Surgical intervention
Gynaecologist in central or peripheral hospitals will cover diagnosis and treatment of POP cases and will do the surgery for POP. But access to surgical care in Nepal is inadequate.1,8,9To address this, the Nepalese government has been providing since 2008 free POPsurgery to women in mobile surgical camps. During the following 6 years, about 47.000 women have been benefited from this programme. Concerns about the quality of surgery and follow-up care in the camp setting have been addressed by developing and dissemination of a clinical protocol on management of POP in 2012 and a competence-based training manual on surgical management of POP in 2015.2 The prospect of surgery faces many barriers including costs, limited availability of trained providers, and lack of transportation to specialized hospitals. Temporary health camps have been established in some rural areas; however, these services are inadequate to address the burden of disease. Over 30% of cases among women aged 15 to 49 years in Nepal are estimated to warrant surgical intervention.1
Nepalese data
A longitudinal study on the impact of surgical treatment on Quality Of Life (QOL) was conducted in selected central and peripheral hospitals in Nepal where POPsurgery was being performed free of cost.3 A baseline study first measured the QOL domains (physical, psychological, social relationships and environment) among 252 women with advanced POP. Follow-up data were collected at six weeks and at three months after surgery. Among the 177 women that were available at six weeks post-surgery, 166 participated also in the three months post-surgery follow up. To evaluate QOL at baseline, 142 women with no history of POP were included as a comparison group.
The mean scores across QOL domains improved from baseline to 3 months after surgery. In the comparison group there was no improvement at all. The conclusion was that QOL progressively improved among women undergoing surgery for POP. In this study, the anatomical result of surgery was not an objective.
Vaginal hysterectomy and pelvic floor repair has been the preferred treatment for long time. Also in women > 60 years of age this procedure is safe.12
Because of high recurrence rate (vault prolapse) other procedures like sacrospinous fixation are also being carried out in recent years.7,11
Clinical patient follow-up to determine surgical outcome is essential in low-resource settings. A study, done in Bangladesh and Nepal have demonstrated that surgical up-skilling in vaginal hysterectomy, vaginal repair and introduction of SSF were necessary to achieve acceptable prolapse recurrence rates.10
WfWF data
In 2004 and 2006 74 women with POP from remote areas around Dhulikhel Hospital underwent POPsurgery.4 All these operated women were invited for a followup visit in their own VDC in 2007. Thirty-three patients attended the follow-up. Of them, 28 (85%) found the effect of the surgery as an improvement. A satisfactory anatomic outcome was found in 32 women. A remarkable finding was the reduction in physical labour after the surgical procedure. Problems related to the political situation, the illiteracy and the geographical constraints in the districts were the women lived, were obstacles in carrying out the follow-up.
In 2009 a micro level ethnographic study both exploratory and descriptive in nature was done.5 The study was conducted in the community where the women lived who have had POP surgery at Dhulikhel Hospital in the preceding years. The researchers used key informant interviews, observation and in-depth interviews techniques to generate information. The study was conducted to find out the effectiveness of POP surgery and to explore the impact and consequences of POP surgery. The effectiveness of the POP surgery has been found varying. Almost all women, especially the elder ones, have opined that the life situation in general has improved significantly in their community. Moreover, they have observed and experienced that suppression of women has declined remarkably in every sphere of their life. Along with the decline of joint family, younger women have found some improvement in their life situation in comparison to that of the women of preceding generation.
In 2011 another microlevel, qualitative study was done with the perspective to understand the sexuality of the women in post-surgery situation.6 The specific objectives of the proposed study are: 1. to assess the psycho-sexual impact of pelvic organ prolapse surgery on sexuality of the operated women; and 2. to analyse the coping strategies they have developed in the emerging situation. This study included women of different ages from Kabhre and Sindhupalchowk districts, who have had POP surgery. Two medical anthropologists interviewed altogether forty operated women. The operation of POP has mixed results: most of the women have been able to get rid of miseries whereas few others have not found themselves lucky enough to be in such path. Most of the women who got recovery from the ailment, after many years of waiting, a common practice in the research sites, valued their post-operative situation as a new life. It was because most of them had given up hope in their life, or they were living with much compromise in their life. The surgery has assisted them to alter their situation, helped them in resuming normality, including the sexual intercourse, in their life. For these fortunate women, their present situation is the stage of liberation from the past miseries. Not only the operated women, but alsotheir husbands also expected them to emerge as a new person, to be able to contribute in household works and resume sexual relation.
References
1. Non-surgical intervention for pelvic organ prolapse in rural Nepal: a prospective monitoring and evaluation study. Fitchett JR, Bhatta S, Sherpa TY, Malla BS, Fitchett EJA, Samen A, Kristensen S. Journal of the Royal Society of Medicine Open, 2015
2. Study on Selected Reproductive Health Morbidities among Women attending Reproductive Health Camps in Nepal. UNFPA Government of Nepal, Ministry of Health, Department of Health Services, 2016
3. Improved quality of life after surgery for pelvic organ prolapse in Nepalese women. Dhital R, Orsuka K, Poudel K, Yasuoka J, Dangal G, Jimba M. BMC Women’s Health 2013,13:22
4. Follow-up of prolapse surgery in rural Nepal.Schaaf JM, Dongol A, van der Leeuw-Harmsen, L. Int Urogyneccol J (2008) 19:851-855
5. A Study on Impact of Pelvic Organ Prolapse (POP) Surgery in Nepal. Dahal KB, 2009
6. Psycho-sexual Impact of Pelvic Organ Prolapse (POP) Surgery: A Medical Anthropological Research. Dahal KB, 2011
7. Outcome of sacrospinous ligament fixation of the vault during repair of pelvic organ prolapse. Dangal G, Poudel B, Shrestha R, Karki A, Pradhan HK, Bhattachan K, Bajracharya N. J Nepal Health Res Counc 2018 Jul-Sep;16(40):321-4
8. Surgical need in an ageing population: a cluster-based household survey in Nepal.Stewart BT, Wong E, Gupta S, Bastola S, Shrestha S, Kushner AL, Nwomeh BC.www.thelancet.com
9. Barriers to surgical care in Nepal. Van LoenhoutJAF, DelbisoTD, Gupta S, AmatyaK, KushnerAL, Cuesta JG,Guha-SapirD.BMC Health Services Research (2017) 17:72
10. Pelvic organ prolapse surgical training program in Bangladesh and Nepal improves objective patient outcomes.Hall B,Goh J,Islam M,Rawat A.Int Urogyn J (2021) 32:1031–1036
11. Clinical outcome of sacrospinous fixation followingpelvic organ prolapse surgery. Poudel S. NJOG. Jan-Jun. 2021;16(32):81-84
12. Assessment of safety of vaginal repair of pelvic organ prolapse in elderly in Birat Medical College Teaching Hospital, Nepal. Neupane B, Man Singh Karki G, Pokhrel H, Adhikari A. Journal of Nobel Medical College. Volume 10, Number 02, Issue 19, 2021, 20-25
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