Lived experiences of women with pelvic organ prolapse at Gurage zone, Central Regional State, Ethiopia: an interpretive phenomenological analysis

Abstract

Introduction

Pelvic organ prolapse (POP) is the descent of one or more pelvic organs through the vaginal canal, including the vagina, uterus, rectum, bladder, cervix, posthysterectomy vaginal cuff, and small or large bowel, which compromises a woman’s physical, mental and social well-being.

Objective

This study aimed to explore how women with POP experience their living and its impact on their quality of life (QoL).

Design

This was a qualitative study using interpretive phenomenological analysis, following in-depth structured interviews. Analysis was undertaken to identify superordinate themes relating to how women are living with POP.

Setting

3 public hospitals and 3 woredas in Gurage zone, Central Regional State, Ethiopia.

Participants

A purposive sample of 12 women who were diagnosed with POP was recruited.

Results

Five core themes with subthemes were identified; general health judgement, POP symptom, life situation related to POP, feeling about POP and limitation in daily life/activity. The majority of respondents expressed concern that the prolapse had negatively impacted their general health and voiced hope that pelvic floor reconstruction would improve their general well-being. The majority of the informants stated that disclosing to others might significantly lower their QoL and that having the condition was extremely embarrassing. The women were most affected by the actual physical symptoms of prolapse (bulge, back pain, heaviness, bowel problems, urinary incontinence) as well as by the impact prolapse has on their sexual function.

Conclusion

Women with POP should be offered psychosocial support, early care and counselling because they have physical, personal, emotional, social and sleep/energy problems. Healthcare providers should take the initiative in educating women regarding prolapse and to make them aware that it is a treatable condition which can improve their QoL.

Strengths and limitations of this study.

• This study uses interpretative phenomenological analysis in order to explore the living experience of women with pelvic organ prolapse (POP).

• Researchers with varied competencies and backgrounds were included to minimise potential bias due to clinical preunderstandings in the data analysis.

• The study’s limitations include a relatively small number of women recruited, which may have a potential impact on the transferability of findings.

• The topic of prolapse is perceived as extremely sensitive in the current study area, which may have affected the women’s readiness to speak openly.

Introduction

Pelvic organ prolapse (POP) is a defect of the pelvic floor structure and is not fatal. It is a significant cause of morbidity in women and has a well-documented impact on quality of life (QoL).¹ POP is caused by both internal and extrinsic factors, including parity, a history of previous hysterectomy, comorbidities, occupation, age, postmenopausal status and intra-abdominal pressure.2,4 POP increases with age and high parity was the single most important risk factor among women in rich as well as poor countries.⁵

Worldwide prevalence of POP has recently been reported to be around 9%.⁶ There is a dearth of prevalence data for POP and most existing prevalence data are based on symptoms rather than physical examination in the range of 1%–50%.⁷ With a frequency of 42.2%, POP is substantially more of a burden in low-income and middle-income countries.⁸ In Ethiopia, 23.5% of women experience POP,⁸ while in the Gurage zone, the prevalence was 25.5% and most of the women with POP were managed by vaginal hysterectomy with anterior colporrhaphy and posterior colporrhaphy.⁹ Those between the ages of 20 years and 29 years account for 6% of those with POP, women aged 50–59 years account for 31%, and about 50% of women with POP are aged 60 years or older.⁷

Evidence supported that women who have POP were most affected by the actual physical symptoms of prolapse (bulge, pain, bowel problems and sexual function).¹⁰ A qualitative study in Iran revealed that all women with POP stated that they have had experiences of discomfort with intercourse, and the POP problem made their sexual life uncomfortable. Most of the participants stated they were mentally distracted during intercourse due to many aspects of their problems resulting in a reduction in libido, arousal, sexual interest and dyspareunia.¹¹

Another study in the USA showed that POP appeared to bother women concerning their emotional well-being, sleep or energy. A minority of women felt depressed, anxious and sad by the presence of their prolapse or so fatigued that they no longer felt they had any energy left at the end of each day.¹² With POP symptoms and their comorbidity, such as constipation and urge urinary incontinence (UUI), some women didn’t attend to their job and lost time with rest.¹³ In addition, a study conducted in South Africa and India stated that women having POP presented with UUI, stress urinary incontinence, constipation and faecal incontinence, which affected their QoL by limiting physical activity, social interaction, personal relations and home tasks.^{14 15}

The women reported that the presence of POP had negatively impacted their general health, and a majority of women felt limited in their role and physical/social activity (including housework, travel, sport, exercise, professional work and holidays). The rest faced defecatory problems (a need to digitate to defecate) and a sensation of dragging discomfort. Also, women with POP were psychologically disturbed by the presence of their prolapse. While this led to issues such as lack of confidence in some women, others felt unattractive or less womanly.^{11 16}

Pelvic floor dysfunction is a substantial cause of suffering and a burden of disease among adult women, particularly as they get older, but is largely hidden and unacknowledged, although the socioeconomic consequences are often severe, in developing countries.^{8 17} Frequently, women in many developing countries are socialised to endure pain and discomfort, particularly if this is associated with their reproductive functions.⁸

Even though POP affects women in both high-income and low-income nations, epidemiological research indicates that the disease is more common in low-income nations, perhaps as a result of higher parity and earlier childbirth.¹⁸ In sub-Saharan Africa, including Ethiopia, the effects of POP on women’s QoL were more severe, and the effects of the illness burden brought on by pelvic floor dysfunction are much less understood.⁸ Low-income surroundings, cultural norms and geographical conditions may impact the women’s ability to participate fully in their families and communities and carry out everyday tasks.^{8 19} It is unclear how POP affects women’s QoL in low-income nations like Ethiopia.²⁰ Based on these indicators, Ethiopia is a low-income setting that may be well suited to the study of women’s perceptions, experiences and the management of prolapse. The present study aimed to explain, experience and handle the potential implications of prolapse in their QoL.

Methods

Study area and period

This study was conducted in the Gurage zone, Central Regional State, Ethiopia. It is bordered on the south-east by Hadiya and Yem special woreda, on the west, north and east by the Oromia Region, and the south-east by Silt’e.²¹ Woreda refers to the third level of administrative division, after regions and zones, which has an average of 100 000 people and multiple kebeles.^{22 23} According to the 2021 Ethiopian Mini Data, the Gurage zone area covers 5932 square kilometres, and has a population of 2242 131, with about 84% living in rural areas.²⁴ According to the 2018/2019 annual report of the Gurage zone health office, there are seven hospitals (five public and two non-governmental) and 74 health centres serving the total population of the zone. Among these hospitals, five are primary hospitals, one general hospital and one comprehensive specialised hospital. All hospitals deliver comprehensive obstetrical and gynaecological care.²⁵

Study design

A qualitative study using interpretive phenomenological analysis was used. The use of the phenomenological approach helped explore and understand people’s perspectives and descriptions of the events from their lived experiences.²⁶ The phenomenology approach examines perceptions, experiences and how people think back on the events in their lives that they consider important.²⁷ The subjective nature of experience, which can only be accessed through interpretation, is acknowledged by interpretive phenomenological analysis (IPA). The ideographic technique of IPA enables the researcher to thoroughly examine the potential effects of these events on an individual.²⁸ Because of its ideographic method, which enables researchers to thoroughly examine how particular occurrences may affect a patient and therefore effect patient care, IPA has become more and more popular in healthcare research. In terms of the analytical process, IPA shares elements with many other types of thematic analyses, aiming to identify, analyse and report patterns within qualitative data.²⁹ The method entails examining people’s everyday experiences while putting aside any preconceived notions the researchers may have about the phenomenon.³⁰ Therefore, in IPA, the researchers describe and also interpret the experiences of the participants. The study was conducted from 15 May to 30 June 2022.

Population

Source population

All women who had POP at Gurage zone.

Study population

Women who had symptomatic POP, stage II POP and above.

Eligibility criteria

Inclusion criteria

All women who were diagnosed with POP in the Gurage zone.

Exclusion criteria

All women having a pelvic cancer diagnosis were excluded.

Sample size and sampling procedure

Out of seven hospitals and 13 woredas found in the Gurage zone, three hospitals and woredas were selected via a lottery method. Then purposive sampling was used to select the study participants from the selected area. This means participants involved in the in-depth interview (IDI) were selected by considering their age, residence, educational status, symptoms and prolapse stage (stage II and above, because the cut-off point for symptom development, particularly the feeling of a vaginal bulge, was stage II).³¹ A total of 12 informants were recruited.

Operational definition

According to the simplified POP quantification staging system (S-POPQ), stage 0—no prolapse, stage I—leading point of the wall of the vagina or cervix remains at least 1 cm above the hymeneal ring, stage II—leading point descends to the introitus, defined 1 cm below the hymeneal ring, stage III—leading point descends >1 cm outside the hymeneal ring, but does not form a complete vaginal vault eversion and stage IV—complete prolapse.³²

Data collection tool

To explore the experience of the women, an IDI questionnaire was conducted which was developed by the principal investigator. This method was the preferred method for addressing a specific research question or focused research topic. The interview guideline was adapted from previous literature.¹⁰ This interview guide for IDI was developed by considering clinical relevance, repetitive effect in life and getting detailed information about their experiences in POP (online supplemental file 1). An IDI with open discussion and description was supplemented by simultaneous note-taking. During the interview, participants were asked to narrate what they experienced throughout their life and daily life. The interviews were conducted in a room onsite in the hospital (quiet office) or a location convenient to the participant and were audio-recorded. Each IDI took an estimated time range of 40–60 min. Data collection and probing of ideas were continued during IDI.

Data quality assurance

The interviews were transcribed by experienced and certified qualitative data transcribers and translators. Two independent transcribers listened to audio records and transcribed the interviews verbatim. The difference between the audio record and transcribed text was verified through the member check (share the findings with study participants, allow participants to provide feedback on the researcher’s interpretation and representation of their experiences), and then translated into English. Generally, the trustworthiness of the study was ensured by considering the criteria of credibility, dependability, conformability and transferability.³³ To ensure credibility, data were collected from respondents from different background perspectives (depending on client education, residence, POP stage and occupation). For dependability, accurate documentation by minimising spelling errors through frequent checks was ensured. The analysed and interpreted data were continuously peer-reviewed. Conformability was achieved by using quotes (linking the words of the participants with the discoveries). Transferability was achieved by providing evidence and a detailed description of the study, starting from sampling to data analysis, to provide opportunities for replication or to determine the generalisability of results.

Data analysis

First of all, the researcher managed the data by creating and organising files through data collection. Audio-recorded and field notes of IDIs were transcribed verbatim and then translated from Gurage to Amharic to English. Then the translated data were read and reread until the full meaning of the contents was understood. The field notes were referred to and added to the transcribed notes. The transcription was coded by using Open Code qualitative analysis software. The coding was based on the research questions concerning key components of their experiences and was grouped into subthemes and themes.

Patient and public involvement

None.

Result

Sociodemographic characteristics

A total of 12 women with symptomatic POPs, ranging from stage II–IV, were recruited in this study. Their mean age was 48.16 years (range 36–60). Nine informants were married, whereas the remaining three included two widows and one divorcée. The majority of the study participants were not formally educated. According to the S-POPQ, the majority of women are diagnosed with stage III/IV. Their main presenting symptoms were a ‘lump’ in the vagina, constipation, pain or discomfort during sexual intercourse, and a few numbers of women suffering from urinary incontinence. The IDI took an average of 51 min (table 1).

Table 1. Sociodemographic characteristics of women who have POP in Gurage zone, Central Regional State, Ethiopia, 2022 (n=12).

S. No	Code	Age	Residence	Marital status	Educational status	Occupational status	POP stage
1	P01	Middle adulthood	Urban	Married	Secondary and above	Government employee	Stage III
2	P02	Early Adulthood	Rural	Married	Not formally educated	Farmer	Stage II
3	P03	Middle adulthood	Rural	Widowed	Primary educated	Farmer	Stage II
4	P04	Late adulthood	Rural	Married	Not formally educated	Farmer	Stage IV
5	P05	Late adulthood	Rural	Married	Not formally educated	Farmer	Stage II
6	P06	Middle adulthood	Rural	Married	Not formally educated	Farmer	Stage III
7	P07	Late adulthood	Rural	Married	Not formally educated	Farmer	Stage III
8	P08	Middle adulthood	Rural	Divorced	Not formally educated	Farmer	Stage IV
9	P09	Late adulthood	Rural	Widowed	Not formally educated	Housewife	Stage III
10	P10	Middle adulthood	Urban	Married	Primary educated	Private employee	Stage III
11	P11	Late adulthood	Rural	Married	Secondary and above	Housewife	Stage II
12	P12	Middle adulthood	Urban	Married	Secondary and above	Merchant	Stage III

POP, pelvic organ prolapse.

Findings

Five overarching themes were identified in the participant accounts, characterising their experience of living with POP: (1) General health judgement; (2) POP symptom; (3) Life situation related to POP; (4) Feeling about POP, and (5) Limitation in daily life and activity. Each theme was described in detail in separate sections. Most of the women with POP compromised their QoL (such as psychological, sexual, physical, social and emotional well-being) and had a substantial influence on their desire to accomplish specific goals.

Theme 1. General health judgement

Category 1. Perception of overall health

The majority of the respondents expressed a concern that their general health had been compromised by the presence of their prolapse, and they hoped that pelvic floor reconstruction would restore their overall health.

…I am ill now that I am aware of the prolapse issue in the hospital, and I am unable to feel better. I guess I’m worried about my body and health right now. I didn't feel any better, and I had good intentions for my health. I firmly believed that once the prolapsed mass was surgically removed, I hope that, I am well (p07, late adulthood, prolapse stage III).

Others claimed that the most typical issue with POP was unfavourable insight. It caused a flood of complexes endangering their health. If it disappears, they comment that it is sound and sensible.

Since the beginning of my pelvic organ prolapse, I have not experienced any health or calm.

I feel healthier without this pelvic organ prolapse, therefore I worry about myself. I hope that after this, I will feel much more at ease and in good health … (P11. late adulthood, prolapse stage II)

Because of their multiple births, heavy workloads and inability to get a car when giving birth, some women believed that prolapse would occur and negatively impact their health.

……. the hospital is far from my house, I chose not to give birth there. I was careless at my birth. Our female responsibility was heavy; I assisted my husband on the farm and had domestic responsibilities, and this was ultimately revealed. When I avoid heavy work, I feel fine. (p01, middle adulthood, prolapse stage III)

Category II. Impact on overall health

The majority of the informants claimed that having a prolapse was exceedingly embarrassing and that telling people about the illness may seriously harm their QoL. It has a considerable negative effect on the affected women’s ability to function and emotional health.

….As the pain worsened, so did its negative effects on my life. My life has been affected today, I said. Before this issue, everything was stable. Now, everything is warped. This is a big issue, and it will have a significant impact on my life for the rest of it. I experience less humanity with its impact. (p02, early adulthood, prolapse stage II)

The affected women were more symptomatic as their bulging mass increased, which made them more vulnerable in daily life. For instance:

….Beginning before six months, the protruding bulk grew, and it is negatively affecting my life. It has had an enormous impact now. I believed that the prolapse would have a greater impact on my life if I delayed seeking treatment. (p11, late adulthood, prolapse stage II)

Furthermore, the majority of women said that women lack awareness about prolapse treatment and care and are adversely affected by its symptoms as they worsen, and most of these women have died at home without seeking medical assistance.

……I am not educated, and I haven’t been aware of its treatment, I perceive it as a tumor and must be fatal, I know most women in our community would die with a lack of awareness about its treatment, today I came to this after being told by my child. Intern, I told the women who sleep in their house to get care (p10, middle adulthood, prolapse stage III).

Theme II. POP symptoms

Category I. Gastrointestinal symptom

The majority of the affected women expressed prolapse symptoms like abdominal pain, and a minority of the women were suffering from constipation (difficulty of defecation), and few of them took traditional medicine for their pain and easily defecated.

……I tried a variety of things. Someone said that aloe was beneficial. Some people reported positive effects. But I get a lot of stomach aches and unpleasant side effects after eating. I suppose this was due to the two-year duration and chronic nature of my prolapse. (p1, middle adulthood, prolapse stage III)

Chronic constipation affects women in some ways, including increased bulging mass, increased fatigue, and limitations on walking and working from home. Additionally, some of the impacted women suffer consequences in their daily lives, including job loss.

….I require medicine, but the physicians haven't listened to me while sitting more time for feces caused the prolapse of mass to increase more, which prevents me from walking and from performing my daily activities at home…… p02, early adulthood, prolapse stage II)

I sat more to defecate, I weakened, I would be in such agony and stress, and I could not attend in my job through the work day and frequently spent the weekend sleeping…. p12, middle adulthood, prolapse stage III).

Category II. Urinary tract symptom

The minority of participants can stress due to the unpredictable nature of urinary tract symptoms. Because they didn't employ alternative techniques outdoors, they had no idea where or when the symptoms could appear.

……I frequently have a small amount of urine leak; it is noticed, but nobody will understand. Most of the time, we farmers wore no pants. I worry so much about what to do with my urine when I want to go out (p01, middle adulthood, prolapse stage III)

I experience urine leaks while I'm sleeping. I can't hold my urine till I get to the bathroom because I have a strong urge to urinate. I have a strong urge to urinate, yet my bladder leaks uncontrollably. …… (p02, early adulthood, prolapse stage II)

A few of the women talked about using a variety of strategies to empty their urine. For example, one of the participants described:

……Because of the increased pelvic organ prolapse, urination is prevented. I have a hard time getting my bladder to empty. It causes a bladder blockage. I urinate by pushing on the prolapsed masses back with my clothed hand…… (p10, middle adulthood, prolapse stage III).

Theme III. Life situation related to POP

Category I. Social life

Most of the women were found to be extremely concerned about how their condition was limiting them socially. They worried about not being able to interact with belief organisations and social ceremonies. In turn, it worried them about not being able to go away to meet up with their family as they would have liked to.

I can't go to the church since it’s far from my house; I also can't visit my distant family or go to the funeral home. I'm unable to see my family, which makes me miss them. They gave me a good time! I detest not being able to greet my grandchildren outside …. (p09, middle adulthood, prolapse stage III).

A minority of the women feared social consequences such as discrimination in their social interaction, and culturally the people didn't understand them.

I went to the hospital for treatment now, but I didn't speak on behalf of anyone. Many people lack manners. Our rural residents are rude about this issue. There are so many different kinds of people who degrade and insult me (p08, middle adulthood, prolapse stage IV).

Some women were having difficulty participating in social gatherings with friends and relatives due to discharge and its bad-smelling characteristic.

….I was afraid to sit or stand near people anywhere, and now I have white vaginal discharge. I used to clothes to cover it, but it wet and could be visible from outside resulting patches and bad smell …. p11, middle adulthood, prolapse stage II)

Category II. Personal relationship

Most of the participants stated that they usually felt shameful due to their problem, and they did not want it to be told openly to their family, relatives or husbands.

… Before the prolapse occurred, my spouse and all of my children had an honest conversation. We would be able to speak openly and receive care if someone was ill. I am not now telling them outright. I feel bad about my prolapse. My child and husband’s connection suffered as a result. They were unfamiliar with this kind of issue. It interferes with my sexual life and my spouse.…… (p12, middle adulthood, prolapse stage III).

However, very few participants stated that they only talked to kind family people, who understood them and supported them. For example, one participant said:

….Fearing the issue, I spoke with my mum. She agreed and advised me to go to the hospital. She gave me excellent advice as well. She is constantly by my side and she spoke up for my child. She cares for me and is always by my side. She was looking for a doctor to treat my difficulties at the time. When she receives them, she stays with me through the final therapy.… (p01, middle adulthood, prolapse stage III.

Category III. Sexual life

A few of the women suggested that they were bothered about the impact of the prolapse on their sexuality. A third of the participants were dissatisfied with their sex lives as a result of their prolapse. They felt pain because of a reduction in libido, arousal and sexual interest.

….I’d like to have my sex life back. Because I'm not happy, and neither is my husband. During sexual activity, the prolapsed mass in my vagina pushes my husband’s penis, and I experience agony. I didn’t have vaginal discharge during sex as before, it is dry and painful during sex. (p12, middle adulthood, prolapse stage III).

…I am not interested in sex since prolapse, but my husband insulted me, he says I will bring another wife, then I will perform it after pushing the mass back by my hand…… (p01, middle adulthood, prolapse stage III.

Very few women stated that they had experienced oppressive sex with their husbands against their wishes, and they used a variety of strategies for consensual sex with their beloved husband.

……Following the prolapse, I'm not pleased with the sexual relationship. I only engage in sexual activity because my husband requests it. I only experience pain during sexual activity, and I don't like it when it does. I push the prolapsed uterus into the vagina during sexual contact…. (p07, late adulthood, prolapse stage III).

Theme IV. Feeling about POP

Category I. Emotion

A majority of women were stressed, felt bad, blamed themselves and were depressed by the presence of their prolapse and so felt lonely at the end of each day.

I feel terrible about it and am disappointed that it happened. I'm upset about my prolapsed pelvic organ. Regarding the prolapse of my pelvic organs, I blame myself. Because it may result from overworking, most likely. I genuinely feel exhausted by it; I am constantly exhausted and lack the motivation to do anything. Finally, I'm anxious and genuinely feel alone. …… (p07, late adulthood, prolapse stage III).

Some number of women having POP, experienced incompatible approaches from their family, and they refresh them by adopting to go the extended family.

……After this prolapse happened, I became emotional, felt bad, and depressed, and I now argue frequently with my family and neighbors. I can occasionally visit my distant family to forget what they have said to me. I stay at my sister’s house after that and am gone for at least a week. I don't experience pain or hear anything negative throughout that week, nor am I anxious. (p09, late adulthood, prolapse stage III).

Category II. Sleep/energy

POP looked mildly troublesome to the women where sleep or energy was concerned, and few participants experienced fatigue, were not able to move longer or work, and had no energy left each day.

…"…No sleep; I see my deceased hubby while I'm asleep. I'm concerned. I'm tired and I fall for it. I occasionally find it difficult to eat, and my frailty makes me lose my appetite. I am exhausted…… (p03, middle adulthood, prolapse stage II).

……When I'm unable to sleep, I have problems falling asleep and feel exhausted. (p05, late adulthood, prolapse stage II).

Theme V. Limitation in daily life and activity

Category I. Physical limitation

More than half the women were found to be extremely concerned about how their condition was limiting their physical activity. Some women were restricted from walking and travelling, and were not doing their regular physical activity each day.

I am not old and capable of doing anything. But after it happens, I am unable to stand, sit, or move for an extended amount of time. I am unable to go great distances. I simply want to resolve my prolapse issue. Without limitations, I wish to once more move, stand, sit, and carry out any task I like…… (p02, early adulthood, prolapse stage II).

………When I start working, walking, or moving, it hurts so badly. I am unable to work or go home because it has severely prolapsed and is preventing me from moving… (p05, late adulthood, prolapse stage II).

However, some women who do regular physical exercise have good health and well-functioning abilities during their daily life.

I've had this issue for five years, and the doctor recently advised me to walk and exercise. For the past four years, I've been content. Before beginning exercising, the bulk would protrude every day. Over the past four years, the swelling and bulging mass have decreased. I recently visited the hospital for evaluation due to experiencing a few symptoms and a bulging increase. But it is not more likely to have an impact on my general health. If I exercise more, I'm hoping it will improve even more (p12, middle adulthood, prolapse stage III).

Category II. Role limitation

POP limits the household tasks of the majority of the women. With work, the prolapse and pain increase. This affects an integral part of women’s daily life.

At the moment, doing my domestic chores is challenging, I am unable to wash clothes, cook, clean, fetch water, or do anything else without feeling this lump. Lastly, I can complete the homework without feeling the lump. But now that I can't take care of my house as well because of the uterine prolapse, I miss a lot of things (p12, middle adulthood, prolapse stage III).

Some women miss their home activity due to the problem and have feelings of discomfort and pain during work.

……Before I had a prolapse, I did my housekeeping quickly and enjoyed spending time with my child while doing it. But now that I've anticipated it, I feel certain that I can pull it off. I put off doing all the tasks till my child could do it. I'm looking forward to doing my house task before because it’s very uncomfortable. …. (p11, late adulthood, prolapse stage II)

Discussion

The present study explored the experiences of women with POP, suggesting that specific symptoms, including back pain, heaviness, a bulging mass, urgency and frequency, were major influencing factors in the women’s aim for specific goals. Some of the participants were dissatisfied with their sex lives as a result of their prolapse and felt pain during sexual intercourse. This may be due to a reduction in libido, arousal, sexual interest and dyspareunia.¹¹

The majority of the women expressed concern that the presence of POP compromised their overall health. The finding was supported by a study in the USA.³⁴ This might lead to shame, embarrassment, decreased feelings of sexual attractiveness, body change and feeling less attractive, which may affect their QoL.³⁴ In addition, most of the women were restricted from walking and working due to their pain and bulging mass. This was supported by a study in Iran.¹¹ This might be chronic pelvic pain caused by stretching and weakening of the pelvic ligaments making it difficult to walk, bend and work.³⁵

Moreover, in our study, the majority of the women who had POP experienced poor personal relationships because of pain, discomfort and change in sexual intimacy, even leading to depressive and irritable moods. This is supplemented by a study in the Amhara region,³⁶ the UK¹⁰ and India.¹⁵ “Sexual dysfunction increased due to persistent or recurrent pain, obstructed intercourse (complaints that vaginal penetration is impeded with a bulging mass), loss of libido or laxity, fear of faecal incontinence and bulging of the genital organs.^{11 37} However, orgasmic function and sexual satisfaction do not seem to be affected by the genital prolapse itself and the related complaints. Some women reported being discriminated against and socially excluded. This finding was supported by a study in the Amhara region.³⁶ Due to the cost and limited availability of surgeons, reasonable access to surgical repair services will remain unattainable for the majority of women with prolapse and incontinence living in low-income countries.¹⁸ Additionally, the advanced stages of POP are associated with foul-smelling vaginal discharge and urinary incontinence, leading to social consequences.³⁸

Similarly, some women with POP were emotional, suffered from insomnia or loss of energy. This was seen in studies in South Africa³⁵ and the USA.¹² Sleep disturbance and emotional feelings have been associated with irritable bowel syndrome,³⁹ nocturnal micturition⁸ and depression. However, as seen in studies in high-income and low-income countries, following surgical treatment the overall QoL, including physical, social, emotional, sleep and sexual performance, improved.^{40 41}

Most women with a diagnosis of POP are affected throughout their lives due to a lack of education, and socioeconomic and cultural factors, affecting its treatment and curability. This result was supported by a study in India.¹⁵ This is especially seen in developing countries such as Ethiopia where women have low status in patriarchal societies and are socially and economically dependent on husbands.^{38 42} In addition, despite impaired functioning as a result of the disorders, many women do not seek appropriate care because of the perception that these conditions are natural consequences of childbirth or ageing, and also due to shyness and cost.

Some women said that those with an increase in bulging mass are prevented from social and personal interactions, and experience depression or anxiety as a result of smelly discharge when POP is in the advanced stage. This was supported by a study in the UK.¹⁰ This could be in advanced stages III or IV, as well as increased symptoms and intensity that adversely impact women’s social lives, emotional well-being and functional activities (work, walking, sitting and standing).⁴¹ The majority of women with POP describe similar problems and bear similar burdens, but in low-income countries including Ethiopia, women face more difficult challenges.¹⁹ Given the socioeconomic, cultural and geographical conditions of many of the nations in this region, women may need to perform more physical labour while taking care of more children and engaging in daily activities like farming, walking long distances to gather firewood and carrying back clean water.

Additionally, women suffer from constipation, which can lead to emotional distress and increased somatisation. Our finding was supported by a study conducted in India.¹⁵ This would explain why some women were more exhausted (inert), suffered from sleeplessness, were unable to fully complete their workdays, spent some time resting, and had restricted social and everyday life.^{12 13}

Similarly, women with POP had an urge to urinate with uncontrollable leakage of urine. This study was supported by the study in the Amhara region.³⁶ This might lead to them compromising their QoL as a result of impaired ability to do household activities, escaping social activities, impaired personal relationships, reduced ability to travel, evaded leisure activities, decreased emotional health and feeling frustrated.¹⁴

Conclusion

Women with POP should be offered psychosocial support, early care and counselling because they have physical, personal, emotional, social and sleep/energy problems. The majority of women have back pain, heaviness, bulging mass, dyspareunia, constipation, urgency and frequency, which have a significant impact on the women’s desire to achieve particular objectives.

Because of their cultural beliefs and traditions, the majority of people continue to rely on various conventional remedies. Therefore, more research should be done to determine whether typical therapy side effects are beneficial or detrimental. The physical, psychological and social effects of uterine prolapse should be handled comprehensively as this improves women’s general health.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.