But women of later generations do want to know more about – and have treatment to fix – pelvic organ prolapse and problems with incontinence, writes Tara Bahrampour
WHEN Carmel Price’s mother had an operation six years ago, Price helped her in the hospital but never really knew what the procedure was for. “I heard that she was having ‘reconstructive surgery’, like that her organs had moved around and they were putting them back where they belonged,” says Price, an American sociology professor.
Then Price had two babies of her own and suddenly she understood – and unlike many women in the past, she is talking about it.
“My bladder was bulging outside of my body, and if I was on my feet for any significant length of time, like if I was giving a three-hour lecture, or running or jumping, it would fall out even further.”
Her mother confirmed that it was the same thing she’d had.
Pelvic organ prolapse – when a woman’s bladder, uterus, or rectum falls down through the vaginal canal – affects millions of women, and becomes more likely the older they get. The average age women start to notice pelvic floor disorders, which include prolapse as well as urinary and faecal incontinence, is 56; by 80, half of all women have one or more symptoms. One in 10 end up in surgery.
And yet for years, few women talked about it. Gynaecologists often do not notice it in routine examinations, and many women have lived with the condition for years or even decades without realising anything could be done.
“This is a stigmatised condition,” says John DeLancey, a professor of gynaecology and urology who pioneered the use of MRIs and biomechanical analysis to diagnose pelvic floor damage. “It’s nothing people would talk about in polite company… And because nobody talks about it, everyone thinks they’re the only one.”
Recently, however, the conversation has opened up ever so slightly. Actress Kate Winslet has spoken publicly about her urinary incontinence since having babies.
In the US, the Food and Drug Administration (FDA) recently approved several versions of a pelvic floor muscle trainer, which provide feedback via a smartphone app. And new internal devices for incontinence and prolapse, which advocates say work better than earlier versions, are just hitting the US market.
“There has definitely been a sea change,” says Missy Lavender, founder and executive director of the Women’s Health Foundation. “We suddenly have people looking at women’s pelvic health, going, ‘Why don’t we do more?’ ”
References to pelvic organ prolapse appear in Egyptian hieroglyphics, medieval woodcuts and the Bible (which says it is a sign a wife has been unfaithful). Treatments throughout the ages included fumigating the lower abdomen with herbs; tying a woman upside-down to a ladder and shaking it; or menacing the wayward organ with a hot poker to frighten it into place.
In reality, pelvic floor prolapse is similar to a hernia, where the organs and vaginal walls are pushed out through an opening in the muscles of the pelvic floor. The condition is most common among women who have given birth.
In 10 to 15 percent of vaginal deliveries, the attachment of the muscles to the side walls tears, weakening the ability of the muscles to support the organs. Most women have no idea there is a problem until years later, when the muscles weaken with age and are no longer able to hold the organs in place.
“It’s not painful so much as uncomfortable,” DeLancey said. “…They feel this intense pressure. Often they say they have a backache.”
Pelvic floor problems run in families; other risk factors include obesity, routine heavy lifting, older maternal age at first birth and the use of forceps during delivery. It is also common after a hysterectomy.
Treatments include the use of a pessary, an internal support device that women can insert to hold the organs in place, or surgery using the patient’s own tissue or a mesh to lift and repair the fallen organs. For less advanced cases, physical therapy can help reduce symptoms.
Left untreated, the prolapse can grow to the size of a grapefruit or larger, and it can become painful if the organs pull on the ligaments that connect to the sacrum. It can become dangerous if the prolapse causes blockage in the tubes that attach kidney to bladder. And it can put older women at risk of reduced activity and social isolation.
“Urinary incontinence is one of the top reasons people end up in nursing homes – people don’t want to deal with the smell,” says Cheryl Iglesia, a professor of gynaecology and urology, noting that it is often the last straw for caregivers.
In the US, more pads are sold for incontinence than menstruation, Iglesia says. “It is a problem because we don’t have enough trained experts (in pelvic floor issues) to handle the ageing population.”
Even when it is not dangerous, it erodes enjoyment of life. Women stop exercising because physical activity tends to worsen the condition – especially running or jumping, or activities involving weights, sit-ups or squats. Some avoid intimacy, fearing that prolapse or incontinence will repel their partners.
New attention to the problem is driven in part by differing expectations of the baby boom generation as they age, Lavender says. “We’re the generation of ‘Our Bodies, Ourselves’. We grew up wanting to know more than our moms did.”
Information about pelvic floor disorders tends to spread by word of mouth. Urogynaecologists joke that when one member of a bridge club, mah jong group or neighbourhood coffee klatch comes for treatment, the other members are sure to follow. “I did a whole cul-de-sac, one woman in the cul-de-sac after the other,” Iglesia says.
Ethel Potts, 90, a potter, heard about the surgery from an acquaintance, and had an operation a few years ago.
“The surgery was like a miracle,” says Potts, whose uterine prolapse had worsened over eight years and was not alleviated by a pessary. “I didn’t have to worry if was I going to need more pads or have difficulties about if I went out of the house for a few hours.”
But even when women do speak up, they can hit a gender bias.
“My ob-gyn said ‘Oh, your body just changes after having a baby’ and it’s just life,” says Price, 38, who since her diagnosis has shifted her research to study the issue. “It felt really dismissive. It made it seem like my surgery was elective, as if I was having cosmetic surgery, In other words, if I was willing to be sedentary and just live with it, it wasn’t necessary.”
Pelvic floor physical therapy can help reduce the tension on the ligaments by strengthening the surrounding area, but the service can be hard to find. Julie Janes, a pelvic floor physical therapist, has patients who drive more than 160km to see her and she has colleagues whose patients drive much further.
“It’s a very new field in the US,” she says. “In France, women receive 10 sessions (with a physical therapist), starting in the hospital after every vaginal delivery. One of my old colleagues was coming from France and her biggest culture shock when she moved to the US were the aisles of (adult nappies) and incontinence products.”
An upcoming article in the Journal of Biomechanical Engineering proposes measuring a pregnant woman’s anatomy and the size of her baby’s head to predict the likelihood of an injury.
If such diagnostics had been available to Jeanne McMahon when she delivered a 4.1kg baby in 1988, she would have considered a caesarean section.
Her doctor used a suction device to deliver her son and afterwards told her to expect problems with a prolapsed uterus.
“They used to just say it was a ‘female problem’,” says McMahon, 58, who had two more children and lived with bladder and uterine prolapse for over 20 years. She finally got surgery in October, and has since been able to resume activities such as tennis and hiking.
“I actually feel younger, which is a nice side-effect,” she says. “Truly, I do wish I had done it sooner.” – The Washington Post