THE incidence of urogenital prolapse in our country is unknown. What is known is that many women with this condition suffer in silence as they do not seek medical advice.
Urogenital prolapse is one of the main reasons for major gynaecological surgery in developed countries like Britain and the United States.
After the doctor has confirmed the diagnosis, one can undertake several measures to make life easier.
Regular pelvic floor (Kegel’s) exercises will reduce leakage of urine, strengthen the pelvic muscles, and assist in recovery after surgery. To locate the muscles, imagine trying to stop passing urine or opening the bowels. The muscles squeezed are the pelvic muscles.
Alternatively, one can insert two fingers into the vagina and squeeze until one can feel the vagina tighten around the fingers. The muscles contracted are the pelvic muscles.
Start tightening the muscles by counting to five, then relax the muscles by counting to five. As muscle strength improves, increase the count to 10. Repeat this 10 to 15 times.
Kegel’s exercises can be done lying down, sitting up or standing with the knees together or slightly apart. It is important to check that the muscles in the legs, abdomen or buttocks are not tightened, and to continue breathing normally during the exercises.
The exercises should be done daily; the frequency will depend on the doctor’s advice.
As prolapse symptoms can be aggravated by standing, it helps if one avoids standing for a long period of time.
The consumption of a high-fibre diet can reduce constipation and straining. Other alternatives to sexual intercourse should be considered if there are such difficulties. Advice can be sought from the doctor.
If one is overweight, measures should be taken to reduce weight and then to maintain it. These include diet, exercises, behaviour therapy and medication, advice for which can be provided by the doctor.
Non-surgical treatment
Currently, the pessary is the only available non-surgical treatment. It is a small device that is inserted into the vagina to reduce prolapse, to provide support to related pelvic structures and to relieve pressure on the bladder and bowel.
It is made of silicone or plastic, and comes in different sizes and shapes.
Pessary use is suitable for the pregnant, those who want to have more children, those who are awaiting surgery, are unsuitable for surgery or who choose not to have surgery.
Before fitting a pessary, the factors to be considered include the nature and extent of the prolapse, the patient’s manual dexterity and level of sexual activity. A pessary has to be individually fitted. The doctor may have to insert a pessary more than once to find one that is comfortable for the patient. After insertion, the patient will be asked to carry out various activities to check that the pessary stays in place.
Once a suitable pessary is found, the doctor will then arrange for a follow-up appointment, after which further appointments will be arranged accordingly.
The doctor may also teach the patient how to remove and re-insert the pessary, as well as how to clean it.
Some pessaries can be left in place during sexual intercourse but others may get in the way. Sometimes there may be a foul discharge. If this or other problems arise, it is essential to consult the doctor. The need for regular follow-up has to be emphasised.
Pelvic floor exercises, as described in the preceding section, are helpful in preventing the prolapse from getting worse and may reduce some of the symptoms. However, it will be some months before the benefits of regular exercise can be felt.
Hormone therapy (HT) may strengthen the pelvic muscles and vaginal wall by increasing the oestrogen and collagen levels. However, it has not been shown to be effective in treating prolapse.
Before commencing HT, there should be a frank discussion with your doctor about its pros and cons. Arrangements will also have to be made for regular follow-ups.
Surgical treatment
There are two types of surgery available for urogenital prolapse – reconstructive or obliterative surgery.
Before deciding on surgery, women are advised to have a frank discussion with their gynaecologist. The questions to be addressed include, among others:
Reconstructive surgery aims to correct the prolapsed vagina, while relieving symptoms and maintaining or improving vaginal sexual function. The surgical routes may be vaginal or abdominal, with the former being preferred by the majority of gynaecologists.
Anterior colporrhaphy is a procedure that repairs anterior vaginal wall prolapse, with reported success rates of 80%-100% in case series, and 40%-60% in random trials.
Posterior colporrhaphy is a very effective procedure that repairs posterior vaginal wall prolapse. Because painful vaginal intercourse (dyspareunia) rates are unacceptably high, gynaecologists have modified their operative techniques to reduce this side effect by not narrowing the vagina too much.
Uterine prolapse is treated by removing the uterus (hysterectomy) or suspending it. A hysterectomy is only done if the patient does not plan to have any more children.
The uterus is usually removed by the vaginal route, unless it is very large. After the removal of the uterus, the pelvic ligaments may be shortened and re-attached to hold up the vagina.
After a hysterectomy, there are no more periods and one cannot get pregnant. It is a major decision that must be discussed thoroughly with the doctor.
Operations that suspend the uterus are done in women who do not want to lose their uterus or who want to get pregnant in the future. The surgical routes are abdominal or vaginal with some evidence to suggest there are better results with the abdominal routes. The uterus is held up with mesh or stitches to the pelvic ligaments.
There is widespread use of mesh to correct prolapse. However, the safety and effectiveness data published is limited. Some mesh products reportedly have high success and high complication rates.
This led the World Health Organisation, at its 3rd International Consultation on Incontinence in 2005, to declare that transvaginal mesh “should only be used in well designed clinical trials and not in general practice until more data is available.”
Obliterative surgery corrects the prolapse by putting the pelvic organs back into place and then closing off the vaginal canal totally or partially.
Such operations are seldom done nowadays and are reserved only for senior women who have severe medical conditions and are no longer sexually active.
The advantages of this type of surgery are shortened operating time, decreased risks and a very low prolapse recurrence rate.
The obvious disadvantage is the elimination of the potential for vaginal intercourse.
As such, before such procedures are carried out, both the patient and her partner must be completely comfortable about the loss of vaginal sexual function.
Prevention
There is limited data on the measures that can prevent urogenital prolapse. However, there are a number of things that one can do to reduce the risk of getting a prolapse, or to prevent a mild one from worsening. They include:
Some doctors advocate elective Caesarean section to prevent the development of subsequent prolapse. However, there are no criteria available that can tell who would or would not benefit from such intervention.
It is important for women with prolapse to seek medical advice and not suffer in silence, as untreated prolapse has a significant impact on the quality of life.
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