Dr. Keith Roach

DEAR DR. ROACH: I’ve been wearing a pessary since my youngest child was born 28 years ago. I’m grateful for it, since I’ve been able to continue backpacking, skiing, playing tennis, dancing, etc., without leakage! Anyway, now that I’m approaching 70, I’m realizing that removing and reinserting it may become an issue as my hands weaken with age. Also, it needs to be removed for sex, which interferes with spontaneity. So, I’d like to revisit the possibility of surgical repair.
When I looked into surgery 28 years ago, procedures were new-ish, and I heard mixed reviews. What’s the state of prolapse surgery now? What’s recovery like? Are there new kinds of pessaries to consider? — Anon.
ANSWER: Pelvic organ prolapse is a general term to describe when the muscles and soft tissues in the female pelvis weaken with age (and usually childbirth). The pelvic organs move to or beyond the vaginal walls. Not all people with pelvic organ prolapse have symptoms, and treatment is only for people with symptoms. Symptoms may include abnormal pressure or a bulging sensation; urinary symptoms, especially stress-type incontinence; and bowel symptoms.
Conservative management includes pelvic floor muscle training or a pessary, a prosthetic device inserted into the vagina, which helps reduce the abnormal position of the organs and improves the symptoms of pelvic organ prolapse. It sounds like you have had very good results. Pessaries may cause side effects, such as vaginal erosions and discharge.
Pelvic floor muscle training is another conservative treatment and essentially has no adverse effects. Training takes months and is done ideally by a physical or occupational therapist trained in pelvic floor therapy. Pelvic floor muscle training has outcomes that are as good as a pessary once a person is trained.
When conservative management isn’t effective or causes adverse effects, or in a person who doesn’t want to try it, surgical approaches are then considered. There are several different types of surgical procedures, none of which I am an expert in, so I refer my patients to a gynecologic surgeon who is. I will note that surgery is not 100% effective, and most centers who have reported their data find that about 30% of people require a second procedure.
Given your generally good results with your pessary so far, I would think twice before surgery, but I certainly encourage you to talk to an expert in this condition who can do a careful exam and recommend a different pessary, pelvic floor muscle training or perhaps surgery.
DEAR DR. ROACH: Whatever happened to drinking a glass of prune juice for constipation? — F.A.D.
ANSWER: I think you are referring to a recent column where a reader was taking multiple medications for constipation. Several readers asked why I didn’t recommend prune juice, since prune juice contains several substances that increase movement in the colon. It is a safe, effective treatment for mild constipation and can be taken as needed or on occasion. But, in a person who still has problems despite the most powerful medicines we have, prune juice isn’t likely to benefit them much.
One concept taught early in medical school is that the severity of a condition varies greatly between different people. A disease or condition can have mild symptoms in one person and debilitating, or even life-threatening, symptoms in another. What works really well for one person can be ineffective in another, sometimes for no discernable reason.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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