Kegels, Pessaries and Slings

When I finally confessed and complained to my female gynocologist about my unfortunate tendency to pee when I sneeze, slip, trip, cough or laugh, I had been dealing with it for almost seven years. Out of a combination of denial, wishful thinking and indignation, I refused to wear a pad, so for me, that meant seven years of too many trips to the dry cleaners. Seven years of embarrassment, inconvenience and humiliation that could very closely approach self-loathing.

After an errant sneeze produces a leak, I feel a wet spot in my clothing, and I wait for an opportune moment to sneak a downward peek at my crotch and inner thighs. Does it show? Will people smell it? How soon can I get home to change my clothes?

I used to think incontinence was only a problem for old people. I have long known that people with Alzheimer's eventually lose control of their bladder and bowels. Television commercials for adult diapers (like Depends) do not, so far as I know, feature women riding horseback or playing tennis the way tampon commercials do. Consequently, I never thought it was something people had to deal with in the prime of their life, while they were still premenopausal, very active, and otherwise fit.

A lovely older woman, who is no longer among the living and whose name I will respectfully withhold, coached my string quartet at the Manhattan School of Music the year I turned fifteen. In her prime, she had been a glamorous and sought after virtuoso, whom I had seen photographed in sparkling gowns, cradling her violin in her arms and gazing confidently into the camera. We worked together in a practice room, where she would walk around the four of us as we sat and tried to make beautiful music. When she would pass by me, or stop to adjust my shoulder or hand, her hips were close enough to my face that I detected a strong odor of stale urine.

It broke my heart that this woman, whom I so loved and admired, smelled so much like the stairs in the subway station. I assumed that if she could not prevent this unfortunate condition, then there must not be anything that a person could do about it. I know that this sensory memory of my quartet coach negatively affected my expectations when faced with my own stress incontinence at age 36. I know it is one of the reasons I remained silent as long as I did. It is one of the reasons I had so little hope.

I knew from the "what to expect" books that the way to strengthen pelvic floor muscles was to do Kegels, the same contraction exercises we are taught to do in preparation for labor. I did Kegels on command at the end of every prenatal water aerobics class, which I took in both Michigan and Ohio, where my second and third babies were born.

This is what I remember:

Five or six of us stand in a wide circle, neck deep in cool water, our distended bellies challenging the remaining elasticity of our maternity bathing suits. We giggle self-consciously as the teacher instructs us to clench the muscles of our posterior, and we try to follow, desperately hoping that we are doing ourselves some good. She tells us we should tape an index card to our rear view mirror reminding us "to Kegel" at stop lights, so I know they are important to do.

Somehow, though, I remain unaware that there is any point to "Kegels" other than physically preparing you to push your baby's head more effectively through what will feel like a blazing wall of fire. I remember from my first childbirth experience how frightening and painful this stage of delivery is, and the memory is enough to motivate me. Somewhere along the way, I also hear that it's good to have strong "Kegel" muscles after childbirth, too, and that it feels good for both partners when a woman "Kegels" during intercourse. But even in a circle of women in almost the same exact circumstances, there is very little discussion, in either the pool or the locker room, about our incontinence, a humiliating and inconvenient part of our shared experience. We are focused on labor and delivery, on how many weeks of pregnancy we each have left, on our weight gain, on whether we will nurse or bottle feed, on our hope of taking home a healthy baby. Nobody ever once mentions anything about peeing on herself.

When I brushed off my doctor's suggestion, a year ago, that I undergo "simple, bladder sling" surgery to get better support for my urethra, she told me there was just one other thing that could help. She was reluctant to recommend a pessary for me because I am sexually active, preferring to give them to elderly widows. But I was insistent that I needed an alternative to surgery, and assured her that I was willing to deal with considerable incovenience in order to avoid it. Explaining that I would have to remove it before having sex, my doctor reluctantly fit me for my a pessary, which is rather like a diaphragm with several holes in it, inserted into the vagina and positioned so as to restrict the movement of the urethra.

As I left her office with my new pessary in place, I was hopeful that the device would improve the situation enough to resolve the matter and turn my focus to more pleasant things. On my way out, my doctor urged me again to consider sling surgery, emphasizing that it was not elective, like a breast lift, but rather, quality of life. I could appreciate the disctinction. My husband had just undergone knee surgery for quality of life reasons, and that had been the right decision for him, with great results. But every surgery, no matter how "simple", involves risk.

Also, the fact that a torn flap of cartilage is painfully getting in the way of a moving joint is a very different thing to explain to patient than the fact that her urethra is insufficiently supported by her tired, over stretched muscles. For one thing, we are already familiar with the relatively simple, accessible anatomy of the knee, and if we don't "get it" from looking at the x-ray, there are charts, models and brochures all over an orthopedist's office to help make it very clear.

By contrast, we don't grow up looking at models of vaginas and bladders in our grade school science classrooms. As an English major, I never had to locate or identify a urethra on any test. Most of us don't spend a lot of time looking at these parts of our own anatomy. It's inconvenient, for one thing, requiring a mirror and specially angled lighting. Peeing, for girls and women, is fairly mysterious, at least compared to peeing for boys and men. Most of us learn where and how to insert a tampon, but there is never any reason to help a girl locate her urethra. We don't teacher our daughters to aim their stream at m & m's floating in the toilet; we just tell them to sit down and let it flow.

This is already a long post, so I will pick this story up again another time. I am busy doing my new pelvic floor exercises frequently, both the "quick flicks" and the "long holds", and I am very hopeful. The knowledge I received in just one physical therapy appointment exceeds anything I was ever told previously about the physiological cause and nature of my condition. In my next post, I will tell you more about that appointment and why I walked out of it feeling so very optimistic.