Dr. Kegel Cliffnotes

While Dr. Kegel's paper is very informative, it is also exhausting reading. Here's my layman's attempt at summarizing it:


A Nonsurgical Method of Increasing the Tone of Sphincters and their Supporting Structures

ARNOLD H. KEGEL, M.D., F.A.C.S.
Assistant Professor of Gynecology
University of Southern California School of Medicine
1948

 

Background

Through experience as a surgeon and research with cadavers, Dr. Kegel had noted that the pelvic muscles of women were often weak and thin from disuse. He theorized that just as we exercise other body parts to tone and improve the strength of weak muscles, surely there must be a way to repair these muscles that way as well-- instead of resorting to surgery, which was not effective long-term anyway.

He focused his attention on the pubococcygeus, nicknamed PG. He describes it as the most versatile muscle in the human body. It helps support all the pelvic organs, helps the muscles that control the openings, and is essential for maintaining the tone of the other pelvic muscles. The PG gives off countless fibers which interlock and insert themselves into the muscles of the urethra, middle third of the vagina and rectum.

When a patient's organs were in the right positions, the PG and its components would be found to be well developed. When the muscles were weak and thin, symptoms like uterine prolapse (uterus falling down), incontinence and sexual disfunction would occur. The next step is to test whether a patient can voluntarily contract various muscle groups. First he would have them retract and draw in the perineum (the diamond-shaped area corresponding to the outlet of the pelvis, containing the anus and vulva.) Next, the index finger is inserted to the middle third of the vagina (as above) and the patient is asked to squeeze it. A normal patient can immediately respond with a firm grip felt over a wide area. Others will state that they didn't know it was possible to contract those muscles. These patients will have the most weakened muscles.

Dr. Kegel would quantify this response using a device he developed called a Perineometer. It was inserted in the vagina and could measure the pressure exerted by contractions of the vaginal muscles. In a well developed vagina, a slight rise in pressure is detected when the device is inserted, without any patient effort. In weakened patients, this initial pressure is much lower. The pressure change caused by intentional contractions were then measured. Strong, immediate increases in pressure indicated a strong, well-developed PG. A weakened PG resulted in small or even imperceptible increases in pressure with attempted contraction.

Therapy

He points out that it is super important while doing these movements to make sure the patient is actually contracting the PG muscles and not just the muscles around the outer edges of the openings. He points out that women with poor PG function have compensated all their lives by depending on these external, surface muscles. So the goal is to focus more inward and upward, so that the inserted finger feels the contractions as these movements are made.
 

Most patients can learn pretty quickly to find these muscles, but some may require weeks of this practice. There is no point in further therapy until this can be done.

Diagnosis

A firm vaginal canal indicates that the fibers of the PG are well developed. Loss of tone and and prolapse of the vaginal walls indicates that the PG fibers are weak and thin. You can test the vaginal muscles by inserting an index finger into the vagina, up to about the second joint, so that you are feeling the middle third of the vagina. In a normal vagina, the canal is tight and the tissue resists from all directions. The walls naturally close around the finger. The walls feel firm and deeply attached to the surrounding tissue. On the other hand, if the middle of the vagina is roomy in all directions, regardless of whether the opening is wide or tight, and the walls offer little resistance to touch and feel thin and loose, this indicates that the PG fibers have weakened from lack of use. 

Education

The first step in therapy is to help the patient find and learn to activate the muscles. He found that 1/3 of patients could not contract their PG voluntarily on the first visit. He would use a process of pushing with a finger at different internal locations to prompt the patient to contract the correct muscles. He'd basically find a connected muscle that they could contract and then work from there towards the PG. This teaches the patient to find and feel these disused muscles. For continued practice, the patient is directed to squeeze the inserted finger, draw up and in the perineum, draw up the rectum as though checking a bowel movement and contract as though interrupting the flow of urine. 
 

Resistive Exercise

Dr. Kegel felt that patients were unlikely on their own to be able do continue to use the correct muscles without help and supervision. He also felt that without measurable results, they were likely to become discouraged and stop exercising. So he recommended his Perineometer for contraction practice at home. It provided resistance to the muscles that needed strengthening and provided measurable results. Patients were advices to use the device for 20 minutes, 3 times a day. They were also encouraged to do additional contractions without the device throughout the day. He found that 50% of patients would slip back into their old habit of using the external muscles, so he recommended weekly appointments for the first month to firmly establish proper technique. He found that most complaints of fatigue and aching muscles were due to improper technique. 

Results

Patients who dutifully did their exercises experienced the following changes: stronger and more sustained contractions, thicker muscles throughout the pelvic area, improved positioning of the pelvic organs, firmer and longer vaginal walls, and reduced uterus prolapse. Patients with urinary incontinence showed dramatic results. 212 patients with severe urinary stress incontinence were treated and 84% were able to establish good urinary control through the therapy. 

The widest application is for women with genital relaxation after childbirth since 30% of women complain of this condition. Previously, women had to just suffer through symptoms until after menopause when surgical intervention would be recommended. Dr. Kegel found that progress was a slower with these cases, probably because since their symptoms were less debilitating they are less motivated and more haphazard in their exercise. But patients who were diligent felt improvement after 2-4 weeks of exercise but exercises needed to be continued longer to build lasting, structural changes. 

Preventative use

Pelvic resistance exercise during pregnancy builds thicker, stronger muscles, resulting in easier postpardum repair and less postpardum relaxation.

Exercise is also recommended after any pelvic surgery to help return muscles to working condition.

 

Conclusion

I noticed this statement in his conclusion, "On the basis of therapeutic results achieved, it seems possible that other ill-defined complaints referable to the genital tract in women might profitably be studied from the standpoint of muscular dysfunction." 

 REFERENCES:
 Anson, Barry J. Atlas of Human Anotomy. Philadelphia: W.B. Saunders Company, 1950
 Bushnell, Lowell F.: Physiologic Prevention of Postpartal Relaxation of Genital Muscles. West. J. Surg., Obst & Gynec. 98: 66-67, February, 1950
 Counsellor, Virgil S.: Methods and Technics for Surgical Correction of Stress Incontinence, J.A.M.A.46: 27-30, May 3, 1951.
 Curtis, Arthur HJ., Anson, Barry J., and McVay, Chester B.: The Anatomy of the Pelvic and Urogenital Diaphragms in Relation to Urethrocele and Cystocele. Surg., Gynec. & Obst. 68: 161-166, February, 1939
 Jones, Edward Gomer: The Role of Active Exercise in Pelvic Muscle Physiology. West. J. Surg., Obst. & Gynec. 58: 1-10, January, 1990
 Kegel, Arnold H.: The Nonsurgical Treatment of Genital Relaxation, West, Med & Surg. 31: 213-216, May, 1948
 Kegel, Arnold H.: Progressive Resistance Exercise to the Functional Restoration of the Perineal Muscles. Am. J. Obst. & Gynec. 56: 238-248, August, 1948.
 Kegel, Arnold H.: The Physiologic Treatment of Poor Tone and Function of the Genital Muscles and of Urinary Stress Incontinence. West, J. Surg., Obst. & Gynec. 57: 527-535, November, 1949
 Kegel, Arnold H.: Active Exercise of the Pubococcygeus Muscle. Meigs, J.V., and Sturgis, S .H., editors: Progress in Gynecology, vol. II, New York: Grune & Stratton, 1930, pp. 778-792
 Kegel, Arnold H.: Physiologic Therapy for Urinary Stress Incontinence. To be published in J.A.M.A.
 Kegel, Arnold H., and Powell, Tracy O.: The Physiologic Treatment of Urinary Stress Incontinence. J. Urol 63: 808-813, May, 1990
 Read, Charles D.: The Treatment of Stress Incontinence of Urine. Meigs. J.V., and Sturgis, S.H., editors: Progress in Gynecology, vol II, New York: Grune & Stratton, 1950, 690-697
 Collins, Conrad G.: Chicago Med., Soc. Bull. 241-246, October 13, 1931

 Source: Arnold H. Kegel, MD, FACS. Stress Incontinence and Genital Relaxation. CIBA Clinical Symposia, Feb-Mar 1952, Vol. 4, No. 2, pages 35-52.

Am. J. Obst. & Gynec. Aug 1948. “Progressive Resistance Exercise in the Functional Restoration of the Perineal Muscles.” Dr. Arnold H. Kegel, MD FACS

Sources for the orginal content:
GyneFlex
Do the Kegel



 

Personal background - Female Urethral spasms and prolapsed uterus

To learn about our solution, read here background is below.


For any wanting more background on my symptoms and diagnosis of urethral spasms:
Nearly 15 years ago, not long after weaning my second child, I started finding myself in terrible pain every month with urinary tract infections. At least that's what it felt like--a feeling of urgency and painful cramping that pain killers wouldn't touch. I became a regular visitor to my primary care physician's office. Occasionally I would test fully positive for a urinary tract infection. More often, I would test positive for high white blood cell counts but negative for nitrates which would cause my physician to shake her head in confusion and sometimes give me antibiotics, sometimes not. Of course, going on antibiotics nearly every month also started leading to an endless merry-go-round of urinary tract infection, yeast infection, urinary tract, yeast infection and eventually a little bit of BV thrown in as well. And as so often seems to happen in the medical world, no matter how many times I came back to the doctor's office, the routine never changed. The doctor never seemed bothered by the repeated visits. She treated each one as a fresh occurrence independent of the others. Finally, after months and months of pain and frustration I came in armed with my list of how many times I'd been in, how many rounds of antibiotics I'd been on, etc. even though I knew all this information was in her charts and I demanded, " Why is this happening over and over?" and "Shouldn't we be trying to address the underlying cause?" Her answer was very illustrative of the limitations of our medical system. She explained that she wasn't trained to do that--to investigate and figure out medical mysteries. She said that primary care doctors are trained to treat symptoms and that's it. I was insistent that wasn't good enough and demanded she give me a referral to see a specialist. She wasn't too excited about doing so (thank you cost-saving insurance companies) but finally agreed.

In the mean time, I also went to my gynecologist's office for my annual well woman exam (more info about why this may be a waste) and to see if maybe there was something going on in that realm that was causing my discomfort. An earnest resident I talked to suggested that maybe I was dealing with Interstitial Cystitis and recommended I try eliminating various foods from my diet to see if that helped. As I researched IC, I didn't think it quite matched but it was closer anyway. And I greatly appreciated her at least trying to think outside the box. My actual gynecologist was less useful. She sent me in for a pelvic ultrasound, found nothing, and suggested they could try birth control pills or a hysterectomy and see if that helped. Umm, no thanks.

When I finally saw a urologist, he sent me in for a kidney x-ray and cystoscopy to eliminate possibilities. They were normal. He explained that I was having urethral spasms-- where the urethra thinks it is infected and acts accordingly. He said they had no idea why and no cure, but that it was fairly common in women my age. He gave me the helpful suggestion that if I got pregnant I might feel better during the pregnancy-- he'd noticed that was the case for at least one patient. Once again, no thank you. He put me on a couple medicines-- a low dose daily antibiotic and a muscle relaxant used to treat prostrate problems in men. Neither seemed to help much and I didn't like the side effects of the muscle relaxant (or the fact that it wasn't designed or tested for use with women) so I dropped that one but kept taking the antibiotic for a while. It didn't actually stop the symptoms, but it calmed my mind. When the pain would start, I wouldn't have to wonder and worry whether it was an actual infection that I needed to go get medicine for. Gradually I concluded that it was just as effective to only take it the days of the month I was feeling bad rather than every day. Eventually I moved and didn't bother finding a new urologist. I would just talk my primary care physician into low dose antibiotic prescriptions which I'd keep around for when I had flare ups.

And so it continued for the next decade plus. I learned that if I kept my stress down and got plenty of rest, I had fewer attacks. But they still would happen occasionally and I would just suffer through the pain. It wasn't until recently that we found something that worked. To learn about our solution, read on here.

What no one tells you about the dreaded pap smear

If you or your partner is promiscuous, this post is not for you. If you are in a long-term, completely monogamous relationship or celibate, read on.

For years I suffered through the annual torture of a pap smear. I was told that birth control pills upped my risk of cancer so I needed to be screened annually. I sort of looked at it as the price I had to pay-- I wanted the prescription so I had to take the test. Once I was off of birth control pills I no longer had to make the annual visit and the window between when I'd bother with a well woman exam kept spreading wider. I was feeling a bit guilty about not having a pap smear in a number of years, until we looked it up to see how often it was recommended... and then learned even more.

Honestly, I'm not even sure I knew which cancers a pap smear tested for-- just female part cancers. I'd just had it continually drummed in to me that it was a super important way to prevent cancer (and who doesn't want to prevent cancer, right?) The government said that I need this test. My insurance company said I need this test. I definitely didn't understand that it only tests for cervical cancer and I most certainly didn't know that a person had to had to be infected with HPV virus, a sexually transmitted disease, to get cervical cancer.  (According to the American Cancer Society "a woman must be infected with HPV in order to develop cervical cancer" link)

I have been happily married for 20+ years. My husband and I were both virgins when we married. I was aghast to find out I'd endured this uncomfortable test for a disease I had zero percent risk for! In this article it mentions a study of 13,000 nuns (not sexually active).  ZERO got cervical cancer.  Think about that next time someone quotes cancer risk statistics.  Zero in 13,000.  In another article clearly very pro testing for HPV it states, you can get HPV "unless you are both virgins and have never fooled around".  Love it when a very pro testing article makes the argument against testing for me :-)

Frankly it makes me angry. It comes down to the fact that doctors don't believe their patients' sexual history. They don't believe it is possible for someone to not sleep around and be married to someone who does not sleep around.  They don't take you seriously when you say that is the case. They do not create testing recommendations for a group they don't believe exists.  Or is it all about the money?

Pap smears are a huge industry. Think of how many tests the labs run and charge insurance for every year. Think how many annual exams are scheduled with gynecologists and family practitioners because of these recommended tests. Whatever the motivations, there is a bunch of unnecessary testing going on.

And some might say, better safe than sorry. What can it hurt to do too many tests?  You might say, well, if you really have no risk, your pap smear will always be negative. No worries. Unfortunately, pap smears are also wildly inaccurate--somewhere in the neighborhood of 70% accurate. So 30% of all pap smear readings are WRONG.  And due to our lawyer happy society if the results aren't clear they will error toward the conservative side, call the test irregular and order a cervical biopsy.

From Web MD link
"Paradoxically, increasing PAP smear sampling among low risk women actual increases your chance of getting a “false positive” one day. For example (DeMay, 2000), if you get a yearly PAP between the ages of 18 to 78, and one assumes a 5% incidence of false positives, you would have a 95% chance of getting a false positive report during that time."

From the NY times link
"In general, about 10% of Pap smears have abnormal results, but only about 0.1% of the women who have these results actually have cancer."

In other words, out of 100 women with abnormal pap smears 99 of them were scared out of their wits and likely had their cervix scarred because of an inaccurate pap test.

Biopsies are talked about as a simple test all the time, so I don't think many people register what they are. A biopsy equals cutting a decent sized chunk out of your cervix! To test for a disease which I would not have. So it is very possible that a person with no risk could have a false positive and have to undergo a cervical biopsy.  A biopsy which WILL cause scar tissue that will be there for life.  And can cause all kinds of side effects.  Not to mention the pain of the actual test.  All "just to be on the safe side"

Want to see what they do for a cevical biopsy.  Here is a video. VERY GRAPHIC.
Biopsy of Vaginal and Cervical Lesions   https://www.youtube.com/watch?v=1JgsW-HjtWs

Colposcopy Procedure (with biopsy)
At time 3:23 is when they take the biopsy.  https://www.youtube.com/watch?v=u7ld_JWH8tU

Biopsy is HIGHLY invasive "just to be safe" isn't good enough.


The other frightening aspect is the risk of cross-contamination. My husband and I both are HPV free. Zero risk there. I'm sure there are other patients that go to my gynecologist's office who have HPV. One sloppy moment-- cleaning equipment, changing gloves, etc.--and it could be transferred to me. Yes, it's not super common, but it does happen.  It is a risk.  Just like there is a risk of getting cancer. Having an exam and pap smear actually increases my risk of cervical cancer. But no doctor or nurse or goverment program will ever warn me of that!

Links to some articles about cross contamination.  Google and you'll find lots more.  Does unnecceary testing put people at risk?  Yes it does.

2010 in texas 70 speculums were not sterilized cross contaminating patients link
Discussion of several incidents link
Dangers of using reusable speculums link
Study finds HPV on spculums AFTER cleaning link

Another good article:
Top Five Reasons for Opting Out of Pap Tests link

Female urethral spasms and prolapsed uterus - Cure without surgery

After about 15 years of living with female urethral spasms (or bladder spasm) we did some big time internet searching and reading about all sorts of things.  Lots and lots of different things.  Some useful and some well..not so much.  And some just down right terrifying.  I forget how but somehow my husband ran across information on uterine prolapse and we started wondering if this might be part of what was causing my urethral spasms. I didn't have an obvious, extreme prolapse-- although recently I had a few days when my tampon felt like it was mysteriously trying to push itself out. The only things I knew about prolapse were that it happened after births and that lots of women couldn't hold their pee because of it. I had never had any issue holding in my urine, so I had never considered it an issue for me, and I'd certainly never had a doctor even suggest it as a possibility-- even though I'd had two very large babies.  More on my personal experience.

All the things we didn't know about the female body:
As we started to learn more, we found there were so many things we had never read or been told about female anatomy. Maybe you already know this stuff and we're just clueless, but I had no idea that the uterus moves around during the monthly cycle. I'd always thought of my internal organs as fixed points but its more a jumble of stuff shoved in together.

As the following diagram shows, the uterus changes orientation throughout the monthly cycle. It's density and texture also changes. This seems to be typically discussed in relation to pregnancy and ovulation.  But this movement will have an effect on what and how much a prolapsed uterus is pushing on.  Seems this is useful information that should be mentioned more.
Complete page

Looking at these diagrams, it made it clear how intimately related the female bladder and uterus really are. And it made sense that at certain times of month (when I would have urethral spasms) the orientation could cause the uterus to push on the bladder if the uterus shifted downward because the muscle walls were not strong enough to support things.

Physical therapy is available instead of surgery
We learned that there are actual physical therapists out there who specialize in pelvic therapy. We would have visited one, but we live in the middle of nowhere where such things are not available, so we decided to learn and try it ourselves. We found descriptions of how to measure the amount of uterine prolapse and tried to measure how low my uterus was. We found that it would slip downward at certain times of the month. And would, as described above, change orientation during the cycle.

As my husband got more experience with feeling inside me and how it would change, we learned that as the uterus would tip various ways it would cause bladder discomfort or alternately constipation, depending on it's orientation.  On the days I was having pain or discomfort, we learned that through a combination of external massage and internal pressure he could press gently up on the uterus to coax it back into a higher and more normal proper position. There were times when I was in extreme discomfort and he would shift it and I could feel this huge release of pressure from my bladder and urethra. It was the first thing I've ever found that actually relieved the pain! Anyone who has experienced chronic pain will understand how exciting that was.  On days when my husband/DIY therapist was not handy, laying in different orientations to help the uterus slide away from the bladder also was helpful in reducing discomfort.

While the pelvic adjustments had helped relieve the acute symptoms, our goal was to eliminate them starting in the first place. In researching ways to combat or cure prolapse the options seemed grim.  Most were surgical options and honestly their success rate was VERY low.  One day in reading about Dr. Kegel he suggested that increasing vaginal muscle tone could have positive effects.  And that some surgeries he had tried without exercise were only temporarily successful. I have done Kegel exercises at various times, but like many people, I think I'd mostly done them wrong. The instructions typically given are not very helpful. "Activate your muscles while urinating to stop the flow. Remember that feeling and then practice doing it later." I had activated and strengthened the muscles at the exit (which had probably saved me from incontinence)-- but that had done nothing for the muscles that make up the side walls of the vagina. They were completely weak.  The exercise described by Dr. Kegel specifically targeted strengthening the "pubococcygeus".  Muscles "of the proximal urethra, middle third of the vagina and rectum".  The "pubococcygeus" is not merely muscles around the orifices.  Something that somehow didn't get passed on clearly to the rest of us.

My summary of Dr. Kegels article

How does one strengthen their vaginal walls?
Ever hear of "Vagina Weightlifting"? Neither had did I. But check out this lady.

Complete article
Some medical folks (probably surgeons) argue that the muscles of the vagina can't hold up a uterus, even if they are in good condition. I have a hard time believing that since  the average uterus only weighs between 0.06 and 0.22 pounds. Check out this video of some average young women, with no strength training, and how much they can hold. A typical bottle of water is 1 lb for reference.  They are lifting 5 times the weight of a uterus.  Still think a vagina couldn't hold up a uterus?

 Sounded like it was worth a try.  Really didn't have anything to lose by trying.  After looking into different contraptions for pelvic strengthening, I bought a simple set of weights. There are tons of sizes and shapes available. I bought this set because I liked that I'd be able to easily increase the amount of weight.

Honestly, since I'd never had the urinary incontinence, that a lot of reviewers were fighting, I figured I'd be able to hold the heavier weights without too much trouble. First day I tried and was shocked to find that  I could only hold the very lightest weight, only .05 lbs for a few seconds before it would slip out. Those girls were holding 20 (twenty) times the weight I could.  Despite having typical pelvic exams over the years, no medical professional ever suggested my vaginal muscles were sub par and could use some strengthening.  But here was proof as I couldn't even do the lightest weight.

I started practicing twice a day-- working with a weight until I could easily hold it for 15 minutes and then moving up to the next weight. The progression happened fairly quickly, within a few weeks, I had worked my way up to the heaviest weight. Then I started holding it for longer periods of time-- 30-60 minutes and adding additional weight onto it.

And it has made a big difference! The muscles are obviously stronger than they were, and I've had fewer and fewer bad days. I rarely need my husband to do adjustments for me anymore because the uterus seems to be staying up higher where it belongs. It is so nice to finally, after years and years of discomfort, we have found a solution.  And much to our elation it didn't involve cutting on my body.  It frustrates me that no one-- not my primary care physician, not my gynecologist, not my urologist ever suggested anything like this. It makes me wonder how many other people are suffering needlessly.  This blog is my attempt to help those others out there.

And guess what, I can even lift a water bottle now.  Only for about 10 seconds, but that is still exciting. And no, I won't be posting a video of that. :-)


Some additional links:
A woman's experience strengthening her insides to relieve incontinence.  Great descriptions of how to find the correct muscles and some good humor Link

A physical therapist commenting on vaginal weight lifting.  Link

UPDATE 9/2017 If you're interested in how well this has worked for me 

Different ways to protect your privacy

Carilion vs Lewis Gale hospital

HIPAA is to help you. Not to control you

Most of us have heard of HIPAA.  It's a law to PROTECT patients privacy.  HIPAA is not there to take away the patients rights.  However some hospitals hide behind the term HIPAA.  Since most patients do not know what all it means they get away with it easily.

Example:

Carilion clinc, Carilion hospital or also know as New River Valley Medical Center incorrectly hide behind HIPAA to get the patient away from their emotional support, family or friends.  Carilion fools patients into thinking that HIPAA requires them to be alone when discussing medical issues.  They use HIPAA as an excuse to isolate the often frightened patient so they can interrogate them more effectively.  This may be better for Carilion but it is harmful to the patient.  Iit is NOT what HIPAA requires.  Shame on you Carilion for taking advantage of your patients lack of understanding of HIPAA.  In what other ways do you take advantage of your patients lack of knowledge?  Makes one wonder.

At Lewis-Gale their policy is simply ask for permission to discuss medical issues in front of the patients emotional support.  This gives the patient the choice and leaves the patient in control.  Lewis-Gale doesn't inconvenience the patient while still complying with HIPAA. Good for you Lewis-Gale. 



Why would a hospital want to deceive patients?  It doesn't seem good business.  When I questioned the nurse at New River Valley Medical Center outpatient surgery she said to me "how would you like someone to watch you do your job?".  But I guess that doesn't look very good on a sign.  HIPAA is a convenient policy to hide behind.

Something to consider when choosing between Lewis-Gale and Carilion.  Sorry Carilion after years of using your services we have seen your true colors and have switched to Lewis-Gale.  The only regret I have is that we didn't do it MUCH sooner.

From the joint commission: who oversees Carilion Hospital (New River Valey Medical Center)

"Communication with a patient’s family members or friends – Health care providers can share and discuss health information with family, friends or other individuals who are directly involved in a patient’s care (HHS, Office of Civil Rights, Sharing health information with family members and friends). The law allows sharing information when the patient either agrees or if present in the room with the patient, the patient does not object. For example, providers can talk to a patient about his or her condition when a family member or friend is present at the patient’s request. Information about a patient’s needs also can be shared with a health aide, interpreter, or person driving a patient. In some situations, HIPAA also allows health care professionals to use their own judgment about whether the patient wants health information discussed in front of family members, friends, or other individuals involved in a patient’s care (HHS, Office of Civil Rights, Sharing health information with family members and friends). If a patient specifically asks a provider not to share information with an individual, then that decision must be respected. (HHS, Office of Civil Rights, Sharing health information with family members and friends)." link


 HIPAA is not about isolating the patient. 

So why does Carilion do it?  Speaking with some of the management, trying to get them to change their policies, I got a different answer than the nurse.  The management said that "patents lie" and they get better answers if they are isolated from their friends and family.  Nice to find out that Carilion treats all their Patients like liars.  Lewis-Gale, you have some new customers.

Here is an interesting article discussing patient privacy laws being misused to hurt not help patients.
http://www.propublica.org/article/who-do-federal-privacy-laws-protect-patients-or-medical-centers

Front the Government on HIPAA:

From http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html
"The HIPAA Privacy Rule provides federal protections for individually identifiable health information held by covered entities and their business associates and gives patients an array of rights with respect to that information."

and http://www.hhs.gov/ocr/privacy/hipaa/faq/safeguards/197.html
"Does the HIPAA Privacy Rule require hospitals and doctors' offices to be retrofitted, to provide private rooms, and soundproof walls to avoid any possibility that a conversation is overheard?"
The answer is "NO".

Even from Carilion on HIPAA https://www.carilionclinic.org/hospitals/carilion-roanoke-memorial-hospital/hipaa

"The Health Insurance Portability and Accountability Act (HIPAA) of 1996 established national standards to protect patients' personal and medical records. The regulations outlined by HIPAA protect the medical records and other personal health information maintained by healthcare providers, health plans and health insurers, and healthcare clearinghouses."

Carilion New River Valley Medical is also known as Carilion Clinic, or Carilion Hospital.  Radford Hospital

For reviews
on yelp: http://www.yelp.com/biz/carilion-new-river-valley-medical-center-christiansburg
The better business bureau BBB

We see you naked, and we don’t care

From a doctor:

"during the first operation that I witnessed as a medical student, I immediately realized that no one in there cares. We’ve all seen it a million times, and trust me, despite what you may believe, yours is no different than anyone else’s. I’ve had many patients who have been apprehensive about disrobing before surgery, but there is nothing remotely titillating in the operating room. Nothing."link

 I've heard this so many times.  It just makes me sick.  It is such a big lie.  First off, he says "the first operation that I witnessed."  There is a first time for EVERYONE.  There is no med student or nurse that was born with having "seen it a million times".  And keep in mind not only doctors are in the operating rooms.  A nurse, scrub tech, other techs, trainee, visitor, auditor, management could be there, too.  I've read a story where a guy boasts that his friend that worked in the O.R. took him in to see a woman being prepped for a GYN surgery.  Woman totally exposed to a stranger off the street.

Second " there is nothing remotely titillating in the operating room. Nothing." heard that from medical professionals all the time too:  Let's look at this a bit more:

Examples:
 "New Orleans breast surgeon sent himself 'surreptitious' photos of naked patients during surgery"
"A noted New Orleans breast surgeon “surreptitiously” took nude photographs of patients during surgery, emailing himself pictures showing the patients’ “faces, breasts and vaginas,”

Seems this doctor didn't get the message.  Maybe he hasn't seen enough yet?  And notice he took pictures of their "vaginas"  He is suppose to be working on their breasts but he takes advantage of the fact that the hospital doesn't allow patients to cover themselves.  Have to wonder what kind of person is making the rules.

"Doctor accused of taking photo of unconscious patient's private area"
How could she notice the tattoo and be interested enough to take a photo.  I thought they had seen it all a million times. Nice to know they do whatever they want when someone is out.

Cardiologist snapping nude pictures of a girl in the bathroom.
If he's seen it all a million times why is he trying to sneak a pic?

Doctor taking photos of Sedated patient
Tell me again they treat everyone the same and don't notice anything?

Doctor sexually assaults patient while unconscious
He also performed genital exams on a female despite being an Ear Nose and Throat specialist.  But they have seen it all.  There's no problem in that.

Prominent Emergency Room Doctor accused of four sexual assaults
This doctor seems to have made a habit of preying on young adult women who happened into his emergency room-- yet they all look the same...

And it is not just a problem with male health care workers. Female workers notice and respond to their patients' bodies as well.
Nurse texts photo of unconscious patient's penis

Female ENT doctor accused of routinely giving genital exams to male patients while they were sedated. 

Here's a whole article on protecting patients from sexual predators in the OR.

These are just a few examples of countless cases of criminal sexual misconduct in a medical setting. A few of the many cases where someone actually got caught which you know is a drop in the bucket. Since they've "seen it all" and there is "nothing stimulating," why do these things happen?

And obviously there are many, many healthcare professionals who are good, upstanding people who would never perform an abuse like those listed above. But why do we pretend that these professionals aren't human and don't even see their patients? That's simply unrealistic. A document on medical training published by the government of the United Kingdom states:

"Students must be taught that there is nothing unusual or abnormal about having sexualised feelings towards certain patients, but that failing to identify these feelings and acting on them is and likely to result in serious consequences for their patients and themselves."

"If a healthcare professional is sexually attracted to a patient and is concerned that it may affect their professional relationship with them, they should ask for help and advice from a colleague or appropriate body in order to decide on the most professional course of action to take. If, having sought advice, the healthcare professional does not believe they can remain objective and professional, they must:
• find alternative care for the patient
• ensure a proper handover to another healthcare professional takes place
• hand over care in a way that does not make the patient feel that they have done anything wrong."
link

"There is nothing unusual or abnormal about having sexualized feelings towards certain patients." It is biology. It is going to happen. So rather than pretending that doctors can turn off their sexuality like a switch, why isn't the topic dealt with realistically so that proper protections for patient and doctor can be provided for?

What about chaperones in the room during exams? This article talks about how seldom chaperones are used and how often patients are more uncomfortable when one is used. I can understand this since the general approach to chaperones is to grab some other employee (so generally a stranger to the patient), so now the patient has two strangers ogling them instead of one. And sometimes that extra has little medical training. Plus, if there is an environment of inappropriate behavior at a medical facility, it often involves more than one employee or else other employees are quiet out of fear of employment repercussions. This case, where a surgical tech was both sexually assaulted and witnessed inappropriate behavior towards patients, is an example. Bringing in a coworker does little to encourage patient trust. In fact, when chaperones are used, it is generally to protect the doctor (from accusations and lawsuits) rather than the patient. This article  explains how and why chaperones are typically used and how they aren't much help to the patient. It also includes this great reminder that doctors are human and aren't magically blind to their patient's appearance:
"A third reason respondents said they used chaperones was protection from their own sexual feelings. One male doctor talked about a female patient of his who he considered “gorgeous.” He had a difficult time examining her. “…I needed to use a chaperone." he admitted. "A chaperone not for her comfort but for mine.”

Wouldn't increased modesty for patients make the situation more comfortable for both the patient and for the doctor and other medical staff who may be sexually aroused, in spite of his/her best intentions? The less they can see, the less likely they will be notice something they wish they hadn't. You can read more on this topic here.

Isn't there also a very logical argument for using doctors and nursers of the patient's gender for intimate procedures and exams? This article shows that patients would prefer it, but are often too embarrassed to request it, in part because of the derision with which medical personnel tend to respond to these requests.

More on this topic:
Patient Modesty
How to Protect Your Modesty in a Medical Setting
Take it All Off

Topics to cover

Everyone has different preference on how they want to care for themselves and how they want others to treat them.  If your lifestyle and preferences are like the majority of people, then you will may be happy with what the standard recommendations and practices.  But some of us are in very low risk groups (Groups that much of the medical community won't even admit exist) or have preferences that the average patient doesn't have.  For us we have to dig more and make decisions on our own.  Here are some topics to think about:

Topics to cover, in no particular order:

• The cost of over testing.  Both in dollars, time and emotion.
• Concent and informed concent forms
• Patient has the option to edit or partially accept or refuse what is on the concent form.
• Hospitals make the concent forms as broad as possible.  If you sign them then it covers them.  It does NOT mean that you must concent to all of those things to be provided service.  Eliminate the things you are not comfortable with and see if they are ok with that.  Make it a dialog.
• Informed concent is not the same as just Concent.  If informed concent is required just having you sign a form without being informed is the same as no concent.
• It is all about risks.  Statistically, no one with a baby Giraffe in their car gets in an accident. 
• Cause vs Effects.  Seems this easily gets confused
• Surgical prep. -  What will they do to me once I'm unconscious?  Details they leave out.
• Moving your limp unconcious helpless body and positioning it
• Patient positioning injuries -
• Why can't I position myself before being put out?
• Shaving & Scrubbing
• Antibiotic painting
• Attaching monitors to your chest (will be made topless)
• For many surgeries the staff removes the patients gown completely.
• Draping -
• Some times drapes (cloths) are stapled to the Patients Skin
• Why don't they let me wear underwear?
• Anethesia
• Tube in the throat
• Intentional using sedatives who's side affect is Amnesia
• Peri-operative Hypothermia
• Getting cold while being operated on. 
• You're practically naked but the Dr. has on lots of layers
• Dr. controls the temperature
• HIPAA - It's there to help you.  Don't let hospitals use it against you.
• Learn more about HIPPA abuse
• Pelvic Organ prolapse - The undiscussed plague
• Female Urethral Spasms
• Dr. Kegel.  His research.
• A Nonsurgical Method of Increasing the Tone of Sphincters and their Supporting Structures
• My summary of Dr. Kegels 1948 paper
• Most common misunderstandings
• Weight lifting
• Breast X-Rays (AKA Mammograms). - We'll keep X-raying until we find something
• How does life time Monogamous relationships affect my risks and need for testing of:
• HPV - Pap smears & Cervical Cancer.  Study shows Nuns don't get Cervical Cancer.
• STDs
• Usefulness of pelvic exams on people that aren't sick.
• Cervical biopsies.  How much do they cut off?
• Probiotics - What are they?  Why haven't we heard of them?
• UTI's - Simply wipe front to back.  Yah if it was just that simple.
• Colonoscopy vs sigmoidoscopy
• Colonoscopy pants

People should make informed decisions on their medical care.  It should be up to the individual to decide what is right for them.  Not the government, not the medical community, not a non profit orginization funded by government money and certainly not the doctors.  You.  It is your body and you have to live with the decisions.  Yes we should seek out the opinions of all of those mentioned.  But keep in mind they all have different values and goals.  They might align with your values but they might not.  They write their policies or procedures to cover the masses or the average or more often the most concervative case.  If you are not "average" then what they suggest may not apply.  Or it might apply.  Learn for yourself and make an informed decision.

We are not telling you what to decide.  Just learn and make your own decision.