SINGAPORE — For more than 30 years, mother-of-two Teo Kim Geok did the heavy lifting when it came to household chores and grocery shopping.

Her routine took a toll, but Mdm Teo was none the wiser until last year, when her pelvic floor gave way and her womb, bladder and rectum slipped out of their normal positions.

She experienced light bleeding and an obvious bulge at the opening of the vagina whenever she stood up.

But a group tour to Taiwan with her husband beckoned at the time and, not wanting to disrupt their plans, Mdm Teo, 60, kept mum about her discomfort and proceeded with the seven-day trip.

“Although it wasn’t painful, it was very uncomfortable. Each time I stood up or walked, a piece of flesh would protrude out. I was really worried that everything would simply fall out, and kept looking for a place to sit down during my trip,” Mdm Teo said candidly.

“I had never heard of pelvic organ prolapse but I suspected that something was wrong with my uterus.”

She sought treatment at the KK Women’s and Children’s Hospital (KKH) immediately after returning home.

Although it is one of the common conditions affecting women aged 45 to 75, doctors say public awareness of pelvic organ prolapse remains low. The urogynaecological condition occurs when the pelvic organs such as the uterus, bladder, urethra, rectum and vagina  fall out of their normal positions due to a weakened pelvic floor.

It is estimated that half of all women have mild prolapse (Stage 1) after the age of 30 and 10 per cent have its moderate to severe forms, said Associate Professor Han How Chuan, head and senior consultant of KKH’s department of urogynaecology.

The majority of the women – or about three in five – who sought treatment for the condition at KK Urogynaecology Centre were severe cases that are usually more complicated and difficult to treat.

The centre managed about 2,800 new cases of urogynaecological conditions annually in the last five years, and saw about 1,200 women with pelvic organ prolapse from 2012 to 2016.

Some of the most complex cases that Assoc Prof Han has seen involve patients with severe pelvic organ prolapse, who also suffer from other medical conditions such as a history of heart attack and stroke. This group of patients may not be suitable for surgery due to the risks of undergoing anaesthesia and may have to live with the condition.

“Some women wait a long time and by the time they seek treatment, the bulge (of tissue) is already outside (the vaginal opening). This isn’t something that will recover on its own over time,” said Assoc Prof Han, adding that early treatment is key to achieving good health outcomes.

Some women do not know treatment is available or where to seek treatment, said obstetrician and gynaecologist Lee Lih Charn. At her practice at Mount Elizabeth Novena Hospital, however, less than 10 per cent of patients show up when their condition has reached the late stage.

Although pelvic organ prolapse through the vagina affects only women, both women and men may encounter rectum prolapse through the anus, but such an occurrence is rarer, said Dr Lee.

A HEAVY SENSATION

There are usually no obvious symptoms of pelvic organ prolapse in the earliest stage, which can be detected during a Pap smear test. But some women may experience a heavy sensation that feels like “something is dropping out” of the vaginal opening, or have lower-back ache, said Assoc Prof Han.

Other symptoms include difficulty having sexual intercourse, passing urine or motion (in severe cases) and chronic vaginal discharge or bleeding that results from repeated injury to the prolapsed organ.

Menopause, pregnancy and vaginal births are risk factors for pelvic organ prolapse.

Conditions that increase the pressure in the abdominal cavity over long periods of time can also affect the pelvic floor, said Assoc Prof Han. They include chronic cough, constipation, obesity and the carrying of heavy loads or objects.

About 5 per cent of the patients he sees have never gone through pregnancy.

While uncommon, Assoc Prof Han has also seen younger women in their early 30s who experience pelvic organ prolapse after childbirth, due to pregnancy and delivery weakening the pelvic floor. Complicated deliveries requiring forceps or vacuum intervention can also raise their risk.

Pelvic floor exercises, or Kegel exercises, can lower the risk of prolapse, but not all women are aware of it.

In a recent KKH study involving 100 pregnant women in their third trimester, up to 40 per cent of them did not know that pelvic floor exercises during pregnancy could help prevent urogynaecological disorders like urinary incontinence after childbirth. About 35 per cent reported symptoms of pelvic floor disorders but none sought medical attention.

“Ideally, women should start daily pelvic floor exercises before and during their pregnancy. Like any muscle, it’ll get better if you keep training it,” said Assoc Prof Han, who cautioned against lifting heavy loads exceeding 8kg for prolonged periods of time.

Using a baby carrier, sling or haversack may help to distribute the weight of the load to other muscles around the shoulders, he said.

Other preventive measures include avoiding straining while passing urine, and having healthy bowel habits by drinking sufficient fluids and consuming enough fibre to prevent constipation.

COMPLICATIONS CAN BE SERIOUS

While the condition is not usually life-threatening, the more severe cases can affect patients’ quality of life due to the discomfort and pain.

Serious complications have been known to arise from pelvic organ prolapse. For instance, bladder prolapse can lead to recurrent urine infections, which can potentially progress to kidney infection or septicaemia (a potentially life-threatening blood infection), said Dr Lee.

A 2013 KKH study found that more than a fifth (22 per cent) of patients with severe pelvic organ prolapse suffer enlargement of the kidney due to a buildup of urine, said Assoc Prof Han. Three per cent had kidney failure, according to the study involving 121 patients.

Conservative and surgical treatments are available, but not every patient requires surgery. Patients with milder degrees of prolapse may consider using non-surgical treatment in the form of pelvic floor exercises, which can help slow down the progression of the prolapse although they cannot cure it.

Patients with more severe forms of the disorder, but who are not suitable for surgery or do not wish to undergo surgery, may consider having a device called vaginal pessary fitted to support the prolapsed organ, said Assoc Prof Han. One of its downsides is the need for regular follow-ups and changing of the pessary.

Several surgical options are available to manage pelvic organ prolapse. Mdm Teo, whose condition was considered moderate, chose to undergo surgery to remove her womb, repair her pelvic floor, as well as place a mesh attached to ligaments in the pelvic area to support the bladder.

At a follow-up doctor’s visit last month, she showed no signs of prolapse or any urinary symptoms.

Mdm Teo, whose sons are in their 30s, no longer dares to carry or lift heavy items. Urging women to seek help early, she said: “We women should learn to take care of ourselves. I now leave the heavy lifting to my husband.”

*KKH is organising a Chinese public forum on urogynaecological conditions on July 22 (Sunday), from 1.30pm to 4pm at the Training Centre, Women’s Tower, Level 1, KKH. It costs S$12 per participant and those interested may call 6394 3096/ 6394 1027 to register.

HOW TO DO PELVIC FLOOR EXERCISES

• Squeeze and lift the pelvic floor muscles and vagina. It should feel like you are trying to stop passing wind and urine at the same time.
• Do not hold your breath.
• Aim to do 10 long squeezes, holding each for 10 seconds, then relax the muscles for 10 seconds followed by 10 short squeezes.
• Aim to do these exercises thrice a day. There should be improvement in three to five months, after which the exercise can be performed once daily.

Source: KKH