Dear Doctor,

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I am turning 40, and I have had three normal deliveries. Of late, I am getting the feeling of something coming down in my pelvis. I am also finding it difficult to control my urine. What’s wrong with me? Alice

Dear Alice,

What you are describing is referred to as pelvic organ prolapse. It is basically a weakness in the pelvic support system. The uterus (womb), which is normally positioned much higher in the pelvis, gets displaced downwards into the vaginal canal. Thus the feeling of ‘something coming down’. There is also inevitable weakening of the vaginal walls. Other pelvic organs, like the bladder and bowels may also prolapse into the vagina.

Several factors are at play in the causation of pelvic organ prolapse. For starters, pregnancy and vaginal childbirth cause enormous strain on the pelvic muscular support system. The muscles may not completely recover from birth trauma, and their tone weakens further with subsequent deliveries. In addition, some pelvic nerves may also get injured during delivery, further compromising pelvic support mechanisms. Nearly half of all women who have had children are affected by some degree of prolapse.

With advancing age, there is a gradual decline in the female hormones which play a significant role in pelvic organ function. Thus prolapse symptoms are more common towards the menopause. Some women may have an inherent muscular weakness, though this is rare. Lifestyle factors like obesity and smoking also predispose people to pelvic prolapse.

What you require is a gynaecological assessment. The degree of the prolapse will determine the treatment options. As you also have urinary symptoms, these too will be assessed. You may be experiencing what is referred to as stress urinary incontinence, which is associated with pelvic prolapse. Additional tests may also be advised.

Treatment options for pelvic prolapse range from simple measures to complex surgical procedures. Those with mild symptoms can be treated with supervised pelvic floor exercises. These may gradually improve pelvic muscular tone, relieving prolapse symptoms and improving bladder function. Pelvic support devices, called pessaries, may be inserted into the vagina to aid uterine support.

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Corrective surgical procedures may eventually be advised, both to correct the prolapse and cure the urinary incontinence. Surgery is best done by a gynaecologist specialized in pelvic organ disease, commonly referred to as a urogynaecologist.

Women can take preventive measures to limit pelvic organ prolapse. Regular pelvic floor exercises will maintain the pelvic muscular tone. Maintaining a healthy weight will limit the strain on the pelvic support systems. Avoid heavy lifting which strains the pelvic muscles. Eat a high fibre diet to help avoid straining when opening your bowels. For smokers, stopping smoking will reduce the risk of prolapse.

Some women will have a prolapse, but no symptoms at all. Others may feel embarrassed to seek help, but this should never be the case especially when quality of life is affected.

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