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ORIGINAL ARTICLE
Year : 2017  |  Volume : 20  |  Issue : 1  |  Page : 26-29

Pelvic organ prolapse managed at Usmanu Danfodiyo University Teaching Hospital, Sokoto: A 10-year review


Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication11-Apr-2017

Correspondence Address:
Abubakar Abubakar Panti
Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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DOI: 10.4103/1118-8561.204335

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  Abstract 


Background: Pelvic organ prolapse can have a detrimental effect on woman's quality of life by limiting physical, social, psychological, and sexual functions. We determined the prevalence, predisposing factors, and complications of pelvic organ prolapse at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. Materials and Methods: A retrospective study of the cases of pelvic organ prolapse managed at UDUTH, Sokoto, between January 1, 2003, and December 31, 2012. Results: The prevalence of pelvic organ prolapse was 1.4% of all gynecological admissions. The mean age of the patients was 45.3 ± 16.1 years. Majority of the patients, i.e., 63.7% were premenopausal. The grand multiparous women constituted 65.9% of the patients. The most common presenting symptom was a mass protruding through the vagina. The prolapsing organs included uterus 75.8%, bladder 12.1%, rectum 6.6%, and a combination of bladder and rectum 5.5%. The most common predisposing factor identified was unsupervised home delivery. Most of the patients had surgical intervention that included vaginal hysterectomy 59.3%, anterior colporrhaphy 7.7%, posterior colpoperineorrhaphy 6.6%, and combined anterior colporrhaphy and posterior colpoperineorrhaphy 5.5%. Hemorrhage was the most common intraoperative complication encountered in anemia 10.7% and wound infection 2.7% was most prevalent in the postoperative period. Conclusion: Multiparity, prolonged labor, and unsupervised deliveries were significant predisposing factors of pelvic organ prolapse antenatal care; skilled supervised deliveries and access to effective family planning methods will decrease the prevalence.

Keywords: Hysterectomy, Nigeria, pelvic organ prolapse, predisposing factors


How to cite this article:
Yakubu A, Panti AA, Ladan AA, Burodo AT, Hassan MA, Nasir S. Pelvic organ prolapse managed at Usmanu Danfodiyo University Teaching Hospital, Sokoto: A 10-year review. Sahel Med J 2017;20:26-9

How to cite this URL:
Yakubu A, Panti AA, Ladan AA, Burodo AT, Hassan MA, Nasir S. Pelvic organ prolapse managed at Usmanu Danfodiyo University Teaching Hospital, Sokoto: A 10-year review. Sahel Med J [serial online] 2017 [cited 2020 Dec 3];20:26-9. Available from: https://www.smjonline.org/text.asp?2017/20/1/26/204335




  Introduction Top


Prolapse is the protrusion of an organ or structure beyond its normal anatomical confines.[1],[2] Various other terms have also been used to describe this condition in the pelvis, and these include pelvic organ prolapse, genital prolapse, urogenital prolapse, uterine prolapse, uterovaginal prolapse, and vaginal prolapse.[1],[2],[3],[4] Vaginal prolapse is further classified depending on the anatomical location of the prolapsed structure into rectocele, cystocele, urethrocele, enterocele, and vaginal vault prolapse.[1],[2],[3],[4] It is due to defects in the supporting structures of the uterus and vagina, namely, uterosacral and cardinal ligaments complex and connective tissue of the urogenital membrane.[1],[2],[3],[4]

Pelvic organ prolapse is a very common problem and has a prevalence of 41–50% in women over the age of 40-year.[2] There is a lifetime risk of 7% of having an operation for prolapse in women.[2] The incidence of prolapse in African society is difficult to determine with accuracy as most of the women do not seek medical attention unless symptoms are pronounced and disturbing.[1] This is even more so in the rural areas.[1] In Nigeria, vaginal hysterectomy on account of uterovaginal prolapse accounted for 1.6% of each gynecological surgery in Gombe State and Abraka, Delta State,[5],[6] 2.3% in Ibadan in Oyo State,[7] 3.4% in Enugu State,[8] and 3.7% in Nnewi in Anambra State.[9] A rural community survey revealed a prevalence of uterovaginal prolapse of 14% in Gambia, West Africa.[10]

The development of pelvic organ prolapse is multifactorial.[1],[2],[3],[4],[5],[6],[10],[11] Pelvic floor defects may develop as a result of repeated pregnancies and childbirth and are caused by the stretching and tearing of the endopelvic fascia, levator ani muscles, and perineal body.[1],[2],[3],[4] Prolapse may also follow labor, in which the woman attempted to bear down before full cervical dilatation or during vacuum extraction in the first stage of labor.[11] When compared with vaginal delivery, cesarean section has a protective effect in the development of genital prolapse.[8] Parity is associated with increasing chance of prolapse.[1],[2],[3],[4],[8] Prolapse was seven times more common in women who had more than seven children compared to those who had one.[8] Following menopause, there is withdrawal of the ovarian hormones and this renders the pelvic tissues and ligaments atrophic and unable to perform their supportive roles.[8] Increase intra-abdominal pressure is another predisposing factor which may be from chronic cough, ascites, constipation, and intra-abdominal tumor.[1],[2],[3],[4] This study assessed the prevalence, predisposing factors, and complications of pelvic organ prolapse in Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria.


  Materials and Methods Top


A 10-year retrospective review of all cases of pelvic organ prolapse managed at the UDUTH, Sokoto, Nigeria, between January 1, 2003, and December 31, 2012.

Data were retrieved from gynecological ward admission register, case files, and theater records of the women who were treated for pelvic organ prolapse using a pro forma.

The information obtained included sociodemographic characteristics (age, parity, occupation, tribe, and menopausal status), presenting complaints, and duration of symptoms. Others were type and degrees of pelvic organ prolapse, management modality, and outcome. The data was analyzed using the statistical package for social sciences (SPSS) version 20 (IL, Chicago, USA) and the results expressed in simple percentages with frequency tables.


  Results Top


During the 10-year study period, there were a total of 7410 gynecological admissions, 105 of which were due to pelvic organ prolapse giving a prevalence of 1.4%. Only 91 (86.7%) patients were suitable for analysis.

The mean age at presentation was 45.3 ± 16.1 years [Table 1]. Majority of the patients, i.e., 96.7% were Muslims of Hausa/Fulani ethnic group. Most of the women 90.1% were homemakers and were not gainfully employed. About 63.7% were premenopausal while 36.3% were postmenopausal. The women of parity 5 and above (grand multiparous) constituted 65.9% of the patient [Table 1].
Table 1: Sociodemographic characteristics of patients

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The most common presenting symptom was “something protruding through the vagina” which was observed in all the patients. The mean duration of symptoms was 2.16 ± 0.9 years. The mean interval between the last pregnancy and presentation was 12.2 ± 11.7 years. The diagnosis of uterovaginal prolapse was made among 75.8% of the patients. The most common risk factor identified was unsupervised home delivery [Table 2]. Many of the women 48.3% had the 2nd-degree uterovaginal prolapse while 27.5% had the 3rd-degree uterovaginal prolapse. Isolated cases of cystocele were reported in 12.1% of women and rectocele in 6.6% and prolapse of anterior and posterior wall in 5.5%.
Table 2: Distribution of risk factors for prolapse in the study population

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Majority of the patients had surgical intervention that included vaginal hysterectomy 59.3%, anterior colporrhaphy 7.7%, posterior colpoperineorrhaphy 6.6%, and combined anterior colporrhaphy and posterior colpoperineorrhaphy 5.5%. The unit consultants performed the surgeries in 63.7% of cases while senior registrars carried out the rest.

Intraoperative hemorrhage was encountered in 10.7% of the patients who had surgery. Anemia 10.7% and wound infection 2.7% were the most frequent postoperative complications.


  Discussion Top


The prevalence of uterovaginal prolapse in this study is 1.4% which is closely related to the 1.6% reported from Gombe and Delta States in Nigeria [5],[6] but lower than the 2.3–3.7% prevalence from Ibadan in Oyo State, Enugu State, and Nnewi in Anambra State.[7],[8],[9] It is much lower than the rate of 14% from a previous population-based study in Gambia, West Africa.[10] It may be that the higher rate of admission of other gynecological conditions may have reduced the proportion contributed by genital prolapse to gynecological admissions in this hospital. Sixty-five percent of the women were grand multiparous, and this buttresses the fact that multiparity was a significant risk factor in the development of uterovaginal prolapse.[1],[2],[3],[4],[4],[6],[7],[8] Multiple unsupervised vaginal deliveries at home and prolonged labor were probably the main factors in these women. Unsupervised delivery with maternal bearing down efforts before full cervical dilatation weakens the genital supporting ligaments and pelvic fascia.[1],[2],[3],[4],[4],[6],[7],[8] The presence of genital prolapse in a young multipara was observed in this study even though it is not common among them. This may be due to the practice of early marriage in our environment.

Thirty-six percent of the women with pelvic organ prolapse were postmenopausal. This was not surprising because hypoestrogenism and genital atrophy are strong risk factors for genital prolapse. The supports of the pelvic organs are estrogen dependent.[1],[2],[3],[4],[4],[6],[7],[8],[9] However, majority of the women 63.7% were premenopausal which is similar to previous studies.[5],[6],[7],[8],[9],[10],[11] This may probably be due to the early age at marriage and quest for high parity in the study environment.

Many of the women (47.3%) had the 2nd-degree uterovaginal prolapse which is unlike the studies from Ilorin, Port Harcourt, and Ibadan where more than two-thirds of the patients had the 2nd-degree prolapse.[12],[13] More than one-third of the patients presented with the 3rd-degree prolapse in this study (27.5%), which may be due to poor health seeking behavior among the women in our environment.

Vaginal hysterectomy and pelvic floor repair were the main definitive treatment offered to the patients with uterovaginal prolapse in 59.3% of cases this study. This was lower than previous studies where almost all the patients had vaginal hysterectomy and pelvic floor repair.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] This may be due to the fact that in this study, some young patients presented with either anterior or posterior vaginal wall prolapse only. The patients that presented with only cystocele or rectocele had anterior colporrhaphy or posterior colpoperineorrhaphy in 19.8% of cases. However, vaginal hysterectomy may be indicated in young patients if there is a 3rd-degree prolapse, especially if they are of high parity, has been properly counseled, and hS achieved their desired family size. The unit consultants performed two-third of the operations in this study while at Jos,[11] all the operations were performed by consultants.[9],[11] This suggests that residents exposure and training on the performance of vaginal hysterectomy may be inadequate. This has potential implications on future gynecologist proficiency to perform this method of surgery that has documented advantages and better outcome for patients.

However, some of our patients were managed conservatively with vaginal pessaries, especially among the elderly women who could not withstand surgery and in those who were still desirous of childbirth 16.5%. This conservative mode of management was higher than that of previous studies probably because the Manchester operation was offered to some patients of childbearing age in the previous studies.[11],[12],[13],[14]

The immediate postoperative complications observed were anemia and wound sepsis. These were reported in similar studies carried out elsewhere.[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] There was only one case of vault prolapse reported as long-term postoperative complication after vaginal hysterectomy and pelvic floor repair. Other possible complications are stress incontinence, genital fistulae, apareunia, dyspareunia, shortened vagina length, and vaginal stenosis.[1],[2],[3],[4],[8],[9] None of these complications were present in the women studied.


  Conclusion Top


Uterovaginal prolapse affects women both in the childbearing and postmenopausal age groups. Multiparity, prolonged labor, and poorly supervised and unsupervised deliveries were identified predisposing factors. Efforts should be made toward public enlightenment, effective antenatal care, supervised hospital deliveries, limiting of family size, and efficient use of contraception.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Agboola A, editor. Urogenital prolapse and the displacement of the uterus. In: Textbook of Obstetrics and Gynaecology for Medical Students. 2nd ed. Ibadan: Heinemann Educational Books PLC; 2006. p. 33-88.  Back to cited text no. 1
    
2.
Monga A, Dobbs S, editors. Gynaecology by Ten Teachers. 19th ed. London: Book Power; 2011. p. 154-62.  Back to cited text no. 2
    
3.
Tarnay CM. Pelvic organ prolapse. In: Derneney AH, Nathan L, Goodwin TM, Laufer N, editors. Current Diagnosis and Treatment, Obstetrics and Gynaecology. 10th ed. New York: McGraw-Hill Medical Publishing Division; 2007. p. 720-34.  Back to cited text no. 3
    
4.
Smith AR. Utero-vaginal prolapse. In: Edmonds DK, editor. Dewhurst's Textbook of Obstetrics and Gynaecology. 8th ed. West Sussex, UK: John Wiley and Sons Ltd.; 2012. p. 627-34.  Back to cited text no. 4
    
5.
Bukar M, Audu MB, Yahaya UR. Hysterectomy for benign gynaecological conditions at Gombe, North Eastern Nigeria. Niger Med J 2010;51:35-8.  Back to cited text no. 5
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Onwhakpor EA, Omo-Aghoja LO, Akani CI, Feyi-Waboso P. Prevalence and determinant of utero-vaginal prolapse in Southern Nigeria. Niger Med J 2009;50:29-32.  Back to cited text no. 6
    
7.
Bello FA, Olayemi O, Odukogbe AA. An audit of vaginal hysterectomies at the University College Hospital, Ibadan. Niger J Med 2011;20:426-31.  Back to cited text no. 7
    
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Okeke TC, Ani VC, Ezenyeaku CC, Ikeako LC, Enwereji JO, Ekwuazi K. An audit of utero-vaginal prolapse in Enugu, Southeast Nigeria. Am J Clin Med Res 2013;1:23-5.  Back to cited text no. 8
    
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Obiechina NJ, Ugboaja JO, Onyegbule OA, Eleje GU. Vaginal hysterectomy in a Nigerian tertiary health facility. Niger J Med 2010;19:324-5.  Back to cited text no. 9
    
10.
Scherf C, Morison L, Fiander A, Ekpo G, Walraven G. Epidemiology of pelvic organ prolapse in rural Gambia, West Africa. Int J Obstet Gynaecol 2012;109:431-6.  Back to cited text no. 10
    
11.
Ocheke AN, Ekwempu CC, Musa J. Underutilization of vaginal hysterectomy and its impact on residency training. West Afr J Med 2009;28:323-6.  Back to cited text no. 11
    
12.
Ugboma HA, Okpani AO, Anya SE. Genital prolapse in Port Harcourt, Nigeria. Niger J Med 2004;13:124-9.  Back to cited text no. 12
    
13.
Osinusi BO, Adeleye JA. The symptomatology and clinical presentation of utero-vaginal prolapse in Ibadan. Niger Med J 1976;8:451-4.  Back to cited text no. 13
    
14.
Omokanye LO, Salaudeen AG, Balogun OR. Predisposing factors, clinical presentation and management of utero-vaginal prolapse: Experience from a teaching hospital in Nigeria. Niger J Health Sci 2012;12:12-5.  Back to cited text no. 14
    



 
 
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