When pelvic organs bulge out

The medical internship period remains one of the most exhilarating moments in any doctor’s lifetime. The excitement of actually treating patients, being able to perform medical and surgical procedures by your own hand, albeit under supervision, is unparalleled. 

Every doctor, however old, remembers this intense one-year period, which is the real drill in the profession. The endless work hours, the crazy responsibility of being the first contact with patients at the hospital, the discipline to be the first to arrive and the last to leave, and the expectation to know every detail about every single patient in your care is almost inhuman. Every doctor goes through this baptism by fire for them to be certified to independently touch patients in the Republic of Kenya. 

Internship stories abound, told through the eyes of the greenhorn doctors, full of wonder, whose perspective hasn’t been jaded by years of experience. The most amazing of these are medical conditions seen in the wards, unique to the region served by the hospital. In Mwingi for instance, working in the emergency department on night shift when sudden downpours happen after a prolonged dry spell meant treating all manner of snake bites.

Apparently, heavy rains wash snakes out of their underground hideouts as water fills these earthy tunnels, forcing the snakes into warm areas of people’s homes. Humans and snakes meet in bed and the likelihood of a bite happening is very high. Folks in Mwingi are so used to bites they hardly panic. The patient shows up at the hospital holding a piece of black stone over the bite. This stone is native to the area and is believed to soak out the snake venom from the bite! My colleague swears by the stone, saying that those who came with the stone had better outcomes than those who didn’t!

In Meru, the surgical department is the most dramatic. My friend was urgently called to the hospital one night and was totally unprepared for the sight she walked in on. Apparently, two young men fought over their father’s precious miraa plantation. Their fight escalated to the use of machetes and once the tempers settled, they escorted each other to the hospital. One was holding his intestines in his hands while his brother was holding his left hand, which was hanging loosely by the skin as it was slashed through. We were told that if one wanted to become a surgeon, Meru was the place to gain experience!

Listening to my friend, it was crystal clear in my mind that I preferred to deal with patients who kept their internal organs inside where they belonged. I was doing a perfectly good job of it, right up until I was called to the gynaecological emergency room one night during my specialty training. My patient was lying on the stretcher with her internal organs resting right outside!

No amount of reading about pelvic organ prolapse prepares you for the sight before me. Marren* lay on the stretcher looking desolate. She had ridden in the ambulance for almost 16 hours to get to the national referral hospital. She had spent another six hours on the stretcher in the chaotically busy emergency department, receiving basic emergency care to stabilise her. She had an initial review by my colleague covering the day shift, and sent for a slew of laboratory and imaging tests. She was exhausted, hungry, and bewildered at the experience of being hundreds of miles away from home being poked repeatedly by strangers.

Marren’s uterus and cervix had literally been displaced downwards through the vagina and were resting between her upper thighs. Due to lack of access to healthcare and the stigma attached to talking about one’s genital organs in her community, Marren suffered from the condition for years without medical attention. When she was finally able to get to a health facility, the external uterus was irritated, infected, and grossly discoloured. It was an intimidating sight, even to a gynecologist.

She suffered from pain, difficulty in passing urine and stool, and a terrible stench clung to her due to the pus discharge from the infected organs. Her self-esteem was on the floor and she did not even feel like a human being. This was made worse by the language barrier as she spoke very little Swahili and absolutely no English.

Pelvic organ prolapse is the displacement of organs within the pelvic cavity into the vagina. Many women of childbearing age will suffer minor degrees of pelvic organ prolapse with no overt symptoms, hence will never have anything to complain about. However, a few will suffer a severe degree of prolapse with debilitating symptoms such as Marren’s.

The pelvic organs are held in place by special pelvic floor muscles and ligaments so as to maintain their correct anatomical position. Because as humans, we walk upright, these organs sit on the pelvic floor due to gravity. Injury or weakness of this floor means that organs will easily displace vertically downwards. Hence conditions such as pregnancy, difficult vaginal deliveries requiring the use of instruments and tumours of the pelvic floor put one at risk of pelvic organ prolapse.

Prolapse may involve the urinary bladder displacing into the vagina, causing incontinence and incomplete emptying of the bladder, which results in repeat infections and may damage the system all the way to the kidneys. Conversely, it may involve the rectum or intestines displacing into the vagina from the back, causing constipation and trouble passing stool. Lastly, it may involve the upper vagina, the cervix, and the uterus descending downwards in the vagina, through to the outside.

Patients without symptoms require no treatment. Those with minor symptoms may be treated using a special medical device, the vaginal pessary, which provides support to the displaced organs. The pessary is used together with pelvic floor exercises to strengthen the floor muscles and with vaginal oestrogen cream for older women in menopause. Patients who do not respond to the pessary require surgery to remove the uterus and cervix and correct any other organ displacement, to relieve symptoms.

Marren stayed with us for weeks. She underwent surgery twice; first to remove the infected uterus and cervix, and later to correct the urinary incontinence. It was amazing to see the transformation from the desperate, listless woman I met, to the beautiful lady with a heartwarming smile who had just gotten her life handed back to her! It was a bitter-sweet moment to see Marren leaving us, heading back to the Northern Frontier she called home; back to her 13 children and 9 grandchildren!

Dr Bosire is an obstetrician/gynaecologist