WHAT IS PELVIC ORGAN PROLAPSE (POP)?
IMAGINE You are a mother of four in a rural village in Nepal. You are heading back home from the nearest water source, carrying a container filled with 20 liters of water, and you still have a kilometer to walk uphill. You suddenly feel a lump slipping and protruding out of your body. It is your uterus hanging between your thighs. You are in pain, but you won’t seek help. You hold your belly tightly, go behind a tree, and push your uterus back in. It keeps slipping out, and you keep pushing it back in as you walk home carrying your water container. Once you reach home, you continue with your chores, cooking, cleaning, feeding cows, and carrying more loads like wood and fodder for cattle throughout the day. You have secretly suffered from this painful and debilitating condition for years, but you won’t seek help because it is too embarrassing - it involves your private body parts. Your husband has threatened to find a new wife, and your mother-in-law thinks that you are lazy and not taking care of your hygiene. You don’t even want to ask if this condition is curable, as you are scared that people will find out and you will face isolation.
This is a terrifying situation for us to imagine even for a few seconds; however, this is a reality lived by hundreds of thousands of women in Nepal. The health condition is called uterine prolapse, and a significant number of Nepalese women have been suffering quietly for years, some for over twenty years.
Pelvic organ prolapse (POP) is a health condition where the bladder, uterus, vagina, small bowel, and/or rectum protrude through the vaginal canal or anus due to weak pelvic floor muscles. The prevalence of uterine prolapse, in particular, is disproportionately high in Nepal. A 2015 study by UNFPA estimates that 10 percent, or 600,000 Nepali women, suffer from uterine prolapse, and approximately 200,000 of them qualify for immediate surgery.
The Supreme Court of Nepal recognized for the first time in 2008 that the high incidence of uterine prolapse in Nepal may constitute a violation of human rights, including specifically women’s reproductive rights. (Prakash Mani Sharma v. Government of Nepal). Amnesty International in 2014 also urged the Government of Nepal to acknowledge the high prevalence of uterine prolapse in Nepal as a human rights issue as it is a consequence of widespread system gender discrimination.
Causes
Pelvic organ prolapse is caused by weak pelvic musculature from multiple childbirths, doing heavy lifting work shortly after childbirth, and diminished circulating estrogen. The Supreme Court of Nepal notes multiple risk factors for the unusually high rate of uterine prolapse in Nepal:
lack of proper nutrition
excessive smoking
lack of access to family planning
lack of awareness of reproductive rights
lack of knowledge about importance of care during and immediately after pregnancy
violence against women
UNFPA notes that early pregnancies are a significant contributing factor as well.
Consequences
This is a debilitating condition for many women as it causes pain, can make it difficult to walk, sit, lift objects and participate in daily activities. It is associated with urinary incontinence and difficulty having bowel movements. It is uncomfortable, and if chronically prolapsed, can form ulcers and have increased chance of infection.
There is also considerable social stigma and shame around the condition. Sometimes women are ostracized or described as “lazy” by families and communities when they are in too much pain due to the work expected of them. In 2013 UNFPA interviewed 357 women across 11 districts who had undergone surgery for uterine prolapse about their experience of the condition. 80% said that after developing the condition they “lost hope in life.” An average of 5% of respondents said that “their mother- in-law and family members started hating them” because of their uterine prolapse and this figure was as high as 23% in some districts.
Amnesty International's research also found that often women are unable or reluctant to seek healthcare, or to even talk about their pain because of “embarrassment” or because some of them felt that it was normal to have the condition.
Treatment Options
There are two primary treatment modalities.
Pessaries are the first treatment option, a rubber or silicone ring is fitted to the patient and inserted into the vagina to help support the pelvic organs. These are effective for first and second-degree prolapse. However, a lower quality pessary can be uncomfortable and many women refuse to use them.
Surgery is the other option, especially for women with 3rd and 4th degree prolapse. Surgery is conducted either to support the pelvic muscles or to remove the uterus entirely, with a common procedure called a hysterectomy.