Posts Tagged ‘vaginal looseness’

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

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”:

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

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


Vaginal Tone: How Tight Is Right?

June 11, 2016

Andrew Siegel, M.D.   6/10/16


The strength and firmness of the vagina is largely determined by the strength and tone of the pelvic floor muscles .  As a urologist who treats many female pelvic problems, questions about vaginal tightness and tone are not infrequently raised by concerned patients.  It is important to distinguish strength from tone.  A condition exists in which the pelvic floor muscles are tight and over-toned (“hypertonic”), yet weak, inflexible and with an impaired ability to relax after a contraction.  This is a pathological condition of the pelvic floor muscles which can give rise to pelvic pain, sexual dysfunction and numerous other symptoms.

The Effect of Vaginal Delivery

The most compelling factor affecting vaginal form is vaginal childbirth.  A recent article from the British Journal of Obstetrics and Gynecology (Kamisian et al, 2015; 122:867-872) studied the relationship between childbirth and vaginal dimensions in women presenting with urinary control issues and pelvic organ prolapse. The average measurement of the vaginal opening (obtained upon abdominal straining) was 29 cm² in women who had vaginal deliveries versus 21.5 cm² in women who had not delivered vaginally. Having more than one child did not further increase the size of the vaginal opening in a significant way. Bottom Line: The researchers concluded that there are clearly anatomical differences present in women who have delivered vaginally versus those who have not and that most of the stretching effect of vaginal childbirth is related to the first delivery.

 The Vagina: A Mysterious But Amazing Place

Trivia: The word “vagina” derives from the Latin word for “sheath,” a cover for the blade of a knife or sword. The word “penis” derives from the Latin word for “tail.”

Although for many people–both women and men–the vagina is a dark and mysterious place, it is impressive how versatile and multifunctional an organ it is. The vagina wears many “hats,” functioning as an entryway for the penis during sexual intercourse, an inflow pathway and receptacle for semen, an outflow pathway for menstruation and a birth canal. The elasticity of the vagina is extraordinary, with an astonishing ability to stretch to accommodate a baby’s head and then return to a relatively normal caliber. That stated, pregnancy, labor and delivery–particularly vaginal deliveries of large babies–has the potential to profoundly affect the anatomy and function of the vagina and its supportive pelvic muscles.  Although not inevitable, this can result in vaginal laxity (looseness) and other pelvic floor dysfunctions including pelvic organ prolapse (dropped bladder and other pelvic organs), stress urinary incontinence (urinary leakage with coughing, sneezing and physical exertion) and sexual issues.

Trivia: Elective C-section (no labor) is generally protective against vaginal laxity, whereas emergency C-section (after prolonged labor) is equally as potentially damaging to the vaginal support system as is vaginal delivery.

Is Your Vagina Toned/Tight Enough?

If you have ever wondered if your vagina is toned enough and how it might compare with others, you are by no means alone. Like penis size for men, this can be a source of concern and anxiety for many women. A “fit” vagina and pelvic floor is a desirable physical attribute, correlating with youthful vitality, better sexual function for women and their partners and less risk for pelvic organ prolapse and stress urinary incontinence.

Trivia: Leonardo Da Vinci observed that while women generally desire the size of a man’s genitals to be as large as possible, men typically desire the opposite for a woman’s genitals.

Vaginal tone is strongly impacted by the strength and tone of the pelvic floor (Kegel) muscles, but is also influenced by the strength and tone of the muscle layers of the vagina itself. Vaginas come in all sizes and shapes and run the gamut from being very snug to very loose. The vast majority of vaginas are between these too extremes,  “toned sufficiently.” On one extreme, the vagina and pelvic muscles can be so snug that the vagina cannot be penetrated, a medical condition known as vaginismus, which can be a devastating physical and emotional problem. It is an extreme form of pelvic floor tension myalgia, a pelvic pain syndrome referred to earlier resulting from pelvic floor muscles that are chronically over-tensioned. Extremely narrow and tight vaginas are also common in the elderly population that is not sexually active, on the basis of disuse atrophy and the lack of hormone stimulation that accompanies menopause.

On the other hand, the vagina, pelvic floor muscles and other connective tissue support can be so lax that the vagina gapes open, allowing one or more of the pelvic organs to fall into the space of the vagina and at times, outside of the vagina. This can also give rise to other pelvic issues having to do with sexual function and urinary/bowel control. Laxity can lead to difficulties with retaining the penis with vaginal intercourse, retaining tampons and in achieving orgasm.  Vaginal laxity can also result in the vagina filling up with water while bathing and vaginal passage of air (vaginal flatulence). The perception of having a loose vagina can lead to self-esteem issues.

 The Role of Vaginal Tone In Sexual Function

To reiterate, vaginal fitness is an important factor in terms of sexual function and is largely determined by pelvic floor muscle strength and tone. Vaginal laxity is caused by weakened pelvic muscles, vaginal muscles and connective tissue that no longer provide optimal vaginal support. Women with a lax vagina who are sexually active may complain of less satisfying sexual intercourse with diminished sensation for themselves and their partners with an impairment in “accommodating” the penis, with the vagina “surrounding” the penis rather than firmly “squeezing” it.

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 sufficient traction on the inner vaginal lips, there can be decreased clitoral stimulation and less satisfaction in the bedroom.

Trivia: George Carlin did a routine about women who have a special gift with the strength, tone and finesse of their vaginas and pelvic floor muscles that I will attempt to paraphrase. He referred to the vaginas of these women as “snapping,” which he defined as “quick muscular control and vaginal elasticity that can grab ahold of you.”  What he was actually describing was women with excellent command of their pelvic floor muscles. 

 So How Tight Is Right?

Dr. Arnold Kegel in the 1940s invented a device called a perineometer that was inserted into the vagina to record the pelvic floor muscle contractile strength.  There are numerous sophisticated measurement devices that exist today.

A simple means is the digital method (a finger in the vagina) to assess your pelvic muscle strength. Do so supine (lying down, face up) with knees bent and slightly parted. Use a hand-held mirror to get a visual of your vulva. The inner vaginal lips should be closed and touching, appearing like a shut clamshell. A sign of vaginal laxity is when the lips are parted like an open clamshell. Another sign of laxity is a reduction in the distance from the bottom part of the vaginal opening to the anus (the perineum). A more severe sign of vaginal laxity is gaping lips with a pink bulge (pelvic organ prolapse) emerging between the lips. Take a look while pushing and straining your abdominal muscles—as if you are pushing out a baby—as a “vaginal stress test.”

Gently place a lubricated finger of one hand in the vagina and contract your pelvic muscles, squeezing around the finger and trying to lift it upwards and inwards, ensuring that you are not contracting your gluteal (butt), rectus (abdomen) or adductor (inner thigh) muscles. Do this by placing your other hand on each of these other muscle groups, in turn, to prove to yourself that these muscles remain relaxed.

Grade your strength using the modified Oxford grading scale, giving yourself a number between 0-5. Note that the Oxford system is what physicians use and it is relatively simple when done regularly by those with experience performing pelvic exams. It is granted that since this assessment is subjective and is not your specialty, you may find it challenging, but do your best, as your goal is to get a general sense of your pelvic strength.

Oxford Grading of Pelvic Strength

0—complete lack of contraction

1—minor flicker

2—weak squeeze (without a circular contraction or inner and upward movement)

3—moderate squeeze (with some inner and upward movement)

4—good squeeze (with moderate inner and upward movement)

5—strong squeeze (with significant inner and upward movement)

What To Do About Vaginal Laxity

If you are unhappy with your vaginal tone, do not despair. Pelvic floor exercises (a.k.a. Kegels) can and will often help improve the situation. Achieving a well-conditioned pelvic floor will optimize vaginal tone, pelvic organ support and sexual, urinary and bowel function as well as positively impact core strength and stability, posture and spinal alignment.

Bottom Line:  A firm and fit vagina is desirable from the standpoint of pelvic, sexual and general health.  Having well-conditioned pelvic floor muscles can help prevent and treat vaginal laxity, pelvic organ prolapse, urinary and bowel control issues as well as contribute to a healthy and enjoyable sex life. Just as you make an effort to keep your external muscles in good shape, It makes sense to apply a similar effort to these important internal muscles.

Please check out the following 3 minute video entitled “Why Kegel?”:

Wishing you the best of health,

2014-04-23 20:16:29

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”:

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at

Author page on Amazon:

Apple iBook:

The Kegel Fix trailer:  

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.  In the works is the female PelvicRx pelvic floor muscle training DVD. 

Pelvic Rx can be obtained at, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 


A Brief History of Kegel Exercises

April 16, 2016

Andrew Siegel MD  4/16/16

This first piece (of a two-part entry) reviews the history of pelvic floor training from antiquity up to 2015. The second piece (the 4/23/16 entry) is a discussion of the Kegel “renaissance” and “revolution” that is underway. This “sea change” in pelvic floor medicine that is currently evolving in the urology/gynecology medical community will most certainly permeate into the mainstream in the near future.


His and hers pelvic floor muscles (Dr. Henry Gray, Gray’s Anatomy, 1918, public domain)

The pelvic floor muscles have long been recognized as instrumental for their roles in  pelvic organ support, healthy sexual functioning and for their contribution to urinary and bowel control. They also contribute to core stability and postural support. The pelvic muscles anatomically and functionally link the female pelvic organs—the vagina, uterus, bladder and rectum—and also affect the independent function of each. Pelvic muscle “dysfunction” (when the pelvic muscles are impaired and not functioning properly) in females can contribute to pelvic organ prolapse and vaginal looseness, urinary and bowel control problems, sexual issues and pelvic pain (tension myalgia). Pelvic floor dysfunction in males can play a role in the urinary incontinence that follows prostate cancer surgery, dribbling of urine after the completion of urination, erectile dysfunction, ejaculation issues and pelvic pain.

Pelvic floor muscle fitness is vital to healthy pelvic functioning and pelvic muscle training therefore plays an important role in the management of many pelvic conditions. Pelvic muscle training has the potential of not only treating pelvic floor dysfunction, but also delaying and preventing its onset.

Pelvic floor exercises date back over 6000 years ago to Chinese Taoism. The Yogis of ancient India practiced pelvic exercises, performing rhythmic contractions of the anal sphincter muscle (one of the pelvic floor muscles). Hippocrates and Galen described pelvic exercises in ancient Greece and Rome, respectively, where they were performed in the baths and gymnasiums and were thought to promote longevity as well as general health, sexual health and spiritual health.

However, for millennia thereafter, pelvic floor exercises fell into the “dark.” Fast-forward to the 1930s when Margaret Morris, a British physical therapist, described pelvic exercises as a means of preventing and treating urinary and bowel control issues. In the 1940s, the seminal work of Dr. Arnold Kegel resulted in pelvic floor exercises achieving the stature and acclaim that they deserved. Dr. Kegel wrote four classic articles that put the pelvic floor muscles and the concept of training them to achieve pelvic fitness “on the map.” Kegel’s legacy is the actual name that many use to refer to pelvic exercises—“Kegels” or “Kegel exercises.” Kegel determined that a successful program must include four elements: muscle education, feedback, resistance, and progressive intensity. He stressed the need for pelvic floor muscle training as opposed to casual exercises, emphasizing the importance of a diligently performed routine performed with the aid of an intra-vaginal device known as a perineometer to provide both resistance (something to squeeze against) and biofeedback (to ensure that the exercises were being done properly).

Despite Kegel’s pelvic regimen proving effective for many female pelvic issues, what is currently referred to as Kegel exercises bears little resemblance to what he so brilliantly described in his classic series of medical articles sixty-five years ago. His regimen incorporated a critical focus and intensity that are unfortunately not upheld in most of today’s programs.

In the post-Kegel era, we have experienced a regression to the Dark Ages with respect to pelvic training. Easy-to-follow pelvic exercise programs or well-designed means of enabling pelvic exercises to improve pelvic floor health have been sorely lacking in availability. The programs that are out there typically involve vague verbal instructions and a pamphlet suggesting a several month regimen of ten or so pelvic contractions squeezing against no resistance, to be done several times daily during “down” times. These static programs typically do not offer more challenging exercises over time. Such Kegel “knockoffs” and watered-down, adulterated versions—even those publicized by esteemed medical institutions—are lacking in guidance, feedback and rigor, demand little time and effort and often ignore the benefit of resistance, thus accounting for their ineffectiveness. With women often unable to identify their pelvic muscles or properly perform the training, outcomes are less than favorable and the frustration level and high abandonment rate with these regimens is hardly surprising.

Bottom Line: In the post-Kegel era, pelvic floor muscle training has been an often ignored, neglected, misunderstood, under-respected and under-exploited resource.

Coming next week: The Kegel Revolution

Wishing you the best of health,

2014-04-23 20:16:29

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”:

Author of The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health– newly available on Amazon Kindle (paperback and Apple iBooks, B&N Nook and Kobo editions will be available in May 2016).

Author page on Amazon:

Trailer for The Kegel Fix:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health and Promiscuous Eating: Understanding Our Self-Destructive Relationship With Food   

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.  In the works is the female PelvicRx.

Pelvic Rx can be obtained at, an online store home to quality urology products for men and women.   Use code UROLOGY10 at checkout for 10% discount.