Pregnancy and childbirth are the most common causes of pelvic organ prolapse (womb, bladder or bowel prolapsing or protruding through the vagina) and stress urinary incontinence. The good news is that this is a largely preventable problem. This is by means of the pelvic floor (Kegel’s) exercise, during pregnancy, after delivery and forever after that. Unfortunately, many pregnant women do not do this exercise regularly and some don’t do it at all!
Pelvic Organ Prolapse: Why It Is Common In Singapore
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From a national survey done by Dr Christopher Chong, it is estimated that more than 30% of women in Singapore have prolapse and incontinence.
It was also found that many of the sufferers were too embarrassed to talk about it, did not know that that was a problem, did not know where to seek treatment and did not know that we can prevent it and treat it easily.
- 50% of women who had delivered before have mild pelvic organ prolapse.
- 10% have moderate or severe prolapse.
- 50% of patients with prolapse have urinary incontinence and vice versa. They are linked as the pelvic floor muscles support the pelvic organs and the pelvic floor muscles are overstretched during pregnancy and traumatised during child-birth.
If the pelvic floor muscles are not protected via the kegel’s exercise or do not heal well from tears and trauma, prolapse and incontinence will occur.
Different Stages Of Pelvic Organ Prolapse
Pelvic organ prolapse can be divided into mild, moderate and severe degrees. When it is mild, the prolapse remains within the vagina. It is moderate if the prolapse is at the door of the vagina and it is severe when the prolapse is outside the vagina.
Once prolapse has occurred, it will not revert back to normal on its own – it can only get worse.
Kegel’s exercise can only prevent it from getting worse but will not cure it. It is important for us to diagnose the problem early and treat at the mild stage, and this can help to avoid progression to that requiring surgery. The same can be said of urinary incontinence.
An important part of my practice as a Urogynaecologist is to look out for such problems. This is via the “Prolapse and Incontinence Screening and Prevention Clinic.”
Screening helps us to identify the problem. In the Prevention Clinic, I teach the Kegel’s exercise( even to well patients ) in order to prevent prolapse and incontinence.
Sometimes, a computer test of the bladder (Urodynamic Studies) is needed to properly assess the problem.
How Do We Do Kegel Exercise?
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Imagine that you are at the shopping centre and your faeces are about to drop out, but there is no toilet around. You will squeeze or close your anus to prevent the faeces from coming out. By doing this, you are doing squeezing the pelvic floor muscles.
Alternatively, while passing urine halfway, stop your urine flow – you are squeezing the pelvic floor muscles. These analogies are just to help you to understand how to do the Kegel’s exercise but do not do it while passing urine or when you have faeces.
You do not need to set aside a time for the exercise – do it any time and as often as you can.
Lifetime Risk Of Pelvic Organ Prolapse
The lifetime risk of pelvic organ prolapse has been assessed to be 11%, with a recurrence rate of 30% for moderate to severe prolapses. Anterior compartment and apical vaginal prolapses are the most difficult to treat. Pelvic organ prolapse is a problem of the ageing population.
Singapore is the fastest ageing population in Asia. Life expectancy has gone up to 81 – 83 for women in Singapore. The incidence of pelvic organ prolapse, being associated more with the elderly, is thus expected to rise.
Mild prolapse is treated with Kegel’s exercise. If this can prevent further prolapse, nothing else needs to be done. Moderate and severe prolapses are usually surgically treated especially if the patient is fit and has a good quality of life. Unfit patients or patients who do not want surgery can be treated with vaginal ring pessaries to hold in the prolapse.
These rings have to be changed every 3 – 4 months and complications include bleeding and infections. The success of surgery for moderate prolapse is above 90% in good hands, but recurrence for severe prolapse is quoted to be at least 30%. Hence it is important to treat before a prolapse reaches the severe stage.
Surgical Treatment For Pelvic Organ Prolapse
Surgical treatment for pelvic organ prolapse is aimed at restoring anatomy and preserving functions, including sexual function. This can be done via the abdominal ( open or laparoscopic ) or vaginal route. Severe prolapses are challenging for doctors to treat as very few are trained in special techniques to prevent recurrent prolapses.
When pelvic organ prolapse is severe, the existing tissues of the patient are expected to be very weak.
Re-using these weak tissues for support is likely to result in a high recurrence rate. It is with this in mind that meshes are developed to try to reduce recurrence rates without compromising on restoring anatomy or function.
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There are many types of meshes developed, both synthetic and non-synthetic. Non-synthetic meshes such as Fasia Lata from autograft or allograft are difficult to come by and to harvest. Latest studies have ventured into injecting stem cells into meshes.
Synthetic meshes have the problems of rejection, infection and erosion. The advancement is then to find the best synthetic mesh to use. These meshes are classified into different grades, grade 1 being those with the least infection, rejection and erosion rates.
How To Reduce Complications
It is also important that we reduce complication rates other than the proper selection of the mesh. Gentamicin wash of the mesh and the operative site, and antibiotics during and after surgery have been used to reduce infection rates. The mesh should be laid loose. Vaginal skin should not be cut.
The use of a vaginal pack for a day after surgery should be considered. Oestrogens before and after surgery, when the wound has healed, especially in severely atrophic vaginal epithelium has helped me to prevent erosions.
The question is whether meshes should be used. In Singapore, meshes are not used as a first line of treatment – they are reserved for severe prolapses and recurrent prolapses.
Only Grade 1 meshes should be used. The success rate of the modified mesh Anterior Repair with prolene mesh, and more recently the Elevate Mesh procedure is about 94%, with low complication rates ( most commonly mesh erosion and voiding problems ).
Dr Christopher Chong’s series of Mesh Repair for Severe Bladder Prolapse achieved a short term success of 94.6%. This series won a prize in the Royal College of O&G Conference in Cairo in 2005 and has been published in a journal. A few western countries have taken the mesh off the market as they were faced with many complications.
One main reason was that surgeons who were not specially trained in this technique were performing the surgery and there was also the question of proper selection of patients for this surgery.
In Asia, where governance is exceptionally strict, only selected trained Urogynaecologists perform such surgeries. Hundreds of thousands of such mesh cases had been performed for more than 15 years with very good results and low complication rates. In Asia, it is still the technique of choice for selected cases. In Singapore, at present, only 2 Urogynaecologists are trained in this mesh repair technique.
Gone are the days when women should suffer pelvic organ prolapse in silence. We are working towards improving our success rates for severe prolapses, including using meshes for selected cases.
Patients need to be educated, and doctors to be vigilant to prevent pelvic organ prolapse, failing which, it is very important to seek treatment early for better success rates.
Dr Christopher Chong is a pioneer in Incontinence, Prolapse and Pelvic Reconstruction Surgery, being one of the first Urogynaecologist in Asia to perform such surgeries and has performed thousands of such surgeries to date.
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