In the latest instalment of our Clinical Conversations series, Dr Bitew Abebe, medical director and surgeon at Hamlin’s Bahir Dar Fistula Hospital, explains the causes and impacts of pelvic organ prolapse.
What is pelvic organ prolapse?
Pelvic organ prolapse is the downward displacement of the pelvic organ organs, such as the uterus or bladder, due to a weakening of the supporting structures, which are the pelvic muscles.
The most common cause is vaginal delivery. A prolapse can occur where a woman gives birth to a large baby, following multiple pregnancies, or when a woman only has a short duration between her pregnancies.
There are many other factors which also play a role in a woman’s likelihood of experiencing pelvic organ prolapse. Aging results in the reduced production of oestrogen which, in combination with the weakening of the pelvic supporting structures, increases the risk. A family history of pelvic organ prolapse can predispose a woman to experiencing the condition.
Obesity puts an increased pressure on the pelvic supporting structures while a chronic cough due to asthma, smoking, or bronchitis can increase the intra-abdominal pressure resulting in pelvic organ prolapse. Constipation, where a woman must bear down for extended periods during bowel movements, can add stress to the pelvic supporting structures.
Pelvic surgery, which can alter the ligaments, muscles and the fascia, can lead to pelvic organ prolapse. So too can nerve injuries or nerve disease which impacts the strength of the pelvic supporting structures.
What are the symptoms of pelvic organ prolapse?
We group them into four main types. The first is where women experience vaginal symptoms, with a sensation or there being a mass in the vaginal column. They may feel pressure and a dragging pain, which can be followed by spotting and vaginal discharge.
The second symptoms are urinary where a woman experiences greater frequency and urgency when urinating or has recurrent urinary tract infections. She may also struggle to urinate or have incomplete emptying.
The third group of symptoms relate to the bowels. This may result in constipation and incomplete movement.
The final symptom is when women experience discomfort during sexual contact. This usually occurs during stages three and four, which is referred to as advanced pelvic organ prolapse.

How do you diagnose pelvic organ prolapse?
First we look at a women’s history. Have they had previous surgery? Is there a family history of pelvic organ prolapse?
Next is an examination to assess the stage of the prolapse. We examine the pelvis in different positions and undertake an ultrasound, which can determine the position of the pelvic organs. We can also undertake an MRI to identify further detail about the supporting structures.
What are the stages of pelvic organ prolapse?
We use a pelvic organ prolapse quantification system, ranging from one to four. The zero stage is where the pelvic organs are at their normal position.
Stage one is where there is a prolapse, but it doesn’t extend beyond the vaginal walls.
Stage two is where the prolapse descends to the hymen, and the leading edge of the prolapse is within one centimetre above or below the hymen.
Stage three is a prolapse that extends beyond the hymen, above or below, by more than one centimetre.
Stage four is what we call a complete prolapse, where prolapse extends outside the vaginal canal.
Stages three and four are defined as advanced stage pelvic organ prolapse.
What impact does pelvic organ prolapse have on women?
Where the symptoms are severe, when a women has advanced pelvic organ prolapse, it has a negative impact on their quality of life.
First, their physical health. A woman cannot stand too much, cannot sit too much, cannot bend, cannot lift heavy objects. This makes it challenging for her to undertake daily activities.
It also impacts a woman’s psychological health. She will feel embarrassed and may experience anxiety and depression. Her social activity will reduce, and she may withdraw from any gatherings, such as a coffee gathering, a burial ceremony, or just attending the market or church.
Her sexual intimacy will also be affected. Because of the pain, bleeding, and discomfort, a woman may want to avoid any sexual contact.

What are the treatment options?
Prior to any surgery, we have a range of non-surgical options. This can include pelvic floor or Kegel exercises, where a woman is asked to hold urine and not let any gas escape and, by doing these exercises, she can train her muscles.
Lifestyle modifications may also be adopted such as a change to diet. This means mainly eating fibrous foods, drinking plenty of water, and eating only moderate amounts. Moderate exercise such as walking, but not lifting or carrying, may also be beneficial.
Another non-surgical treatment option is the use of pessaries. These are not in common use in Ethiopia but during my research but I was able to access them from the United States. Pessaries are generally divided into supporting pessaries and space occupying pessaries.
One of the supporting pessaries we use are ring pessaries, which support the pelvic organs in their normal position. We show women how to insert the pessary so they can do it on a daily basis. It can be removed at night when they’re having sexual contact. The pessary can be easily cleaned with soap and is an important treatment option. We need more available in this country.
The fourth non-surgical option is a physiotherapy focusing on the pelvic floor muscles.
In terms of surgery, we use open surgery in Ethiopia. For pelvic organ prolapse, there are two options. The first is reconstructive surgery, to preserve the uterus for women who want to have another child. The second is obliterative surgery for older women or those with other health issues, such as advanced heart or kidney disease. This involves removing the uterus or closing the vaginal canal.
Restoring women to health
All six Hamlin Hospitals provide advanced pelvic organ prolapse surgery to women. Thank to the generosity of our supporters, this is available free of charge.
For women like Selenat, surgery has been life-changing. Selenat endured her condition for over two decades before finally being cured. “I never thought that I could get cured. Thanks to everyone here I am now a free woman ready to face life challenges by myself. I wish I had known you earlier but still feel so happy and I am ready to begin life again. Thank you.”