Urinary Incontinence and Prolapse

Today in my office I gave Kegel instructions about 20 times. Admittedly, it was a busy day, but there was nothing unusual about that number.

What is the problem? The problem is that about a billion dollars a year are spent on adult diapers in USA alone. And there are about 16 billion dollars a year spent on incontinence, it's control, and it's correction. Most of the incontinence is urinary, but some is fecal as well.

And, much more important than the money spent, is the awful discomfort of being incontinent. Women are unnecessarily filled with shame. They feel like they cannot go outside the home. They cannot go on trips. They are mortified when or if they might wet their pants. They are mortified when the have to buy giant pads, or even worse, adult diapers. And they are ashamed and discomforted with the thought of having sex.

The solution to getting diapers discretely is easy. Just buy them online, maybe from Amazon. No one will have to face the clerk. The clerk that fills the order will be very far away. And someone might get a very good deal. Although, they will have to be forevermore targeted by Amazon with adult diaper ads. Most likely even I will be targeted just because I wrote this blog.

What do Kegel instructions have to do with it?

There is a giant muscle that exists in women and men that elevates the structures in the pelvis, and keeps everything from falling out of the bottom of the pelvis. This muscle has a bunch of different names. Doctors like to call it the Levator Ani, and the bulbocavernosus muscle, along with some smaller muscles with different names. We can just call the whole thing the pelvic floor. This pelvic floor muscle acts like a sling under the pelvis. But it has some other very important functions. It also wraps around the external urine carrying tube. In both women and men this tube is called the urethra. In men, it extends through the penis. In women it is very short, and goes from the bladder, just under the pubic bone, and ends externally anterior to the vagina, and about 2 cm below the clitoris. So, this muscle wraps around the urethra, vagina, and rectum. And, when it is tight, it closes these openings tightly. And when it is tight, it blocks the flow of urine, it holds the vagina together, it keeps fecal material inside the rectum until it is time to defecate, and keeps the structures near the vagina from falling out the vaginal opening. When this muscle is loose, the urine leaks. The uterus falls into or out of the vagina. The rectum falls out of the vagina. The bladder falls out of the vagina. Even the intestines call fall out. These problems are called incontinence, uterine prolapse or procidentia, rectal prolapse, cystocele, and enterocele, respectively.

Most women do not ever exercise this muscle. I might have a menopausal women patient who runs marathons, and is fitter than any 20 year old, who never exercises this muscle. This is not uncommon at all.

Most women are told to exercise this muscle when they are pregnant. It is fine to do this, but the real problem begins later, when they are older. The muscle atrophies from lack of use, and these problems I noted above begin to show up.

This is where I come in. During a regular checkup, I will many times ask the patient to do a Kegel. Many times they are reluctant because they aren't sure they are doing the right muscle. With coaching, almost all women are able to contract the right muscle. It is the same muscle that can be used to stop a urine flow if the doorbell rings, or the phone rings, or the baby screams for attention. If the women can close off the urine mid flow, then she has the right muscle. Some women do not have the option of shutting off the flow, because they don't know how. With encouragement, I can teach them how. I don't advise women to routinely stop the urine flow, because that can lead to some urinary retention or infections. But it is fine to do this as a test of learning once in awhile.

In my experience, some women have such a strong muscle that they can break fingers. Some women have such a tight muscle that they cannot release it. This, if symptomatic, is called vaginismus. Vaginismus, if bad, can make exams impossible, and even sex impossible. Vaginismus is curable with proper stretching exercises, sometimes muscle relaxers, and sometimes pain meds.

But many more women have such a weak muscle that there is no detectable contraction despite full effort and coaching. These women are at high risk for incontinence and prolapse symptoms.

The good news is that I have seen women who could not hold a drop of urine completely cure themselves with exercises. I can remember patients who were so sure that they could not repair the prolapse that they opted for a surgical repair. I would try to delay them to give them a chance at exercises. Many times, after a few weeks there is improvement, and after a few months there is a complete cure. These women are dry again. And they are very happy. And they do not have surgical risks.

There are things called "Pessaries" that can go into the vagina to hold up the other structures. Pessaries are great because they are simple, mostly free of side effects and risks, and assist the Kegel exercises to repair the prolapse. Pessaries can cure the problem with enough time and exercise. Although, many older women keep them forever. And they are happy because it gives nice support and does not hurt, and has no surgical risks.

The surgeries do work, that is for sure. They are not completely reliable, in that there is an unfortunate failure rate, and an even higher recurrence rate. There are hundreds of surgeries described to tighten the bladder  control, fix the fallen uterus and enterocele, and fix the fallen rectum. Which surgery is done is mostly up to the surgeon you pick. The urologists will frequently pick a mesh implant repair. I am not a huge fan of the mesh due to some of the mesh problems that have occurred. Although it is ok when it is done properly, and the success rate is high. I have my favorite types of surgery because I have had good results.

Most of these prolapse surgeries are done through the vagina, because that is where the problem is. There are abdominal approaches. They do not have a higher success rate than the vaginal procedures, and add a lot of surgery to the technique. So, with some exceptions, I prefer the vaginal route to repair. That makes me an old fashioned Gynecologist. Because the newer Gyne's usually prefer meshes, implants, and sometimes abdominal and even robotic repairs. Those procedures are all technically demanding, higher risk operations.

So, to get back to the original point, Kegel exercises really do work. There is solid scientific evidence to this claim that it works. Kegel exercises can prevent and or repair a fallen pelvic floor. You just have to keep doing it enough. It can save a huge amount of problems later.  I encourage all of my patients to do it. I can teach them.

Sometimes a little bit of estrogen in the vagina can help strengthen these tissues as well, and complement the Kegel efforts.

Comments are appreciated.

Thank you sincerely,

John W Marcus MD FACOG
Ridgewood, NJ, 07450

201-447-0077

Article updated on 5/28 at 1 AM to tighten up the prose, and to change pronouns to nouns.