The Breach in the Dam
Do you have incontinence or 
prolapse? One of the fundamental contributors to prolapse/incontinence is an increase in the size of the genital hiatus. Did you know you can decrease the size of your genital hiatus by 50% without surgery? If you don’t know what your genital hiatus is, it’s an approximate quantification of pelvic muscle function by measuring the distance between the urethra and the anal opening. The genial hiatus (i.e. the muscles surrounding and interweaving the vagina, urethra, and rectum) is essential for normal sexual, bladder, and bowel function and you can learn more about it here (blog post illustrating the genital hiatus) and here (ACOG patient education brochure on prolapse).
Incontinence of urine, gas, and stool affect half of all women at some point in their lives, and is especially common after pregnancy, whether delivery occurs by vaginal birth or c-section. C-section does not prevent incontinence.
An article published in Obstetrics and Gynecology looked at pessary use in women 90 women with incontinence and found a 20% reduction in the size of the genital hiatus in just two weeks! This is really exciting news and I think it should have made the New England Journal of Medicine (or at least Good Morning America…a scroll-by on CNN?). After just two weeks of daytime use, the women wearing a pessary decreased their genital hiatus from an average of nearly 5 cm to about 4 cm, a twenty percent reduction!
In fact, several studies over the past few years have indicated prolapse and incontinence are dynamic conditions dramatically impacted by factors within a person’s control: weight, exercise (Kegels), smoking status, and other factors.
There have been two approaches to incontinence: surgery and pessaries. Surgery has been the predominant approach because IMHO (in my humble opinion), that’s where the money is: incontinence surgery earns income for medical device companies, hospitals, and doctors. In comparison pessaries are cheap.
Why We Lack Data on Pessaries
Pessaries don’t make the news because 1) they aren’t “sexy” like “surgery”; 2) they aren’t a “quick fix”; and 3) they are cheap. The only entities who earn income off the pessary are the physician who does the fitting and the pessary company–pessaries cost about $40-60 (an office visit for a pessary fitting costs a tiny fraction–$100-$250 depending on what is addressed and the duration of the visit–of what surgery pays; a sling surgery pays 10-20X that depending on how complex the reconstructive surgery is.)
Little medical research has been devoted to the study of pessaries versus surgery for incontinence and there have been zero large randomized controlled trials comparing pessary use with surgery. For example, a search of articles published since 2000 in Obstetrics and Gynecology using the term “pessary” returns about 10 actual related results; while a search with the terms “incontince and surgery” yields about 5200 related articles. That’s just sad.
As a physician, if I don’t have the clinical and scientific data, I cannot inform patients well. Treatment of incontinence/prolapse costs over 80 billion dollars annually; why haven’t the NIH and other research funding agencies supported more pessary research??? For example, why don’t we have larger numbers on how pessary vs. surgery affects something measurable like the genital hiatus?
Why To Do Kegels Even if You’re Sold on Surgery
- Reveal latent incontinence
- Improve pelvic blood flow–will aid healing from any surgery
- Improve neuromuscular function
Even if you’re considering surgery for incontinence/prolapse you will benefit from Kegels. Pre-operative Kegels for 10 weeks before surgery will improve your surgical outcome because you will improve the blood flow to all pelvic structures, muscle strength, and neuromuscular function of the pelvic muscles.
Kegeling with a Pessary or Weight
Kegels with a pessary, vaginal weights, or other feedback device such as an Athena, will make your Kegels more effective in a shorter amount of time. The use of these devices provides “resistance” which, as with any muscle training, makes it more effective faster. Wearing a pessary during the day will cause you to do Kegels in an isotonic fashion, unconsciously (to keep the pessary in place). This is probably the mechanism by which wearing a pessary decreases the size of the genital hiatus.
If you have prolapse, sometimes corrective surgery can unmask incontinence that was previously masked by a kinking of the urethra due to the prolapse. Using a pessary pre-operatively can diagnose if you have incontinence that will need to be addressed at your surgery, in addition to the prolapse repair.
If you want to use a pessary, a fitting takes 10 or 15 minutes. Pessaries are very easy to insert, and come in all shapes and sizes.
How to Kegel and How Many
To Kegel, contract the muscles inside the vagina as though you’re trying to stop the flow of urine. You don’t want to do Kegels during urination because it can “confuse” your bladder. Make sure your bladder is empty when doing Kegels.
- Try to hold each muscle contraction for 3-5 seconds.
- Do ten sets of ten per day for six to twelve weeks, then as needed or desired.
- Don’t confuse abdominal muscle exercises, e.g. “crunches” with Kegels. The Kegel muscles are inside your pelvis, not in your abdominal wall.
Still Debating About a Pessary? Kegels?
Consider this, if you have surgery for prolapse or incontinence, you will have a six week recovery period. Pelvic reconstruction is major surgery and is not always successful.
Using a pessary can’t hurt, is very cheap, effective, and may even abate your symptoms enough you no longer feel you need the surgery.
If you do proceed with surgery, Kegels pre and post-op will improve your outcome.
- What do you think?
- What was your experience with incontinence surgery, prolapse surgery, or Kegels?
(Here is one woman’s testimonial to her use of an Athena pelvic floor muscle trainer. I have no financial interest in Athena or any medical device company.)
{ 13 comments… read them below or add one }
I am always so happy to see continuing education for women in regards to prolapse issues. There are so many problems that women face with the different types of prolapse and it is such a hush-hush scenario most of the time.
A book I have recently written about pelvic organ prolapse also addresses the many faceted issues of prolapse; I feel so strongly that all women should be aware of this condition so when they start to have symptoms, whether with bladder leakage or any of the many other symptoms like fecal incontinence, pain, or sexual dysfunction, they are aware of what may be occurring and seek help before the condition progresses to a stage needing radical treatment. The title of my book is
“Pelvic Organ Prolapse, The Silent Epidemic”
and information is available at the website below. I’d be very happy to share my views on this topic with anyone interested.
Sherrie Palm
http://www.eloquentbooks.com/PelvicOrganProlapse.html
Hi Sherrie,
Thank you so much for writing a book on POP (pelvic organ prolapse). I would love to have a great resource to which to refer my patients. There is very little information out there for women on POP. The more people write about this issue, the more awareness will be raised and women can learn, not only how to treat POP non-invasively, but to prevent it. Thank you so much for your comment. I can’t wait to read your book!
–Shelley
My mother, 86, asked me to check into pessaries. Over the last few years, she is becoming ‘dribbly’ incontinent. She visited an urologist that checked and found nothing out of the ordinary. She had tried several meds over the last few years and says she doesn’t like the side-effects. After reading the article, it seems to me that she may benefit from exercise first; she has become more and more sedentary in her lifestyle. Is there a device other than a pessary that could provide additional muscle exercise in the pelvic floor.
@Jeff Thank you for reading and commenting. Other devices to assist with Kegels are the Athena and various weighted vaginal cones. These can be purchased on-line. The Athena has a pressure sensor in it to relay feedback to the individual re: strength of their kegels. A pessary would probably be less expensive than either the Athena or the weighted vaginal cones. Here are some options for purchasing either the Athena or weighted vaginal cones. http://www.athenaft.com/ and http://www.vaginalweights.org/incontinence_products.html
Thank you for this article. I’m seeing the urogynocologist Monday and this has been immensely helpful to know what I want to try, as well as giving me valuable information about pessaries. Before reading this I didn’t really want to try one, now I think that should be the first step.
This is a very interesting website and lots of good information. I am a physical therapist specializing in womens health – primarily urinary/fecal incontinence, prolapse, pelvic pain. I do disagree with your description of how to do Kegels – trying to do 10 sets of 10 reps is way to much exercise for the pelvic floor muscles, especially since these muscles usually weak and that is one of the reasons for incontinence. Also, the endurance training for these muscles has been shown very important, having women progress to 8-10 second contract/relax for 3+ sets of 10. The key factor though is making sure women are doing them correctly, not holding their breath, not using othe muscle groups instead of the pelvic floor muscles. There are good studies that have shown verbal instruction is not sufficient for women to learn how to exercise their pelvic floor muscles. Many of my patients have told me that they were “told to do the exercises, but not taught.” I would highly recommend physicians and health care practitioners not assume by verbal instruction that women know how to do these exercises – physical therapists have specialized training in evaluation of the pelvic floor/abdominal muslces, in teaching these exercises and in progressing patients through treatment including a home exercise program.
Can you have sexual intercourse with the device in? My situation is that my bladder has fallen. I had very heavy babies! Currently sex is painful and there is no sensation. Thank you
Yes, you can have intercourse wearing a pessary. If it’s bothersome, just take it out during intercourse.
When my doctor suggested the use of a pessary I felt just a little bit squeamish. Silly, because I used a diaphragm before my first baby came via low forceps delivery. After that low forceps delivery (following a 46 hours delivery, baby spent a lot of time int he birth canal and was very cone headed afterward with swollen spots on her face from the forceps that lasted about one month) the muscles supporting my bladder were damaged and I could no longer hold a diaphragm in place.
Thank you so much for your post on this subject. The last thing we want as women is to no longer feel like we are attractive and appealing. But, not coping with this problem only serves to make us feel like we are less.
I know other women are struggling with this, but somehow we do not dare to talk about it at book club or other places where women meet.
I know other women struggle. I had friends say, “my friend has this problem…” Only to later hear they had a hyster for prolapse…
Now I just need to learn about what kind of pessary to try. I think I am going to be a bit more willing to talk to my Dr. I am going to ask to see the pessary tray during my visit. I want to talk to my Dr. about the benefits of each type.
Thank you for the information!
Shelley–
Is it possible that a pessary can actually ‘cure’ a uterine prolapse, or at least reverse it enough to not need surgery? I am 56, post-menopausal and went in about two years ago for a prolapsed uterus. It turned out I have both a cystocele and a rectocele as well. I was reluctant to have the recommended surgery so used a pessary for almost 2 years. Finally the leakage got so bad that I gave in and agreed to the surgery, which is scheduled for next week. However, my doctor removed the pessary a month ago in preparation for the surgery and I have not had a recurrence of the uterine prolapse–it seems to be back to where it was before I started having problems. I do realize the cystocelee problem is probably being masked by some kinking.
This leaves me even more reluctant to do this. I’m pretty sure my doctor is going to want me to go through with it anyway. Any
suggestions?
Does anyone know if you can use muscle stimulation with a probe if you have a pessary in? (I was just fit with a pessary, but have been using a home machine for months).
Hi C, Yes, a pessary can certainly reduce uterine or vaginal prolapse enough to make it less symptomatic or not symptomatic at all. The reason the urine leakage may have gotten worse when the pessary was removed, is that by reducing the prolapse you un-kink a presumably kinked urethra. The factors that caused the pelvic prolapse in the first place can also cause a “funnel” urethra. This is a urethra in which the internal urethral sphincter is so relaxed it it non-functional. The urethra has 2 sphincter muscles, one at the junction at the bladder and the urethra (the internal urethral meatus), and the other where the urethra opens to the outside (the external urethral meatus). With a funnel urethra the internal sphincter is so slack, the urethra becomes funnel shaped, rather than tube-shaped. Sometimes a sling will be placed to “cure” the funnel urethra. Placing a sling partially obstructs the too-relaxed urethra, thus helping it to close better and provide continence. It usually works, but slings are not without complications and do have a three year failure rate of 15%. The ten year failure rate is not as well known, but may be fairly high. Thank you for reading the blog and sharing your information with other readers. Let me know if I can answer any other questions. -SB
Yes, you can use a muscle stimulation insert and/or weighted vaginal cones with a pessary in place, if you can fit all that in there. The difficult thing could be fitting all the items in at the same time. Instead, if you are comfortable with removing and reinserting your pessary, I’d recommend removing the pessary while you are using the pressure-sensing insert or weighted vaginal cones, then replacing the pessary when you are not using it. Thank you for reading the blog and for sharing your information, which I know will help other women. Please let me know if you have any additional questions or comments. -SB