abstract Haslam, J. (2008) Vaginal cones in stress incontinence treatment. Nursing Times; 104: 5, 44–45.
Jeanette Haslam explains the theory that underpins the use of vaginal cones in stress urinary incontinence and how this translates into practice.
Pelvic floor muscle training (PFMT) is recommended for stress urinary incontinence (SUI) in women (NICE, 2006). One method of training is the use of vaginal cones. From the literature, it is apparent that there is no difference in the success rates between the use of vaginal cones and pelvic floor muscle (PFM) exercise (NICE, 2006).
Theory of vaginal cones
Vaginal cones were developed in the 1980s by Stan Plevnik, a bioengineer in Ljubljana, Slovenia (formerly Yugoslavia). In a study of women with SUI he noted that those receiving placebo vaginal electrical stimulation also showed some improvement. He surmised that the feeling of ‘losing’ the vaginal electrode was causing the women to contract their pelvic floor muscles. This led him to developing weighted vaginal cones for the treatment of SUI.
The cones were originally designed as a set of nine cones of equal shape and volume but a weight range from 20–100g. The aim was that the woman would gain sensory feedback from the feeling of the weight on the pelvic floor and the need to increase PFM activity to retain the cone.
Plevnik termed the heaviest weight that could be retained for one minute without a voluntary contraction while the patient walked as being the ‘passive weight’. This was taken as being the resting pelvic floor tone. The heaviest weight that could be retained with a voluntary PFM contraction was termed the ‘active weight’.
The use of vaginal cones concurs with the principles of muscle training: overload, specificity and maintenance (Table 1).
The earliest paper published about vaginal cones had a comparatively low number of participants (n=39) of whom only 30 completed the one-month cone therapy with weights from 20–100g (Peattie et al, 1988). The women were instructed to use the passive weight for 15 minutes twice per day. When they were able to retain the cone on two consecutive occasions, they were instructed to start using the next heaviest weight of cone. Of the 30 women completing the month of treatment, 70% reported a cure or an improvement.
A review of vaginal cone studies by Bø (1995) found most studies reported a cure/improvement rate of 70–90%. However, when those dropping out of the study were included, this decreased to 30–63%. A Cochrane review found that cones have similar outcomes to PFMT (Herbison et al, 2002). NICE (2006) has reported that the studies of good quality used different protocols:
Range of weights;
Number of times used per day (one to
Duration of therapy;
Comparison with electrical stimulation;
Versus no treatment;
Versus PFMT or combined with PFMT.
Different protocols make comparisons between studies difficult.
Vaginal cones have been shown to be as effective as PFMT using exercise. However, not all women are happy with using a vaginal device.
Prashar et al (2000) found that only 30% of older women with urinary incontinence are comfortable with touching their own genitals. If a woman says she has used tampons, a diaphragm or cap, she may be more likely to be happy to use cones.
Vaginal assessment should always take place prior to any health professional advising the use of vaginal cones. This is to ensure there is nothing more than a minor degree of prolapse, that the woman is not suffering from atrophic vaginitis and that the vaginal capacity is appropriate for the recommended cone. The woman should be informed that thrush or any urinary tract infection must be treated and resolved before vaginal cones can be used. They should not be used if the woman is pregnant or during menstruation, nor should they be loaned to anyone else.
It is also vital that there is valid consent to any form of proposed therapy (Department of Health, 2001).
Availability of cones
Women can self-treat, in which case they can purchase their own cones. In doing so, they are responsible for their own actions, with product liability lying with the manufacturer provided that they are used in accordance with the accompanying instructions. However, if a health professional advises the use of vaginal cones, they must ensure that the woman fully understands the instructions and complies with them.
Ideally, a woman should be assessed for her starting weight of cone while at the clinic.
There are several types of cones on the UK market and available via the internet. One type that has been used for many years is the Aquaflex. The set contains two cones of different dimensions that unscrew to reveal a spindle on which weights from 5–20g totalling 55g can be inserted. This means that they are versatile in both cone size
Other systems include a set of cones each of a different weight. Advice on the use of weights is outlined in Box 1.
The NHS has limited resources and does not provide vaginal cones on prescription. However, as they have been found to be an effective therapy, they can be recommended to appropriate women. Many find that they are happier to use cones once or twice a day rather than having to remember PFM exercises.
Exercise principles and the use of cones
Overload Muscles must work harder than their usual everyday activity The vaginal cone weight can be increased as muscle strength improves
Specificity The correct muscles must be used in functional activities Providing the cone is accurately placed in appropriate patients, functional activities can be practised while the cone is retained
Maintenance A reduced level of exercise may be employed once desirable strength and ability is achieved After successful therapy, cones can be used occasionally to maintain success
Box 1: a practical guide to using a vaginal cone
An appropriate training weight is usually the heaviest weight that can be retained for one
minute while walking around. If the woman is using a shell cone, the larger one is used first
(if it is comfortable to insert without lubrication).
When a cone is inserted for the first time, the position should be checked to ensure it is in the correct position, resting just above the PFM with the woman being able to feel the cone with her fingertip. When the woman contracts her PFMs, the cone should be felt lifting away from her fingertip. If the cone pushes outwards, the woman is not contracting her PFMs appropriately.
Tight-fitting underwear may help in retaining the cone and should be avoided.
Women using shells with separate weights should note that, if all the weights can be retained in the large shell, they should change to the small shell, gradually increasing the weight when able.
The training weight should be used at least once a day. When it can be retained for 10–15 minutes, the woman can increase the weight by choosing a heavier cone or adding weights to the shell, depending on the system being used.
Daily use of cones should result in an improvement in about eight weeks. It is recommended that exercises are continued for 12–20 weeks.
It is important to continue to maintain PFM training with occasional PFM exercises. Often women find it advantageous to continue to use the cones on an occasional basis to maintain PFM tone.
Bø, K. (1995) Vaginal weighted cones. Theoretical framework, effect on pelvic floor muscle strength and female stress urinary incontinence. Acta Obstetricia et Gynecologica Scandinavica. 74; 2, 87–92.
Department of Health (2001) Good Practice in Consent Implementation Guide: Consent to Examination or Treatment. London: DH.
Herbison, P. et al (2002) Weighted vaginal cones for urinary incontinence. Cochrane Database Systematic Review, 2002; (1): CD002114. Oxford: Update Software.
NICE (2006) Urinary Incontinence: The Management of Urinary Incontinence in Women. London: NICE.
Peattie, A.B. et al (1988) Vaginal cones: a conservative method of treating genuine stress incontinence. British Journal of Obstetrics and Gynaecology; 95:
Prashar, S. et al (2000) Attitudes to vaginal/urethral touching and device placement in women with urinary incontinence. International Urogynecology Journal and Pelvic Floor Dysfunction; 11: 1, 4–8.