And now, a word from our readers.

Women are pissed off—so to speak— about lack of discussion of a problem that is causing a lot of grief. A visitor to the Vermont Woman website writes:

I would like to encourage you to do an article on pelvic organ prolapse, a widespread problem for women, which includes but is not synonymous with incontinence. There is an appalling lack of comprehensive information addressing and integrating medical and non-medical options for women who want to remain healthy and active with POP. Continence is seen as the main issue; indeed, as we all know, incontinence products are becoming almost fashionable. But prolapse itself can have a significant impact not only on quality of a woman’s life but also on how she earns her living.There is a great deal of good to come for women from a thorough treatment of the topic in your periodical.

Right on, sister. Here we go. But first, some ancient history.

Early POP

Pelvic organ prolapse has been described since 2000 B. C.E. Hippocrates wrote of numerous nonsurgical treatments for the problem. In 98 C. E., Soranus of Rome first described surgical removal of a prolapsed uterus after it turned black.

The first successful vaginal hysterectomy for the cure of uterine prolapse was self-performed by a peasant woman named Faith Raworth in 1670. She was so distressed by her problem that she pulled down on her protruding cervix with one hand, and with the other, sliced off the prolapse with a knife. She survived the hemorrhage, but was debilitated by urinary incontinence afterward.

As surgical techniques evolved, from the early 1800s through the turn of the century, various operations were introduced, with varying degrees of success. We now have new restorative procedures that work with varying degrees of success.

It has been suggested that women’s fashion—the hoop skirt, the bustle—evolved in part to conceal the padding needed for managing the leakage associated with prolapse, before the days of disposable protective undergarments, whose widespread availability shows the extent of this problem.

Gentlewoman Refresher

If you’ve been following Dr. Trixie’s self-exam instructions, you know that your cervix—the bottom part of your uterus, with its variable-width opening that lets the menstrual blood and the baby out—normally lives at the top or back of your vagina. Pelvic organ prolapse happens when the ligaments holding the uterus and its neighbors in place stretch and sag or are damaged; and when the pelvic floor, the muscle layer Down There that you squeeze to stop from peeing, also loses its support function.

What happens then is the problem that our correspondent and about 3.3 million other women across the U. S. are dealing with, according to the National Institutes of Health. Because aging itself may be a factor, that number is predicted to be 4.9 million women by 2050.

Symptoms of pelvic organ prolapse include vaginal pressure or fullness; low back pain with standing; tissue bulging into or protruding from the vagina; painful or difficult intercourse; pelvic pain; bowel problems; and urinary leakage (the most common symptom) or, conversely, urinary retention. Some women with mild pelvic organ prolapse are asymptomatic. But one thing is certain: life is not the same once symptoms begin.

Why Oh Why

Pelvic organ prolapse may occur after pregnancy and childbirth. The ligaments holding the uterus and its neighbors—rectum and bladder—in place are sheets and strands of connective tissue. These may be stretched or torn by the weight and movement of pregnancy— and the more pregnancies, the greater the possibility of damage. The forces of labor and birth stress these supports further, particularly with the labor-boosting drug Pitocin, which increases the forces of contractions and can prolong the “pushing” stage.

Surgical birth—elective Cesarean, intended to avoid the trauma of vaginal birth—turns out not to be as preventive as people had hoped, though it’s now the number two most common inpatient surgery in the U. S. Instrument delivery—the use of forceps or vacuum extractors—and episiotomy—the slicing open of the vaginal opening at the moment of birth—are associated factors.

Medical conditions that increase intra abdominal pressure, such as obesity, pulmonary disease, smoking and constipation, can also contribute to pelvic organ prolapse. Genetic abnormalities of connective tissue and collagen have also been linked to prolapse, which may be the reason for generations of women in a family having (and hiding) this problem.

Hysterectomy or uterectomy, the surgical removal of the uterus, may itself be a risk; about 5 percent of women who’ve had one now have pelvic organ prolapse. In 2010, uterectomy was performed on about a half-million women in the U. S., making it one of the top ten most common surgical procedures.

After the uterus is removed, it’s the bladder that commonly prolapses, a condition called cystocele. If the rectum prolapses, it’s called rectocele. One in nine women will experience some sort of prolapse after a uterectomy; 10 percent of these women will need surgical repair.

Unmentionable

As our correspondent—a nurse—pointed out, this increasingly common problem gets zero publicity. Even The Wall Street Journal noticed this in a story last year:

“Many of these issues get little attention among women and some obstetricians for a complex web of reasons. A spokesman for the American Congress of Obstetricians and Gynecologists says there is a ‘tremendous amount of information that must be conveyed’ at a postpartum visit and that doctors refer patients to specialists when they find problems with the pelvic floor. ’”

Obstetricians send women to hospital-approved prenatal classes that may or may not teach women about preventive Kegel exercises (squeezing the muscles of the pelvic floor to strengthen them). But, as our correspondent points out, “Kegels often don’t help prolapse. These organs aren’t held together from the bottom; the problem starts up high. ”

Unlike breast cancer, whose awareness movement has fostered open discussion of the problem, pelvic organ prolapse is widely under acknowledged. “It’s very intimate. It’s hard to talk about. It’s embarrassing to describe, ” our correspondent says. There are no “pelvic organ prolapse” or even “incontinence” support groups listed in local papers or hospital sites, though there are several online groups.

Management Strategy

Reproductive and sexual history—the root of the problem—and quality of life are important in crafting a plan. Medical or surgical therapy may not be necessary in patients without symptoms. Nonmedical treatments may include posture work, exercises, physical therapy, weight management and protective pads or undergarments as needed.

The next step is trying out a pessary, an internal vaginal support device to help hold the uterus and bladder in place. These come in a variety of shapes and sizes; most fit in the palm of your hand. A certain amount of trial-and-error is involved—by doctor prescription, of course. Our correspondent protests: “If the first one doesn’t fit or work, you can’t just go into the drugstore and pick out another size.” She notes, “All practitioners, medical and nonmedical, are in this for their livelihood.”
If physical therapy and the pessary aren’t enough, several surgical approaches may be offered to reposition ligaments, reinforce vaginal walls and pelvic floor, or even to remove prolapsed protruding organs.

We are grateful to our R. N. correspondent for opening the floodgates of this important topic. She shared some of her favorite resources with us (see below). She says: “The best approach is a whole-woman approach. I send good wishes to my sisters in prolapse and incontinence and toast our courage and audacity in facing this problem we share.”

Katharine Hikel, MD, is a women’s health-care activist who lives in Hinesburg.