The inter-system association between the simplified pelvic organ prolapse quantification system (S-POP) and the standard pelvic organ prolapse quantification system (POPQ) in describing pelvic organ prolapse

Association of the second birth mode of delivery and interval with maternal pelvic floor changes: a prospective cohort study

BACKGROUND

This study aimed to explore the association of the second birth delivery mode and interval with maternal pelvic floor changes.

METHODS

This prospective cohort study included women who had a first delivery and were in weeks 36-41 of a subsequent pregnancy at Panzhihua Central Hospital between July 2017 and June 2018. The primary outcomes of the study were the hiatus area at 6 months postpartum and bladder neck (mm) at rest and during a maximum Valsalva maneuver.

RESULTS

There were 112 women with vaginal delivery and 182 with Cesarean section. The hiatus area and hiatus circumference decreased at all time points (all P < 0.001). The women with Cesarean section had a smaller hiatus area and circumference (P < 0.001 and P < 0.001). The hiatus diameters decreased with time in both groups (all P < 0.001) and were smaller after Cesarean section (both P < 0.001). The bladder neck at maximum Valsalva increased with time (all P < 0.001) without significant differences between the two groups. Finally, the proportion of patients with POP-Q stage 0/I increased with time in both groups (all P < 0.001), with the proportions being higher in the Cesarean group (P = 0.002). The birth interval was negatively correlated with the hiatus area (B=-0.17, 95%CI: -0.25, -0.08, P < 0.001) and positively correlated with the bladder neck at rest (B = 0.22, 95%CI: 0.08, 0.35, P = 0.001) and at maximum Valsalva (B = 0.85, 95%CI: 0.65, 1.05, P < 0.001).

CONCLUSIONS

In conclusion, the mode of delivery at the second birth could influence the hiatus area and circumference and bladder neck size. The birth interval was negatively correlated with the hiatus area and positively correlated with the bladder neck at rest and at maximum Valsalva.

International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction.

METHODS

An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed.

RESULTS

The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP.

CONCLUSIONS

The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

Modified Oxford technique of colpopexy for the treatment of uterine and vaginal vault prolapse: a retrospective pilot cohort study

Introduction

Pelvic organ prolapse is a common health issue that affects 30.8% of women. Laparoscopic sacrocolpopexy and colpopectopexy are two of the most common procedures to restore the pelvic anatomy. Mesh application on the other hand carries an increased complications risk over the short and long terms. The aim of this study is to provide a basis for meshless sacrocolpopexy and colpopectopexy.

Methods

This study is a retrospective cohort pilot study that analyzed the data of patients with a pelvic organ prolapse according to the pelvic organ prolapse quantification system and underwent the modified technique for sacrocolpopexy and colpopectopexy. Descriptive statistics were used to express the different variables.

Results

A total of 36 patients met the inclusion criteria and provided consent for the participation in this study. The majority of patients were postmenopausal. 22 out of 36 patients received a previous prolapse surgery. All patients presented with reducible vaginal lump. Dyspareunia and sexual dysfunction were the most commonly reported symptoms. The intraoperative complications rate was 0%. Only one patient had a postoperative persistent urinary retention that was managed medically.

Discussion

Sacrocolpopexy and colpopectopexy seems to be a safe alternative to the mesh-based pelvic surgeries with a very low rate of intraoperative complications and favorable follow up outcomes.

Reliability and validity of the Sidaamu Afoo version of the pelvic organ prolapse symptom score questionnaire

BACKGROUND

Both for clinical and research purposes, it is critical that clinicians and researchers use a tool that is trans-culturally adapted and tested for its psychometric properties. The English version of the Pelvic Organ Prolapse Symptom Score (POP-SS) questionnaire was developed in 2000. Since then it has been translated into other languages and verified. However, the tool has not been adapted for use in Sidaamu Afoo language in the Sidama Region of Ethiopia.

OBJECTIVE

This study aimed to translate and adapt the Pelvic Organ Prolapse Symptom Score questionnaire into Sidaamu Afoo and evaluate its psychometric properties.

METHODS

A total of 100 women with symptomatic prolapse completed version-2 of the POP-SS questionnaire during the first round of interviews, and 61 of them completed the questionnaire during the second round of interviews (to establish the test-retest reliability). We adapted the scale translation process recommended by Beaton and his colleagues. The content validity was assessed using the content validity index and the construct validity was done based on exploratory factor analysis using the principal component analysis model. The criterion validity was evaluated by using the Kruskal-Wallis test based on stages of the prolapse established via pelvic examination. The internal consistency reliability of the scale was assessed using Cronbach's alpha value, and test-retest reliability was evaluated using the intraclass correlation coefficient.

RESULTS

The questionnaire was successfully translated to Sidaamu Afoo, and achieved a good content validity index (0.88), high internal consistency (Cronbach's alpha of 0.79), and test-retest reliability (an intraclass correlation coefficient of 0.83). The exploratory factor analysis revealed two factors based on an eigenvalue of 1. The two factors explained 70.6% of the common variance, and each item loaded well (0.61 to 0.92) to its corresponding factor. There is a significant difference in the median score of prolapse symptoms across different stages of prolapse (Kruskal-Wallis χ², 17.5, p < 0.001).

CONCLUSION

The Sidaamu Afoo version of the POP-SS tool is valid and reliable. Further studies that involve a balanced number of women in each stage of prolapse are needed to avoid the ceiling and floor effects.

Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Wolaita zone, Southern Ethiopia: Hospital based mixed method study

BACKGROUND

Despite increasing efforts to improve access to diagnosis and treatment services, women with pelvic organ prolapse tend to stay at home for years before getting treatment. A large number of women, particularly in rural areas do not get early diagnosis and treatment, and they come with an advanced stage; but the reason for this appears unclear. Thus, this study aimed to determine the proportion and associated factors of delay in seeking treatment among women with pelvic organ prolapse (POP) in the Wolaita zone, Southern Ethiopia.

METHODS

A hospital-based cross-sectional study mixed with qualitative method was conducted in the Wolaita zone, Southern Ethiopia, from September to October 2021. A total of 422 women with pelvic organ prolapse were selected by systematic random sampling for quantitative data. The women recruited for in-depth interviews were purposefully selected until data saturation reaches via phenomenological study design. The quantitative data were collected by interviewer-administered questionnaire and reviewing clients' medical records via an open data kit and then exported to and analyzed with a statistical package for social science version 25. The associated variables were determined by conducting a logistic regression model and are presented with the crude odds ratio (COR) and adjusted odds ratio (AOR) with their respective 95% confidence intervals (95%CI). All statistical tests were conducted at a 5% level of significance. The interview was first transcribed, coded, and categories and themes were generated by applying thematic analysis.

RESULTS

The study showed that 82.0% (95% CI: [74.8-89.3%]) of women with POP delayed seeking treatment. The delay to seek treatment was associated with a lack of support (AOR = 4.9; 95% CI [1.8-13.2]), low-income (AOR = 6.4; 95% CI [2.2-19.2]), fear of disclosure (AOR = 5.0; 95% CI [1.3-19.2]) and fear of social stigma (AOR = 4.6; 95% CI [1.5-14.2]). The reasons for the delay were feeling shameful to disclose, fear of stigma and cultural and spiritual beliefs.

CONCLUSIONS

More than three-fourths of women with POP delayed seeking treatment, and improving support, improving the economy, raising awareness, and involving influential people in interventions are all necessary to avert it.

A Comparative Study on the Clinical Efficacy of Simple Transobturator Midurethal Sling and Posterior Pelvic Floor Reconstruction

Background and Objectives: The purpose of this study was to compare the complications, success rate and satisfaction of pelvic floor reconstruction after transobturator midurethral sling (TOT) and TOT combined with pelvic floor reconstruction in the treatment of female stress urinary incontinence. To explore the pathogenesis of stress urinary incontinence after pelvic floor stress injury and improve the surgical treatment strategy. Materials and Methods: From 15 August 2018 to 24 February 2022, patients diagnosed with stress urinary incontinence (SUI) and secondary prolapse of the anterior pelvis were selected to receive surgically. Participants were followed up and evaluated at 2 months, 6 months and 1 year after treatment. According to the patient's chief complaint, the patient can urinate automatically without incontinence. The number of urinary incontinence and urine leakage was significantly reduced compared with those before operation. Urinary incontinence symptoms did not improve or worsen as ineffective, observing the efficacy and complications. Results: We included 191 patients in the TOT group and 151 patients in the pelvic floor reconstruction group after TOT was combined. The operation time and hospital stay in the TOT group were short, but the TOT group needed a second operation to treat recurrent SUI. Perioperative complications were mostly dysuria, and the incidence of postoperative complications in the group of TOT combined with pelvic floor reconstruction was low. The complete success rate and effective rate of pelvic floor reconstruction after TOT in the merger group were significantly higher than those in the TOT group, and the patient satisfaction and complete success rate were also higher. Conclusions: TOT combined with posterior pelvic floor reconstruction has a definite short-term effect on patients with SUI and anterior pelvic secondary prolapse. The operation design should pay attention to the support of the posterior wall of the perineum to the bladder neck and the middle and proximal end of the urethra.

Translation, reliability, and validity of Amharic versions of the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7)

Purpose

Pelvic Floor Disorders (PFDs) affects many women and have a significant impact on their quality of life. Pelvic Floor Impact Questionnaire (PFIQ-7) and Pelvic Floor Distress Inventory (PFDI-20) help to assess PFDs; however, both are not culturally translated into the Amharic-language. Hence, we aimed to translate the English versions of short forms of the PFDI-20 and PFIQ-7 into Amharic-language and evaluate their psychometric properties in Amharic-speaking Ethiopian women with symptomatic PFDs.

Methods

The PFDI-20 and PFIQ-7 were translated into Amharic language using standard procedures. The Amharic versions were completed by 197 patients (response rate 92%) with PFDs from University of Gondar specialized and comprehensive Hospital. Internal consistency and test-retest reliability were examined through Cronbach’s alpha and Intraclass correlation coefficients (ICC). A relative criterion standard, POP-SS-7 score, was correlated with total PFDI-20 and subscale POPDI-6 scores using spearman’s rank order correlation (SCC). Construct validity was evaluated by known group validity using the Mann–Whitney U test.

Results

Both instruments were successfully translated and adapted with an excellent content validity (> 0.90). The Amharic versions of the PFDI-20 and PFIQ-7 showed excellent internal consistency and test-retest reliability in both summary and subscales (Cronbach’s alpha: 0.92 for PFDI-20 and 0.91 for PFIQ-7; and ICC: 0.97 for PFDI-20 and 0.86 for PFIQ-7). Criterion validity was good for POPDI-6 (SCC = 0.71; p < 0.001). Moreover, construct validity was acceptable, showing significant differences among groups of PFDs in the PFDI-20 and PFIQ-7 scores (Mann–Whitney U Test; p < 0.001).

Conclusions

The Amharic versions of the PFDI-20 and PFIQ-7 are comprehensible, reliable, valid, and feasible in Ethiopian Amharic-speaking women with PFDs to evaluate symptoms and its impact during research and clinical practice. However, further studies are needed to evaluate the responsiveness.

Prevalence and surgical outcomes of stage 3 and 4 pelvic organs prolapse in Jimma university medical center, south west Ethiopia

Background

Pelvic organ prolapse (POP) affects about half of the women and affects their quality of life. The current study is, therefore, aimed at determining the prevalence and surgical outcomes of severe stage POP at Jimma University medical center from November 2016 to May 2018.

Method

A Hospital-based cross-sectional study was conducted on all patients with stage 3 and 4 POP, who were admitted, and had surgery. Data were collected from the patient’s chart, and logbooks, which were filled up from entry till her discharge. A Simplified POPQ(S-POPQ) was used to stage the prolapse at admission, at discharge, and three months follow-ups.

Results

Among 92 patients who were analyzed, POP accounts for 10.6% of all gynecologic admissions, and 43.8% of all gynecologic surgeries. The mean age of patients is 46 (± 12) years, and nearly 34% of the patients had stage 3 and 66% had stage 4 POP. Based on the type of prolapse, 93.5% of patients had stage 3 and more anterior vaginal wall prolapse (AVWP) and apical prolapse, while 57.6% had stage 3 or more posterior vaginal wall prolapse.

Out of 72 patients who had anterior colporrhaphy, 58.7% had anterior colporrhaphy with colposuspension. Out of 83 patients who had apical suspension, 48.2%, 39.8%, and 12% had uterosacral, sacrospinous, and Richardson respectively.

Ninety-seven patients had stage 0 or 1 POP at discharge while 90% of 20 patients who returned for follow-up at three months had stage 0 or 1 POP. Eight patients had surgery-related complications; bladder injury, urinary retention, Hemorrhage during SSLF, and rectal injury.

Conclusion

The prevalence of pelvic organ prolapse is high and the majority of patients presented with advanced-stage pelvic organ prolapse, with a long duration of symptoms and associated problems. The surgical techniques used have resulted in a high immediate success rate of 97% and 90% at discharge and three months follow up respectively. Therefore, awareness creation activities are important to facilitate an early presentation for treatment to improve the quality of life and the current surgical technique; native tissue vaginal repair (NTVR), being practiced in the setup has had better success.

Comparison of outcomes between pessary use and surgery for symptomatic pelvic organ prolapse: A prospective self-controlled study

Purpose

We compared the degree of pelvic floor symptom improvement between pessary use and prolapse surgery.

Materials and Methods

Pessary-naïve women who elected prolapse surgery were enrolled and used a pessary preoperatively (for ≥7 days and ≤30 days). Pelvic floor symptoms were assessed at baseline, after pessary use, and at 3 months postoperatively. The primary outcome was concordance in the degree of symptoms improvement between pessary use and surgery, as assessed by Patient Global Impression of Improvement (PGI-I). Secondary outcomes were related to prolapse specific symptoms on validated questionnaires (POPDI-6, PFIQ-7). The McNemar test was used for comparisons of discordant pairs for comparisons of the PGI-I ratings after pessary use and surgery.

Results

Sixty-one participants were enrolled (March 2016 through April 2019) and 58 patients used a pessary. Mean±standard deviation age was 60.7±10.7 years; 24.1% had prior hysterectomy, and 13.8% had prior prolapse surgery. While both treatments demonstrated symptomatic improvement, concordance in the degree of overall improvement on the PGI-I score was poor (n=40); responses significantly favored more improvement postoperatively (p<0.001). Pessary use and surgery were associated with significant improvements in prolapse symptoms from baseline on POPDI-6 (both p<0.001) and POPIQ-7 (pessary, p=0.002; surgery, p<0.001). The degree of improvement was larger postoperatively compared to post-pessary use on POPDI-6 (p<0.001) and PFIQ-7 (p=0.004).

Conclusions

Both pessary use and surgery significantly improved pelvic floor symptoms from baseline. However, concordance in degrees of improvement between these treatments was poor, with more favorable outcomes after surgery for prolapse symptoms.

Comparison of Pelvic Organ Prolapse Quantification and Simplified Pelvic Organ Prolapse Quantification Systems in Clinical Staging of Iranian Women with Pelvic Organ Prolapse

Background

Pelvic organ prolapse is a common pelvic disorder among women. A standard staging system is needed to carefully evaluate the extent and severity of the disease, and initiate appropriate treatment. The aim of this study was to compare the two methods of standard and simplified pelvic organ prolapse quantification systems in clinical staging of Iranian women with pelvic organ prolapse.

Methods

This observational cross-sectional study was conducted on all women with complaints of seeing or feeling a vaginal lump or bulge and/or a dragging sensation who were presented to a pelvic floor disorders clinic of Imam Khomeini Hospital in Tehran, Iran, from October 2018 to June 2019. All patients were evaluated in terms of pelvic organ prolapse severity and staging using both instruments. Also, length of time needed to complete the questionnaires were calculated. After data collection, the results of pelvic organ prolapse staging and degree of agreement between two examiners were evaluated.

Results

A total of 120 women with mean age of 50.92±13.12 years were evaluated. It was shown that there is an almost perfect agreement (kappa coefficient > 0.8) between standard and simplified pelvic organ prolapse quantification systems in all the 3 compartments. Also, there was almost a twofold increase in the time needed to perform standard pelvic organ prolapse quantification (4.16±1.01 minutes) compared to performing simplified pelvic organ prolapse quantification (2.12±1.14 minutes) (p=0.03).

Conclusion

According to the results of this study, there is a substantial and almost perfect agreement between standard and simplified pelvic organ prolapse quantification systems in clinical staging of Iranian women with pelvic organ prolapse. It seems that using simplified pelvic organ prolapse quantification system is more applicable in clinical practice for staging of pelvic organ prolapse, with high reliability coefficient.

Prevalence and associated factors of pelvic organ prolapse among women attending gynecologic clinic in referral hospitals of Amhara Regional State, Ethiopia

INTRODUCTION AND HYPOTHESIS

While pelvic organ prolapse is common in clinical observation, there is a lack of evidence regarding its actual proportion and associated factors in the study area. Understanding the prevalence and risk factors could potentially help with prevention. Thus, this study aimed to determine the prevalence and associated factors related to pelvic organ prolapse in the Amhara region, northwest Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted among 424 women, recruited by the systematic random sampling technique. Data were collected in a face-to-face interview using a structured and pre-tested questionnaire to assess the symptoms of pelvic organ prolapse and the socio-demographic, obstetric, gynecologic, medical and surgical characteristics. The stage of prolapse was determined by pelvic examination using the Simplified Pelvic Organ Prolapse Quantification staging system. Descriptive statistics and logistic regression analyses were employed.

RESULTS

The overall prevalence of pelvic organ prolapse (stage I-IV) was found to be 37.6% when determined by pelvic examination and 9.2% as assessed by prolapse symptoms. Age ≥ 40 years [AOR 2.46 (1.320, 5.314)], age at first delivery ≤ 20 years [AOR 4.719 (2.44, 9.11)], carrying heavy objects for ≥ 5 hours a day [AOR 12.724 (4.89, 33.07)], parity ≥ 4 [AOR 3.739 (1.693, 8.208)], prolonged labor [AOR 3.487 (1.699, 7.159)], constipation [AOR 2.835 (1.273, 6.317)] and anemia [AOR 2.22 (1.049, 4.694)] were significantly associated with pelvic organ prolapse.

CONCLUSION

Prevalence of pelvic organ prolapse is high in the area; thus, developing information and education programs on avoiding risk factors is advisable to reduce the problem.

Pelvic organ prolapse surgery and health-related quality of life: a follow-up study

BACKGROUND

Symptomatic prolapse impairs quality of life. Health-related quality of life (HRQoL) is considered an important outcome of pelvic organ prolapse (POP) surgery. However, it is rarely reported, and measures are inadequately used. Thus, studies reporting patient-reported surgical outcomes in low-income contexts are needed. This study aims to evaluate the effect of prolapse surgery on patient HRQoL and determine the predictive factors for change in HRQoL.

METHODS

A total of 215 patients who had prolapse stage III or IV were enrolled. Patients underwent vaginal native tissue repair, and their HRQoL was evaluated at baseline, 3 and 6 months postoperatively. Effect of surgery on subjective outcomes were measured using validated Prolapse Quality of Life (P-QoL-20), Prolapse Symptom Score (POP-SS), Body Image in Prolapse (BIPOP), Patient Health Questionnaire (PHQ-9), and Patient Global Index of Improvement (PGI-I) tools. A linear mixed-effect model was used to compare pre- and postoperative P-QoL scores and investigate potential predictors of the changes in P-QoL scores.

RESULTS

In total, 193 (89.7%) patients were eligible for analysis at 3 months, and 185 (86.0%) at 6 months. Participant's mean age was 49.3 ± 9.4 years. The majority of patients had prolapse stage III (81.9%) and underwent vaginal hysterectomy (55.3%). All domains of P-QoL improved significantly after surgery. Altogether more than 72% of patients reported clinically meaningful improvement in condition-specific quality of life measured with P-QoL-20 at 6 months. An improvement in POP-SS, BIPOP, and the PHQ-9 scores were also observed during both follow-up assessments. At 6 months after surgery, only 2.7% of patients reported the presence of bulge symptoms. A total of 97.8% of patients had reported improvement in comparison to the preoperative state, according to PGI-I. The change in P-QoL score after surgery was associated with the change in POP-SS, PHQ, BIPOP scores and marital status (p < 0.001). However, age, type of surgery, and prolapse stage were not associated with the improvement of P-QoL scores.

CONCLUSIONS

Surgical repair for prolapse effectively improves patient's HRQoL, and patient satisfaction is high. The result could be useful for patient counselling on the expected HRQoL outcomes of surgical treatment. Surgical service should be accessible for patients suffering from POP to improve HRQoL.

Prevalence and Risk Factors of Urinary/Anal Incontinence and Pelvic Organ Prolapse in Healthy Middle-Aged Iranian Women

Objectives

Urinary incontinence (UI) and anal incontinence (AI) cause concern, social exclusion, and ultimately reduced quality of life in women. The aim of present study was to assess the prevalence and related risk factors of UI, AI, and pelvic organ prolapse (POP).

Methods

The present study recruited 340 menopausal women living in Tabriz in northwest Iran. The data collection tools included the Pelvic Floor Distress Inventory-20 and a personal and social information questionnaire. POP was diagnosed via clinical examination using the simplified pelvic organ prolapse quantification system.

Results

The prevalence of UI and POP was approximately 50%, and approximately 16% of participants reported AI. Based on the odds ratios, the most remarkable risk factor of urinary stress incontinence was the number of vaginal deliveries, whereas that of urinary urge incontinence was obesity. Episiotomy and age were the most major risk factors of AI and POP, respectively.

Conclusions

The results of the present study showed that the prevalence of POP, UI, and AI is remarkably high among postmenopausal women, warranting the need to prioritize the assessment of POP and various incontinences in middle-aged women in the primary health care system. Furthermore, increased emphasis should be put on modifiable risk factors.

A new technique of laparoscopic fixation of the uterus to the anterior abdominal wall with the use of overfascial mesh in the treatment of pelvic organ prolapse

Introduction and hypothesis

Pelvic organ prolapse is one of the most common pathological conditions in postmenopausal women. There is still a lack of fully effective and safe surgical techniques, especially in the advanced stages of apical defects. The purpose of the video is to present a new technique of laparoscopic treatment in women with an advanced stage of genital prolapse, stage III and IV according to the POP-Q scale. The technique involves uterine fixation for the anterior abdominal wall using overfascial mesh.

Methods

We used a live-action surgical demonstration to describe laparoscopic fixation of the uterus to the anterior abdominal wall with the use of overfascial mesh.

Results

This video provides a step-by-step approach to laparoscopic fixation of the uterus to the anterior abdominal wall with the use of overfascial mesh. The video can be used to educate and train those performing female pelvic reconstructive surgery.

Conclusions

Based on our experience, this technique of laparoscopic suspension of the uterus to the anterior abdominal wall with the use of overfascial mesh is an effective, safe, and easy procedure for the treatment of advanced stages of pelvic organ prolapse.

Electronic supplementary material

The online version of this article (10.1007/s00192-020-04287-4) contains supplementary material. This video is also available to watch on http://link.springer.com/. Please search for this article by the article title or DOI number, and on the article page click on ‘Supplementary Material’

Pelvic organ prolapse in Northwest Ethiopia: a population-based study

INTRODUCTION AND HYPOTHESIS

Epidemiological studies aimed at pelvic organ prolapse and its risk factors can help to identify women at a higher risk and therefore promote prevention strategies. We aimed to assess the prevalence of and factors associated with symptomatic prolapse.

METHODS

A community-based study was conducted in Dabat district, Northwest Ethiopia. Initially, women were interviewed on their prolapse symptoms using validated questionnaires at their home. Subsequently, they were invited for pelvic examination and examined by gynecologists using the simplified pelvic organ prolapse quantification. Symptomatic prolapse was assessed by pelvic examination findings and patient-reported symptoms. Multivariate logistic regression was used to assess the factors associated with symptomatic prolapse.

RESULTS

A total of 880 women were interviewed and invited for pelvic examination, of whom 824 (93.6%) showed up for examination. Of the 824 women examined, 464 (56.3%) had POP stages II-IV and 145 (17.6%) had POP stages III-IV. The overall prevalence of symptomatic prolapse was 46.7% (217 out of 464). Of these, 41.0%, 42.8%, and 3.2% accounted for stage II, III, and IV respectively. Increasing age, multiparity, and heavy lifting/carrying significantly increased the odds of developing symptomatic prolapse.

CONCLUSIONS

Symptomatic prolapse affects a substantial proportion of women in the study area and increased with age. Multiparity and carrying heavy objects are associated with prolapse, all of which have the potential to be modified. More attention is needed to improve prevention, diagnosis, and treatment services to mitigate the health burden of these at-risk women.

Translation, transcultural adaptation, reliability and validation of the pelvic organ prolapse quality of life (P-QoL) in Amharic

BACKGROUND

The Prolapse Quality of Life (P-QoL) is a disease-specific instrument designed to measure the health-related quality of life in women with prolapse; however, there is no Amharic version of the instrument. The aim of this study were to translate the P-QoL into Amharic and evaluate its psychometric properties among adult women.

METHODS

We followed an intercultural adaptation procedure to translate and adapt the P-QoL. A forward-backward translation, face validity interviews with experts and cognitive debriefing of the translated version with ten adults from the target group were performed. The Amharic version was then completed by 230 adult women with and without POP symptoms. All women were examined using a simplified Pelvic Organ Prolapse Quantification (SPOP-Q) system. We examined internal consistency (Cronbach's alpha) and test-retest reliability (intraclass correlation coefficient = ICC). Confirmatory factor analysis (CFA) was conducted and model fit was discussed. We extracted a new factor structure by exploratory factor analysis (EFA). Criterion validity was also assessed against the SPOP-Q stage.

RESULTS

The translated measure was found acceptable by the experts and target group, with only minor adaptations required for the Amharic context. It had high internal consistency (α = 0.96) and test-retest reliability (ICC = 0.87; p <  0.001). In CFA results, the model fit indices were unacceptable (CFI = 0.69, RMSEA = 0.17, SRMR = 0.43, TLI = 0.65, and PCLOSE = 0.00). EFA extracted three-factor with satisfactory convergent and discriminant validity. The P-QoL median scores were significantly higher in symptomatic women (Mann-Whitney U Test; p <  0.001). The score was also significantly correlated with stage of prolapse (Spearman's correlation coefficient = 0.42 to 0.64, p <  0.001).

CONCLUSIONS

The P-QoL scale was successfully translated to Amharic and appears feasible, reliable and valid for Amharic-speaking women. Factor analysis confirmed a three-factor structure, inconsistent with the original English version. Further studies are needed to evaluate responsiveness of the Amharic P-QoL score.

The lucky ones get cured: Health care seeking among women with pelvic organ prolapse in Amhara Region, Ethiopia

Background

The majority of women suffering from maternal morbidities live in resource-constrained settings with diverse barriers preventing access to quality biomedical health care services. This study aims to highlight the dynamics between the public health system and alternative healing through an exploration of the experiences of health care seeking among women living with severe symptomatic pelvic organ prolapse in an impoverished setting.

Methods

The data were collected through ethnographic fieldwork at the hospital and community levels in the Amhara region of Ethiopia. The fieldwork included participant observation, 42 semi-structured interviews and two focus group discussions over a period of one year. A group of 24 women with severe symptomatic pelvic organ prolapse served as the study’s main informants. Other central groups of informants included health care providers, local healers and actors from the health authorities and non-governmental organisations.

Results

Three case stories were chosen to illustrate the key findings related to health care seeking among the informants. The women strove to find remedies for their aggravating ailment, and many navigated between and combined various available healing options both within and beyond the health care sector. Their choices were strongly influenced by poverty, by lack of knowledge about the condition, by their religious and spiritual beliefs and by the shame and embarrassment related to the condition. An ongoing health campaign in the study area providing free surgical treatment for pelvic organ prolapse enabled a study of the experiences related to the introduction of free health services targeting maternal morbidity.

Conclusions

This study highlights how structural barriers prevent women living in a resource-constrained setting from receiving health care for a highly prevalent and readily treatable maternal morbidity such as pelvic organ prolapse. Our results illustrate that the provision of free quality services may dramatically alter both health-and illness-related perceptions and conduct in an extremely vulnerable population.

Validation of the Amharic version of the Pelvic Organ Prolapse Symptom Score (POP-SS)

INTRODUCTION AND HYPOTHESIS

We aimed to translate and culturally adapt the Pelvic Organ Prolapse Symptom Score (POP-SS) into Amharic and evaluate its psychometric properties.

METHODS

We followed an intercultural adaptation procedure to translate and adapt the POP-SS. One hundred and eighty-six women with POP symptoms completed the Amharic POP-SS and Prolapse Quality of Life (P-QoL) questionnaires. All women were examined using a simplified Pelvic Organ Prolapse Quantification (SPOP-Q) system and were divided into four groups based on the POP-Q scores as stage 1, 2, 3, and 4. Internal consistency and test-retest reliability were determined using Cronbach's alpha and the intraclass correlation coefficient (ICC), respectively. Criterion validity was assessed against the SPOP-Q stage and the P-QoL scale. Furthermore, we tested construct validity using exploratory factor analysis.

RESULTS

The POP-SS score was successfully translated and achieved good content validity. It had high internal consistency (Cronbach's alpha = 0.86) and test-retest reliability (ICC = 0.81; p < 0.001). There was a statistically significant difference among four groups of stages in POP-SS score. and women with stage 3 had the highest median score (Kruskal-Wallis test; p < 0.05). The POP-SS score was also significantly correlated with the P-QoL score (Spearman's correlation coefficient = 0.28, p < 0.001). The exploratory factor analysis identified two factors, namely, physical symptoms and evacuation symptoms.

CONCLUSIONS

The POP-SS scale was successfully translated to Amharic and appears reliable and valid for women with symptoms of POP. However, further studies are needed to evaluate its responsiveness.

Five-year outcome after pelvic floor reconstructive surgery: evaluation using dynamic magnetic resonance imaging compared to clinical examination and quality-of-life questionnaire

Background Dynamic magnetic resonance imaging (dMRI) captures the entire pelvis during Valsalva maneuver and helps diagnosing pelvic floor changes after reconstructive surgery. Purpose To evaluate therapeutic outcome five years after reconstructive surgery using clinical examination, dMRI, and quality-of-life (QOL) questionnaire. Material and Methods Clinical examination, dMRI, and QOL questionnaire were conducted before surgery and in the follow-ups at 12 weeks, one year, and five years in women with pelvic organ prolapse (POP) stage ≥2. dMRI was performed at 1.5-T using a predefined protocol including sagittal T2-weighted (T2W) sequence at rest and sagittal T2W true-FISP sequence at maximum strain for metric POP measurements (reference points = bladder, cervix, pouch, rectum). Pelvic organ mobility (POM) was defined as the difference of the metric measurement at maximum strain and at rest. Results Twenty-six women with 104 MRI examinations were available for analysis. dMRI results mostly differ to clinical examination regarding the overall five-year outcome and the posterior compartment in particular. dMRI diagnosed substantially more patients with recurrent or de novo POP in the posterior compartment (n = 17) compared to clinical examination (n = 4). POM after five years aligns to preoperative status except for the bladder. POM reflects best the QOL results regarding defecation disorders. Conclusion A tendency for recurrent and de novo POP was seen in all diagnostic modalities applied. dMRI objectively visualizes the interaction of the pelvic organs and the pelvic floor after reconstructive surgery and POM correlated best with the women's personal impression on pelvic floor complaints.

Life after pelvic organ prolapse surgery: a qualitative study in Amhara region, Ethiopia

BACKGROUND

Women living in resource constrained settings often have limited knowledge of and access to surgical treatment for pelvic organ prolapse. Additionally, little is known about experiences during recovery periods or about the reintegration process for women who do gain access to medical services, including surgery. This study aimed to explore women's experiences related to recovery and reintegration after free surgical treatment for pelvic organ prolapse in a resource-constrained setting.

METHODS

The study had a qualitative design and used in-depth interviews in the data collection with a purposive sample of 25 participants, including 12 women with pelvic organ prolapse. Recruitment took place at the University of Gondar Hospital, Ethiopia, where women with pelvic organ prolapse had been admitted for free surgical treatment. In-depth interviews were carried out with women at the hospital prior to surgery and in their homes 5-9 months following surgery. Interviews were also conducted with health-care providers (8), representatives from relevant organizations (3), and health authorities (2). The fieldwork was carried out in close collaboration with a local female interpreter.

RESULTS

The majority of the women experienced a transformation after prolapse surgery. They went from a life dominated by fear of disclosure, discrimination, and divorce due to what was perceived as a shameful and strongly prohibitive condition both physically and socially, to a life of gradually regained physical health and reintegration into a social life. The strong mobilization of family-networks for most of the women facilitated work-related help and social support during the immediate post-surgery period as well as on a long-term basis. The women with less extensive social networks expressed greater challenges, and some struggled to meet their basic needs. All the women openly disclosed their health condition after surgery, and several actively engaged in creating awareness about the condition.

CONCLUSIONS

Free surgical treatment substantially improved the health and social life for most of the study participants. The impact of the surgery extended to the communities in which the women lived through increased openness and awareness and thus had the potential to ensure increased disclosure among other women who suffer from this treatable condition.

Current trends and future perspectives in pelvic reconstructive surgery

Pelvic organ prolapse is a prevalent disorder with a high lifetime incidence of surgical repair. Pelvic organ prolapse surgery has greatly evolved over the past years, and pelvic floor reconstructive surgeons are faced with a vast array of treatment options for their patients. Our review article illustrates the current trends and future perspectives for the surgical treatment of pelvic organ prolapse.

Living with pelvic organ prolapse: voices of women from Amhara region, Ethiopia

INTRODUCTION

The objective of the study was to explore how women with symptomatic pelvic organ prolapse in a low-income setting explain, experience, and handle the potential practical and social consequences of the condition.

METHODS

An explorative qualitative design was employed using in-depth interviews in the data collection. A total of 24 women with different degrees of symptomatic pelvic organ prolapse were included; 18 were recruited at the hospital and 6 from the community. Fieldwork was carried out in the Amhara region of northwest Ethiopia in 2011 and 2015.

RESULTS

The informants held that the pelvic organ prolapse was caused by physical strain on their body, such as childbirth, food scarcity or hard physical work, particularly during pregnancy and shortly after delivery. Severe difficulties and pain while carrying out daily chores were common among the women. The informants used a variety of strategies to manage their work while striving to avoid disclosure of their condition. Disclosure was related to embarrassment and fear of discrimination from people living close to them, including the fear of being expelled from the household. Most of the informants, however, experienced substantial support from relatives, friends, and at times also from their husband, after disclosing their condition.

CONCLUSIONS

The study highlights how symptomatic pelvic organ prolapse may severely affect women's lives in a low-income setting. The condition is perceived to be both caused by and aggravated by the heavy physical burdens of daily work.

Determinants and management outcomes of pelvic organ prolapse in a low resource setting

Background:

The last decade has seen significant progress in understanding of the pathophysiology, anatomy and management modalities of pelvic organ prolapse. A review of the way we manage this entity in a low resource setting has become necessary.

Aim:

The aim of the study is to determine the incidence, risk factors and management modalities of pelvic organ prolapse.

Materials and Methods:

A 5-year cross-sectional study with retrospective data collection of women who attended the gynecologic clinic in Nnamdi Azikiwe University Teaching Hospital, Nnewi, south-east Nigeria and were diagnosed of pelvic organ prolapse was made. Proforma was initially used for data collection before transfer to Epi-info 2008 (v 3.5.1; Epi Info, Centers for Disease Control and Prevention, Atlanta, GA) software.

Results:

There were 199 cases of pelvic organ prolapse, out of a total gynecologic clinic attendance of 3082, thus giving an incidence of 6.5%. The mean age was 55.5 (15.9) years with a significant association between prolapse and advanced age (P < 0.001). The age range was 22-80 years. The leading determinants were menopause, advanced age, multiparity, chronic increase in intra-abdominal pressure (IAP) and prolonged labor. Out of the 147 patients with uterine prolapse, majority, 60.5% (89/147) had third degree prolapse. Vaginal hysterectomy with pelvic floor repair was the most common surgery performed. The average duration of hospital stay following surgery was 6.8 (2.9) days and the most common complication was urinary tract infection, 13.5% (27/199). The recurrence rate was 13.5% (27/199). Most of the patients who presented initially with pelvic organ prolapse were lost to follow-up.

Conclusion:

The incidence of pelvic organ prolapse in this study was 6.5% and the leading determinants of pelvic organ prolapse were - multiparity, menopause, chronic increase in IAP and advanced age. Most were lost to follow-up and a lesser proportion was offered conservative management. Early presentation of women is necessary so that conservative management could be offered if feasible.

Comparative study to evaluate the intersystem association and reliability between standard pelvic organ prolapse quantification system and simplified pelvic organ prolapse scoring system

PURPOSE

The purpose of this study was to determine the association between the standard pelvic organ prolapse quantification (POPQ) classification system and the simplified pelvic organ prolapse (S-POP) classification system.

METHOD

This is an observational study, in which 100 subjects, whose average age was 60 ± 10 years, with pelvic floor disorder symptoms underwent two systems of examinations-POPQ classification system and S-POP classification system at Safdarjung hospital-done by four gynecologists (two specialists and two resident doctors) using a prospective randomized study, blinded to each other's findings. Data were compared using appropriate statistics.

RESULTS

The weighted Kappa statistics for the intersystem reliability of the S-POP classification system compared with standard POPQ classification system were 0.82 for the overall stage: 0.83 and 0.86 for the anterior and posterior vaginal walls respectively; 0.81 for the apex/vaginal cuff; and 0.89 for the cervix. All these results demonstrate significant agreement between the two systems.

CONCLUSION

There is almost perfect intersystem agreement between the S-POP classification system and the standard POPQ classification system in respect of the overall stage as well as each point within the same system.

Vaginal trachelectomy following laparoscopic supracervical hysterectomy and sacrocervicopexy

BACKGROUND

Current evidence supports cervical preservation at the time of abdominal prolapse repair using synthetic mesh to minimize vaginal mesh extrusion. This report aims to describe management of benign cervical disease following laparoscopic sacrocervicopexy including successful trachelectomy performed vaginally.

CASE

A 70-year-old sexually active woman presented with symptomatic pelvic organ prolapse and stress urinary incontinence. Her Papanicolaou smears over several years were unremarkable, and she had a benign endocervical polyp removed in the office 3 months before surgery. She underwent an uncomplicated robotic-assisted laparoscopic supracervical hysterectomy and sacrocervicopexy. She presented 8 months after surgery with persistent vaginal spotting after intercourse and was found to have a recurrent endocervical polyp. Ultimately, she underwent uncomplicated trachelectomy performed vaginally with resolution of her symptoms.

CONCLUSIONS

Retention of the cervix at the time of mesh-augmented abdominal prolapse repairs introduces a unique set of evaluation and management considerations for benign cervical disease. Trachelectomy performed vaginally was successful and uncomplicated in this case.

Depression among women with obstetric fistula, and pelvic organ prolapse in northwest Ethiopia

BACKGROUND

The prevalence of depression is not well studied among women with pelvic floor disorders. Hence, this study aimed to determine the prevalence of depression and its associated factors among women with pelvic floor disorders.

METHODS

A cross-sectional study was conducted among 306 women with one or more of the advanced pelvic floor disorders who attended at the gynaecologic outpatient clinic of Gondar university referral hospital in the six months data collection period. Women who complained of urinary or faecal incontinence or protruding mass per vagina were assessed and staged accordingly. Eligible women i.e. those with advanced pelvic organ prolapse or obstetric fistula were included consecutively. A structured questionnaire was used to obtain socio-demographic data and medical histories for all consenting women. Interviews were done by a female midwife nurse. Depression measures were obtained using the Beck's Depression Inventory (BDI) tool administered by the midwife nurse after intensive training. Data were entered into a computer using Epi Info version 3. 5.3, and then exported to SPSS version 20 for analysis. Multiple logistic regressions were fitted and Odds ratios with 95% confidence intervals were calculated to identify associated factors.

RESULTS

Of the 306 women interviewed, 269 had advanced pelvic organ prolapse (stages 3 and 4), 37 had obstetric fistula. All four women (100%) with both faecal and urinary incontinence, 97.0% those with urinary incontinence due to obstetric fistula and 67.7% of those with advanced pelvic organ prolapse (stages 3 and 4) had symptoms of depression. Depression was significantly associated with age 50 years or older (P < 0.01), marital status (P < 0.05), history of divorce (p < 0.01), self perception of severe problem (P < 0.05), and having stage 3 pelvic organ prolapse (P < 0.01).

CONCLUSION

Women with advanced pelvic organ prolapse, and obstetric fistula had high prevalence of depressive symptoms. A holistic management approach, including mental health care is recommended for women having such severe forms of pelvic floor disorders.

Pelvic floor disorders among women in Dabat district, northwest Ethiopia: a pilot study

INTRODUCTION AND HYPOTHESIS

Pelvic floor disorders affect many women in high-income countries. Since little is known about such disorders in Africa, this study aimed at assessing the prevalence and risk factors in an Ethiopian community. We also assessed the validity of a prolapse questionnaire.

METHODS

A community-based cross-sectional study was conducted among 395 women, recruited by a systematic random sampling technique. Women were interviewed about symptoms of urinary incontinence, faecal incontinence and pelvic organ prolapse by female nurses. Additionally, pelvic examinations were performed in 294 (74.2%) participants to assess anatomical prolapse using the simplified Pelvic Organ Prolapse Quantification staging system. Descriptive statistics and logistic regression analyses were employed.

RESULTS

The median age of participants was 35.0 years. Thirty-one women reported urinary incontinence (7.8%), 25 (6.3%) symptomatic pelvic organ prolapse and 2 (0.5%) faecal incontinence. Anatomical pelvic organ prolapse stage II-IV was detected in 162 (55.1%) of women who underwent pelvic examination. The questionnaire for prolapse assessment had poor validity (38.3% sensitivity and 95.4% specificity) even in cases of clinically relevant prolapse (stage III or IV). After adjustment, carrying heavy objects for 5 or more hours a day, history of prolonged labour and highland rural residence were associated with anatomical pelvic organ prolapse.

CONCLUSIONS

Self-reported incontinence seems low in northwest Ethiopia. The prevalence of symptomatic prolapse was low despite a high prevalence of prolapse signs. Notably, heavy carrying and prolonged labour increased the risk of anatomical prolapse stage II-IV. The methods of assessing pelvic floor disorders in a low-income context need further development.

Center-by-center results of a multicenter prospective trial to determine the inter-observer correlation of the simplified POP-Q in describing pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This study was conducted to determine the differences in the inter-observer agreement of the simplified Pelvic Organ Prolapse Quantification (POP-Q) system from center to center in a large international multicenter study.

METHODS

This is a secondary analysis of the results of a large prospective single blind multicenter trial studying the inter-observer agreement of a simplified POP-Q exam. Twelve centers from four continents with a total of 511 subjects were included in this study. The number of subjects recruited per center ranged from 20 to 81. Each patient was independently examined by two investigators, with examination order randomly assigned and investigators blinded to each other's result. The weighted kappa statistic was used to evaluate the inter-observer agreement.

RESULTS

Good and significant associations were observed on the anterior, posterior, and apical segments. Six out of 11 sites did not provide adequate number of subjects with prior hysterectomy for weighted kappa statistics or achieve significance regarding vaginal cuff measurement.

CONCLUSIONS

The simplified POP-Q demonstrated good inter-examiner agreement across multiple centers.

Motion estimation in ultrasound imaging applied to the diagnostic of pelvic floor disorders

The main purpose of this paper is to show the potential of tissue motion estimation in ultrasound imaging for the diagnostic of pelvic floor disorders. We propose to evaluate the tissue motion using a method based on a local deformable model and on image features (local phase and orientation) extracted from the monogenic signal. The proposed method is well adapted to the pelvic organ deformations and estimates motion with subpixel precision without the need for interpolation. The estimated motion is used to visualize the bladder local deformation and to extract quantitative figures such as the deformation parameters and the bladder angle variation. These results could potentially be interesting to characterize the degree of the pelvic organ prolapse.