Vaginal prolapse--perceptions and healthcare-seeking behavior among women prior to gynecological surgery

Clinical and cost-effectiveness of pessary self-management versus clinic-based care for pelvic organ prolapse in women: the TOPSY RCT with process evaluation

Background

Pelvic organ prolapse is common, causes unpleasant symptoms and negatively affects women's quality of life. In the UK, most women with pelvic organ prolapse attend clinics for pessary care.

Objectives

To determine the clinical effectiveness and cost-effectiveness of vaginal pessary self-management on prolapse-specific quality of life for women with prolapse compared with clinic-based care; and to assess intervention acceptability and contextual influences on effectiveness, adherence and fidelity.

Design

A multicentre, parallel-group, superiority randomised controlled trial with a mixed-methods process evaluation.

Participants

Women attending UK NHS outpatient pessary services, aged ≥ 18 years, using a pessary of any type/material (except shelf, Gellhorn or Cube) for at least 2 weeks. Exclusions: women with limited manual dexterity, with cognitive deficit (prohibiting consent or self-management), pregnant or non-English-speaking.

Intervention

The self-management intervention involved a 30-minute teaching appointment, an information leaflet, a 2-week follow-up telephone call and a local clinic telephone helpline number. Clinic-based care involved routine appointments determined by centres' usual practice.

Allocation

Remote web-based application; minimisation was by age, pessary user type and centre.

Blinding

Participants, those delivering the intervention and researchers were not blinded to group allocation.

Outcomes

The patient-reported primary outcome (measured using the Pelvic Floor Impact Questionnaire-7) was prolapse-specific quality of life, and the cost-effectiveness outcome was incremental cost per quality-adjusted life-year (a specifically developed health Resource Use Questionnaire was used) at 18 months post randomisation. Secondary outcome measures included self-efficacy and complications. Process evaluation data were collected by interview, audio-recording and checklist. Analysis was by intention to treat.

Results

Three hundred and forty women were randomised (self-management, n = 169; clinic-based care, n = 171). At 18 months post randomisation, 291 questionnaires with valid primary outcome data were available (self-management, n = 139; clinic-based care, n = 152). Baseline economic analysis was based on 264 participants (self-management, n = 125; clinic-based care, n = 139) with valid quality of life and resource use data. Self-management was an acceptable intervention. There was no group difference in prolapse-specific quality of life at 18 months (adjusted mean difference -0.03, 95% confidence interval -9.32 to 9.25). There was fidelity to intervention delivery. Self-management was cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained, with an estimated incremental net benefit of £564.32 and an 80.81% probability of cost-effectiveness. At 18 months, more pessary complications were reported in the clinic-based care group (adjusted mean difference 3.83, 95% confidence interval 0.81 to 6.86). There was no group difference in general self-efficacy, but self-managing women were more confident in pessary self-management activities. In both groups, contextual factors impacted on adherence and effectiveness. There were no reported serious unexpected serious adverse reactions. There were 32 serious adverse events (self-management, n = 17; clinic-based care, n = 14), all unrelated to the intervention. Skew in the baseline data for the Pelvic Floor Impact Questionnaire-7, the influence of the global COVID-19 pandemic, the potential effects of crossover and the lack of ethnic diversity in the recruited sample were possible limitations.

Conclusions

Self-management was acceptable and cost-effective, led to fewer complications and did not improve or worsen quality of life for women with prolapse compared with clinic-based care. Future research is needed to develop a quality-of-life measure that is sensitive to the changes women desire from treatment.

Study registration

This study is registered as ISRCTN62510577.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/82/01) and is published in full in Health Technology Assessment; Vol. 28, No. 23. See the NIHR Funding and Awards website for further award information.

A mixed methods systematic literature review of barriers and facilitators to help-seeking among women with stigmatised pelvic health symptoms

BACKGROUND

Women's pelvic health is a globally important subject, included in international and United Kingdom health policies, emphasising the importance of improving information and access to pelvic health services. Consequences of pelvic symptoms are intimate, personal, and varied, often causing embarrassment and shame, affecting women's quality of life and wellbeing.

AIM

To understand the experience of seeking healthcare for stigmatised pelvic health symptoms by synthesising all types of published primary research and mapping the results to behavioural theory, to identify potential targets for intervention.

METHODS

Systematic search of MEDLINE, CINAHL, PsycINFO, SocINDEX, PubMED databases, CDSR and CENTRAL registers, from inception to May 2023 for all types of research capturing women's views and experiences of seeking help with stigmatised urogenital and bowel symptoms. Studies only reporting prevalence, predictors of help-seeking, non-health related help-seeking, or written in languages other than English, German, French, Spanish and Swedish were excluded. Reference checking and forward citation searching for all included studies was performed. A results-based synthesis approach was used to integrate quantitative and qualitative data. Themes were mapped to the Common-Sense model and Candidacy framework. The Mixed Methods Appraisal Tool was used for critical appraisal. Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research for assessing certainty of review findings.

RESULTS

86 studies representing over 20,000 women from 24 high income countries were included. Confidence was high that barriers to help-seeking were similar across all study types and pelvic symptoms: stigma, lack of knowledge, women's perception that clinicians dismissed their symptoms, and associated normalising and deprioritising of low bother symptoms. Supportive clinicians and increased knowledge were key facilitators.

CONCLUSIONS

Using the Common-Sense Model to explore women's help-seeking behaviour with stigmatised pelvic symptoms reveals problems with cognitive representation of symptom identity, emotional representations of embarrassment and shame, and a subjective norm that women believe their symptoms will be trivialised by clinicians. Together these barriers frustrate women's identification of their candidacy for healthcare. Addressing these issues through behavioural change interventions for women and clinicians, will help to achieve universal access to pelvic healthcare services (United Nations Sustainable Development Goal 3.7).

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021256956.

Inequality in healthcare-seeking behavior among women with pelvic organ prolapse: a systematic review and narrative synthesis

INTRODUCTION

Pelvic organ prolapse (POP) affects women's quality of life in various aspects. However, evidence on the healthcare-seeking behavior of women with POP is limited. Therefore, this review aimed to identify and synthesize the existing evidence on the healthcare-seeking behavior among women with POP.

METHODS

This systematic review and narrative synthesis of the literature on healthcare-seeking behavior among women with POP was conducted from 20 June to 07 July 2022. The electronic databases PubMed, African Journals Online, Cumulative Index to Nursing and Allied Health Literature, African Index Medicus and Directory of Open Access Journal, and Google Scholar were searched for relevant literature published from 1996 to April 2022. The retrieved evidence was synthesized using a narrative synthesis approach. The characteristics of included studies and the level of healthcare-seeking behavior were summarized in a table and texts. Error bar was used to show the variability across different studies.

RESULTS

A total of 966 articles were retrieved of which only eight studies with 23,501 women (2,683 women with pelvic organ prolapse) were included in the synthesis. The level of healthcare-seeking behavior ranges from 21.3% in Pakistan to 73.4% in California, USA. The studies were conducted in four different populations, used both secondary and primary data, and were conducted in six different countries. The error bar shows variation in healthcare-seeking behavior.

CONCLUSIONS

The level of health-care seeking behavior among women with POP is low in low-income countries. There is substantial variability in the characteristics of the reviewed studies. We recommend a large-scale and robust study which will help to better understand the healthcare-seeking behavior among women with POP.

Development of symptomatic pelvic organ prolapse over 10 years of mid-life follow-up is affected by occupational lifting and/or pushing for parous women

OBJECTIVE

To document the risk of new-onset symptomatic pelvic organ prolapse (POP) among perimenopausal women and examine whether occupational lifting and/or pushing is a risk factor in the development of POP over a 10-year follow-up window.

STUDY DESIGN

Secondary analysis of prospective, longitudinal data from the Study of Women's Health Across the Nation (SWAN) cohort study.

MAIN OUTCOME MEASURES

We analyzed women with current employment at the start of SWAN who were followed annually during mid-life. At baseline, women self-reported the frequency of occupational lifting and pushing, which was classified as Never, Infrequent (less than half the time), or Frequent (half the time or more) occupational lifting and/or pushing. Women were asked about new-onset symptomatic POP from the second to tenth annual follow-up. Modified Poisson regression was used to quantify crude and adjusted risk ratios (RRs) and 95 % confidence intervals (CIs) for POP according to load-bearing categories. Parous women were modelled separately, as initial analyses suggested effect modification by parity status.

RESULTS

In our sample of 1590 parous women, 8.2 % reported new-onset symptomatic POP over 10 years of follow-up. Multivariable analysis revealed that Infrequent (aRR 1.51, 95 % CI 1.04-2.20) and Frequent (aRR 2.03, 95 % CI 1.29-3.17) occupational lifting and/or pushing were associated with the development of POP.

CONCLUSION

Frequent occupational lifting and/or pushing significantly increased parous women's risk of developing POP symptoms. This strengthens existing evidence that occupational exposures can be risk factors for POP. Gender-based education and prevention strategies in the workplace and in primary health care are necessary to reduce the burden of this condition for mid-life women.

International Urogynaecology Consultation chapter 1 committee 4: patients' perception of disease burden of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reports on the patients' perception of disease burden associated with pelvic organ prolapse.

MATERIALS AND METHODS

An international group containing a team of eight urogynaecologists, a physiotherapist and a statistician performed a search of the literature using pre-specified search terms in PubMed and Embase (January 2000 to August 2020). The division of sections within this report includes: (1) perception of POP and the relationship with body image and poor health; (2) a vaginal bulge as it impacts health and wellbeing in women; (3) the impact of POP on sexual life; (4) body image and pelvic floor disorders; (5) POP and mood; (6) appropriate use of treatment goals to better meet patients' expected benefits; (7) using health-related quality of life questionnaires to quantify patients' perception of POP; (8) The financial burden of POP to patients and society. Abstracts were reviewed and publications were eliminated if not relevant or did not include populations with POP or were not relevant to the subject areas as noted by the authors. The manuscripts were next reviewed for suitability using the Specialist Unit for Review Evidence (SURE) checklists for cohort, cross-sectional and case-control epidemiologic studies.

RESULTS

The original individual literature searches yielded 2312 references of which 190 were used in the final manuscript. The following perceptions were identified: (1) women were found to have varying perceptions of POP including shame and embarrassment. Some regard POP as consequence of aging and consider there is no effective therapy. (2) POP is perceived as a vaginal bulge and affects lifestyle and emotional wellbeing. The main driver for treatment is absence of bulge sensation. (3) POP is known to affect frequency of sexual intercourse but has less impact on satisfaction. (4) Prolapse-specific body image and genital self-image are important components of a women's emotional, physical and sexual wellbeing. (5) POP is commonly associated with depression and anxiety symptoms which impact HRQoL although are not correlated with objective anatomical findings. (6) Patient-centered treatment goals are useful in facilitating communication, shared decision-making and expectations before and after reconstructive surgery. (7) Disease-specific HRQoL questionnaires are important tools to assess bother and outcome following surgery, and there are now several tools with Level 1 evidence and a Grade A recommendation. (8) The cost of POP to the individual and to society is considerable in terms of productivity. In general, conservative measures tend to be more cost-effective than surgical intervention.

CONCLUSIONS

Patients' perception of POP varies in different patients and has a far-reaching impact on their overall state of health and wellbeing. However, recognizing that it is a combination of body image and overall health (which affects mental health) allows clinicians to better tailor expectations for treatment to individual patients. There are HRQoL tools that can be used to quantify these impacts in clinical care and research. The costs to the individual patient (which affects their perception of POP) is an area that is poorly understood and needs more research.

A systematic review and meta-synthesis of qualitative studies on pelvic organ prolapse for the development of core outcome sets

AIMS

In the current climate of evidence-based health care, the aim of this meta-synthesis was to collect and systematically analyse data from primary qualitative studies on pelvic organ prolapse (POP), to identify patient-centered perspectives on the natural course of POP. Information acquired in this study may be useful for ongoing research towards the development of core outcome sets (COS) in pelvic floor disorders.

METHODS

A CHORUS Working Group performed a standardized search of three different databases (Medline, Embase, Scopus), from inception to October 2019. We selected qualitative studies on women's perspectives on POP that were published in the English language. Three reviewers independently evaluated the quality of eligible papers and highlighted recurrent themes based on patient perspectives.

RESULTS

Eighteen qualitative studies including a total of 497 patients were assessed in this analysis. Our study revealed five superordinate themes, recurrently encountered in qualitative studies on POP: awareness of POP (6 studies), communication (9 studies), treatments (10 studies), effects on quality of life (6 studies), and self-image (3 studies). Five out of 10 quality criteria were met by all the studies included, based on an assessment performed using the critical appraisal skills program.

CONCLUSIONS

This is the first synthesis of qualitative studies that address POP-related experiences of women, highlighting five superordinate themes, of which treatment was the most commonly reported one. This synthesis' findings may guide quantitative research priorities and will hopefully contribute to the development of a COS for POP.

Knowledge of pelvic floor disorders in women seeking primary care: a cross-sectional study

Background

Pelvic floor disorders including urinary incontinence (UI) and pelvic organ prolapse (POP) are common conditions; however, most women with these symptoms do not seek care. Failure to seek care may be related to misconceptions about these conditions. The aim of this study was to assess the baseline knowledge of UI and POP among adult women presenting to primary care clinics, as well as factors associated with knowledge levels.

Methods

A survey with questions from previously validated UI and POP knowledge questionnaires (PIKQ-UI and PIKQ-POP, respectively) was self-administered to a cross-sectional group of adult female patients presenting to three primary care clinics: geriatric, community-based, and hospital-based. Participants’ demographics and medical histories were compared using ANOVA or Kruskal-Wallis for continuous variables and Chi-square test or Fisher’s exact test for categorical variables. In order to compare various covariates with knowledge non-proficiency on PIKQ-UI and PIKQ-POP scales, unadjusted and adjusted ORs with 95% CIs were calculated using bivariate analysis and multivariate logistic regression, respectively.

Results

Of 346 participants, knowledge non-proficiency was similar and consistent across clinic sites and reached 72.0% for UI and 53.6% for POP. On multivariate analysis, lower educational attainment, being unaware of UI or POP as medical conditions, and having no history of care-seeking for these conditions were significantly associated with knowledge non-proficiency on UI, POP, or both.

Conclusions

Knowledge non-proficiency for UI and POP is common among women presenting for primary care. For UI, healthcare providers should assess patients’ actual understanding of the disease, especially among those with lower educational attainment, to eliminate any possible misconceptions. For POP, the focus should be on increasing awareness of this disease, as many women may have not previously heard of this condition. Simple strategies may increase knowledge in these areas and change care-seeking behaviors.

Study registration

None.

The role of ADAMTS-2, collagen type-1, TIMP-3 and papilin levels of uterosacral and cardinal ligaments in the etiopathogenesis of pelvic organ prolapse among women without stress urinary incontinence

OBJECTIVE(S)

To investigate the potential role of 'a disintegrin-like and metalloproteinase with thrombospondin type motifs-2 (ADAMTS-2), collagen type-1, tissue inhibitor of metalloproteinases-3 (TIMP-3) and papilin' levels in the uterosacral ligament (USL) and cardinal ligament (CL) of the uterus on the etiopathogenesis of pelvic organ prolapse (POP) among postmenopausal women without stress urinary incontinence (SUI).

STUDY DESIGN

A total of 45 postmenopausal women, 22 diagnosed as POP stage III-IV and 23 age- and body mass index (BMI)-matched controls referred for hysterectomy due to POP or benign gynecological disease, respectively, were recruited prospectively for our study. The biopsies of the USL and CL were obtained during hysterectomy. ADAMTS-2, collagen type-1, TIMP-3 and papilin levels were determined by enzyme-linked immunosorbent assay (ELISA) method after tissue homogenization. We excluded patients who smoked or presented with SUI.

RESULTS

There were no differences in terms of demographic features including age, BMI, obesity, duration of menopause, gravidity, parity, delivery modes and family history for POP between the POP and non-POP groups. Significant differences in the levels of ADAMTS-2, collagen type-1, TIMP-3 and papilin of USL were noted among the groups. Females with POP had lower levels of ADAMTS-2, collagen type-1, TIMP-3 and papilin in the USL compared to non-POP females. All investigated markers in the CL were also decreased in the POP group, but this relationship was not statistically significant. When age, duration of menopause, gravidity, parity and obesity were taken as covariates, only the USL papilin levels were negatively predictive for the development of POP.

CONCLUSION(S)

ADAMTS-2, collagen type-1, TIMP-3 and papilin levels of the USL play essential roles in the etiopathogenesis of POP among postmenopausal women without SUI. Moreover, significantly decreased USL papilin levels in females with POP suggest the importance of the USL and the impact of papilin on the development of POP.

The degree of bother and healthcare seeking behaviour in women with symptoms of pelvic organ prolapse from a developing gulf country

Background

The healthcare-seeking behaviour of women with pelvic organ prolapse (POP) is affected by several factors including the cultural background. There is limited number of studies which addressed the healthcare-seeking behaviour in women with POP. The aim of this study was to determine the degree of bother, social impact and healthcare seeking behaviour of symptoms of POP in one of the Gulf countries and compare the results to published data from other areas.

Methods

All women who attended the three family development centres in our city between January 2010 and January 2011 and who had symptoms suggestive of POP were included in the study. The data was collected by well-trained interviewers.

Results

One hundred twenty-seven women reported symptoms of POP (mean age: 38.2 years; range: 18–71). Out of these, 111 (87.4%) had at least one activity (physical, social or prayers) or sexual relationship affected by POP symptoms. In 49 women (38%), the effect on at least one of these activities or relationships has been described as moderate and in 18 women (14%), the effect was severe.

Sixty-nine women (54%) did not seek medical advice due to: embarrassment to see medical doctors (51%), the belief that POP is normal among women (51%), hope for spontaneous resolution (48%), embarrassment to see male doctors (33%) and unawareness of the existence of medical treatment (30%).

On univariate analysis, the need to insert the finger in the vagina to empty the bladder or bowel and the interference of symptoms with physical activities, had significantly determined healthcare seeking attitude (P < 0.05 for all). However, on multivariate analysis interference with physical activities was the only significant determinant (P = 0.04).

Conclusions

Although POP had affected the quality of life in the majority of the affected women, unlike some other societies, more than half failed to seek healthcare advice mainly due to shyness and embarrassment and lack of proper knowledge about the condition. Interference of symptoms with physical activities was the main significant determinants of healthcare-seeking behaviour. Additional teaching campaigns designed according to cultural backgrounds in each society are required to address these sensitive issues.

Counseling in urogynecology: A difficult task, or simply good surgeon-patient communication?

Surgical treatments for pelvic organ prolapse (POP) and urinary incontinence (UI) have greatly changed in recent years. Prompted by increases in reports of adverse outcomes in relation to such treatments, several scientific societies and researchers have emphasized providing patients with thorough counseling before treating them. Patient-centered communication has become the gold standard for excellence in clinical care. This challenges clinicians to be cognizant of their patients' perspectives, motivations, expectations, fears, concerns, and social contexts to enable them to reach a shared understanding with patients. Considering this, urogynecology counseling represents a crucial process through which women can gain a clear understanding of their clinical condition and the risks and benefits of potential treatment options. However, many urogynecologists believe that proposing a treatment and providing only enough detail to secure informed consent constitutes counseling. This article is intended to describe good counseling for women undergoing urogynecological surgery and to suggest optimal methodologies for implementation.

Climacteric women at work: What lurks behind poor occupational quality of life?

Physical and psychological changes during menopausal transition may affect various aspects of everyday functioning including women's work ability and work productivity. Presence of menopausal symptoms has been well-acknowledged to negatively affect quality of life (QOL). However, data on factors associated with occupational QOL among women at this period of life are lacking. The authors' purpose in this study was to evaluate factors affecting occupational QOL in a sample of employed mid-life women who are experiencing menopause. The authors performed a cross-sectional study among 335 employed women aged 40 to 65 years from Serbia. Socio-demographic questionnaire, Utian's Quality of Life Scale, and Beck's Depression Inventory were used in data collection. Women's average monthly household income and educational level were positively correlated, while having uterine prolapse was negatively associated with occupational QOL. Significant regression models assessing impact of gynecological illnesses and menopause-specific symptoms on occupational QOL (direct value and categories-below vs. above mean) showed that having insomnia, uterine prolapse, and genital inflammations may differentiate "good" from "poor" occupational QOL. Uterine prolapse, genital inflammation, and insomnia were associated with worse occupational QOL among working women in menopausal transition.

Are women adequately informed before gynaecological surgery?

BACKGROUND

Surgery for pelvic organ prolapse, urinary incontinence, and hysterectomy are the most common gynaecological surgeries that can affect the function of the bladder and bowel as well as one's sexual life. There is evidence that adequate patient information given preoperatively regarding expected outcomes of surgery is important because well-informed patients are more satisfied with the results of surgery and recover faster. However, there is little known about the amount and quality of information given to women before surgery. This study investigates whether women received information before gynaecological surgery on the effect of surgery with respect to the functioning of the bladder (micturition, ability to stay continent) and the bowel (empty bowel) as well as the surgery's effect on sexual functioning.

METHODS

A prospective, cross-sectional study was conducted. Women undergoing hysterectomy, surgery for vaginal prolapse, or surgery for urinary incontinence (n = 972) and included in the Swedish National Register for Gynaecological Surgery participated in the study. A questionnaire was developed and distributed to the women along with the preoperative questionnaire from the register.

RESULTS

About 50% of the women undergoing prolapse surgery were supplied with information regarding the effect of the surgery with respect to remaining continent, to emptying bowels, micturitaion, and sexual life. One out of four women undergoing hysterectomy received information about the effect of the surgery on the sexual life and bladder function. In the incontinence group, the given information about the surgery's effect on bladder function and sexual function was 80 and 30%, respectively.

CONCLUSION

Surgery in the vagina and the genital organs may affect function of the organs close to the surgical area (i.e., bladder and bowel) and may affect sexual function. According to this study, women are inadequately informed before surgery. Access to information via oral and written counselling needs to be improved.

Knowledge of pelvic organ prolapse in patients and their information-seeking preferences: comparing Vienna and Moscow

Introduction and hypothesis

We hypothesized that knowledge of pelvic organ prolapse (POP) and patient information-seeking preferences are the same in the two capital cities.

Methods

First-visit patients were recruited at tertiary referral urogynaecological units in Vienna (137) and in Moscow (112). A 16-item scale was used to assess the patient knowledge of POP. The 16 items comprised 12 specific items taken from the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) and four added items. The preliminary psychometric assessment of the knowledge scales in German and Russian was performed in the Vienna and in Moscow centres.

Results

The mean total knowledge scores in patients in Vienna and in Moscow were not significantly different: 9.7 ± 3.5 vs. 9.8 ± 2.9 (p = 0.92). Patients in Vienna were more likely to answer questions about the pathogenesis of POP correctly. Patients in Moscow achieved higher scores for items assessing knowledge about the diagnosis of POP. Women in the two study groups equally preferred to obtain information about POP from medical specialists (72 % and 82 %; p = 0.61), followed by friends and family for patients in Vienna (25 %), and the internet for patients in Moscow (23 %). Patients in Vienna were more likely to use printed sources (18 % and 7 %; p = 0.001) than patients in Moscow.

Conclusions

The mean level of knowledge of POP did not differ between patients in Vienna and patients in Moscow. The differences between the specific knowledge domains might be explained by different cultural preferences for seeking health information and by the range of the information sources available.

Two-year effects and cost-effectiveness of pelvic floor muscle training in mild pelvic organ prolapse: a randomised controlled trial in primary care

OBJECTIVE

To compare effects and cost-effectiveness of pelvic floor muscle training (PFMT) and watchful waiting in women with pelvic organ prolapse.

DESIGN

Randomised controlled trial.

SETTING

Dutch general practice.

POPULATION

Women (≥55 years) with symptomatic mild prolapse, identified by screening.

METHODS

Linear multilevel analysis.

MAIN OUTCOME MEASURES

Primary outcome was change of pelvic floor symptoms (Pelvic-Floor-Distress-Inventory-20 [PFDI-20]) during 24 months. Secondary outcomes were condition-specific and general quality of life, costs, sexual functioning, prolapse stage, pelvic floor muscle function and women's perceived improvement of symptoms.

RESULTS

PFMT (n = 145) resulted in a 12.2-point (95% CI 7.2-17.2, P < 0.001) greater improvement in PFDI-20 score during 24 months compared with watchful waiting (n = 142). Participants randomised to PFMT more often reported improved symptoms (43% versus 14% for watchful waiting). Direct medical costs per person were €330 for PFMT and €91 for watchful waiting but costs for absorbent pads were lower in the PFMT group (€40 versus €77). Other secondary outcomes did not differ between groups. Post-hoc subgroup analysis demonstrated that PFMT was more effective in women experiencing higher pelvic floor symptom distress at baseline.

CONCLUSION

PFMT resulted in greater pelvic floor symptom improvement compared with watchful waiting. The difference was statistically significant, but below the presumed level of clinical relevance (15 points). PFMT more often led to women's perceived improvement of symptoms, lower absorbent pads costs, and was more effective in women experiencing higher pelvic floor symptom distress. Therefore, PFMT could be advised in women with bothersome symptoms of mild prolapse.

TWEETABLE ABSTRACT

Pelvic floor muscle training can be effective in women with bothersome symptoms of mild prolapse.

Trends in hysterectomy for genital prolapse: rural experience

The present study was conducted to investigate the trends of vaginal hysterectomy for genital prolapse in last 20 years by analyzing case records of affected women.

During the analysis period, 4831 women underwent hysterectomy; records of 4223 (87.5%) were available. Of these, 911 (21.6%), 2.7% of 34,080 gynecological admissions, had vaginal hysterectomy for genital prolapse (study subjects).

Eighty percent women who had vaginal hysterectomy for genital prolapse were over 40 years of age; however, most of these women had had the disorder for years before they presented. Only 4 (0.4%) women had not given birth, 874 (96%) women had had two or more births, and 383 (42%) had had 5 or more births. Having given birth was the major factor responsible for genital prolapse. In all, 94.2% of women presented with something coming out of the vagina.” Some women presented with abnormal vaginal bleeding or pain in abdomen as the chief complaint although they had had uterovaginal prolapse for years.

There was no mortality and morbidity decreased over the years. There has been no change in the rate of vaginal hysterectomy for genital prolapse over the years. Surgical morbidity decreased trend, possibly because of the preoperative, intraoperative, and postoperative precautions taken, especially preoperative treatment of urinary and genital tract infection.

Attempts need to be made to have safe births and a healthy life style so as to prevent genital prolapse and in case it occurs, therapy to prevent progression so that major interventions like hysterectomy are averted. Meticulous preoperative evaluation and planned therapy help in reducing surgical morbidity, if surgery becomes essential.