I hear that statement often from women who are fearful about what has happened to their bodies. They are concerned about a fleshy pink-colored ball that drops toward or through their vaginal opening. Sometimes they report a heaviness in the pelvis, low back pain, or sense a pinching vaginally.
What exactly is happening and what can we do about it?
We need to understand anatomy to really comprehend what is occurring. Our bladder, uterus, and rectum are all stacked next to each other in the pelvis. Our pelvic floor muscles have several different functions: pelvic organ support, bowel and bladder control, elimination, sexual function, breathing, pregnancy and childbirth. Norton explained this role of support for the organs by the pelvic floor muscles using a metaphor of a boat in a dock. 1 The dock represents the bony pelvis, the moorings or strings holding the boat in place are the ligaments, the boat represents all three of the pelvic organs, and the water represents the pelvic floor muscles. If there is water under the boat, then the moorings are on slack. If there is little to no water under the boat, the boat will drop down, like in low tide, and the moorings (ligaments) will be on strain. If this strain is long enough or forceful enough, there can be a gradual stretching or tearing of the moorings (ligaments). We need water under the boat—a strong pelvic floor muscle to keep the boat from dropping!
How do we address this?
Pelvic physical therapy is a sub-specialty of physical therapy that addresses the pelvic floor muscle function. Our muscles need to have just the right amount of tension: too much and we can have pelvic pain. Too little and we can have incontinence or pelvic organ prolapse. There are typically three methods to address pelvic organ prolapse: pelvic physical therapy, pessary use (support device for your vagina), or surgery. Research shows that pelvic physical therapy is effective for reducing symptoms of pelvic organ prolapse as well as severity.2 This therapy should be the first line of treatment for those patients who have mild to moderate prolapse, with the goal of symptom reduction.3, 4 Even women scheduled for surgical repair can learn great techniques for improving surgical outcomes.
Using a pessary can be a temporary or a long-term use for managing pelvic organ prolapse. Pessaries previously only used for the elderly are now being used for younger women as well. This is a silicone disc or form filling shape to support the pelvic organs from dropping into the vaginal canal.
I personally wear a pessary, so I’m including a Q&A for the most common questions I receive:
Q: Is a pessary uncomfortable to wear?
A: No, a good fitting pessary should be supporting your pelvic organs but you should not be able to feel it in your body. It shouldn’t fall out during exercise nor should you be in any pain while wearing the pessary.
Q: Do I need to have my physician clean it?
A: As long as you have good strength and dexterity in your hands, you should be able to care for the pessary yourself.
Q: How often do I need to clean the pessary?
A: This answer depends on your physician, but in general, women who are sexually active should remove before sexual activities and later clean the pessary before re-insertion. Menstruating women should also remove the pessary daily or frequently during their cycles for hygiene reasons. Women who are unable to remove the pessary themselves, and are not sexually active, should return to their physician for removal, cleaning, and subsequent reinsertion of the pessary.
Q: If I engage in sexual activities, will it hurt?
A: You should remove the pessary prior to sexual activities, but there should be no pain from having pelvic organ prolapse during sexual activities. It may look a little different “down there”, but you will not harm any organs or muscles by engaging in sexual activities.
Q: What type of pessary will my physician recommend? Is the fitting process quick?
A: Your physician will use a circular fitting kit to determine the proper size, but it is truly a trial and error process for the type of pessary. You must be patient during this process—there are guidelines for prescribing pessaries, but there are no hard and fast rules for fitting pessaries. Be prepared for you to need 2-3 or even 5 different pessaries in your quest for the appropriate pessary. Some insurances will not pay for multiple pessaries, so you may be responsible for the purchase price of each separate pessary during the pessary fitting process.
Q: What is the role of a pelvic physical therapist for pessaries?
A: This depends on the physician/pelvic physical therapist relationship. I work with several physicians who trust me to train their patient in the care, cleaning, removal and insertion of the pessary. The pelvic physical therapist also works on training the pelvic floor muscles for optimal use even when the patient is wearing a pessary.
References Norton PA. Pelvic floor disorders: the role of fascia and ligaments. Clin Obstet Gynecol. 1993; 36:926-938. Li, C., Gong, Y., & Wang, B. (2016). The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. International urogynecology journal, 27(7), 981-992. Wallace, S. L., Miller, L. D., & Mishra, K. (2019). Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Current Opinion in Obstetrics and Gynecology, 31(6), 485-493. Hagen, S., Glazener, C., McClurg, D., Macarthur, C., Elders, A., Herbison, P., ... & Collins, M. (2017). Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial. The lancet, 389(10067), 393-402. Image credits Images are licensed under the Creative Commons Attribution-Share Alike 4.0 International license. No changes were made. BruceBlaus / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) BruceBlaus - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=61465361 BruceBlaus / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)