Posts Tagged ‘pelvic organ prolapse’

Understanding Female Sexual Fluids

August 11, 2018

Andrew Siegel MD  8/11/2018

Women are capable of releasing a “cocktail” of genital fluids during sexual activity. Controversy exists regarding the nature, volume, and composition of these secretions and their mechanisms of expulsion. Today’s entry delves into the origins of female sexual fluids—vaginal, glandular (Skene and Bartholin glands) and the urinary bladder—and the means of their release.  In the image below, the anatomical structures in boldface are those responsible for the genital fluids.

Image below: note Swedish “slida” is vagina (literally “sheath”); note Skenes and Bartholins gland  openings, “urinrorsmynning” = urethra; “klitoris” = clitoris

Skenes_gland-svenska.jpg

Attribution of image above: By Nicholasolan (Skenes gland.jpg) [GFDL (http://www.gnu.org/copyleft/fdl.html), CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/) or CC BY-SA 2.5 (https://creativecommons.org/licenses/by-sa/2.5)%5D, via Wikimedia Commons

 

Vaginal secretions

Lubrication that originates from the vagina is an ultra-filtrate of blood resulting from the increased blood flow and pelvic congestion that happens with erotic and tactile stimulation. The surge of blood to the genitals at the time of arousal results in the seeping of this natural lubrication fluid. There is often a substantial drop in the amount of vaginal lubrication that occurs after menopause with the sudden cessation of estrogen production by the ovaries.  By the way, if you are interested in testing your knowledge of female anatomy, visit: how high is your vaginal I.Q.?

Skene gland secretions…the female “prostate”

The Skene glands (a.k.a. para-urethral glands) are homologous to the male prostate gland.  These paired glands are located within the top wall of the vagina near the urethra and drain into the urethra and to tiny openings near the urethral opening (see image above). At the time of sexual climax, they can release a small amount of fluid into the urethra, paralleling the male release of prostate fluid at the time of ejaculation.

Bartholin gland secretions…the female “bulbourethral” glands

The Bartholin glands (a.k.a. greater vestibular glands) are paired, pea-size structures located in the superficial perineal pouch.  These glands open below and to the sides of the vagina (see image above).  They are homologous to the male bulbourethral glands that produce a clear, sticky fluid that lubricates the male urethra, often referred to as “pre-cum.”  The Bartholin glands secrete mucus that functions to provide lubrication to the inner labia that helps moisten the opening into the vagina.

Bladder and urethra

Because of the anatomical proximity of the bladder and urethra to the vagina, urine stored in the urinary bladder can be involuntarily released at the time of sexual activity.  Urine can be expelled during initial vaginal penetration, in the midst of the act of sexual intercourse, or at the time of sexual climax.

Urinary discharge that occurs during initial vaginal penetration and/or during sexual intercourse often occurs because of the presence of the penis in the vagina that displaces and elevates the bladder (anatomically situated directly above the vagina) and the massaging effect of penile thrusting.  This is not uncommonly seen in women who have either stress urinary incontinence, the involuntary leakage of urine with exercising, coughing, sneezing, etc., or bladder prolapse, a condition in which weakened bladder support allows descent of the bladder into the vaginal space.

Urine can also be involuntarily expelled from the urethra at the time of sexual climax.  For many women it is unpleasant, highly frustrating and embarrassing  situation for which they seek treatment, a condition known as coital incontinence. This orgasmic release of urine often occurs in women who suffer with overactive bladder, a condition in which the bladder contracts without its owner’s permission (a.k.a., involuntary bladder contractions).  For other women, the release of urine at the time of climax is viewed positively, correlated with intensive sexual arousal and a powerful and cathartic orgasm.  Under these circumstances, this situation is known as “squirting.”

(Excellent reference: Differential diagnostics of female “sexual” fluids: a narrative review   Z Pastor and R Chimel, Intern Urogynecological Journal (2018) 29:621-629)

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health

Cover

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor

 

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60 Minutes Disses Boston Scientific Meshes: WTF?

May 18, 2018

Andrew Siegel MD  5/18/2018

60 Minutes Trashes Boston Scientific and Pelvic Meshes

Last Sunday, a piece aired on the CBS weekly 60 Minutes concerning Boston Scientific meshes that are used in the field of female urology. The segment was spun in such a way that many viewers were likely to get the wrong impression about Boston Scientific products that are used for two common pelvic floor issues–stress urinary incontinence and pelvic organ prolapse.  These meshes are composed of polypropylene, a synthetic material that is commonly used inside the human body for many purposes, including  hernia repairs as well as a suture material.   I cannot speak for the provenance of the raw materials used for Boston Scientific meshes, although the issue has apparently been addressed by Boston Scientific as well as the FDA, but I can certainly vouch for the safety and effectiveness of their slings and meshes.  After watching the 60 Minutes piece, one might wrongly conclude that Boston Scientific meshes specifically, and all polypropylene meshes generally, are downright dangerous and should never be used in humans.

Au contraire!  Boston Scientific is a reputable company dedicated to both female and male pelvic health and their mesh products (Obtryx mid-urethral sling for stress urinary incontinence and the Uphold Lite for anterior and apical pelvic organ prolapse) are well-designed and clinically effective. I have implanted these products successfully in hundreds of women with stress incontinence and pelvic organ prolapse over the course of many years and will continue to use them.  Furthermore, I have always found the Boston Scientific “reps” to be knowledgeable, available and helpful and the company always willing to provide ample educational opportunities for physicians.  With respect to meshes used for pelvic reconstructive surgery, polypropylene has been the “gold standard” for many years.  Many clinical publications support the safety and effectiveness of polypropylene pelvic floor meshes and numerous medical societies and regulatory bodies have endorsed the utility of polypropylene pelvic meshes for pelvic floor dysfunction.

Proper Repair of a Dropped Bladder (Cystocele)

Not every cystocele is the same, differing in type, extent, symptoms, and degree of bother. The central type (top image below) is a central weakness of the support tissues of the bladder that can cause a pronounced degree of prolapse. The lateral type (bottom image below) is a detachment of the bladder support from the pelvic sidewalls, usually causing only a modest degree of prolapse. Most women have a combination of these two, a combined central-lateral type.

CD

lat defect

 

In my opinion, the classic “plication” repair (sewing together of native tissues)— a.k.a. colporrhaphy—is best suited to a central cystocele in which satisfactory native tissues are present.  However, this will not adequately address a lateral defect cystocele or a combined cystocele. Thus, it is important to determine the type of cystocele in terms of repairing it with native tissues. One of the advantages of a mesh repair is that it addresses all three types of cystocele. Additionally, instead of using native tissue that has already failed in terms of providing adequate structural support, mesh repairs use a strong and durable material to provide support.

Factors influencing me to do a mesh repair over a classic colporrhaphy are the following: poor tissues; risk factors for recurrence including chronic constipation, cough, obesity, and occupations that require manual labor; a relatively young patient who will need a durable repair; and those patients who have already failed a native tissue repair.

In the appropriately selected patient operated on with the proper surgical technique, the results of polypropylene mesh repairs have been extraordinarily gratifying. These procedures pass muster and the “MDSW” test—meaning I would readily encourage my mother, daughter, sister or wife to undergo the procedure if needed. When performed by a skilled pelvic surgeon, the likelihood for cure or vast improvement is great and the likelihood for complications is minimal. Meshes are strong, supple and durable and the procedure itself is relatively simple, minimally-invasive and amenable to outpatient surgery. When patients are seen years after a mesh repair, they are usually extremely satisfied and their pelvic exams typically reveal restored anatomy with remarkable preservation of vaginal length, axis, caliber and depth.

Meshes act as a scaffold for tissue in-growth and ultimately should become fully incorporated by the body. I think of a surgical mesh in a similar way to a backyard chain-link fence that has in-growth of ivy. Meshes examined microscopically years after implantation demonstrate a dense growth of blood vessels and collagen in and around the mesh.

As compared to the classic plication, when a mesh is used for bladder repair, there is rarely any need for trimming the vaginal wall, which makes for a more anatomical repair in terms of vaginal preservation. Another advantage of mesh repairs is that if the patient has a mild-moderate degree of uterine prolapse accompanying the cystocele, the base of the mesh can be anchored to the cervix and thus provide support to the uterus as well as the bladder, potentially avoiding a hysterectomy.

In my opinion, the keys to success are the following: estrogen cream preoperatively in the post-menopausal patient; intravenous and topical antibiotics; a small vaginal incision; good surgical exposure; careful technique making sure the mesh is anchored at the appropriate anatomical sites; trimming the mesh to use the least mesh load possible; avoiding mesh folding, redundancy and tension; and vaginal packing and oral antibiotics post-operatively.

The bottom line is that mesh repairs for pelvic organ prolapse have been revolutionary in terms of the quality and longevity of results—a true game changer. They represent a dramatic evolution in the field of female urology and urological gynecology, offering a vast improvement in comparison to the pre-mesh era. That said, they are not without complications, but the complication rates should be reasonably low under the circumstance of proper patient selection, a skilled and experienced surgeon performing the procedure, excellent surgical technique, utilization of the optimal mesh and patient preparation.

Mesh Integration

Three factors are integral to mesh integration, the process by which the mesh incorporates seamlessly into the body: mesh, patient, and surgeon factors. The goal is for the mesh to fully incorporate into the body so that it can serve its role in providing support to the urethra and/or bladder to cure/improve the stress incontinence and/or cystocele, respectively.

The “gold standard” mesh is large-pored, elastic, monofilament polypropylene. This has been the standard for sling surgery for stress urinary incontinence for over 20 years and for pelvic reconstructions for many years as well. This material is also the standard for mesh hernia repairs and also serves as a hardy suture used for closure of the abdominal wall.

Patient considerations are equally vital.  Risk factors for integration problems include: compromised or poor-quality vaginal tissues; radiated tissues; diabetes; patients on steroids; immune-compromised patients; and patients who use tobacco.

Foremost, a well-trained, experienced pelvic surgeon should be the person doing the mesh implantation. The surgeons most skilled and adept fake newsat this type of surgery are those who have undertaken fellowship training in female pelvic medicine and reconstructive surgery after completion of their urology or gynecology training. It is sensible to check if your surgeon is specialized, and if not, at least has significant clinical experience doing mesh implantation procedures. It is particularly important that the surgeon performing the mesh implant is capable of taking care of any complications that may arise.

The “Mesh-up”

Historically, many of the problems that occurred resulting from mesh implantations were not intrinsic to the mesh itself but were potentially avoidable issues that had to do with surgical technique and/or patient selection. Complications with integration such as mesh exposure—a situation where the mesh is “exposed” in the vagina and is not positioned in the correct surgical plane—can and do occur in a small percentage of patients (even when properly selected and when done by a well-trained pelvic surgeon).  When this situation occurs, it is generally quite manageable, although it will often involve revision surgery if it does not respond to conservative measures.

The crux of the “mesh-up” problem was that a few years ago several of the companies that sold mesh products–in an effort to amplify sales and profits–inappropriately and aggressively promoted their products to physicians who were not trained pelvic surgeons.  They offered “weekend training courses” to general gynecologists, many of whom started implanting pelvic meshes into patients after only a brief training period, often with disastrous results, with many patients sustaining incorporation issues.  This ultimately led to lawsuits and litigation and thereafter several of the mesh companies including Johnson and Johnson Gynecare and American Medical Systems pulled their mesh products off the market.  Fortunately for pelvic surgeons and patients alike, Boston Scientific remained in business, and it is their sling and mesh products that I most commonly implant for female pelvic surgical procedures.

This is not to say that there have not been bad mesh products on the market.  Historically, both the Mentor ObTape and the Tyco IVS sling were poorly designed mesh slings that did not have favorable incorporation features, had horrific results and were ultimately withdrawn from the market.

All of the slings and meshes that remain on the market that are used for pelvic floor surgery in the USA—including the Boston Scientific products–have favorable incorporation features and have been time-tested and have demonstrated their utility. Boston Scientific did not deserve a reaming on 60 Minutes, but I suppose it is irresponsible “spin” that makes for a story and commands advertising dollars.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

Kegels-on-Demand: Use Them As Needed

March 24, 2018

Andrew Siegel MD   3/24/2018

The concept of pelvic floor muscle training is not just to develop a strong and flexible pelvic floor, but also to put that capacity into practical use.  By knowing how to use your pelvic floor in real-life situations, you can improve your quality of life and many pelvic floor-related issues that may have surfaced over the years. This is the  essence of “functional fitness.”   Although this entry is primarily geared towards females, Kegels-on-demand on equally useful for men who have overactive bladder, stress incontinence, tension myalgia and premature ejaculation.

shutterstock_femalebluepelvic

 

Putting Your Pelvic Floor Muscle Training Into Action: Kegels-on-demand

Functional pelvic fitness is the practical and actionable means of applying pelvic floor muscle (PFM) proficiency to common everyday activities to improve pelvic function. This encompasses the knowledge of how to contract and relax PFM muscles through their full range of motion in the real world (as opposed to isolated, out-of-context contractions), when to do so, how often do so and why to do so.  For many women, this is the essence of PFMT–having stronger and more durable PFM to improve their quality of life.  These purposeful and consciously applied PFM contractions are not intended as exercise or training—although they will secondarily serve that purpose—but as management of the various pelvic floor dysfunctions at the times and moments that the problems become apparent.  When practiced diligently, these targeted PFM contractions can ultimately become automatic and reflex behaviors.

“Gotta” Go: Urgency Management

When you feel the sudden and urgent desire to urinate or move your bowels, snap your PFM several times, briefly but intensively. When your PFM are so engaged, the bladder muscle reflexively relaxes and the feeling of intense urgency should disappear. Understand that this is most effective when the bladder or bowels are not full, but are contracting involuntarily.

Staying Dry

For urgency incontinence, prior to exposure to the specific provoking trigger—hand washing, key in the door, running water, entering the shower, cold or rainy weather, etc.—snap your PFM rapidly several times to preempt the involuntary bladder contraction before it occurs (or diminish or abort the bladder contraction after it begins).

With respect to stress urinary incontinence (SUI), by actively contracting the PFM immediately before exposure to the activity that prompts the SUI, the incontinence can be improved or prevented. For example, if changing position from sitting to standing results in SUI, do a brisk short duration PFM contraction prior to and when transitioning from sitting to standing to brace the PFM and pinch the urethra shut.

Keeping Your Insides In

If you have pelvic organ prolapse (POP) and have defined activities that cause the prolapsed pelvic organ to drop or protrude—often standing, bending or straining—engage the PFM prior to or during these triggers. If you need to manually reduce the POP (by pushing the prolapse in with your fingers), after doing so, consciously engage the PFM to maintain the prolapsed pelvic organ in its proper anatomical position.

Better Sex for You and Your Partner

Integrate your newfound PFM powers in the bedroom and intensify your sensation as well as his by tightening your vaginal “grip” around his penis during sexual intercourse.  Alternatively, you can pulse your PFM rhythmically while pelvic thrusting or pulse your PFM without pelvic thrusting, the snapping providing penile stimulation in the absence of active thrusting.

As you develop increasing PFM proficiency, you may be able to selectively contract individual PFM in isolation, simultaneously, or in such a sequence that can result in a titillating experience for both you and your partner. You may be able to develop as much fine motor control of your vagina as you have of your fingers and hands! At the time of sexual climax, focus on the involuntary rhythmic contractions of your PFM and try to heighten the experience by explosively contracting them.

Try This: “Pompoir” is a technique in which a woman contracts her PFM rhythmically to stimulate the penis without the need for pelvic motion or thrusting. Women who diligently practice Kegel training can develop powerful PFM and become particularly adept at this, resulting in extreme vaginal “dexterity” and the ability to refine pulling, pushing, locking, gripping, pulsing, squeezing and twisting motions, which can provide enough stimulation to bring a male to climax. 

Relaxing the High-strung Pelvic Floor

If you suffer with tension myalgia of the PFM, focus on consciously unclenching the PFM over the course of your day. Be particularly aware of the natural PFM relaxation that occurs when urinating or moving your bowels and strive to replicate that feeling of PFM release.

 Limber hip rotators,

A powerful cardio-core,

But forget not

The oft-neglected pelvic floor.

 

Wishing you the best of health!

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

 

 

Nuts and Bolts of Pelvic Floor Muscle Training: Part 4

March 3, 2018

Andrew Siegel MD   3/3/2018

There are few, if any, pelvic programs in existence targeted for specific pelvic floor dysfunctions, as what you will generally find is a “one-size-fits-all” approach.

What follows are focused pelvic training programs, each designed for the nuances of the specific pelvic dysfunction at hand.  I have designed a general program as well as programs for poor pelvic muscle endurance, stress urinary incontinence (SUI), overactive bladder (OAB), pelvic organ prolapse (POP)/vaginal laxity, sexual/orgasm issues, bowel incontinence and pelvic pain. These programs have been carefully crafted based on my specialized training in pelvic medicine and surgery, clinical experience, interactions with physical therapists, exercise/fitness experts, Pilates and yoga instructors, and most importantly, my patients.

 General PFMT Program

The general program is a balanced program that incorporates strength and endurance training.  It is intended for women who are found to have poor PFM strength or poor strength and endurance on the preliminary testing. It is also appropriate for women without specific pelvic issues who wish to pursue a PFM exercise program to make their PFM stronger, more durable and to help prevent the onset of pelvic floor issues.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each week try to step up the intensity of the PFM contractions and duration of the short contractions; allot equal time to relaxing phase as contracting phase; refer back to previous pages if you need a refresher on snaps, shorts and sustained.

 Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

 Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

 Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x3 = 1 set 

Week 5 and on: Advance to resistance training. However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue this as a “maintenance” program, consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

 PFMT for Poor PFM Endurance

This program is designed for those with satisfactory PFM strength (Oxford grades 3-5), but poor endurance. The number of contractions performed and contraction duration are gradually increased over the course of the training program as adaptation occurs.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; allot equal time to relaxing phase as contracting phase.

 Week 1: snaps x15; 2 second shorts x15; 6 second sustained x1 = 1 set 

 Week 2: snaps x25; 3 second shorts x20; 8 second sustained x2 = 1 set 

 Week 3: snaps x35; 4 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 5 second shorts x30; 10 second sustained x4 = 1 set 

 Week 5 and on: Advance to resistance training.  If you found yourself severely challenged by this non-resistance program or cannot/prefer not to use resistance (which requires the placement of a device in your vagina), you can continue this as a “maintenance” program consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for POP/Vaginal Laxity

Endurance training is especially relevant for those with POP and poor vaginal tone. Focusing on sustained contractions will benefit the slow twitch endurance PFM fibers that are the prime contributors to pelvic tone and support. 

 Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week, work on stepping up the intensity of the PFM contractions; allot equal time to relaxing phase as contracting phase.

 Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

 Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

 Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

 Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue using this as a “maintenance” program, which will consist of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for Sexual/Orgasm Issues

The PFM contract intensively at the time of climax with each contraction lasting about 0.8 of a second, about how long snaps last. A series of vigorous snaps is precisely the PFM contraction pattern experienced at the time of orgasm. If you have issues with achieving an orgasm or with orgasm intensity, this natural contraction pattern is replicated in this program, which focuses on high-intensity pulses of the PFM (snaps) that benefit the fast twitch explosive fibers.  Endurance training is also important for sexual function since sustained contractions benefit the slow twitch endurance PFM fibers that contribute to pelvic support and vaginal tone.    

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each week work on stepping up the intensity of the snap PFM contractions; allot equal time to relaxing phase as contracting phase.

Week 1: snaps x30; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x40; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x50; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x60; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advancing to the resistance training.  However, if you were severely challenged by this non-resistance program or cannot/prefer not to use resistance—which requires the placement of a device in your vagina—you can continue using this as a “maintenance” program, consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for SUI

Strength and power training are critical for managing SUI, with the power element (i.e., how rapidly you can maximally contract your PFM) vital in order to react quickly to SUI triggers.  Focusing on moderate intensity contractions that last for several seconds (shorts) will benefit SUI, as this type of PFM contraction deployed prior to and during any activity that induces the SUI will help prevent its occurrence.  Attention directed to these short contractions will allow earlier activation of the PFM with SUI triggers, as well as increased contraction strength and durability to counteract the sudden increase in abdominal pressure that induces SUI.  Effort applied to sustained contractions is equally important since the slow twitch endurance PFM fibers are prime contributors to pelvic tone and pelvic support of the urethra, which promote urinary continence.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week try to step up the PFM contraction intensity as well as the activation speed (how long it takes to get to peak intensity); allot equal time to relaxing phase as contracting phase.

Week 1: snaps x20; 5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x30; 5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x40; 5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x50; 5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue this as a “maintenance” program, which consists of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for OAB and Urinary/Bowel Incontinence

Focusing on high-intensity pulses of the PFM (snaps) will benefit the fast twitch explosive fibers that are critical for inhibiting urinary and bowel urgency/urgency incontinence. These snaps will generate increased PFM strength and power to enhance the inhibitory reflex between PFM and the bladder/bowel, permitting a speedy reaction to urgency and facilitating the means to counteract urinary and bowel urgency, frequency and incontinence. Of equal importance is endurance training of the slow twitch, fatigue-resistant fibers that contribute to baseline tone of the voluntary urinary and bowel sphincters.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week try to step up the intensity of the PFM contractions; allot equal time to relaxing phase as contracting phase.

Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot/prefer not to use resistance (which requires the placement of a device in your vagina), you can continue using this as a “maintenance” program, which will consist of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for Pelvic Pain Due to Tension Myalgia: “Reverse” PFMT

Focusing on the relaxing aspect of the PFM contraction/relaxation cycle is the key to “down-train” the PFM from their over-tensioned, knot-like state. Those with over-contracted and over-toned PFM will not benefit from the typical strengthening PFMT done for most PFM dysfunctions—and can actually worsen their condition—so the emphasis here is on the relaxation phase of the PFM. This is “reverse” PFMT, conscious unclenching of the PFM in which the PFM drop and slacken as opposed to rise and contract. Reverse PFMT strives to stretch, relax, lengthen and increase the flexibility of the PFM. 

“Reverse” Kegels can be a confusing and difficult concept, particularly because these exercises demand conscious relaxation of the PFM, which only occurs subconsciously in real life. Recall that the PFM have a baseline level of tone and that complete PFM relaxation only occurs at the time of urination, bowel movements, passing gas or childbirth. 

To make this easier to understand, think of a PFM contraction on a scale of 0-10, with 0 being complete relaxation and 10 being maximal contraction. I have arbitrarily chosen 2 as the baseline level of PFM tone.  In reverse Kegel exercises you strive to go from 2 to 0 as opposed to standard exercises in which the effort is to go from 2 to 10.  When you urinate, move your bowels or pass gas, the PFM relax to a level of 0, so this is the feeling that you should strive to replicate, while continuing to breathe regularly without straining or pushing.  A deep exhalation of air will facilitate PFM relaxation, as it does for other muscle groups.

Perform the following: A very gentle PFM contraction to initiate PFM engagement, followed by deep relaxation and release of the PFM lasting as long as the contraction; 3 sets; one-minute break between each set; do 3-4 times weekly.

Week 1: reverse snaps x20; reverse 2-5 shorts x15; reverse 10 second sustained x1 = 1 set 

Week 2: reverse snaps x30; reverse 2-5 shorts x20; reverse 10 second sustained x2 = 1 set 

Week 3: reverse snaps x40; reverse 2-5 shorts x25; reverse 10 second sustained x3 = 1 set 

Week 4: reverse snaps x50; reverse 2-5 shorts x30; reverse 10 second sustained x3 = 1 set 

Week 5 and on: There is no role for using resistance exercises for tension myalgia. Continue using this program as a “maintenance” program, consisting of the Week 4 regimen done twice weekly (as opposed to every other day). Make a concerted effort at keeping the PFM relaxed at all times, not just while pursuing the PFMT program.

…To be continued.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

Femicushion: Conservative Management Of Pelvic Organ Prolapse

July 1, 2017

Andrew Siegel MD  7/1/17

Medical trivia: Did you know that July 1 is the transitional day in which medical students become interns, interns become residents, residents become fellows, and residents and fellows become attending physicians? It is typically a day of mass confusion in the hospital. For this reason, it is always better to be treated in June than July!

Pelvic organ prolapse (POP) is a common female condition due to weakened pelvic anatomical support.  It results in one or more of the pelvic organs falling into the vaginal space, and at times, outside of the vaginal opening.  Several of my previous entries have covered the topic of POP and its treatment:

Introduction to POP

More about POP

A pessary is an internal device available in different sizes and shapes that is placed within the vagina to keep the fallen pelvic organ in its proper anatomical position. I reviewed pessaries in a previous blog entry: The basics of pessaries

Today’s entry is on Femicushion, a newly available soft cushion that functions as an external pessary, which offers the advantage of not needing to be positioned deeply within the vagina as is a standard pessary.  This device is ideal for women who cannot or do not want to have surgery for their POP and are not thrilled with the concept of wearing an internal pessary.

femicushion posicionado

The Femicushion is composed of washable, medical-grade silicon and is available in three sizes based upon the anatomy of the vaginal opening.

img116tk3503_1

After the POP is “reduced” (the prolapsed pelvic organ is pushed back into its normal anatomical position), the appropriately sized Femicushion is placed just within the vaginal opening. Its presence prevents the fallen pelvic organ from descending outside the vaginal opening.

IMG_1397

Once in place, it is maintained in proper position with a special pad with Velcro that is attached to adjustable undergarments (all washable):

Femicushion

The Femicushion is designed to be worn during the day and removed at night. It is washed upon removal, to be worn the following day.

The Femicushion causes less complications than an internal pessary, since it is external and is removed and cleaned on a daily basis, reducing the risk for vaginitis and bleeding. Furthermore, it eliminates forgetting to remember the presence of the internal pessary that can give rise to erosions and other serious medical issues.

Dr. Sophia Souto and colleagues performed a pilot study of the Femicushion concluding that it is an effective means of alleviating POP symptoms and improving the quality of life of women suffering with POP.  Dr. Souto was kind enough to send me all of the images used in today’s entry.  For an excellent reference on the topic, see the following article published by Dr. Souto et al: Femicushion: A new pessary generation – pilot study for safety and efficacy.  Pelviperineology 2016: 35: 44-47

The Femicushion device can be purchased online at the Urology Health Store: Use “Urology 10” code for 10% discount and free shipping.

http://www.UrologyHealthStore.com

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  

 

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

Rectoceles And Perineal Laxity: What You Need To Know

May 20, 2017

Andrew Siegel MD  5/20/17

recto copy

Image above: protrusion of the rectum into the floor of the vagina, a.k.a. rectocele (blue arrow); also note catheter in urethra (red arrow) and gaping vagina with scarring of tissues between vagina and anus, a.k.a. perineum (white arrow)

A rectocele is a specific type of pelvic organ prolapse in which the pelvic floor muscles and connective supporting tissue between the lower vaginal wall and rectum weaken, allowing protrusion of the rectum into the floor of the vagina and at times outside the vaginal opening. This not uncommonly follows vaginal childbirth, which places tremendous stresses on the tissues that provide to support of the pelvic organs. Other risk factors for the occurrence of a rectocele are chronic straining, menopause and weight gain.

Rectoceles are also known by the terms “dropped rectum,” “prolapsed rectum,” and “rectal hernia.” The most common symptom is an annoying vaginal bulge that worsens with assuming the upright position and being active and tends to improve with sitting, lying down and being sedentary. It is often quite noticeable when straining to move one’s bowels. It can give rise to bowel difficulties—most notably what is referred to as “obstructed defecation”—including constipation, incomplete bowel emptying, diarrhea and fecal incontinence. The prolapsed rectum often needs to be manipulated back into position in order to be able to effectively move one’s bowels. Rectoceles can also cause vaginal pressure, vaginal pain and painful sexual intercourse.

Relevant trivia: The word “rectum” derives from the Latin word meaning “straight,” because under normal circumstances the rectum is a straight chute, facilitating bowel movements. The presence of a rectocele causes kinking of the rectum to occur, destroying this anatomical arrangement and making bowel movements difficult without “splinting” the rectum (straightening it out) using one or more fingers placed in the vagina.

Often accompanying a rectocele is laxity of the perineal muscles, a condition in which the superficial pelvic floor muscles (those located in the region between the vagina and anus) become flabby. This causes a widened vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal angle. Women who are sexually active may complain of a loose or gaping vagina. This may lead to difficulty keeping a tampon in position without it falling out, the vagina filling with water while bathing, vaginal flatulence (the embarrassing passage of air) and sexual issues including difficulty retaining the penis with vaginal intercourse and difficulty achieving orgasm. Perineal laxity may result in the vagina “surrounding” the penis rather than firmly “squeezing” it during sexual intercourse, with the end result diminished pleasurable sensation for both partners. The perception of having a loose vagina and altered anatomy can lead to self-esteem and other psychological issues.

Relevant trivia: Under normal circumstances, sexual intercourse results in indirect clitoral stimulation. The clitoral shaft moves rhythmically with penile thrusting by virtue of penile traction on the inner vaginal lips, which join together to form the hood of the clitoris. However, if the vaginal opening is too wide to permit the penis to put enough traction on the inner vaginal lips, there will be limited clitoral stimulation and less satisfaction in the bedroom.

Management of Rectoceles

Rectoceles can be managed conservatively with pelvic floor exercises, behavioral modifications and consideration for using a pessary. Alternatively, surgical treatment, a.k.a. pelvic reconstruction, is often necessary for more extensive rectoceles or for those that do not respond to conservative measures.

Pelvic floor muscle training (PFMT) is useful under the circumstances of mild-moderate rectocele, for those who cannot or do not want to have surgery and for those whose minimal symptoms do not warrant more aggressive options. The goal of PFMT is to increase the strength, tone and endurance of the muscles that play a key role in the support of the rectum and perineum. Weak pelvic muscles can undoubtedly be strengthened; however, if there is connective tissue damage, pelvic training will not remedy the injury, but does serve to strengthen the muscles that can help compensate for the connective tissue impairment. If not completely cured with PFMT, the rectocele and perineal laxity can still be improved, and that might be sufficient.  Chapter 5 in The Kegel Fix book  (www.TheKegelFix.com) is devoted to a specific PFMT regimen for rectoceles and other forms of pelvic organ prolapse.  Note that if the pelvic floor muscles are torn or widely separated, PFMT will not be productive until surgical repair is performed.

Another component of conservative management is modification of activities that promote the rectocele (heavy lifting and high impact exercises), management of constipation and other circumstances that increase abdominal pressure, weight loss, smoking cessation and consideration for estrogen hormone replacement, since estrogen replacement can increase tissue integrity and suppleness.

A pessary is a mechanical device that is available in a variety of sizes and shapes and is inserted into the vagina where it acts as a “strut” to help provide pelvic support and keep the rectum in proper position. Pessaries need to be removed periodically in order to clean them. Some are designed to permit sexual intercourse.

Surgery is often necessary in the case of a symptomatic moderate-severe rectocele, particularly when quality of life has been significantly impacted. This type of surgery is most often done vaginally, typically on an outpatient basis. Both the rectocele and the perineal laxity are addressed.  The goal of surgery is restoration of normal anatomy with preservation of vaginal dimensions and improvement in symptoms with optimization of bowel and sexual function.  With improvement of anatomy, function often significantly improves, since function often follows form. Difficulties with evacuation, constipation, straining, incomplete emptying and fecal incontinence should improve, if not resolve. There should no longer be a need to splint the rectum and sexual function (for both patient and partner) should dramatically improve with the rebuilding of the perineum.

Marietta S pre-PP

Pre-operative photo–note gaping vulva, exposed vagina, rectocele and perineal laxity; (c) Michael P Goodman, MD. Used with permission

 

Mariette S 6 wk p.o. PP

Post-operative photo–note closed vulva, unexposed vagina and restored perineum after levatorplasty, vaginoplasty, perineorrhaphy and aesthetic perineoplasty; (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  

Much of the content of this entry was excerpted from Dr. Siegel’s The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health (Chapter 5. Pelvic Organ Prolapse)

Pessaries To Treat Pelvic Organ Prolapse: What You Need To Know

April 15, 2017

Andrew Siegel MD    4 /15 /17

A pessary is a vaginal insert that is used to help provide pelvic support in women with vaginal prolapse of the urogenital organs, a.k.a. pelvic organ prolapse (POP). Pessaries are available in a variety of sizes and shapes and when positioned in place within the vagina, function as “struts” to help keep the prolapsing pelvic organ(s) in proper anatomical position. They are ideal for older patients who have medical issues that preclude surgical treatment and for women who opt for non-surgical management.  Pessaries need to be removed periodically in order to clean them.  Some are designed to permit sexual intercourse.

A Few Words on POP

POP is a common condition in which there is weakness of the pelvic muscles and connective tissues that provide pelvic support, allowing one or more of the pelvic organs to move from their normal positions into the potential space of the vaginal canal and, at its most severe degree, outside the vaginal opening. POP is an important issue in women’s health, with an increasing prevalence correlating with extended longevity. Two-thirds of women who have delivered children vaginally have anatomical evidence of POP (although many are not symptomatic) and 10-20% will need to undergo a corrective surgical procedure. The true prevalence of POP is not known because of the large number of women who do not seek medical care for the problem.

POP is not life threatening, but can be a distressing and disruptive problem that negatively impacts quality of life. Despite how common an issue it is, many women are reluctant to seek help because they are too embarrassed to discuss it with anyone or have the misconception that there are no treatment options available or fear that surgery will be the only solution.

POP may involve any pelvic organ including the urinary, intestinal and gynecological tracts. The bladder is the organ that is most commonly involved in POP. POP can vary from minimal descent—causing few, if any, symptoms—to major descent—in which one or more of the pelvic organs prolapse outside the vagina at all times, causing significant symptoms. The degree of descent varies with position and activity level, increasing with the upright position and/or exertion and decreasing with lying down and resting, as is the case for any hernia.

POP can give cause a variety of symptoms, depending on which organ is involved and the extent of the prolapse.  The most common complaints are the following: a vaginal bulge or lump, the perception that one’s insides are falling outside, and vaginal “pressure.”  Because POP often causes vaginal looseness in addition to one or more organs falling into the space of the vaginal canal, sexual complaints are common, including painful intercourse, altered sexual feeling and difficulty achieving orgasm as well as less partner satisfaction.

3 Options to Manage POP

  1. Conservative
  2. Pessaries
  3. Surgery (Pelvic Reconstruction) 

Conservative treatment options for POP include pelvic floor muscle training (for details on pelvic muscle training for POP see http://www.TheKegelFix.com), modification of activities that promote the POP (heavy lifting and high impact exercises), management of constipation and other circumstances that increase abdominal pressure, weight loss, smoking cessation and consideration for hormone replacement, since estrogen replacement can increase tissue integrity and suppleness.

Pessary Basics

A pessary is a non-surgical option for treating POP, used with the goal of improving quality of life, body image, and bladder, bowel and sexual function. Pessaries are made of soft and pliable hypoallergenic plastic or silicone and can successfully alleviate symptoms of POP in 85% of those who use them.  About 50% or so of women who trial pessaries continue to use them for the long term, with discontinuation typically occurring in those who cannot retain the pessary, those experiencing discomfort or pain, those who desire surgery, and those who are incapable of inserting and removing them.

It is important to know that pessaries are not successful in all women with POP.  They tend to fail in women with significantly enlarged vaginal openings, in which case the pessary can fall out with effort and exertion. Factors associated with a higher risk for failure are younger age, obesity, and weak pelvic floor muscles.

For Whom is a Pessary Appropriate?

  • Older women who are not candidates for surgery
  • Anyone who desires non-surgical management of their POP
  • For those who need to delay surgery, wish to defer surgery or simply desire to trial one prior to surgery

1-Pessary Image

Image Above: A Potpourri of Pessaries

What Types of Pessaries Are Available?

For Mild-Moderate POP

The ring pessary (7:00 position of image above) is the simplest and most commonly used pessary that has the least side effects.  It is widely employed because of its ease of insertion, good vaginal fit and allowance for sexual intercourse without removing it.  A variation of the ring pessary is one with central support. The oval pessary is a variation of the ring used in narrow vaginas.  The Shaatz pessary (4:00 position of image above) is another variation. The incontinence dish pessary (5:00 position of image above) is used for stress urinary incontinence and mild POP.  A variation of this comes with a central support.

For Moderate-Severe POP

The Gellhorn pessary (3:00 position of image above) is used for greater degrees of POP than the pessaries described in the paragraph above, which are typically used for mild-moderate POP.  It tends to produce the greatest degree of vaginal discharge because of its shape.   The Hodge pessary has wires that can be manually shaped to fit the nuances of one’s anatomy. The Gehrung pessary (10:00 position of image above) also has wires that allow it to be manually shaped.  The donut pessary (center position of image above) is soft allowing it to be compressed for insertion, even with its bulk.  The cube pessary (9:00 position of image above) comes with a tie to help with its removal.

What Are Side Effects Of Pessaries?

The most common side effects are vaginal discharge and vaginitis (vaginal irritation or infection).  Occasionally, vaginal ulcerations can occur because of abrasive contact of the pessary with the delicate lining of the vagina.

How Does One Get Fitted For A Pessary?

A pelvic exam is performed prior to the fitting in order to help determine the proper size and type.  A properly fitted pessary should be large enough to function optimally, but not so large that it causes pressure or discomfort. It should be possible to insert a finger between the pessary’s outer rim and the wall of the vagina.

Usually a ring pessary (size 2, 3, or 4) is initially trialled.  It comes in 9 sizes, ranging from 2.00-4.00 in 0.25 increments.  If unsuccessful, a Gellhorn (size 2, 2.25, 2.5, or 2.75), cube or other model is utilized, depending upon particular circumstances. The largest pessary that is comfortable is placed and the patient is asked to walk and strain to ensure that it remains in proper position.  Motivated patients can be taught how to remove, clean and reinsert it. Typically, removal is done once weekly prior to sleeping, with reinsertion the following morning.  For the less motivated patient, the gynecologist can remove, clean and replace the device every three months or so.

Bottom Line: Pessaries are a non-surgical alternative to help provide pelvic support in women with pelvic organ prolapse.  They are available in a variety of sizes and shapes and need to be fitted and sized to the particulars of one’s anatomy.  They fold and compress to facilitate insertion and removal.  They are ideal for older patients who have medical issues that preclude surgical treatment.  If pessaries fail to improve the POP or cannot be retained or are poorly tolerated, a surgical procedure–pelvic reconstruction–can be performed to remedy the problem.  

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 

DON’T Exercise Your Pelvic Muscles… TRAIN Them

April 1, 2017

Andrew Siegel MD  4/1/2017

“Exercise” is not the same as “training” and “pelvic floor exercises” (“Kegels”) are not the same as “pelvic floor training.”

1116_Muscle_of_the_Perineum (1)

Male (left) and female (right) pelvic floor muscles–By OpenStax [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)%5D, via Wikimedia Commons

To anybody interested in the nuances of exercise science, “exercising” and “training” are as different as apples and oranges. Don’t get me wrong—they are both healthy and admirable pursuits and doing any form of physical activity is far superior to being sedentary. However, exercise is more of being “in the moment,” a “here and now” physical activity– the short view. On the other hand, training is a well-planned and thought out process pursued towards the achievement of specific long-term goals– the long view. Every workout in a training program can be thought of as an incremental steppingstone in the process of muscle adaptation to achieve improvement or enhancement of function. The ultimate goal of a training program is being able to apply in a practical way the newly fit and toned muscles to daily activities—functional fitness—in order to achieve a better performance (and when it comes to the pelvic floor muscles, an improved quality of life.)

Muscle training is all about adaptation. Our muscles are remarkably adaptable to the stresses and loads placed upon them. Muscle growth will only occur in the presence of progressive overload, which causes compensatory structural and functional changes. That is why exercises get progressively easier in proportion to the effort put into doing them.  As muscles adapt to the stresses placed upon them, a “new normal” level of fitness is achieved. Another term for adaptation is plasticity–our muscles are “plastic,” meaning they are capable of growth or shrinkage depending on the environment to which they are exposed.

One obvious difference between pelvic floor muscles and other skeletal muscles is that the pelvic muscles are internal and hidden, which adds an element of challenge not present when training the visible arm, shoulder and chest muscles. However, the pelvic floor muscles are similar to other skeletal muscles in terms of their response to training. In accordance with the adaptation principle, incrementally increasing contraction intensity and duration, number of repetitions and resistance will build pelvic muscle strength, power and endurance.

The goal for pelvic floor muscle training is for fit pelvic muscles—strong yet flexible and equally capable of powerful contractions as well as full relaxation. The ultimate goal for pelvic floor muscle training—a goal that often goes unmentioned–is the achievement of “functional pelvic fitness.”  Pelvic floor muscle training really is the essence of functional fitness, training that develops pelvic floor muscle strength, power, stamina and the skill set that can be used to improve and/or prevent specific pelvic functional impairments including those of a sexual, urinary, or bowel nature and those that involve weakened pelvic support resulting in pelvic organ prolapse.

With occasional exceptions, most women and men are unable to perform a proper pelvic muscle contraction and have relatively weak pelvic floor strength. In my opinion, pelvic training programs should therefore initially focus on ensuring that the proper muscles are being contracted and on building muscle memory. It is fundamental to learn basic pelvic floor anatomy and function and how to isolate the pelvic muscles by contracting them independently of other muscles. Once this goal is achieved, pelvic training programs can be pursued.

Programs need to be able to address the specific area of pelvic weakness, e.g., if strength is the issue, emphasis on strength training is in order, whereas if stamina is the issue, focus on endurance training is appropriate. Furthermore, programs need to be designed for specific pelvic floor dysfunctions, with “tailored” training routines customized for the particular pelvic health issue at hand, whether it is stress urinary incontinence, overactive bladder, pelvic organ prolapse, sexual/orgasm issues, or pelvic pain. Aligning the specific pelvic floor dysfunction with the appropriate training program that focuses on improving the area of weakness and deficit is fundamental since each pelvic floor dysfunction is associated with unique and specific deficits in strength, power and/or endurance.

It is easiest to initially train the pelvic floor muscles in positions that remove gravity from the picture, then advancing to positions that incorporate gravity. It is sensible to begin with the simplest, easiest, briefest pelvic contractions, then advance to the more challenging, longer duration contractions, slowly and gradually increasing exercise intensity and degree of difficulty.

In my opinion, the initial training should not include resistance, which should be reserved for after achieving mastery of the basic training that provides the foundation for pelvic muscle proficiency.

Bottom Line: If you are serious about improving or preventing a pelvic floor dysfunction, you need to do pelvic floor muscle training as opposed to pelvic floor exercises. There are numerous differences including the following:

  • Training is motivated by specific goals and purposes while exercise is done for its own sake or for more general reasons
  • Training requires a level of focus and intensity not demanded by exercise
  • Training requires a plan
  • Training can be a highly effective means of improving and preventing pelvic floor dysfunction

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

The Little Muscles That Could: The Mysterious Muscles You Should Be Exercising

November 5, 2016

Andrew Siegel MD 11/5/2016

This entry was a feature article in the Fall 2016 edition of BC The Magazine: Health, Beauty & Fitness.

(A new blog is posted weekly. To receive the blogs via email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com)

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Image above: female pelvic floor muscles, illustration by Ashley Halsey from The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health

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Image above: male pelvic floor muscles, illustration by Christine Vecchione from Male Pelvic Fitness: Optimizing Sexual and Urinary Health

There are over 600 muscles in the human body and they all are there for good reasons. However, some are more critical to health and survival than others. In the class rank it is a no-brainer that the heart muscle is valedictorian, followed by the diaphragm. What may surprise you is that the pelvic floor muscles (a.k.a. Kegel muscles) rank in the top ten of the hierarchy.

The pelvic floor muscles are a muscular hammock that make up the floor of the “core” muscles. They are located in the nether regions and form the bottom of the pelvis. They are among the most versatile muscles in the body, equally essential in both women and men for the support of the pelvic organs, bladder and bowel control and sexual function. Because they are out of sight they are frequently out of mind and often not considered when it comes to exercise and fitness. However, without functional pelvic muscles, our pelvic organs would dangle and we would be diapered and asexual.

Our bodies are comprised of a variety of muscle types: There are the glamour, for show, mirror-appeal, overt, seen and be witnessed muscles that offer no secrets—“what you see is what you get”—the biceps, triceps, pectorals, latissimus, quadriceps, etc. Then there are muscles including the pelvic floor muscles that are shrouded in secrecy, hidden from view, concealed and covert, unseen and behind the scenes, unrecognized and misunderstood, favoring function over form, “go” rather than “show.” Most of us can probably point out our “bi’s” (biceps), “tri’s” (triceps), “quads” (quadriceps), “pecs” (pectorals), etc., but who really knows where their “pelvs” (pelvic floor muscles) are located? For that matter, who even knows what they are and how they contribute to pelvic health?

Strong puritanical cultural roots influence our thoughts and feelings about our nether regions. Consequently, this “saddle” region of our bodies (the part in contact with a bicycle seat)—often fails to attain the respect and attention that other zones of our bodies command. Cloaking increases mystique, and so it is for these pelvic muscles, not only obscured by clothing, but also residing in that most curious of regions–an area concealed from view even when we are unclothed. Furthermore, the mystique is contributed to by the mysterious powers of the pelvic floor muscles, which straddle the gamut of being critical for what may be considered the most pleasurable and refined of human pursuits—sex—but equally integral to what may be considered the basest of human activities—bowel and bladder function.

The deep pelvic floor muscles span from the pubic bone in front to the tailbone in the back, and from pelvic sidewall to pelvic sidewall, between the “sit” bones. The superficial pelvic floor muscles are situated under the surface of the external genitals and anus. The pelvic floor muscles are stabilizers and compressors rather than movers (joint movement and locomotion), the more typical role that skeletal muscles such as these play. Stabilizers support the pelvic organs, keeping them in proper position. Compressors act as sphincters—enveloping the urinary, gynecological and intestinal tracts, opening and closing to provide valve-like control. The superficial pelvic floor muscles act to compress the deep roots of the genitals, trapping blood within these structures and preparing the male and female sexual organs for sexual intercourse; additionally, they contract rhythmically at the time of sexual climax. Although the pelvic floor muscles are not muscles of glamour, they are certainly muscles of “amour”!

Pelvic floor muscle “dysfunction” is a common condition referring to when the pelvic floor muscles are not functioning properly. It affects both women and men and can seriously impact the quality of one’s life. The condition can range from “low tone” to “high tone.” Low tone occurs when the pelvic muscles lack in strength and endurance and is often associated with stress urinary incontinence (urinary leakage with coughing, sneezing, laughing, exercising and other physical activities); pelvic organ prolapse (when one or more of the female pelvic organs falls into the space of the vagina and at times outside the vagina); and altered sexual function, e.g., erectile dysfunction or vaginal looseness.  High tone occurs when the pelvic floor muscles are over-tensioned and unable to relax, giving rise to a pain syndrome known as pelvic floor tension myalgia.

A first-line means of dealing with pelvic floor dysfunction is getting these muscles in tip-top shape. Tapping into and harnessing their energy can help optimize pelvic, sexual and urinary health in both genders. Like other skeletal muscles, the pelvic muscles are capable of making adaptive changes when targeted exercise is applied to them. Pelvic floor training involves gaining facility with both the contracting and the relaxing phases of pelvic muscle function. Their structure and function can be enhanced, resulting in broader, thicker and firmer muscles and the ability to generate a powerful contraction at will—necessary for pelvic wellbeing.

Pelvic floor muscle training can be effective in stabilizing, improving and even preventing issues with pelvic support, sexual function, and urinary and bowel control. Pursuing pelvic floor muscle training before pregnancy will make carrying the pregnancy easier and will facilitate labor and delivery; it will also allow for the effortless resumption of the exercises in the post-partum period in order to re-tone the vagina, as the exercises were learned under ideal circumstances, prior to childbirth. Similarly, engaging in pelvic training before prostate cancer surgery will facilitate the resumption of urinary control and sexual function after surgery. Based upon solid exercise science, pelvic floor muscle training can help maintain pelvic integrity and optimal function well into old age.

Bottom Line: Although concealed from view, the pelvic floor muscles are extremely important muscles that deserve serious respect. These muscles are responsible for powerful and vital functions that can be significantly improved/enhanced when intensified by training. It is never too late to begin pelvic floor muscle training exercises—so start now to optimize your pelvic, sexual, urinary, and bowel health.

Wishing you the best of health,

2014-04-23 20:16:29

www.AndrewSiegelMD.com

Andrew Siegel MD practices in Maywood, NJ. He is dual board-certified in urology and female pelvic medicine/reconstructive surgery and is Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and attending urologist at Hackensack University Medical Center. He is a Castle Connolly Top Doctor New York Metro area and Top Doctor New Jersey. He is the author ofTHE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health (www.TheKegelFix.com) and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health (www.MalePelvicFitness.com). He is co-creator of PelvicRx, an interactive, FDA-registered pelvic floor muscle-training program that empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance, this program helps improve sexual function and urinary function. In the works is the female PelvicRx pelvic floor muscle training for women. Visit: http://www.UrologyHealthStore.com to obtain PelvicRx. Use promo code “UROLOGY10” at checkout for 10% discount.