Prof. Dr. Shyam P Lohani

Uterine prolapse is the condition in which uterus descends from its normal position in the pelvis into the vagina. When the pelvis floor muscle becomes weak and unable to support the uterus, it gets prolapsed. Uterine prolapse may be incomplete or complete. An incomplete prolapse occurs when the uterus is only partly sagging into the vagina whereas complete prolapse occurs when the uterus falls far down that some tissue protrudes outside of the vagina. It is one of the frequently reported causes of poor health among women.

Status
Around 10 per cent of female population worldwide has uterine prolapse and around 50 per cent menopausal women have some degree of prolapse and, of these; 10-20 per cent becomes symptomatic (Medscape, 2018). Approximately, around 50 per cent of all women over 50 years complain of symptomatic prolapse. There are different causes of weakened pelvic muscles and tissues that include pregnancy, difficult labour and delivery or trauma during childbirth, and delivery of a large baby. Other causes include lower estrogen level after menopause, any condition that puts pressure on the abdominal area, such as being overweight, straining to have a bowel movement, or an intense or long-lasting cough such as in smokers or people with asthma and extreme physical activity or lifting of heavy objects.
The risk of uterine prolapse increases as a woman ages which cause hormone called estrogen to decrease. The causes of high uterine prolapse among women of young age in Nepal may be due to early marriage, multiple births which is carried out often at home, poor nutrition and lifting of heavy objects in day to day household work. Women who have a minor uterine prolapse do not show any symptoms while moderate to severe prolapse may cause symptoms, such as awkward feeling while sitting, vaginal bleeding, increased discharge, problems with sexual intercourse, the uterus or cervix protruding out of the vagina, a pulling or heavy feeling in the pelvis, constipation or difficulty in passing stool, discomfort walking and recurring bladder infections or difficulty emptying the bladder. The complications can sometimes result in ulceration of exposed tissue and prolapse of other pelvic organs such as the bladder or the rectum.
Muscle weakness or relaxation may result uterus to sag or come completely out of the vagina in various stages: in the first degree, the cervix drops into the vagina. In the second degree, the cervix drops to the level just inside the opening of the vagina while in the third degree, the cervix is outside the vagina and in the fourth degree, and the entire uterus is outside the vagina. Women should contact nearby health facilities if symptoms are seen such as when women feel the cervix near the opening of the vaginal canal or feel pressure in the vaginal canal and the feeling of something coming out of vagina. Often a physical exam is sufficient to diagnose prolapse. If additional information is needed, a number of tests such as intravenous pyelogram (IVP) or renal sonography and or ultrasound may be done that measure how well each of the pelvic organs is functioning.
The treatment of uterine prolapse depends on the degree of severity of the condition. It ranges from hysterectomy which is the surgical removal of the uterus in cases of severe uterine prolapse to uterine suspension in which the uterus is placed back in its normal position, either by connecting support tissue to the lower part of the uterus, or by using a mesh material that forms a sling to hold it in place. Another method of treatment is Kegel exercises which helps in tightening and relaxing the muscles used to control the flow of urine in order to strengthen the muscles that support the pelvic organs. Sometime supplement hormone estrogen is recommended which helps prevent further weakening of pelvic muscles but has a number of possible negative side effects. To the few patients, vaginal pessary is employed in which a removable rubber or plastic device inserted into the vagina to provide support in the area of the prolapse and pessaries are most often employed when the patient wants to avoid surgery or has medical problems that make surgery too risky.

Human rights issue
In most of the countries, uterine prolapse is seen mostly in postmenopausal women whereas in Nepal, it is commonly seen in younger age. The uterine prolapse can be prevented from deterioration by reducing weight, avoiding constipation by eating a high-fiber diet, doing Kegel exercises to strengthen pelvic muscles and avoiding heavy lifting or straining. It is challenging to find out women with different degree of uterine prolapse in a country like ours with such a diversification in topography. Nepal government has taken uterine prolapse as a human right issue and started to provide hysterectomies free of cost at the health facilities throughout the country. It is important to know that hysterectomies are not necessary in all stages of uterine prolapse. The large scale screening for uterine prolapse is therefore recommended throughout the country. At the same time, countrywide awareness campaign is needed to destigmatise about the uterine prolapse, empower women to seek medical attention and end their misery.

(Prof. Lohani is the Founder and Academic Director of Nobel College and can be reached at lohanis@gmail.com)