Penetration with a Pessary?

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Dear Dr. Myrtle,

My friend has been talking to me about a pessary for her uterine prolapse. Can she still have sex? What does it do?


What is uterine prolapse?

Uterine prolapse is a condition where the uterus slips lower into the pelvic space, usually due to a lack of support by the pelvic floor muscles and ligaments. Although most commonly associated with multiple pregnancies, uterine prolapse is also more common in women who have had their uterus removed surgically (hysterectomy), or women whose abdominal pressure is chronically high (chronic coughing, weight lifting, central obesity, or holding the breath and straining from chronic constipation). During normal pregnancy recovery, the muscles of the pelvic floor will often rebound to their pre-pregnancy length, but the ligaments are less likely to do so. This leaves the organs of the lower pelvis, particularly the uterus, sitting much lower, or “prolapsed” in the pelvis.

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There are three degrees of uterine prolapse: mild, moderate and severe:

  • In mild prolapse, the uterus is lower than the pre-prolapse state, but does not significantly press on other organs. A woman with mild prolapse might notice a sense of pressure on the bladder, or have a bit more trouble with vaginal penetration, as it can feel “as though something is in the way”. The lower uterus can also press on the veins which drain the blood of sexual arousal from the pelvis, leaving the woman with a sense of fullness or pressure in the lower abdomen after penetrative vaginal sex.
  • In moderate prolapse, the uterus is not supported in the pelvic bone structure well, but does not yet 'show’ outside the body through the vaginal canal. This condition is more uncomfortable, with all of the above symptoms becoming more obvious and apparent. Sometimes, for bowel movements to come out the anal canal, a woman with moderate prolapse might have to push up her uterus (through her vagina) to give extra space in the rectum for the stool to come out.
  • Severe uterine prolapse describes the condition when the uterus is easily seen from the outside at the opening of the vagina. The muscles and ligaments of the pelvic floor are so stretched and weak, that they provide essentially no supportive value to holding the uterus in place inside the pelvis. Severe prolapse is very uncomfortable for most women.

Can kegels (pelvic floor exercises) help when prolapse has already advanced? Can you even use a biofeedback tool at this point?

Pelvic floor exercises were developed by Dr. Kegel in the 1950’s. Dr. Kegel developed these to help women re-strengthen their pelvic floor muscles after delivery of a pregnancy, because although the ligaments which attach the muscles to the pelvis remain stretched, the muscles themselves can regain significant supportive strength. He developed bio-feedback exercise tools (much like the one’s we offer), so that women could go home and consistently exercise the muscles, thereby avoiding surgery.

For cases of mild to moderate prolapse, many women find that exercising their pelvic floor muscles in conjunction with bio-feedback tools significantly strengthens their muscles and supports the uterus more comfortably in the pelvis. Urinary stress incontinence is lessened, and vaginal penetration is more comfortable. In cases of severe prolapse, however, the uterus is so far down in the pelvic structure, and often so uncomfortable, that muscle strength alone cannot re-suspend the uterus.

So, what is a pessary? Where does somebody get one?

A pessary is a removable, supportive device placed in the vaginal space that props up the uterus in the pelvis. Pessaries used for uterine prolapse do not have any relationship with abortion, and do not travel inside of the uterus in any way. Generally, they rest against the cervix, back side of the urethra and wedge against the rectum wall from the inside of the vagina. Many women with moderate to severe prolapse find them to be a good, comfortable option, as pessaries mean that they don’t have to have surgery, or can postpone surgery.

Like women wearing a contraceptive diaphragm, a well-fitted pessary allows for comfortable vaginal penetration, and has no negative impact on orgasmic function. Pessaries must be fitted by a health care provider, so check to see if they are comfortable fitting them. For pictures and more medical information on pessaries, click here.

Can you "feel" pelvic floor contractions (the "physical" episode of an orgasm) significantly when prolapse has occurred?

Orgasms are experienced in the brain, but are 'felt’ in the pelvis as the rhythmic contract of the pelvic floor muscles. Therefore, one symptom of weak pelvic floor muscles is the lack of, or reduced sensation of the pelvic floor contractions. Some women describe this as “I started to have the orgasm in my head, but then nothing happened below, and the whole thing was very short--shorter than it used to be.” Without the reflexive contractions in the pelvic floor, less neurologic feedback reaches the brain, so orgasms may appear as a short “blink”, or evaporate completely.

Strengthening the pelvic floor muscles, particularly the posterior or tail-bone portions, can make a huge difference in both the appearance of, and the extended experience of orgasm. Women who feel that the strength of their orgasms is declining over time can address this directly by strengthening their pelvic floor muscles, and for this, kegel/pelvic floor muscle exercises are never too late.

It is for this reason that maintenance orgasms are also beneficial, both because they 'naturally’ strengthen the pelvic floor muscles during orgasm, and because routine orgasm maintains the neurologic and blood flow/vascular pathways necessary for the next orgasm. Avoiding orgasms because the uterus has slipped lower will only make the problem worse over time. If a woman is uncomfortable because of the blood congestion in the pelvis associated with sexual arousal, she will drain the blood and be more comfortable after arousal if she lays on her stomach and props her hips up with a pillow (some women use the liberator shapes *after* sex, not just during).

Is there any benefit to the vaginal renewal program at moderate prolapse? Vaginal renewal will be helpful for her skin, but will not dramatically impact the uterine prolapse. However, often women experience a number of issues in sequence, such that the discomfort with vaginal penetration, followed by menopausal dryness (for example), will lead to less frequent vaginal penetration, which leads to more discomfort, etc. If she has not been able to have intercourse for a longer period of time, then the massage and moisturizing will help her vaginal skin become more flexible and less fragile, and the massage and vibration will positively increase the blood flow to her muscles. Some women get a better sense of where the tail-bone portion of the pelvic floor muscles are when they use a vibrator to increase the level of genital stimulation higher than other activities can, and the more awareness of the location of the muscles, the more actively she can accurately strengthen them. We find that many women benefit from the overlap of pelvic floor exercises with the Vaginal Renewal Program, but it is specific to each woman’s situation.

If a woman chooses to use a pessary, Vaginal Renewal definitely helps with keeping the healthy thickness and flexibility of the vaginal wall. After all, the pessary, by design, is pressing out against the vaginal wall, and small erosions of the wall (but not all the way through) do happen. Vaginal renewal massage can help prevent these erosions for some women.

Good luck, and take care.

Dr. Myrtle