After being diagnosed with prolapse, have you ever had the impulse to take a mirror and look at what’s going on “down there”?
If you did, did anything look different to you? Or was it the first time you ever looked and so you weren’t sure if what you were seeing was “normal” or out of the ordinary. One of the things you might have observed (I say “might” because this is not always the case) is that the opening to the vagina looked kind of large, but again, without having anything to compare to, it was hard for you to tell.
What if what you saw was important and actually did have an impact on your prolapse?
According to this review article (1) by Dr. John DeLancey, Professor of Gynecology at the University of Michigan Medical School and Director of Pelvic Floor Research in the Department of Obstetrics and Gynecology, the size of your vaginal opening can be an important determinant to how much the vaginal wall descends. To explain it simply, the larger the opening, the more vaginal wall tissue is exposed to atmospheric pressure, and the more likely gravity can influence that tissue to come down and out.
So if the size is important, then what is considered normal?
Two recent studies (2,3) found that mean size of the genital hiatus, which is the medical term for vaginal opening was around 2cm and increased as the stage of prolapse increased. This measurement was taken as the distance from mid-urethra to the bottom of the vaginal opening upon maximal bearing down.
Is there anything you can do about a larger opening?
YES! There are certainly things you do to help improve the situation, and they all involve some form of strengthening of the pelvic floor.
If you have ever embarked on a Kegel strengthening program, you probably know that Kegels require a lot of mental focus and visualization to help you connect to those muscles. Different cues can help you target the muscle better and produce an improved muscular activation in that area. For this particular area, try using the following cues:
3 Helpful Pelvic Floor Cues
1. Since the vaginal opening what we are trying to target, you can:
Imagine there is a ping pong ball sitting right at the vaginal opening, half of it is inside, half of it is outside. Try gripping around ping pong ball and then lift it up into the vagina.
2. The other thing to consider is that a good portion of the pelvic floor forms “loops” around the vagina and rectum, and from the picture to the right, you can appreciate the closing effect these loops have on the size of the vaginal opening when contracted. Some cues to try here are:
Imagine lifting the bottom of your vagina up to your pubic bone or
Imagine lifting your anus up to the pubic bone.
Picture: https://obgyn.mhmedical.com/content.aspx? bookid=1758§ionid=118173740
3. Similarly, the upwards motion of a pelvic floor contraction comes from the these same muscles (hence, the name levator ani), and since these “lifting” muscles also include the same “looping” muscles above, any cues that encourage a lifting action can also have a closing effect on the gential hiatus. One of the cues you can use to help with this part of the pelvic floor is:
Imagine lifting a blueberry up and into your rectum.
For even more information on Kegels, take a look at our free video on How to do Kegels here.
As you are first getting acquainted with these different cues, one option is to do them lying down with a slight curve in your back to keep your spine in neutral. This position takes the load off the pelvic floor, thereby giving the muscles the best chance of turning on the way you want to. Once that gets easier, move up to sitting and then to a standing position. Ultimately, we need to have these muscles function in an upright position.
If you find it hard to activate the pelvic floor in standing, you can even try leaning over a counter to see if you it gives you better access to this part of the pelvic floor. As you begin to feel the muscles better in this position, you can slowly move to an erect standing position and continue to work at them there. A good goal is to aim for 10 repetitions of each of these cues, twice a day (aka 30 reps, twice a day).
Another option is to insert your index and middle fingers from one hand into the vaginal opening for manual feedback. What you are trying to feel for is the surrounding muscles “hugging” your two fingers as they contract.
In many cases, some strengthening adjuncts might be considered such as vaginal weights or electronic muscle stimulation. These are great options for women who have a hard time connecting to their pelvic floors and for those who are simply too weak for Kegels to work by themselves.
So as you can see, there are plenty of options to help you! Try and work with your pelvic floor physiotherapist to help you determine which option might be best for you. Once you have gotten stronger in that area, the key is to maintain that strength for life!
1. DeLancey, J. O. (2016). "What's new in the functional anatomy of pelvic organ prolapse?"Curr Opin Obstet Gynecol. Oct; 28(5):420-9.
2. Lowder, J. L. et al (2016). "Genital hiatus size is associated with and predictive of apical vaginal support loss." Am J Obstet Gynecol. Jun; 214(6):718.e1-8.
3. Dunivan, Gena C et al. “Pelvic Organ Prolapse Stage and the Relationship to Genital Hiatus and Perineal Body Measurements.” Female pelvic medicine & reconstructive surgery 22.6 (2016): 497–500. PMC. Web. 10 Feb. 2018.