Posts Tagged ‘obstetrical trauma’

So Your Vagina Is Loose: Now What?

June 3, 2017

Andrew Siegel MD  6/3/17

After your newborn  has used your vagina as a giant elastic waterslide (and perhaps repeated a few times), you may find that your lady parts are not quite the same.  Obstetrical “trauma” to the nether muscles (genital and pelvic muscles) and stretching of the vaginal opening can lead to permanent changes. Multiple childbirths, large babies, use of forceps for delivery, and age-related changes of the pelvic muscles and connective tissues further compound the issue.  This condition, a.k.a. vaginal laxity, is characterized by the vaginal opening being wider and looser than it should be.

recto copy

Image above of vaginal laxity in patient immediately before vaginal reconstructive surgery: rectocele (blue arrow: rectum pushing up into back wall of vagina), perineal scarring (white arrow: scarring between vagina and anus) and catheter in urethra (red arrow: channel that conducts urine)

Trivia: Leonardo Da Vinci had an interesting take on male and female perspectives: “Woman’s desire is the opposite of that of man.  She wishes the size of the man’s member to be as large as possible, while the man desires the opposite for the woman’s genital parts.”

Vaginal Laxity

Vaginal looseness–sometimes to the point of gaping– is one of the most common physical changes found on pelvic exam following delivery.  This often overlooked, under-reported, under-appreciated, under-treated condition commonly occurs following pregnancy and vaginal delivery.  Not only is it bothersome to the woman dealing with the problem, but it can also lead to body image issues, decreased sexual sensation, less sexual satisfaction (for partner as well) and disturbances in self-esteem.

It is important to distinguish vaginal laxity from pelvic organ prolapse (an internal laxity in which one or more of the pelvic organs –bladder, uterus, rectum–bulge into the vagina and at times beyond the vaginal opening).  The photo above illustrates a woman with both issues.

The vagina of a woman with laxity often cannot properly “accommodate” her partner’s penis, resulting in the vagina “surrounding” the penis rather than firmly “squeezing” it, with the end result being diminished sensation for both partners.  Under normal circumstances, sexual intercourse results in indirect clitoral stimulation with the clitoral shaft moving rhythmically with penile thrusting by virtue of penile traction on the inner vaginal lips, which join together to form the hood of the clitoris.  When the vaginal opening is too wide to permit the penis to put enough traction on the inner vaginal lips, clitoral stimulation is also limited, another factor resulting in less satisfaction in the bedroom.

7 Ways to Know if You Have a Loose Vagina

  1. You cannot keep a tampon in.
  2. During sexual intercourse, your partner’s penis often falls out.
  3. Your vagina fills with water while bathing.
  4. You have vaginal flatulence, passage of air trapped in the vagina.
  5. When examining yourself in the mirror you see the vaginal lips parted and internal tissues exposed (it should be shut like a clam shell).
  6. Sexual intercourse is less satisfying for you and your partner and noticeably different than before childbirth.
  7. You have difficulty experiencing orgasm.

Means of quantitating vaginal laxity and the strength of the pelvic and vaginal muscles that are used by physicians include:

  1. Visual inspection of the vulva, which shows vaginal gaping, exposure of internal tissues and decreased distance from vagina to anus
  2. Pelvic exam while having the patient contract down upon the examiner’s fingers, using the modified Oxford scale of 0-5 (0–very weak pelvic contraction; 5–very strong pelvic contraction)
  3. Manometry, a measurement of resting pressure and pressure rise following a pelvic floor muscle contraction
  4. Dynamometry, a measurement of pelvic muscle resting and contractile forces using strain gauges
  5. Electromyography, recording the electrical potential generated by the depolarization of pelvic floor muscle fibers

On a practical basis, means #1 and #2 are usually more than sufficient to make a diagnosis of vaginal laxity

 Vaginal Laxity:  What to do?

  • Over-the-Counter Herbal Vaginal Tightening Creams: Don’t even bother. These non-regulated products can be harmful and there is no scientific evidence to support their safe and effective use.
  • Kegel Exercises, a.k.a. Pelvic Floor Muscle Training: Worth the bother!  This non-invasive, first-line, self-help form of treatment should be exploited before considering more aggressive means. Increasing the strength, power and endurance of the pelvic floor muscles has the potential for improving vaginal laxity as well as sexual function, urinary and bowel control and pelvic prolapse.
  • Use it or lose it: Stay sexually active to help keep the pelvic and vaginal muscles toned.  Although you might think that sexual intercourse might worsen the problem by further stretching the vagina, in actuality it will help improve the problem and increase vaginal tone.
  • Energy-Based Devices: There are a host of new technologies that are being used for “vaginal rejuvenation” in an office setting. These are typically lasers or units that use targeted radio-frequency energy that are applied to the vaginal tissues. One such device uses mono-polar radio-frequency therapy with surface cooling.  It works by activating fibroblasts (the type of cells that makes fibers involved in our structural framework) to produce new collagen stimulating remodeling of vaginal tissue. The vaginal surface is cooled while heat is delivered to deeper tissues.                                                                                                                                                               Note: The jury is still not out on the effectiveness of these procedures. What is for certain is that they are costly and not covered by medical insurance.  Anecdotally, I have a few patients who claim that they have had significant improvement in vaginal dryness and other symptoms of menopause after undergoing laser treatment.      
  • Vaginoplasty/Levatorplasty/Perineorrhaphy/Perineoplasty: This is medical speak for the surgical reconstructive procedures that are performed to tighten and narrow the vaginal opening and vaginal “barrel.”  The goal is for improved aesthetic appearance, sexual friction, sexual function and self-esteem. These procedures are often performed along with pelvic reconstructive procedures for pelvic organ prolapse, particularly for a rectocele, a condition in which the rectum prolapses into the bottom vaginal wall.

 The term vaginoplasty derives vagina and plasty meaning “repair.”  The term levatorplasty derives from levator (another name for deep pelvic floor muscles) and plasty meaning “repair.” Perineorrhaphy derives from perineum (the tissues between vagina and anus) and –rrhaphy, meaning “suture,” while the term perineoplasty derives from perineum (the tissues between vagina and anus) and plasty meaning “repair.”

Within the perineum are the superficial pelvic floor muscles (bulbocavernosus, ischiocavernosus and transverse perineal muscles) and deeper pelvic floor muscles (levator ani).  Perineal muscle laxity is a condition in which the superficial pelvic floor muscles become flabby. Weakness in these muscles cause a widened and loosened vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal axis such that the vagina assumes a more upwards orientation as opposed to its normal downwards angulation towards the sacral bones.

3. superficial and deep PFM

Illustration of pelvic floor muscles by artist Ashley Halsey from “The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health

The surgical reconstructive procedures referred to above narrow the relaxed vaginal opening and vaginal barrel and address cosmetic concerns. The aforementioned muscles are buttressed to rebuild the perineum, resulting in a tighter vaginal opening and vaginal barrel, increased distance from vaginal opening to anus, restoration of the proper vaginal angle and an improvement in cosmetic appearance.

public domain

Illustration above from public domain.  On left is lax vagina with incision made from point A to point B where vagina and perineum meet. On right the superficial pelvic muscles are accessed and ultimately buttressed in the midline, converting the initial horizontal incision to one that is closed vertically.

Marietta S pre-PP

Image above of lax vagina before surgical repair; (c) Michael P Goodman, MD. Used with permission

.Mariette S 6 wk p.o. PP

Image above of lax vagina after surgical repair; (c) Michael P Goodman, MD. Used with permission.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

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Kegel Exercises To PREVENT Pelvic Floor Dysfunction

August 29, 2015

Andrew Siegel MD   8/29/15

shutterstock_v162886

“Prepare and prevent, not repair and repent.”

Restoring function of injured muscles is a well-established principle in sports medicine, orthopedics, plastic surgery and physical medicine and rehabilitation. The premise is simple: a traumatized or injured muscle is treated with rehab and training to accelerate tissue healing and restore working order. Many of the “baby boomers” demographic (age 51-69)—striving to retain their fitness and youth through exercise and “weekend warrior” activities that promote cardiac health but at the same time, musculoskeletal injuries—understand this concept well.

Dr. Arnold Kegel applied this principle to the female pelvic floor muscles to improve muscle strength and function in women after childbirth. Obstetrical “trauma” (9 months of pregnancy, tough labor and delivery of a 9 lb. baby) can cause pelvic floor dysfunction—urinary and bowel control issues, looseness of the vagina and its support tissues with descent of the bladder, uterus and rectum, and altered sexual function.

This principle has also been applied to men with pelvic floor muscle issues to improve urinary, bowel, erectile and ejaculatory health. Obviously, men do not suffer the acute pelvic floor muscle trauma of childbirth that women do, but they can develop pelvic floor muscle dysfunction from aging, weight gain, pelvic surgery (radical prostatectomy, colon surgery, etc.), a sedentary lifestyle, disuse atrophy, participation in saddle sports including cycling, etc.

An Ounce Of Prevention Is Worth A Pound Of Cure

Why not a radically different approach and instead of fixing pelvic floor dysfunction, try to prevent it? Unfortunately, we have a “reactive” oriented medical culture in the USA that does not emphasize prevention, but “repair.”  Another hurdle is that many people prefer having broken things fixed as opposed to making the effort to avoid breaking them in the first place.

So, if obstetrical trauma to the pelvic floor often brings on pelvic floor muscle dysfunction and its urinary, gynecological, bowel and sexual consequences, why not consider starting pelvic floor muscle training well before pregnancy, perhaps at the time of the first gynecological visit? And if aging, surgery and other factors contribute to male pelvic floor muscle dysfunction and its urinary, bowel and sexual consequences, why wait for the system to malfunction? Why not strengthen and tone the pelvic floor muscles when a man is young and healthy to prevent the predictable age-related decline?

Did You Know? The concept of pelvic floor muscle training BEFORE radical prostatectomy for treatment of prostate cancer is rapidly gaining traction and implementation. Instead of waiting to “rehab” the pelvic muscles after the fact, the concept is to “prehab” them. 

Many of us apply wellness principles through regular exercise—aerobic pursuits for cardiovascular health and strength training to maintain muscle tone, integrity and function—so why neglect the pelvic floor? We work out in the gym not only to achieve better fitness, but also to maintain fitness and prevent age-related losses in strength, flexibility, endurance, etc.

Preventive Pelvic Health Paradigm

Why passively accept the seemingly inevitable, when one can be proactive instead of reactive and can address the future problem before it becomes a problem? Why wait until function becomes dysfunction? Whether male or female, the new paradigm is preventive pelvic health. The goal is to avoid, delay, or minimize the decline in pelvic function that accompanies aging and that is accelerated by pelvic muscle trauma and injury, surgery, obesity and disuse atrophy.

Bottom Line: You have the ability to positively influence your health destiny. Instead of being reactive and waiting for your pelvic health to go south, be proactive to ensure your continuing urinary, bowel and sexual health. If you wait for the onset of a dysfunction to motivate you to action, it may possibly be too late. Think about integrating a preventive pelvic floor muscle program into your exercise regimen. Much like a vaccine, it will help to prevent a disease that you hopefully will never get.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: Available in e-book (Kindle, iBooks, Nook, Kobo) and paperback: http://www.MalePelvicFitness.com.  In the works is The Kegel Fix: Recharging Female Sexual, Pelvic and Urinary Health.

Co-founder of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program.  Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: http://www.PrivateGym.com or available on Amazon.

New Paradigm: Preventive Kegel Exercises (Pelvic Floor Muscle Training)

October 4, 2014

Andrew Siegel, M.D.

“To guard is better than to heal, the shield is nobler than the spear!”  Oliver Wendell Holmes

“Honor your pelvic floor–it has done a whole lot for you over the years.”

Restoration of the function of injured muscles is well established in the fields of sports medicine, orthopedics, plastic surgery and physical medicine and rehabilitation. A traumatized or injured muscle is treated with early active rehabilitation and muscle training to accelerate tissue healing and restore it back to working order.

Dr. Arnold Kegel popularized the application of this principle to the female pelvic floor muscles to improve muscle integrity and function in women after childbirth. Obstetrical trauma (9 months of pregnancy, labor and delivery of a 9 lb. baby out the vagina) can cause pelvic floor dysfunction. Pelvic floor dysfunction can cause incontinence (urinary and bowel control issues), pelvic relaxation (laxity of the vagina and its support tissues with descent of the pelvic organs including the bladder, uterus and rectum) and altered sexual function.

Likewise, this principle has been effectively applied to men with compromised pelvic floor muscle integrity and function in order to improve urinary, bowel, erectile, and ejaculatory health. Obviously, men do not suffer with the acute pelvic floor muscle trauma of childbirth that women do, but they can develop pelvic floor muscle dysfunction on the basis of aging, weight gain, a sedentary lifestyle, disuse atrophy, etc.

Don’t Allow Function to Become Dysfunction

Why not take a radically different approach and try to prevent pelvic floor dysfunction instead of fixing it? If you pardon the clichés, although “a stitch in time saves nine,” isn’t a better approach “an ounce of prevention is worth a pound of cure?”. Obstacles to implementing this paradigm are our very reactive and repair-oriented medical culture that does a poor job of being proactive and promoting prevention and our patient population that often prefers fixing things that go awry as opposed to making the effort to prevent them from occurring in the first place. The concept of promoting wellness as opposed to treating diseases is one that resonates powerfully with me.

So, if obstetrical trauma to the pelvic floor often brings on pelvic floor muscle dysfunction and its urinary, gynecological and sexual consequences, why not start pelvic floor muscle training well before pregnancy? And if aging and other factors contribute to male pelvic floor muscle dysfunction and its urinary, bowel and sexual consequences, why wait for the system to malfunction? Why not bolster and strengthen the pelvic floor muscles when one is young, hale and hearty to prevent the age-related decline that is so often predictable? Many of us do apply preventive and proactive means to our health through regular exercise—aerobic for cardiovascular health and strength training to maintain muscle tone, integrity and function.

Whether male or female, the new paradigm is preventive pelvic health. The goal is to preclude, delay, or mitigate the decline in pelvic function that accompanies aging and that is accelerated by pelvic muscle trauma and injury, obesity and disuse atrophy.

Maintaining healthy sexual functioning is important because it contributes to masculine and feminine identity and behavior and has an impact that extends way beyond the sexual domain, permeating positively into many areas of life. Sexual dysfunction—at least to some extent—will eventually surface in most of us and the prospect of this is unsettling.

So, why passively accept the seemingly inevitable, when one can be proactive instead of reactive and can address the future problem before it becomes a current problem? Why wait until function becomes dysfunction? This is a commonly practiced approach for general physical fitness. We work out in the gym not only to achieve better fitness, but also to maintain fitness and prevent age-related losses in strength, flexibility, endurance, etc.

In this spirit, I encourage men and women who are enjoying excellent sexual and urinary health to maintain their pelvic health via preventive PFMT. This preemptive strategy is an opportunity for those who are healthy-functioning to continue enjoying their healthy functioning and prevent, delay and/or mitigate the age-related changes as best as they can.

Bottom Line: You have the ability to affect your own health destiny. Don’t be reactive and wait for your pelvic health to go south. Be proactive to ensure your continuing sexual, urinary and bowel health. If you wait for the onset of a dysfunction to motivate you to action, it may possibly be too late. Think about integrating a preventive PFMT program into your exercise regimen—it’s like a vaccine to prevent a disease that you hopefully will never get. As the saying goes: “Prepare and prevent, not repair and repent.”

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Note: As Arnold Kegel popularized pelvic floor muscle exercises in females in the late 1940’s, so I am working towards the goal of popularizing pelvic floor muscle exercises in males. This year I published a review article in the Gold Journal of Urology entitled Pelvic Floor Muscle Training in Men: Practical Applications to disseminate the importance and applications of these exercises to my urology colleagues. I wrote Male Pelvic Fitness: Optimizing Sexual and Urinary Health, a book intended to educate the non-medical population. I, along with my partner David Mandell and our superb pelvic floor team, co-created the Private Gym male pelvic floor exercise DVD and resistance program.

For more info on the book: www.MalePelvicFitness.com

For more info on the Private Gym: www.PrivateGym.com

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