Can Pessaries "Out-sex" Surgery? A Thoughtful Approach to Incontinence and Prolapse
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 in my post The Genital Hiatus: What It is and Why You Should Care 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.)
