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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 449-453  

Women's experiences and perception of symptomatic pelvis organ prolapse: A Cross sectional study from Uttarakhand, India


Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission29-Aug-2020
Date of Decision27-Oct-2020
Date of Acceptance01-Dec-2020
Date of Web Publication30-Jan-2021

Correspondence Address:
Dr. Rajlaxmi Mundhra
Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_1763_20

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  Abstract 


Background: Pelvic Organ Prolapse (POP) negatively affects the health of a woman in terms of physical, social and emotional wellbeing. Objective: The aim of this study was to elucidate the experience of living with prolapse and its impact on daily life. Methods: Women undergoing surgery for pelvic organ prolapse were interviewed to evaluate their sociodemographic profile with subsequent impact on their daily life. Results: Among the 45 cases with POP, 80% belonged to rural areas. Mean age of study group was 53.68 years. Young age at marriage (mean age 17.31), early first child birth (mean age being 20.5 years) and increased parity (86.66% had parity 3 and above) with majority of children born at home under supervision of untrained dais (77.78%) could probably attribute to their prolapse. Approximately 51% thought that prolapse occurs as a result of hard manual work and 64% cases considered it non treatable. POP was associated with poor quality of life in terms of physical, social and sexual life. Decreased sexual frequency was seen in 86.67% cases. 50% cases reported bladder problems. Sense of incomplete evacuation was seen in nearly 35% and constipation was reported by 37%. Conclusion: Though there exists a social stigma associated with pelvic organ prolapse, this study showed that in majority, it was the woman herself who delayed medical help. Health care providers should take initiative in educating women regarding prolapse and to make them aware that it is a treatable condition which can improve their quality of life.

Keywords: Pelvic organ prolapse, quality of life, sexual function


How to cite this article:
Prateek S, Mundhra R, Bahadur A, Kunwar K, Jha P, Chawla L. Women's experiences and perception of symptomatic pelvis organ prolapse: A Cross sectional study from Uttarakhand, India. J Family Med Prim Care 2021;10:449-53

How to cite this URL:
Prateek S, Mundhra R, Bahadur A, Kunwar K, Jha P, Chawla L. Women's experiences and perception of symptomatic pelvis organ prolapse: A Cross sectional study from Uttarakhand, India. J Family Med Prim Care [serial online] 2021 [cited 2021 Feb 25];10:449-53. Available from: https://www.jfmpc.com/text.asp?2021/10/1/449/307957




  Introduction Top


Symptomatic pelvic organ prolapse (POP) involve many aspects of a woman's life including social, sexual, domestic, psychosocial and occupational.[1],[2] It occurs due to weakened muscles and ligaments of pelvic floor. The causes are multifactorial. Pregnancy and childbirth constitute important risk factors for prolapse, risk increasing with increased number of vaginal deliveries.[3],[4] The incidence may be higher in limited resource settings owing to high fertility rates, young age at deliveries, limited access to health care, and hard manual work.[5],[6] Clinical presentation varies with many women being asymptomatic. Woman often report their complaints as something coming out per vaginum, sensation of bulge or heaviness in perineum, pelvic pressure, difficulty in urination or defecation, urinary or faecal incontinence and sexual dysfunction.[7] Treatment often depends on stage and severity of condition. Simple lifestyle measures like weight loss and use of pelvic floor muscle training is useful in some whereas many require surgery. Pelvic organ prolapse has negative impact on a woman's sense of body image and sexual function.[8] Despite being symptomatic for long duration, women are often reluctant to seek help for this known disease probably attributed to their misinformation, potential embarrassment, cultural and personal silence concerning this condition.[9] Unlike other diseases, pelvic organ prolapse is one disease which has little public promotion. There exists a gap between how women understand their problem and how they cope up with its consequences. The rationale of our study was lack of good data on POP from this region. Women in rural areas often get neglected in terms of health care facilities. Being a hidden disease, women often tend to neglect their symptoms and seek help only when symptom worsens. With this study, we planned to identify the possible causes for delayed medical help and impact of POP on their quality of life which would help us in formulating strategies in providing appropriate services for treatment.

The present study aimed to evaluate how women with symptomatic pelvic organ prolapse experience and its subsequent impact on their day to day life.


  Materials and Methods Top


Setting and study design

This was a hospital based cross sectional study carried out in Gynaecology outpatient department of a tertiary care centre from Uttarakhand, India between June 2019 to November 2019. The study was approved by Institutional Ethics Committee.

Subjects

Women presenting with complaints of something coming out per vaginum or a bulge in the vaginal area and those who demonstrated prolapse of stage more than or equal to II according to pelvic organ prolapse quantification system at their first visit were asked to participate in the study. Once they agreed to participate in the study, they were asked to answer a set of self-made questionnaires.

Study variables

Socio-demographic profile of women (age, religion, marital status, educational status, occupation), age at marriage, age at first child birth, number of children, duration of symptoms, distance from health facility and reasons for delay in seeking health care assistance were noted. In addition, the questionnaire included the impact of prolapse on lifestyle (physical limitations like unable to perform daily chores like cleaning, going out; emotional disturbances like feeling bad about oneself, feeling alone and depressed, being ignored by family due to bad smell, interference with sexual functions and disturbed relationship with husband, impact on bladder and bowel habits)


  Results Top


In-depth interviews were conducted on forty-five women with symptomatic prolapse >=stageII.

[Table 1] shows the demographic profile of pelvic organ prolapse cases. The Mean age of the study group was 53.68 years. Majority belonged to hilly, rural areas and had limited access to health services. Young age at marriage (mean age 17.31) with early first child birth (mean age being 20.5 years) and increased parity (86.66% had parity 3 and above) with majority of children born at home under supervision of untrained dais (77.78%) could probably attribute to their prolapse. Uttarakhand comprises both hilly and plain areas and as we have seen that most cases were from hilly areas, women were used to hard manual labour. They were the ones carrying heavy weights like buckets of water, bundles of grass and wood for household purposes. These were part of their daily activities. Almost all of our subjects were involved in hard labour.
Table 1: Sociodemographic profile

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The mean length of delay in seeking medical help was variable with a range of 1-40 years. Descriptively, the main reason for delay in seeking help was embarrassment and loss of social value in front of family (56%); lack of transportation and distant health facility (24%); financial constraints (15%) ; and lack of family support (5%). In spite of long history of prolapse, around 33% had not even informed their family members (except husband). Regarding awareness of the causes of prolapse, approximately 51% thought that prolapse occurs as a result of hard manual work, 44% attributed it to their increased number of children and 5% considered it as a curse of God. Only 36% were aware of the fact that prolapse is treatable and rest considered it to be non-treatable [Table 2].
Table 2: Reasons for delay in seeking medical help and awareness of causes of prolapse

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[Table 3] depicts the impact of prolapse on daily activities. Bladder function and sexual function were the most affected ones.

As evident from [Table 4], it is clear that prolapse also affects sexual life. Frequency was decreased in nearly 86.67% cases. Approximately 88% cases reported pain during intercourse.
Table 3: Impact of prolapse on daily life

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Table 4: Impact on sexual function

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  Discussion Top


POP affects several aspects of a women's life. Despite being a common and treatable condition, a significant proportion of women still lack a clear understanding of this condition. In low resource settings, women are still dependent on their husband for financial and emotional help. In this study, women were mostly from hilly areas. 80% of the study group belonged to rural areas and approximately 87% were illiterate. They were the ones who were solely responsible for all household chores including childcare and even working in fields and lifting heavy weights on their back. All these works are an integral part of their life. Many of them continued all their work as long as they could. In fact, one of the study subjects continued with her prolapse for nearly 40 years and attended health facility only when her prolapse stated bleeding with a foul-smelling decubitus ulcer. Women usually informed their children only when their condition got worsened in terms of bleeding decubitus ulcer, foul smelling discharge, urinary complaints or difficulty in defecation.

Adefris et al. reported that the mean length of delay for POP was 85.8 months with financial constraints and fear of disclosure as the main reasons for delayed medical help.[10] There exists a social stigma with pelvic organ prolapse making women feel embarrassed. As a result, they tend to hide their problems from family and friends which further aggravates their problem. In this study, the length of delay in attending health facility ranged from 1-40 years which was very wide. In around 56% cases, it was the women herself who didn't seek early treatment, main concern being embarrassment. In a recent population-based study from rural Pakistan, it was noted that despite 50% women reporting that prolapse greatly affected their everyday routine activities, only 21.3% women consulted a doctor for their condition. Nearly 50% of their study cohort had a duration of POP for more than 5 years.[11]

Illiteracy and lack of awareness about prolapse is also a major concern as nearly 64% women in this study considered prolapse as non-treatable disease.

In terms of bowel function, previous studies have demonstrated that constipation, difficult defecation, and faecal incontinence occur commonly in women with Lower urinary tract syndromes.[12] In our study nearly 50% cases reported bladder problems. Sense of incomplete evacuation was seen in nearly 35% and constipation was reported by 37%.

Prolapse affected some patient's self-esteem negatively. Women perceptions about her own body changes with prolapse. Lowder et al. reported that women with prolapse of stage 2 and above feels isolated and less attractive, often changed sexual intimacy practices or starts avoiding sexual intimacy altogether.[2] In fact, in this study, 84.44% revealed that they had started to feel bad about their body as a result of prolapse. This even resulted in their depressive and irritable mood. In fact, prolapse greatly affected women's personal activities like cleaning floor or doing other household chores resulting in loss of interest and distraction in daily activities and thereby making them self- conscious. Prolapse resulted in limitation of women to travel outside their house in nearly 30% cases and around 11% used tampons while travelling to avoid embarrassments.

Sexuality depends on several factors like body image, sexual perception, partner's desire and competency and quality of relationship with partner.[13] Pelvic organ prolapse is known to affect issues of sexuality in terms of desire, orgasm ability and arousal.[14],[15] This study also focussed on sexual life of women with POP. Despite prolapse, women continued with their sexual function as long as they managed. This implies that prolapse per se was not responsible for sexual inactivity. Answers like – I used to push my uterus inside to have sex was quite common (77.77%). Reasons for stopping sexual activity were mainly- pain during intercourse (88%). Novi et al. reported that women with pelvic organ prolapse have a significant negative impact on sexual function as compared to those without prolapse uterus.[15]

Abhyankar et al.[16] in their qualitative study of women's experiences of receiving care for pelvic organ prolapse reported that prolapse treatment services need to be more person centric. Being a hidden disease, women usually ignore early symptoms and hence to break this barrier of embarrassment and stigma, there is a need for increasing education and awareness among general public and also health professionals regarding symptomatology and various treatment options (including conservative modes and pelvic floor muscle training). The goal of treatment for evaluating a woman with pelvic organ prolapse need to focus on her daily life for better understanding her concerns.

This study was limited by its small sample size and lack of any control group. A major strength of this study was that it included only symptomatic women with POP. Information regarding reasons for delayed medical consultation remains scare for women with prolapse and with this study, we also focussed on this aspect.

Conclusion-Fear of disclosure due to embarrassment and lack of transportation with distant health facility remains an important factor contributing to delay in seeking treatment for POP. Being a hidden disease, women often tend to ignore its symptoms. Prolapse is associated with varying degrees of bladder, bowel and sexual problems. There is high prevalence of problems related to bladder function and emotional disturbances in women with POP. Health care providers should take initiatives in educating women regarding prolapse and to make them aware that it is a treatable condition which can improve their quality of life. We suggest incorporating assessment of quality of life and sexual functioning as an integral part in treating women with advanced stage prolapse.

Key points

  1. Symptomatic pelvic organ prolapse remains a common genitourinary condition affecting elderly females
  2. Being a hidden disease and also due to lack of awareness and embarrassment, women often neglect their symptoms and seek help only when situation worsens
  3. Prolapse affects her quality of life involving bladder, bowel and sexual function
  4. We suggest a multidisciplinary team involvement in assessing QoL and sexual function be incorporated as an essential component of POP treatment.


Financial support and sponsorship

No funding was required for this study.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rogers GR, Villarreal A, Kammerer-Doak D, Qualls C. Sexual function in women with and without urinary incontinence and/or pelvic organ prolapse. Int Urogynecol J 2001;12:361-5.  Back to cited text no. 1
    
2.
Lowder JL, Ghetti C, Nikolajski C, Oliphant SS, Zyczynski HM. Body image perceptions in women with pelvic organ prolapse: A qualitative study. Am J Obstet Gynecol 2011;204:441.e1–5.  Back to cited text no. 2
    
3.
Rizk DE. Minimizing the risk of childbirth-induced pelvic floor dysfunctions in the developing world: “Preventive” urogynecology. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:615-7.  Back to cited text no. 3
    
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Rortveit G, Hannestad YS. Association between mode of delivery and pelvic floor dysfunction. Tidsskr Nor Legeforen 2014;134:1848–52.  Back to cited text no. 4
    
5.
Megabiaw B, Adefris M, Rortveit G, Degu G, Muleta M, Blystad A, et al. Pelvic floor disorders among women in Dabat district, Northwest Ethiopia: A pilot study. Int Urogynecol J 2013;24:1135–43.  Back to cited text no. 5
    
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Walker GJ, Gunasekera P. Pelvic organ prolapse and incontinence in developing countries: Review of prevalence and risk factors. Int Urogynecol J 2011;22:127–35.  Back to cited text no. 6
    
7.
Machin SE, Mukhopadhyay S. Pelvic organ prolapse: Review of the aetiology, presentation, diagnosis and management. Menopause Int 2011;17:132–6.  Back to cited text no. 7
    
8.
Zielinski R, Low LK, Tumbarello J, Miller JM. Body image and sexuality in women with pelvic organ prolapse. Urol Nurs 2009;29:239-46.  Back to cited text no. 8
    
9.
Sasso KM. The Colpexin Sphere: A new conservative management option for pelvic organ prolapse. Urol Nurs 2006;26:433–40.  Back to cited text no. 9
    
10.
Adefris M, Abebe SM, Terefe K, Gelagay AA, Adigo A, Amare S, et al. Reasons for delay in decision making and reaching health facility among obstetric fistula and pelvic organ prolapse patients in Gondar University hospital, Northwest Ethiopia. BMC Womens Health 2017;17:64.  Back to cited text no. 10
    
11.
Jokhio AH, Rizvi RM, MacArthur C. Prevalence of pelvic organ prolapse in women, associated factors and impact on quality of life in rural Pakistan: Population-based study. BMC Womens Health 2020;20:82.  Back to cited text no. 11
    
12.
Jelovsek JE, Barber MD, Paraiso MFR, Walters MD. Functional bowel and anorectal disorders in patients with pelvic organ prolapse and incontinence. Am J Obstet Gynecol 2005;193:2105–11.  Back to cited text no. 12
    
13.
Brækken IH, Majida M, Ellström Engh M, Bo K. Can pelvic floor muscle training improve sexual function in women with pelvic organ prolapse? A randomized controlled trial. J Sex Med 2015;12:470–80.  Back to cited text no. 13
    
14.
Athanasiou S, Grigoriadis T, Chalabalaki A, Protopapas A, Antsaklis A. Pelvic organ prolapse contributes to sexual dysfunction: A cross-sectional study. Acta Obstet Gynecol Scand 2012;91:704–9.  Back to cited text no. 14
    
15.
Novi JM, Jeronis S, Morgan MA, Arya LA. Sexual function in women with pelvic organ prolapse compared to women without pelvic organ prolapse. J Urol 2005;173:1669–72.  Back to cited text no. 15
    
16.
Abhyankar P, Uny I, Semple K, Wane S, Hagen S, Wilkinson J, et al. Women's experiences of receiving care for pelvic organ prolapse: A qualitative study. BMC Womens Health 2019;19:45.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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