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.