you should have no problem kicking those pathogens to the curb. So let’s do it! Let’s all just start wiping the toilet seat off with a preliminary toilet paper wipe and sit yourself right down. And enjoy the full pee/poop that comes to follow**. Get the word out-let’s make 2016 the year we start sitting down on those seats and put our “germ-phobia” to rest!

 

*Remember not to flush antiseptic wipes because they are detrimental to our oceans. Instead, throw them in the trash.

 

**That being said, we have found that it is also important to increase the hip flexion angle for best pee/poop success. See this blog for more info.

 

References:

 

1. Moore KH, Richmond DH, et al. Crouching over the toilet seat: prevalence among British gynaecological outpatients and its effect upon micturition. Br J Obstet Gynaecol. 1991 Jun;98(6):569-72.
2. Gibbons S. M., Schwartz T., et al. Ecological succession and viability of human-associated microbiota on restroom surfaces. Appl. Environ. Microbiol. Online. Ahead of print 14 November 2014; doi:10.1128/AEM.03117-14 .
3. “Why Using Toilet Seat Liners Is Basically Pointless.” Interview by Amanda L. Chan. Huffington Post 17 June 2014: n. pag. Web.
4. Tuladhar, E, Hazeleger, W, et al. Residual Viral and Bacterial Contamination of Surfaces after Cleaning and Disinfection. Appl. Environ. Microbiol. November 2012 vol. 78 no. 217769-7775.
5. Flores GE, Bates ST, Knights D, Lauber CL, Stombaugh J, Knight R, et al. (2011) Microbial Biogeography of Public Restroom Surfaces. PLoS ONE 6(11): e28132. doi:10.1371/journal.pone.0028132
6. Gerba, Charles. “Why Your Cellphone Has More Germs than a Toilet.” Interview. Https://cals.arizona.edu/spotlight/why-your-cellphone-has-more-germs-toilet. The University of Arizona, College of Agriculture and Life Sciences, 15 Sept. 2012. Web. 29 Mar. 2016.

By Admin

Disclaimer: I’m a PT and a Pilates instructor.  Often, patients ask if Pilates is the answer for their pelvic floor dysfunction.  You know that old saying, “Kegel-ing all day, keeps the urine at bay.”  Well, unfortunately, this is not always true.  At times Kegel-ing can make actually make your symptoms worse, be it urinary urgency, frequency, incontinence or pain!  Sometimes these type of symptoms are due to the pelvic floor muscles being too contracted.  Since a Kegel is a contraction of your pelvic floor muscles, you can see how contracting muscles that are already too contracted may exacerbate symptoms.  Take a look at Liz’s post to get a little more info. 

 

So, since that’s a bit more settled let’s get to the purpose of this post: Pilates exercises for the short/tight, or in other words, too contracted pelvic floor.  Pilates provides a breadth of repertoire that focuses primarily on contracting or “up-training” pelvic floor muscles along with the rest of the “core” to do certain movements.  However, even though all of pilates repertoire may not be appropriate for all people, there are some helpful themes and sequences that can be beneficial when performed safely and precisely.

 

Since most of pilates is uptraining, i.e. tightening your pelvic floor muscles, I’m going to first introduce some downtraining exercises, i.e. lengthening/relaxing your pelvic floor, as a baseline for movement.  I found in teaching that starting from this baseline actually improves students understanding of the pelvic floor and success in the practice.  Also, it challenges the assumption that most of us have loose/weak pelvic floors that we need to strengthen, when the actual problem is lack of awareness (*more on this later blogs).

 

Please note: Although these exercises are primarily directed towards those with tight or hypertonic pelvic floor musculature they can provide awareness training for any pelvic floor, big or small, tight or loose, weak or strong.

 

Disclaimer:  None of these exercises should increase pain or symptoms.  Feel free to limit the range of motion/movement to what is tolerable and outside of pain.  If you are unsure please seek advice from your physical and occupational therapists or a rehabilitation pilates professional who has experience with pelvic pain.

 

Since most of us don’t have pilates studio in our house I’ll be going through some exercises that can be done at home on a yoga mat and with small props as necessary.  Considering setting aside ~ 10 minutes to give yourself the time to focus and experience the exercises.

 

Breathing

Purpose: improve awareness of breath and mobility of the body when breathing

Start lying on your back with your knees bent feet flat on the floor with shoulders broad and palms turned up.

 

Feel the weight of your body on the floor and sense your breath moving in your body.  As you inhale feel the rise and as you exhale feel the fall.  Where does the breath go?  Just observe this for a few moments…for many people this movement happens at the collar bone and upper chest, for others it’s softly in the belly or sometimes even shared between both areas.  Now we are going to send the breath into other areas.

 

Do you know how big your lungs are?  Do you know they are not only in the front but in the back too?  They are actually longer on the sides and in the back then they are in the front.   

 

See if you can breathe wide, try putting your hands on the sides of your rib cage and feel the movement, wide and down into your fingers.  Try this for a bit…

 

 

Now see if you can breathe back, try putting your hands or a small folded towel behind your midback to feel the movement of your back ribcage.  Some imagery that can be helpful here: Imagine you are creating deep groves in the sand with the expansion of your rib cage and it washes away as you exhale…or the imagine your back ribs are like the wings of a lady bug that are lifting and lowering.

 

 

Get the idea, there is so much movement in the rib cage that we barely even use.

Now we are going to try some belly breathing.  Same start position.  But place your hands on belly.

 

Inhale wide and easy.  Just follow where the breath goes.  Which hand moves more?… See if you can allow the bottom hand to fill up a little more, like a big Buddah belly.  Try this for a couple breaths…as you feel like you can fill up your belly, can you send the breath a little lower, just down to your pubic bone.  Allow the breath to flow all the way down to your belly and pelvis then back up again.  Easy inhale, easy exhale.  Now you may feel some movement in your low pelvis.  With your inhale, feel an easy stretch of your pelvic bowl (i.e. your anus, or vagina or scrotal area), and with you exhale, feel an easy recession.  No problem if you don’t sense anything right away, just keep breathing.  If you do feel this easy stretch then see if you can start sending you breath down and wide towards your perineum between your sit bones.  You can try sending it more towards the front- vagina/ base of the penis, or towards the back- anus.  Just allow it to be easy.  Continue for 5 minutes or so.

 

Take a moment just to feel if the ease or tension has changed in your body and specifically in your hips and pelvic floor area.

 

Pelvic Clocks

Purpose- to improve awareness and mobility of the pelvis, hips, lower back and related muscles, i.e. pelvic floor muscles.

 

Pelvic clocks are used in many exercise regimens, whether you know it or not.  You can do this exercise on your back with your feet flat on the ground, broad shoulders, palms on your hips.

 

NEUTRAL

Essentially the idea is to move you pelvis in a full circle, or through all the numbers of the clock.  Let’s get started.  Feel your pelvis resting on the ground beneath you.  Feel the heaviness of the right back pelvis and the left back pelvis.  Feel where you pelvis starts to make contact at the base of your sacrum, and where it curves away, at your tailbone.  Generally you want to be in your “neutral” or “neutral zone” where you are evenly balanced right to left and forward to back.

Now see if you can start rocking your pelvis easily forward and backward.  Slowly rock your tail under, feel your low spine press into the ground and your tail lift a little.  This position in Pilates is called an “imprint” or “flat back.”

 

 

EASY ROCK BACKWARDS, “IMPRINT”

DON’T SQUEEZE BOTTOM, KEEP IT EASY AND SOFT

Slowly start to rock you pelvis the other direction, past your start position, you may feel your low back pull off the floor even more. Go slow and easy.

 

 

STICK BOOTY OUT A LITTLE, PELVIS WILL TIP FORWARD, LOW BACK WILL COME OFF FLOOR

Continue to go slowly and easily between these two positions, ideally your legs, feet and buttocks are relaxed and you feel as if your bones are just rocking back and forward.  Let’s call the “imprinted” spine 12 o’clock, and the booty out position 6 o’clock.  So now you’re rolling easy between 12 and 6 slowly and comfortably.  Start with only doing about 5 or so.

Now pause in the middle of 12 and 6, so you’re back to your start position, or perhaps at the center dial of your clock.

 

Slowly tip your pelvis over to the left, your 3 o’clock.  You should feel weight come off of the back right pelvis, and become heavy on the back left pelvis.

 

Then slowly come back to the center.  Now, tip your pelvis slowly over to the right, to your 9 o’clock.  You should feel weight come off of the back left pelvis, and become heavy on the back right pelvis.

Now you’ve got your clock 12, 6, 9, 3.  Try going slowly and easily up and down and side to side, don’t be too forceful with it, just imagine your bones are moving and your muscles are easy and quiet.  See if you can let your legs and feet relax so you’re only moving your pelvis.

 

If your still not sure take a look at this video.

 

Once you try this 4-5 times you can now try doing a full circle, or going around the clock.  Start at 12, tip over to 3, then 6, then 9, then 12 again.  Return back to neutral, then go the other direction or “counterclockwise”, from 12 to 9 to 6 to 3 to 12.  Try this 4-5 times keeping your legs relaxed and muscles relaxed.  You can take a look at this video if you are completely lost.  When in doubt keep it easy and smooth.

 

 

Bridging on Wall

Purpose- To integrate your legs and back into pelvic movement to move and massage the pelvic floor muscles.

 

Start with your feet on the wall, legs bent to ~ 90 degrees.  Feel how heavy your pelvis is on the ground and how you can allow your pelvis can sink deeper into the ground and settle.

 

 

Now slowly start to tip your pelvis backwards, as if just the bones were moving. Press firmly but softly into your feet and start to roll your pelvis and low back off the ground so your pelvis can hover just off the ground.  Let your pelvic floor and hips feel loose, relaxed and easy.

 

Take a breath there at your top of the movment and slowly start to roll down one vertebra at a time towards the ground. Once one vertebra presses into the ground see if you can lengthen your hips away towards the wall and drop the next one down, and so on and so on.  Keep it easy.  Try this ~5 times.

Take a look at the video with some additional cueing.  Remember, only go as high as is easy and comfortable.

 

Mermaid

Purpose- To stretch the side body, hips and pelvis and improve expansion of the rib cage and pelvic floor muscles with breathing.

Sitting with your legs in a mermaid position- one leg turned out in front one leg turned in behind.

 

Or, if this is not comfortable at your hips or your knees you can sit cross legged or on a blanket so your pelvis is above your legs.

 

 

 

 

Settle into this position for one or two breaths just allowing your jaw, shoulders and pelvic floor muscles to let go.  Slowly reach your right arm up to the ceiling, keeping the shoulder easy.  Let your left hand provide some support on the ground as you reach up and over to the left.  Think about creating more length in the spine then just compressing the left side of your spine. Take a breath intoour right side body and rib cage.

 

You can play with going to either side, left and right.

 

You can also try rotating your trunk slightly towards the ceiling or towards the ground to move the stretch and find more ease.  As long as it feels good.

Slow return to your start postion.  Once you have completely on side, switch your legs and repeat right to left.  If you are in sitting in a criss-crossed position you can switch which leg is on top and repeat the stretch again either side if you’d like.

*You can try these poses daily.  You should always feel better or no change in your symptoms. Though you may feel some stretching these exercises should never create more pain. When in doubt talk to your Pilates rehabiliatation professional or physical and occupational therapists. For more great exercises to improve pelvic floor mobility check out Casie’s blog on Yoga Poses for Pelvic Pain!

 

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Are you unable to come see us in person? We offer virtual physical and occupational therapy appointments too!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical and occupational therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical and occupational therapistss committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online. 

Virtual sessions are available with PHRC pelvic floor physical and occupational therapistss via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical and occupational therapistss, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical and occupational therapists who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page. 

PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical and occupational therapists at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836

By Melinda Fontaine

Have you heard these common pelvic rumors? Can you guess which ones are true or false?

 

As a pelvic floor physical and occupational therapists, I’ve heard quite a few old wives tales about the pelvis. Test your Pelvic IQ with these 16 true or false statements!

 

1. T/F   Drinking water will make me have to pee more.
2. T/F   Everyone should do kegels to maintain continence and improve sex and orgasm.
3. T/F   You can catch venereal disease from sitting on a public toilet seat.
4. T/F   A normal bowel movement requires straining on the toilet.
5. T/F   Sex is uncomfortable after childbirth.
6. T/F   Needing lube means I am not good enough/not turned on enough.
7. T/F   Kegels are only for women.
8. T/F   I should pee, just in case.
9. T/F   Everyone will probably need adult diapers at some point.
10. T/F   Waking up to pee at night is part of getting older.
11. T/F   At some point, I will get too old for sex.
12. T/F   It’s normal to pee a little when you laugh, cough, sneeze, or jump after childbirth.
13. T/F   Everyone knows how to kegel.
14. T/F   I’m the only one with pelvic problems.
15. T/F   Pelvic PT can help.
16. T/F   Only women go to pelvic physical and occupational therapy.

 

1. Drinking water will make me have to pee more.

 

1. 1. • FALSE. Contrary to popular belief, drinking more water can actually make you have to pee less frequently because it dilutes the urine in the bladder which is less irritating to the lining of the bladder.  However, if you do drink a large amount of water in one sitting, then your bladder will stretch quickly which makes it want to empty, so you will still have to pee.  Your best bet is to drink plenty of water, but space it out evenly throughout your day.   

 

2. Everyone should do kegels to maintain continence and improve sex and orgasm.

 

1. 1. • FALSE. OK, I’m sorry. This is one of those tricky questions that is false because the statement says “Everyone”.  Kegels are a strengthening exercise for the pelvic floor muscles.  These exercises can improve incontinence if the cause is weak muscles that cannot create a good seal.  However, if the incontinence is caused because of overworked muscles or a weak abdominal wall, then kegels will not help and may even make it worse. A PT can help you figure out which category you fall into.  Kegels can also make sex and orgasm better because they strengthen the pelvic floor muscles that are involved in arousal and orgasm.  If the muscles are already strong, then strengthening will not improve function, and may even cause new problems if the muscles become too strong and tight.  Also, if there is something else impairing sex and orgasm, then strength training will not help.

 

3. You can catch venereal disease from sitting on a public toilet seat.

 

1. 1. • FALSE. Chances are extremely low that you will catch a disease from sitting on a public toilet seat.  If you still don’t believe me, then use a toilet seat cover, but pretty please sit down. Hovering over the toilet seat activates the muscles that are supposed to be relaxing in order to open the floodgates and allow you to evacuate. (As a side note, your cell phone probably has more disgusting germs than a toilet seat.)

 

4. A normal bowel movement requires straining on the toilet.

 

1. 1. • FALSE. A normal bowel movement should be soft yet formed, like toothpaste or soft serve ice cream.  It should come out easily with a deep breath with your feet up on a stool, such as the Squatty Potty.  

 

5. Sex is uncomfortable after childbirth.

 

1. 1. • FALSE. If sex feels uncomfortable, this is a clue that something else is going on in the body.  Sex could be uncomfortable due to scar tissue, too much tightness in the muscles of the pelvis, hormone imbalance, active infection, or other causes. Physical therapy can address some of these issues to make sex pleasurable.

 

6. Needing lube means I am not good enough/not turned on enough.

 

1. 1. • FALSE. Some women just need/like extra lubrication, so bring on the lube. This can be especially true for women who have low hormones level, such as women who are on birth control, postpartum, or post menopausal.  Smoking, anorexia, stress, polycystic ovarian syndrome, and pituitary or hypothalamus issues can also cause less lubrication. (Stay tuned in May 2016 for some good hints on how to pick a lube.)

 

7. Kegels are only for women.

 

1. 1. • FALSE. The kegel exercise was first described for women, but it is a strengthening exercise for the pelvic floor muscles.  Both sexes have pelvic floors, so men and women can do pelvic floor exercises.  This involves tightening the muscles used to hold back the flow of urine or the passing of gas.

 

8. I should pee, just in case.

 

1. 1. • FALSE. If you do not have a full bladder, then you do not need to empty it.  Doing this routinely can actually cause your body to get confused and think that it is always supposed to empty when it is partially full.  This may lead to frequent urination or urinary urgency.  

 

9. Everyone will probably need adult diapers at some point.

 

1. 1. • FALSE. Adult diapers and incontinence pads have their uses for sure, but I don’t want people thinking this is the only choice. Often the cause of urinary or fecal incontinence can be treated.  As you reach for that next pack of adult diapers, also make a resolution to speak to your physical and occupational therapists or doctor about treatment options.  Many times, people can regain control over their bowel and bladder with proper medical care and can avoid or stop using diapers.  

 

10. Waking up to pee at night is part of getting older.

 

1. 1. • TRUE, but not as much as you would expect. As we age, our bodies create less of the antidiuretic hormone as we sleep which is what tells our bodies to stop making as much urine, so we can sleep all night. A healthy older individual should be getting up 0-1 times per night.  Conditions such as diabetes, pregnancy, sleep apnea, congestive heart failure, and prostate enlargement will increase the number of times someone gets up to pee.

 

11. At some point, I will get too old for sex.

 

1. 1. • FALSE. This is a bold faced lie!  Everyone should be having pleasurable, satisfying sex for the rest of their lives. If this is not the case, there is help.

 

12. It’s normal to pee a little when you laugh, cough, sneeze, or jump after childbirth.

 

1. 1. • FALSE. Just because it is common does not mean it is normal. This is called stress urinary incontinence, and it can occur because of a change in anatomy, pelvic floor muscles that are too weak or too tight, a weak abdominal wall, or hormone changes.  

 

13. Everyone knows how to kegel.

 

1. 1. • FALSE. Oftentimes, what people think is a kegel is not, or it is not a very effective kegel. Researchers gave women verbal instructions on how to do a kegel and then checked them.  Only 49% were doing it right.  25% were actually doing something that could make incontinence worse! To find out what a kegel really is, check out Allison’s blog post.

 

14. I’m the only one with pelvic problems.

 

1. 1. • FALSE. Why else would we have so many chairs in the PHRC waiting rooms? Up to 30% of the population in the West has urogenital problems. And those are only the people we know about…

 

15. Pelvic PT can help.

 

1. 1. • TRUE. Pelvic PT can help people with pelvic pain, urinary or bowel symptoms, sexual dysfunction, and pregnancy or postpartum concerns.
   2. • Monitoring your diet and proper exercise can help too. 

16. Only women go to pelvic physical and occupational therapy.

 

1. • FALSE. Pelvic physical and occupational therapistss treat men and women. Even gynecologists can treat men with pelvic pain. The anatomy is remarkably similar, with the one obvious exception.  Men, women, everyone who has a pelvis can go to pelvic physical and occupational therapy.

Have you heard any other pelvic myths? Post them in the comments section below!

 

 

Regards,

 

Melinda Fontaine, DPT

Melinda is a native of Concord, California and is part of our Berkeley team. Melinda earned her bachelor’s degree in exercise biology from UC Davis and her doctorate in physical and occupational therapy from Simmons College in Boston. When she’s not at PHRC, you’ll find her either dashing around in her running shoes or cooking up delectable meals in her kitchen. She’s famous for her killer baked chimichangas and her inability to stick to a recipe

 

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Nilsen R. (2014) Where does natural vaginal lubrication come from? http://www.livestrong.com/article/15810-does-natural-vaginal-lubrication-come/

^[1] Kegel AH (1948) The nonsurgical treatment of genital relaxation; use of the perineometer as an aid in restoring anatomic and functional structure. Ann West Med Surg.2(5):213-6.

^[1] Bump RC, et al (1991) Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol.165(2):322-7.

^[1] Legendre G, et al (2013) Menopause hormone treatment and urinary incontinence at midlife. Maturitas 74:26-30.

^[1] Prendergast SA and Rummer EH (2016) Pelvic Pain Explained: What everyone needs to know. Lanham: Rowman & Littlefield.