This blog post originates from a problem I've been reminded recently. The beautiful constellation that marks the ageing of women: urinary incontinence, constipation and hot flushes. I have remarked in my book review of Gavin Francis's 'Shapeshifters' that the post-menopausal woman, through the transformative process of menopause, finally has the right to choose her own path, unencumbered by her duties and obligations superimposed to her by nature. However, as I like to say to many of the females I've become intrinsically entangled with (chiefly my mother and sister, cough cough), with great power comes great responsibility. This responsibility extends to the management of personal health issues. As a woman ages, the emergence of the first signs of menopause suggest the onset of ageing. Women's reproductive ageing can be divided into 7 stages, with the final menstrual period driving a rift between the first five and the last two. Hormonal and menstrual cyclic changes occur gradually. As a woman has progressively high concentrations of FSH (follicle-stimulating hormone - a pituitary hormone which is related to sexual characteristics and the menstrual cycle) and amenorrhoea (other words for no period) for more than 12 months, we can safely say that the woman in question is post-menopausal. The process of menopausal transition is thereby complete. [1]
However, menopause as a key concept in ageing does not mean that it encapsulates the entire process. Ageing carries other implications. This is no less illustrated by a condition called 'genitourinary prolapse' (or uterovaginal prolapse, which is more anatomically-specific). Let's start with a diagram to clear the ground.
Diagram of different types of prolapses in the pelvis (diagram extracted from: http://www.holisticcorerestore.com/wp-content/uploads/2012/12/PROLAPSES_V2-643x450.jpg)
Genitourinary Prolapse is quite a mouthful - what does it mean? As you can see, there is an alternative term - uterovaginal prolapse. Might as well give a third alternative - pelvic organ prolapse. I know medical jargon can be confusing at times, but they still refer to the same pathology. Let's just examine the linguistic nuances between them. 'Genitourinary' is formed from two words: 'genital' and 'urinary'. It only refers to one's genitalia and urinary system, which encompasses structures including the urinary bladder and ureters. For 'uterovaginal', it is formed from 'uterus' and 'vagina' (adjectivised). It is a female, anatomy-specific term, referring to prolapse of only the uterus and vagina. 'Pelvic organ' refers to any organ found in the pelvis, including the urinary system, genitalia and the rectum. Prolapse, on the other hand, refers to the herniation of the organ. Herniation occurs when one or more organs have decided that they want to take control of their life and start making changes. They move downwards and cause chaos since, when they make those changes, the changes also affect the functioning of their neighbours. Progressive downward movement leads to the extrusion of the organ from the introitus (opening). As shown in the diagram, taking uterine prolapse for instance, the downward movement of the uterus leads to the compression of the rectum and urinary bladder. The former results in constipation, since the canal gets narrower and faeces have a harder time forcing through. The latter results in the reduction of capability to hold urine in the bladder for longer periods of time. There is therefore increased need to urinate. [2-3]
Degrees of Uterine Prolapse (extracted from https://beingpostiv.com/wp-content/uploads/2019/05/cover-3.jpg) [Procidentia is another term meaning 'prolapse', that the pelvic organ has moved away from its original position).
As I mentioned, pelvic organ prolapse as one of the features of ageing in women (men also have pelvic organ prolapse- however, since most of the male genitalia are extra-corporal - outside of the body, the most significant remain rectal and bladder prolapse*), is not unusual. The worldwide prevalence is estimated to be 9%, with the figure rising to nearly 20% in low-income countries. [4] This figure is disputed by a study published by the Lancet, stating that up to 40% of women over the age of 50 years report some form of prolapse, with surgical risk at 11% (due to urinary incontinence or prolapse) or 7% (prolapse alone as the cause). [5]
However, this brings us to a more important question: why does it happen? We have established that it occurs as a normal part of ageing and its manner of progression. But how can we correlate this with ageing? Why doesn't it happen earlier? To answer this, we have to talk about babies. Babies are heavy and every pregnancy is a strain to the female body. Every pregnancy starts with the implantation of the embryo to the uterine lining, with the gradual development of blood vessels. During pregnancy, the foetus grows within the womb, leeching off the mother like a blood-sucking parasite, only less bothersome. The most significant impact to the mother, however, occurs during labour - this is an immensely challenging process for mothers. Not just emotionally (since giving birth is one of the most agonising moments and probably one of extreme emotional turmoil), but physiologically. Pelvic floor muscle fibres are likely to be damaged or weakened in the process. Some of the damage can be traced back to the 10-month pregnancy, where the increase in intra-abdominal pressure leads to severe, chronic muscle strain. Every delivery up to five births increases the severity of prolapse by 10 to 20 per cent. Moreover, some mothers are subjected to the excruciating procedure of episiotomy, which involves making cuts along the perineum. This procedure used to be considered as best medical practice, due to purported benefits such as protection of foetal head from undue trauma and prevention of severe perineal laceration. However, this is dismissed by contemporary medicine, where severe long-term consequences such as rectal incontinence, urinary incontinence, sexual dysfunction and, most crucially, pelvic organ prolapse, are found. [6-10, 15] Episiotomy, owing to its nature, also leads to nerve damage. Precisely, we're referring to the pudendal nerve, which is a significant nerve in the pelvis. Among other things, it contributes to the motor function of the levator ani, a key muscle of the pelvic floor (the other one is coccygeus). If the pudendal nerve is affected, the muscle loses its tone. It becomes semi-relaxed and sags. Pelvic organs are therefore not as well-supported and this leads to prolapse. [11]
Diagram showing Pelvic Floor Muscles (namely Levator Ani and Coccygeus) (extracted from Ken Hub).
Ageing is also a significant risk factor of pelvic prolapse [6] - not just because of the fact that women are likely to have had babies (and more than one), it's also because of a huge array of factors. However, as with all things medicine, it is immensely hard for us to delineate the causes of ageing-related muscle weakness (also known as sarcopenia, in which 'sarco-' means muscle and '-penia' refers to the lack of something). Science has provided us with some risk factors which may explain this ageing-related decrease in muscle mass and/or function, including the change in lifestyle and diet. It is postulated that as women grow older, they are more likely to adopt a sedentary lifestyle, preferring staying at home over going out. Moreover, dietary changes involving the deficiency in Vitamin D and protein intake, may also contribute to decreasing muscle strength. After all, muscles account for 60% of our protein stores. [12]
Other factors which might contribute to pelvic organ prolapse in women include genetics and occupation. For the former, it is not related to ageing - sad to say, these women will have to endure the ramifications of genetic mutations from a young age. Connective tissue diseases, in virtue of reduced structural strength of ligamentous tissue, are implicated. In terms of occupation, as a factor pertinent to ageing (the more time you spend on an occupation, the greater its impact on your health), housewives are found to be at higher risk of the disease as compared to women who have a managerial/office job. [13-14] Another study seems to contradict this, stating that women working in a sitting-down position are at higher risk of the disease than those in a standing-up position. [6]
Now that we've established multiparous and maturing women (those who've given birth more than once) are at higher risk of pelvic organ prolapse, we arrive at the most important question: how can we fix it? The truth is, it cannot be fixed. The same applies to most things in medicine. Ageing is a natural process and striving to reverse the process, even by the newest manipulation using telomeres (yes, I've read multiple books about manipulating genes - I remain sceptical), is cheating fate. What we can do, though, is to train up our muscles and make sure it doesn't get any worse. After all, uncertainty is the only certainty in our lives. It entails change and transformation. We have to embrace these changes and adopt remedies to make sure they don't interfere with our established lifestyles and personal comfort that much. At the GP surgery, several things might be done to establish the severity of the prolapse. After a physical evaluation, urine testing will be done. A sample of your urine can be taken to exclude any kidney problems. Then, you might be required to wee. As you return to the consultation room, an ultrasound scan is done to assess the amount of urine that has 'not' been removed. In other words, the amount of urine retained in the bladder. Wait- aren't retention and incontinence polar concepts? Yes! Here, a clarification is needed. With the weakness of the pelvic floor, we are not sure what structures have prolapsed. This can be merely the uterus and vagina, or including the urinary bladder. We simply have no idea. By doing a post-voiding ultrasound scan, we can form a more complete picture as to what's going on. Other specialist investigations might include multichannel cystometry, in which the pressure within the bladder is assessed, both at the resting and voiding (urinating) states. It gives us more information regarding the type of urinary incontinence you have - stress incontinence that is associated with prolapse (caused by weakness in the pelvic floor and urethral sphincter which controls the outlet of urine from the urinary bladder), or urge incontinence, associated with a hyperactive bladder (correlated with the tone of the detrusor muscle - the muscle of the urinary bladder). [16-17]
There are several major things that can 'fix' pelvic organ prolapse. I've put the word fix in quotations because it's more about rehabilitation and reintegration into one's normal life. It's not really about rectifying the issue, since it is a normal, ageing process - after all. There are three main modalities - (a) Kegel exercises (pelvic floor exercises), (b) vaginal pessaries, and (c) surgery. In this article, we are focusing on the first two. The third one is applicable only to severe cases (thus third-line treatment), where the details are not really important. To start with, Kegel exercises are performed by first locating the pelvic muscles. They are the ones you use to stop the flow of urine (but don't do it too often - it hurts the bladder by subjecting it to too much pressure). Once you've identified them, sit down and relax. Try and squeeze the muscles gently, at your own accord. Hold the muscles for a few seconds at first, but try to hold them longer as you keep up the routine. It is advisable to perform such exercises for 10-15 times per day to ensure maximal performance. Remember, it's a routine, so it's crucial to do it daily! Results should be perceptible after a few months. However, there's one thing that must not be done - do not use your abdominal muscles when doing Kegel exercises. In other words, do not hold your breath or contract your abdomen (specifically the stomach when you're staring at the mirror and reflecting wistfully on your tummy). This actually increases the pressure of the abdomen, thus the strain of the pelvic floor muscles. Nothing but more damage results. [18-19] There are also different positions you can adopt to perform Kegel exercises, as illustrated in the diagram below.
Diagram illustrating the various positions one can adopt to perform Kegel exercises (extracted from: https://d39ziaow49lrgk.cloudfront.net/wp-content/uploads/2018/09/FB-The-11-Best-Kegel-Exercises-to-Strengthen-Your-Pelvic-Floor.jpg)
Vaginal pessaries are the first-line medical intervention. Kegel exercises in this case are still helpful, thus are still recommended, but the pessaries can help improve symptoms dramatically for patients with uterovaginal prolapse and urinary incontinence. A pessary is a device inserted up the vagina to the interface between the upper vagina, cervix and the lateral aspect of the bladder. This device is significant in maintaining the angle of the structures, reducing the risk of further downward movement. There are some side effects. The pessary remains a foreign object and can affect vaginal discharge odour and colour. Vaginal irritation may result and this requires the administration of acidic gel for relief. If there is any sign of bleeding or infection, urgent medical attention should be sought. Erosion of the vagina may be significant - this is related to the low oestrogen levels of post-menopausal women. Hormonal replacement therapy, administered intra-vaginally, should be able to mitigate relevant symptoms. As for slipping and misplacement, this depends on the expertise of the physician who has inserted the device. Normally, it shouldn't be an issue but, again, if there is any pain or bleeding, urgent medical attention should be sought. As a word of reassurance, as verified in a study, pessary use in post-menopausal women was continued in 80.8% of the entire cohort. Although the adverse consequence rate was at 31.6%, all of them were of minimal severity. Over 18% are related to the extrusion of the pessary, indicating problems in placement. [20-21] There are different types of pessaries available, with ring, doughnut and Gelhorn being the most common. [22] Ring and doughnut pessaries are used to treat mild and moderate cases of uterine prolapse, whereas Gelhorn, severe ones. Moreover, the ring pessary can be used for patients with concomitant, relatively debilitating, urinary incontinence. [20]
Diagram showing different types of vaginal pessaries (extracted from Mayo Clinic).
It is inherently human to be fearful of changes. Chaos in the pelvis is the least one expects in a blissful retirement life. However, if we change our perspective slightly, we can see that change is inevitable. As long as we adopt measures to reduce the negative impact of such changes, embracing them makes us appreciate the art of being human.
*Bladder prolapse is also known as cystocoele, whereas rectal prolapse, rectocoele.
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