It may not be life-threatening, but it affects the quality of a woman’s life.
THE female pelvic organs, that is, the vagina, uterus, fallopian tubes and ovaries, are supported by the levator ani and the endopelvic fascia. The former is a muscle complex that is contracted at rest to form a stable platform on which the pelvic organs rest. The latter is a connective tissue network that envelops the pelvic organs and attaches them loosely to the pelvic muscles and bones.
The endopelvic fascia holds the pelvic organs, bladder and intestine in their normal position, yet permit sufficient mobility for them to carry out their functions of storage of urine and faeces, defecation, sexual intercourse, and childbirth.
When the levator ani and/or endopelvic fascia are weakened or damaged, there is a downward descent of the female pelvic organs and consequent protrusion of the uterus or vagina, or both. The front or back of the vaginal wall, the uterus and the apex of the vagina can be involved, usually in some combination. This condition is called urogenital prolapse.
Urogenital prolapse is rarely life-threatening but it can affect a woman’s quality of life.
There are different types of prolapse, depending on which part of the vagina is affected. When the bladder prolapses, it causes a bulge in the front wall of the vagina (cystocoele). This is usually associated with a prolapse of the urethra, the tube-like structure connecting the bladder to outside the body (urethrocoele).
A prolapse of both bladder and urethra, which is called cystourethrocoele, is the most common. A prolapse of the rectum causes a bulge in the back wall of the vagina (rectocoele). A part of the small intestine may slip down between the rectum and the back wall of the vagina (enterocoele). This usually occurs together with a rectocoele and/or uterine prolapse.
When the uterus drops into the vagina, it is called a uterine prolapse. This is the second most common type of prolapse. Its severity is graded according to the extent to which the uterus descends into the vagina.
The apex of the vagina is called its vault and its prolapse occurs only after surgical removal of the uterus (hysterectomy). Vault prolapse occurs in about 15% of women who have had a hysterectomy for uterine prolapse and about 1% of women who have had a hysterectomy for other reasons.
Gynaecologists describe the severity of urogenital prolapse with a grading system. Stage one is mild and stage four is severe.
There are several factors that can cause urogenital prolapse but the two most important ones are pregnancy and increasing age.
The weight of the baby and the stress of labour and birth can strain the pelvic muscles and supporting ligaments, resulting in urogenital prolapse in subsequent years. The risk is increased if the baby is big, labour is prolonged or there is instrumental vaginal delivery. A short interval between pregnancies exposes the muscles and ligaments to almost prolonged strain, with limited time for recovery, thereby increasing the risk of prolapse.
The body’s muscles become weaker and less elastic with age, weakening pelvic muscles which may have been damaged when the woman was younger. This is accentuated by the decline of the female hormones at menopause. Pelvic organs and muscles, endopelvic fascia and bladder all contain receptors which are sensitive to the ovarian hormones.
Obesity, the frequent lifting of heavy objects, chronic cough or straining when one is constipated can increase the risk of prolapse.
In rare circumstances, the risk of prolapse is increased in women who are born with deficient collagen, a protein that keeps tissues elastic and strong.
Many women who have urogenital prolapse do not have symptoms. When symptoms occur, they are usually related to the organ that has prolapsed.
The urinary symptoms include an inability to control the flow of urine during increased intra-abdominal pressure when laughing, sneezing or coughing; frequent urination or urge to pass urine; weak or prolonged stream or feeling of incomplete emptying.
The bowel symptoms include incontinence of flatus or stools, straining at defecation, and/or feeling of incomplete emptying.
The vaginal symptoms include sensation of a bulge or protrusion, pressure and/or heaviness. In severe prolapse when the uterus is outside the vagina, the prolapsed uterus will be felt as a lump at the vaginal opening and the overlying skin may be raw and infected.
Other symptoms include pain or lack of sensation during sexual intercourse, pelvic pain or pressure, and/or backache.
Medical attention should be sought if these symptoms are present. Many women are shy and suffer in silence for years. There is no need for this as treatment is available.
The doctor will take a history and then carry out a physical examination. A metal or plastic speculum is inserted into the vagina to detect any bulges in its walls. The doctor will also insert two fingers in the vagina to feel for any masses in the pelvis or lower abdomen.
During the pelvic examination, the patient will be asked to cough or to strain to detect any leakage of urine or bulges in the vaginal walls. Some of the urogenital prolapse may not be obvious when lying down, so the doctor may repeat the pelvic examination with the patient standing up.
The doctor may insert one finger in the vagina and another in the rectum, and ask the patient to cough or strain to enable him to feel for prolapse of the intestine. Blood tests or urine culture may also be carried out.
After the examination, the doctor should be able to determine the type of prolapse, its severity, the treatment options and the rationale for his/her recommendation.
The treatment of urogenital prolapse will be discussed in my next column.
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