Urinary incontinence : An 11- year suffering

Last week a lady of 50 came to the clinic complaining of pain whenever she passes water (urinate) and this has been going on for many years. It has become worse for the last few years and whenever she goes to a private or government clinic in her home town, she is given the standard treatment for urinary tract infection, that is a course of antibiotics and bladder cleansing solution. But the condition keeps on recurring and she has lost track of how many similar treatments she has received.

She traveled a distance of about 130 km ( about two hours' drive) to come to the city to get another medical opinion.

I decided to engage her by asking about the history of her condition. She married in her early teens. Her problem started about 11 years ago since the birth of her last child, her twelfth (12th)! It was a home delivery and she suffered from a uterine inversion , she said "semua peranakan saya keluar" ( my uterus came out ) and had to be pushed back in at the hospital. She has been on an injectable contraceptive ever since then.

I probe on the nature of her urination. From the answers I summarize  the following; she feels a sense of heaviness as if something is coming down there (private part), she has urine dribbling, aching pain in her back and pelvic region, she has frequency (urinating many times a day ) and also urinating many times at nights (nocturia) and at the same time she feels she could not empty her bladder completely and urine keeps leaking and more so whenever she coughs (stress incontinence -loss of control of her bladder).

Her urine test showed the presence of a small amount of red blood cells but it was the physical examination of her genital area which confirmed my suspicion. There was an irreducible bulge coming down her vagina. The condition is referred to as pelvic organ prolapse most likely to be uterine. Prolapse of the uterus is the downward movement of the uterus due to weakened muscle of the pelvis likely as a result of injuries during childbirths.

The obstetrics history (twelve deliveries) of this poor lady testifies to her present predicament. No amount of antibiotics is going to help her unless her basic physical problem is treated. Her long suffering is due to poor diagnosis of her symptoms. A proper history taking could have avoided her unnecessary poor quality of life. As it is, none of the doctors who attended to her ever examine the genital area. Her gynecological problem requires to be managed at the secondary care level (by a hospital  gynaecologist) through referral which was what I promptly did.