Introduction

According to Novak’s textbook of gynaecology, 16^th edition, Pelvic organ prolapse is defined as, “descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus(cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy),” correlating with symptoms, assisted by any relevant imaging.1

It is the progressive herniation of the pelvic organs through the urogenital diaphragm that most commonly leads to vaginal bulge symptoms. Women with prolapse beyond the hymen may also report lower urinary tract incontinence, urgency, frequency or voiding difficulty and bowel symptoms like obstructed defecation, fecal incontinence.1 POP is multifactorial in etiology with combination of anatomical, physiological, genetic, lifestyle and reproductive factors.2 Data from the Women’s Health Initiative revealed anterior POP in 34.3%, posterior wall prolapse in 18.6% and uterine prolapse in 14.3% of women.1 It has a detrimental effect on women’s psychological, social, emotional and physical well being.3 As the women age advance, pelvic floor dysfunction becomes more and more troublesome as it effects quality of life, workforce productivity and cost to the individual as well as whole healthcare system.4 The recognition of determinants for development of pelvic organ prolapse will help physician to target at risk women for professional counseling on preventive behavior and life style changes.

The pelvic organ prolapse determinants will aid in building a risk model for identification of low and high risk women. Since this condition is considered a social taboo, women suffering often do not tell their problems even to the closest kin and continue to suffer which in turn effects their quality of life. Hence, it can be called a “Silent Epidemic”.

Owing to the fact that this condition is very much preventive by better counseling in antenatal and postnatal period, the prevalence of this condition can be curtailed, and thereby quality of life can be improved.

Materials and Methods

Result

The period of study was from January 2019 to January 2021. During this period 11256 patients were seen at the gynaecological clinic, out of which 206 patients had uterovaginal prolapse. The prevalence was 1.8%.

The sociodemographic profile of patients is shown in Table 1. The mean range of patient in our study was 52.84years. The range was between 25years and 74 years. Nearly 35.9% of study population was above 55 years. 4.3% presented with prolapse in the age group below 35 years. 3.8% presented with prolapse in nulliparous age group and 22.8%women were grand muliparous. 33.4% were farmers, 28.6% were labourers.19.9% were well-educated and employed while 17.9% were housewives.

In Table 2, the analysis of determinants and risk factors for uterovaginal prolapse were done. The uterovaginal prolapse was present in multiparous women 84.4% of cases and 74.4% in post menopausal women. 80% of cases were due to chronic intraabdominal pressure like constipation, chronic cough and strenuous physical work. While overweight was in 33.9% of cases and abdominal mass in 0.97% of cases. 62.1% of women had more than 2 risk factors, 77.6% had 2 risk factors and 88.8% had 1 risk factors.

The clinical symptomatology and presentation of patients were done in Table 3. 97% of cases presented with protrusion of mass per vagina, 88% presented with urinary symptoms, 85.4% presented with vaginal discharge, 38.8% presented with vaginal itching, 27.1% presented with ulceration and 4.8% presented with impaired sexual function. The uterine prolapse was present in 94.1% of cases, cystocele in 67.9%, rectocele in 58.2% of cases and enterocele in 41.2% of cases. Further 2.9% had procidentia, 67.9% had third degree prolapse, 7.2% had second degree prolapse and 21.8% had first degree prolapse.

The treatment modalities offered was shown in Table 4. The surgical treatment was given in 77.1% of cases, Vaginal hysterectomy in 7.2% of cases, Vaginal hysterectomy with pelvic floor repair in 69.9% of cases. Non surgical modalities were offered in 22.8% of cases like pessary in 0.97% and kegels exercise in 21.8% of cases.

Discussion

The uterovaginal prolapse accounts for 1.8% of prevalence in gynaecological OPD. The incidence in Okankuo et al. is 2.1%.1 The incidence according to Eleji et al. is 6,5%.2 The difference in incidence may be due to ethnicity, awareness among the patients, social stigma and hesitancy to show to the doctors, ignorance and lack of education and health facilities. The mean age of patients was 52.84 years. The study shows it is more common in postmenopausal age group due to estrogen deficiency and its complications.1, 2

There is significant association with the parity.89.3% of women had 2 or more children. 22.8% of women were grand multipara. Hence, multiple pregnancy and delivery can be attributed as a predisposing factor for symptomatic uterovaginal prolapse.3, 4 There is significant association between number of vaginal deliveries, duration of labour, vaginal tear and sphincter damage in previous childbirths.4, 5, 6 The process of aging and resultant estrogen deficiency causes loss of collagen and weakness of fascia and connective tissue which results in uterine prolapse.7

Regarding the occupation, 28.6% were labourers, 33.4% were farmers and 17.9% were housewives. 62% of the patients were farmers and labourers, involved in heavy and strenuous physical activities.8

The major determinants for uterovaginal prolapse is postmenopausal state (74.7%) and multiparity (84.4%). The chronic intraabdominal pressure contributed to 80%of cases. The study showed excessive stretching and tearing during multiple deliveries attributed to pelvic organ prolapse. Also, postmenopausal state which leads to estrogen deficiency and weakness of fascia and connective tissue contributed to the uterovaginal prolapse.9 70% of women had more the two risk factors.

97% of patients were symptomatic to mass per vagina. The bulging or mass protruding out of vagina was a predominant presenting symptom.10

The other symptoms were obstructive symptoms like urinary symptoms like hesitancy, incomplete voiding, digital reposition before voiding. The impaired sexual function was present in 4.8% of cases. Some patients were worried about social stigma and were hesitant to share the sexual history.11

The posterior compartment defects caused pressure symptoms and constipation. The treatment modalities available are both surgical and non-surgical. About 22.8% were treated nonsurgically and 77.1% were treated surgically in our setup. The women with anaemia, postpartum period, pregnancy, elderly women with comorbidities were offered vaginal pessary. The patients who had first degree prolapse and minimal cystocele were taught kegels exercise. 69.9% of patients underwent vaginal hysterectomy with pelvic floor repair and 7.2% underwent vaginal hysterectomy. This treatment is in accordance to some studies.12, 13

The vaginal hysterectomy with pelvic floor repair still remains treatment of choice for patient with prolapse who have completed family.14, 15

The limitation with the study could be some data may not have been retrieved as it is a retrospective study. The elaborate history on socioeconomic factors, educational status, access to health care, cultural factors may not have been taken in the history.

Source of Funding

None.

Conflict of Interest

None.