Prolapse means shifting down of a body part from its normal position. It can be prolapse of a heart valve, of the rectum or uterus. Prolapse of the uterus or womb in a woman leads to much suffering. As such it is in the domain of gynaecologists to treat it but it causes so many medical problems that internists like me cannot ignore it. Women need to be educated about it from a young age so that they can prevent its development. The uterus is supported in the pelvis by ligaments, muscles and tissues. Any weakness in these supporting structures can lead to its prolapse. Multiple pregnancies and deliveries is the most common cause for prolapse of the uterus. Difficult or prolonged labour is yet another common cause. Chronic constipation, prolonged cough, lifting heavy weights can also precipitate prolapse of the uterus. Prolapsed uterus can also be due to increase in pressure in the abdomen as with obesity or tumours. Tone of the supporting structures is reduced due to advancing age. Deficiency of estrogen aggravates this problem. Therefore middle aged and elderly women are more prone to prolapse of uterus as compared to younger women. When uterus begins to prolapse, in the early stages it comes out only during straining. A woman has sensation of something coming out and it goes inside spontaneously. As the problem progresses, it comes out but can be pushed back manually. In advanced cases, uterus remains outside all the time. Because of the uterus remaining out, it becomes difficult for a woman to walk properly or enjoy sex. Uterus becomes prone to trauma which leads to formation of ulcer, wounds, recurrent infection and inflammation. The affected lady suffers from chronic pain, itching and discharge from the genital parts. If the anterior part of uterus prolapses, it causes pressure on the urinary bladder. This may cause difficulty in passing urine and prevents incomplete evacuation of the bladder. Result is recurrent infection of the urinary bladder and its associated problems. At times the affected individual may develop incontinence, i.e. the voluntary control over urination is lost and urine is passed out spontaneously. Similarly prolapse of the posterior part of uterus can lead to faecal incontinence or constipation. Due to the recurrent infections and pressure of prolapsed uterus in the pelvis, one develops chronic back pain. Thus due to many causes, a prolapsed uterus causes much pain and embarrassment to the affected person. Limited and planned pregnancies are useful in preventing prolapse of the uterus in an individual woman. Women from rural areas should be motivated to go to hospitals for delivery. Proper supervision and management of labour can prevent prolonged labour and birth trauma which are common causes of prolapsed uterus. HRT(hormone replacement therapy) around menopause is said to have some beneficial effect in preventing prolapse of uterus. Women in general, particularly middle aged women need to avoid chronic cough or constipation and also lifting heavy weights. If a lady has already developed prolapse, she can prevent its progression. She should avoid standing continuously for a long time. While sitting, she should spread her legs in front on a chair or stool instead of letting them dangle below. These measures help the uterus to be with some support and prevent aggravation of prolapse. Exercises of the perineal muscles are very useful in preventing progress of prolapse . One can pretend that she is in a place where it is not possible to go for urination. Then hold the pelvic muscles tight as in holding a full bladder, for few minutes. Another useful exercise is to squeeze the perineal muscles tight for few seconds to minutes and then relax them. These exercises can be started for a short time and then number and duration can be increased. Women who have an advanced prolapsed uterus should use a pessary to keep the uterus manually inside. A thick cotton cloth folded and used as a diaper to support the uterus from below, serves as a makeshift pessary. Definitive treatment of prolapse uterus is a corrective surgery or removal of the uterus. But there are the risks associated with major surgery. Therefore prolapse is better prevented than operated. E-mail-rachna212002@yahoo.co.uk
