PELVIC ORGAN PROLAPSE (POP)

Pelvic organ prolapse simply means that the pelvic organs descend into the vagina. This includes bladder (cystocele ) rectum (rectocele), uterus and bowel (enterocele ). All of these are not seen all the time in the same person, different combinations of POP is present in different women. It is also classified in degrees depending how far down it has come , when it is a bit in the vagina it is first degree , when it is at the opening of the vagina it is second degree, when it is outside it is called third degree, when it hangs totally outside it is called procendentia .

Globally one in five female suffers from it. However women do not complain about it, perhaps they are embarrassed about it and do not know that it can be treated. In developing countries almost 50% of women suffer due to difficult child birth at home. The main cause of POP is child birth, chronic cough, smoking, constipation, obesity, and hormone deficiency at during and after menopause. It can be occupational due to standing too long and heavy lifting all the time. POP in women who have never had a child is very rare; it is usually due to developmental defects either in the pelvis or the spine. Women who have POP also suffer from urinary problems such as leakage of urine (incontinence) and even faeces.

The symptoms women experience is a feeling of pressure in the vagina and with a finger they can feel a lump. Other symptoms are, pain on standing, backache, belly ache, difficult sex, urinary and bowel problems. Often in very severe cases the pelvic organs constantly hang out. Treatment can be started very soon after child birth with pelvic floor muscle exercises. In fact in many places when maternal health is taken seriously they are taught to the mother at the time of discharge. The most common is called Kegal exercise which has been going on for generations.  Perhaps some women may remember being told about it, when they had their baby. Changes in life style factors is also important,  such as avoiding constipation, smoking,  being overweight, proper eating habits, use of oestrogens if women are in the menopausal age group.  The other non surgical treatment is pessaries.

These help to keep the pelvic organs pushed inside.  They need to be changed every three to six months. Sometimes the women can do it themselves but it is best if a clinician can do it, so that they can look for any infection, ulceration and can do cervical smear when required. This treatment is ok when the women do not wish for operative treatment or are unfit for it or often too old.

Operative Treatment

This depends on several factors; how old is the women, what is the actual problem, for example a cystocele and what else, most importantly is the preservation of the uterus required or is it a nulliparous POP? (This means a woman has never had a child). The operations are cystocele and, rectocele repair or both and repair for descending cervix.  If it is a nulliparae’s prolapse the cervix is lifted up by different types of sling operation, hitching it to sacral promontory of the spine. These were invented by Indian gynaecologists as this is common in India.

Some other sling operations are also performed if there are urinary and bowel problems. I will discuss these in my next blog. Side effects of these operations are they can recur in 20-30% of women, especially after a child birth and soon after repair, or a POP can come up in another place. If the rectocele repair becomes tight it causes painful sex and bowel problems. In older women when preservation of uterus is not desired a vaginal hysterectomy with the repair for other defects is performed. Following these operations a catheter is left in the urinary bladder while the tissues heal.  Women are usually in hospital for 2-5 days.

One very last operation is the total vaginal fusion. This is done when intercourse is never desired and the uterus is absent. A slightly modified operation called La forts operation was once performed in 1877 and then it sort of died out.  Now it is coming back as women are living longer. This is a very simple operation with a success rate of 90%.  It can be performed under local anaesthesia. Hospital stay of 2 -3days, hardly any complication rate and satisfaction rate of women is very high. With changing demographic this is more often required.

POP is a big subject now so much so that it has become a separate speciality within the field of gynaecology. There should   be more public awareness so that the women are not hesitant to ask for help in early stages of POP problems.

ADENOMYOSIS: ENDOMETRIOSIS OF THE UTERUS

Eva is 37 years of age has 2 children; 6 and 4. For many months she had been having very heavy and painful periods. She was unable to cope with her day to day life; her quality of life was getting progressively worse. She went to see her GP, and complained to him about all her problems. He asked her if she had any difficulty with her bowel and urination, she immediately answered yes. I have pain both on urinating and bowel action and also frequency of passing urination. When the GP examined her he noticed that she was looking pale, he could feel her enlarged uterus on abdominal examination and confirmed this on pelvic examination, that it was about the size of 12 -14 weeks of pregnancy it was hard and tender. The uterine size is expressed with reference to the size of pregnancy; however during pregnancy it is soft. He did her haemoglobin, this was low 9.6gm (Normally it is about 11-12). He was an experienced GP, and gave her a diagnosis of a uterine Fibroid or a condition called Adenomyosis.

Adenomyosis is a condition in which the endometrial cells grow within the uterine muscle layers. It can be scattered in the muscle or form a mass like effect, unlike fibroids it does not have a capsule or an outer cover. It is believed that it affects up to 65% of females in their life time. A few decades ago it was thought that it does not affect young women who have had no children. Recently with the improvement in diagnosing Adenomyosis (ADENO) with Ultrasound and MRI it is believed that 35% of women suffering from ADENO are nulliparae’s (women who have never had a pregnancy), in fact in English medical literature some cases had been reported in adolescent girls. One third of the females suffering from ADENO have no symptoms. Others suffer from heavy painful menstrual periods, lower abdominal pain, and pain on intercourse, passing urine and on bowel actions. It also causes infertility, miscarriages and even premature birth. If associated with polycystic ovarian syndrome it is even worse due to high oestrogen levels. This makes IVF difficult due to altered uterine shape, uterine peristalsis, and makes embryo implantation difficult; a toxic and altered hormonal environment makes it further worse.

One problem is that it is a long disease, which lasts for years almost up to menopause. It often becomes mild after menopause or goes away. I have removed some very enlarged painful uteri, in post menopausal women.   A patient’s medical history and a clinical pelvic examination give a good clue to its diagnosis. Blood tests can be done to assess a woman’s condition. New high resolution ultrasound and MRI give a precise diagnosis. MRI is an expensive test and not always available ultrasound is nearly as good. In recent times it has been advised to always keep AENO in mind if you have a young adolescent girl with intractable pain and painful period, please do an ultrasound.

Why does ADENO happen? It can be due to trauma to the myometrial and endometrial zone during child birth, an operation such as curettage, caesarean, this is a process of tissue injury repair. The endometrium invades into the myometrium.  The other theory is that, stem or embryonic cells change into endometrial cells and make these endometrial nests or even masses.

The treatment of ADENO initially conservative especially if the woman is young and fertility is an issue.  Antinflamatory tablets are given during periods so that they help pain and excessive bleeding, its effect are minimal to moderate. Next in the line of treatment are hormones, they are either given to make the periods milder or stop them completely.  They all have their side effects and most of them stop fertility, however the good thing is that all of them are temporary.  Let’s start from oral contraceptive pills, then progesterone tablets or injections and vaginal rings. These also give Adenomyosis time to heal, but how much it does; we do not know.  When they are stopped the problem starts again. Another treatment is a progesterone implant a small rod implanted in your upper arm under the skin it lives there for 3 years. It can cause some irregular spotting, prevents pregnancy.  One of the good hormone is Danazol tablets, or danazol loaded intrauterine device which fitted in your uterus for 6 months.  This has a great advantage that a woman can still achieve a pregnancy while she is using this.  A strong hormone treatment is Gonnadotrophin releasing Hormone (GnRH). This is given as an injection every at 1 to 3 monthly intervals. This suppresses our pituitary gland, thus our ovaries, hence no more periods. This cannot be a very long term treatment; it causes side effects like menopause. Add on treatments are given for these.  One serious side effect is the loss of bone density. In contrast to this, a group of drugs called Aromatase inhibitors which stop the formation of oestrogens in the body from other hormones that exist in the body fat. They are also found to be useful particularly in obese women where extra oestrogen is formed in the body fat. GnRH is unable to do this.

An present an intrauterine device containing Levonorgestal is found to be the best reversible treatment of Adeno. It prevents fertility and can be used repeatedly, after every 3-5 years.  The failure rate of treating symptoms is only 20 percent. There is a smaller IUD now available and can be tried in adolescents. Local excision of adenomyosis has been tried, but it is not easy and long term results are a bit questionable and unsatisfactory. The treatment of ADENO depends on, if fertility is to be preserved. Hysterectomy is the best treatment, although uterine artery embolization and endometrial ablation is also tried with some success.  As long as a patient agrees to surgery, a hysterectomy can be performed abdominally, vaginally or laparascopically and now even robotically.

Generally ovaries do not need to be removed.  In some very difficult cases it is found to spread into the bladder and bowel.

Adenomyosis is a difficult and painful condition from which women used to suffer a lot in the past, but the new techniques of diagnosis and treatment have helped the gynaecologist in its management.