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My clients often have many questions regarding sex and pelvic organ prolapse (POP). “Can my partner feel my prolapse? Will sex make my prolapse worse? Is sex painful with a prolapse? Can I wear my pessary during sex? Can my partner feel the pessary?” Let’s take a look at each of these questions and more. Answers are from a penile/vaginal perspective, but a lot of the information applies to other variations as well.

1. Can my partner feel my prolapse?
   • No! With mild to moderately severe prolapse, your partner will not be able to feel your prolapse, whether you have a cystocele (bladder), hysterocele (uterus), or rectocele (bowels). It is actually relatively difficult to diagnose a prolapse, so unless your partner is a gynecologist, it is highly unlikely he will notice anything at all! Most of the time, the descended soft tissue simply pushes up and out of the way.
2. Will sex make my prolapse worse?
   • No! The majority of health care professionals would answer with a resounding, “No!” There are no research studies (to my knowledge) that indicate sex worsens POP. In fact, increasing blood flow to the area and orgasming (strong pelvic floor contractions) are all great things for the health of the pelvic floor muscles!
   • Of course, it is of paramount importance for you to be comfortable during sex- starting with you desiring intercourse, keeping your muscles relaxed, using lubricant, communicating positions that feel the best, etc. Most important to keep in mind is your level of comfort and communicating this to your partner.
3. Is sex painful with a prolapse?
   • Some women with POP report discomfort with intercourse but the majority don’t have any pain. If you do experience discomfort, get creative and try different positions. Here are some thoughts on positions to try and others to consider avoiding.
     • Positions to try:
       • Modified missionary: lay on your back with a pillow under your hips and your partner on top. This position not only helps gravity encourage your prolapsed organ(s) to return to their proper position, it is also a great angle for penetration!
       • Side-lying: lay on your side with your back to your partner. Because this position decreases penetration depth, it is particularly useful for uterine prolapse, post-hysterectomy, or vaginal vault prolapse.
       • From behind- on stomach: lying flat on your stomach helps the bladder and uterus remain in their ideal positions. Not great for rectocele.
       • From behind- on all fours: being on your hands and knees is similar to the above position in that it encourages the bladder and uterus to remain in position. Again, not great for rectocele.
       • From behind- standing: bend at the hips and support yourself with your arms on a table, bed, counter, whatever- be creative! Leaning forward will help the bladder and uterus rest on the pubic bone instead of falling backwards into the vagina. Not great for rectocele.
     • Potentially avoid:
       • Cowgirl or reverse cowgirl: gravity is not helpful in this upright position.
       • Exertion: any position where you are exerting a ton of energy and are feeling greatly fatigued (think cowgirl on your feet, doing a million mini squats).
   • Most importantly, communicate what feels good and what doesn’t. If you are uncomfortable or in pain, speak up! You can still have a great sex life with POP, but communication is key! (When isn’t it key?!)
4. Can I wear my pessary during sex?
   • Some pessaries can be worn during sex and others cannot.
     • Can be worn during intercourse
       • Ring without support
       • Ring with support
       • Hodge
     • Cannot be worn during intercourse
       • Ring with knob with or without support
       • Cube
       • Gellhorn
       • Donut
       • Marland
       • Inflatoball
       • Dish/Cup
       • Gehrung
   • If you are not sure if you can leave your pessary in during sex, give us a call. Furthermore, if you have a pessary that must be taken out and would like to try one that you can leave in, book in to trial a differently shaped pessary today!
5. Can my partner feel the pessary?
   • If you have a pessary that you can leave in during sex, such as the ring with or without support, you do not need to worry about your partner feeling it or it hurting him.
6. Use lube
   • This cannot be expressed enough. Use lubricant. And find a good one- one that is paraben and glycerin-free (parabens just aren’t good for us and glycerin can make us more susceptible to infections). Definitely stay away from the fun stuff- cooling/heating, tingling, flavoured, etc. lubes as they are full of chemicals that aren’t especially great for this particularly sensitive area of our bodies.
   • I love going to specialty stores because you can often trial the lubes there- on your hand! This allows you to feel how runny or thick they are, if they are sticky, how long they last with friction, how silky smooth they are, etc. If you just can’t bear the thought of stepping into one of these stores, most drug stores carry “Good Clean Love”, which is paraben and glycerin free.
7. Vaginal dryness
   • While we are on the topic of lubricant, we might as well discuss vaginal dryness. We are more susceptible to vaginal dryness at different times in our lives, including post-partum and post-menopausal stages of life. This needs to be combated by more than just using lubricant for sexual activity. There are many over-the-counter products that can help, including Gynatrof, Replens, and Repagyn, which are all non-hormonal vaginal moisturizers. They come in the form of ovules or cream and are most often inserted at nighttime a few times a week. Check with your doctor if you think a vaginal moisturizer may be helpful for you.
8. Vaginal atrophy
   • Vaginal dryness is one sign of vaginal atrophy, which is the thinning, drying and potential inflammation of the vaginal walls that occurs due to a decrease in estrogen (most often occurs after menopause). Atrophy can make intercourse painful, make us more susceptible to vaginal/urinary tract infections, and set us up for urinary incontinence.
   • The prescription of a topical estrogen can be incredibly useful in the case of vaginal atrophy. Vagifem and Premarin are two commonly prescribed topical estrogens. It is worth mentioning that research has show the administration of these topical estrogens is only absorbed locally and does not have a systemic effect.
   • With severe vaginal atrophy and POP, sometimes it is too painful to insert a pessary. In this case, you will likely be prescribed a topical estrogen and directed to use it for 4-6 weeks before trialing the insertion of a pessary again. Additionally, your physiotherapist may recommend that you use vaginal dilators before commencing pessary use. Check out our blog on vaginal dilator/accommodator use https://torontopessaryclinic.com/using-accommodators-prior-to-pessary-use/. Topical estrogen and the use of dilators can also be very helpful if you experience dyspareunia- painful intercourse. Give us a call today for more information on dilator use if you think you could benefit.

I sense much anxiety, embarrassment, fear, and shame when speaking to my clients about any kind of pelvic floor dysfunction and POP is no exception. Rest assured that you are still capable and deserving of a fully satisfying sex life and that it will not negatively affect your POP. If you have any questions or concerns about sex and POP, give us a call. We would be honoured if you chose to discuss this sensitive and oh-so-important topic with us. Looking forward to hearing from you!

The information in this blog is provided as an information resource only and should not be used as a substitute for seeking personalized direction from your overseeing physician. Please consult your healthcare team before making any decisions about your pessary treatment plan, which is unique to you and your overall health. Toronto Pessary Clinic expressly disclaims responsibility, and shall have no liability, for any damages, loss, injury, or liability whatsoever suffered as a result of your reliance on the information contained in this blog.