Screening of the pelvic organ prolapse without a physical examination; (a community based study)

Value of pelvic examination in women with pelvic organ prolapse: A systematic review

BACKGROUND

Recent recommendations from the French High Authority of Health on pelvic organ prolapse (POP) management underline the value of a pelvic examination.

OBJECTIVES

The aim of this paper was to analyze the literature and identify the best evidence available regarding pelvic examination for women presenting prolapse-associated symptoms in terms of diagnosis and predictability of treatment success.

SEARCH STRATEGY

The databases were queried similarly using Medical Subject Headings (MeSH) and non-MeSH terms broadly related to pelvic examination and POP management.

SELECTION CRITERIA

We included studies assessing the diagnostic contribution of pelvic examination (correlation with symptoms) and its value for assessing the risk of pessary failure or recurrence after reconstructive surgery.

DATA COLLECTION AND ANALYSIS

We assessed peer-reviewed articles on PubMed, Embase, and Cochrane database up to May 2023. The methodological quality of all the included studies was assessed using the ROBINS-E or RoB2 tools.

MAIN RESULTS

In all, 67 studies were retained for the review. Prolapse-associated symptoms are poorly correlated with POP diagnosis. The symptom that is best correlated with the POP stage is the presence of a vaginal bulge (moderate to good correlation). The factors most strongly associated with the risk of recurrence after surgery or pessary failure are clinical: essentially a higher POP stage before surgery, levator ani muscle avulsion, and vaginal and genital measurements.

CONCLUSIONS

In women complaining of prolapse-associated symptoms, a pelvic examination (vaginal speculum and digital vaginal examination) can confirm the presence of POP and identify risk factors for treatment failure or recurrence after surgical management or pessary placement. A higher stage of POP and levator ani muscle avulsion-discernible on pelvic examination-are major risk factors for POP recurrence or treatment failure. These features must be taken into account in the treatment choice and discussed with the patient.

Worldwide Prevalence of Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis

Background

The prevalence of pelvic organ prolapse is varied in different countries. For validating the results of numerous studies on the prevalence of Pelvic organ prolapse in the world, a meta-analysis study seems necessary to provide an accurate and valid prevalence for planners and researchers in this field. Therefore, we aimed to investigate the worldwide prevalence of pelvic organ prolapse using the meta-analysis method.

Methods

By using valid keywords, searching was done in ISI Web of Science, PubMed, Scopus, and Medline databases, and 22 articles were selected based on inclusion criteria between 2009 and 2021. The quality of articles was checked using The Joanna Briggs Institute (JBI) checklist. Meta-analysis was performed on collected data using Comprehensive Meta-Analysis Software (CMA, Version 2). Meta-analysis of data was done with a random-effects model. The heterogeneity of the study was checked using the I2 index. Publication bias was assessed by the Egger test and funnel graph.

Results

The overall prevalence of included studies was 30.9% (95% confidence interval: 24.4-38.2%), (P<0.001, heterogeneity I2=99.8%). Meta-analysis of subgroups in studies that used a questionnaire to estimate the prevalence rate showed the prevalence was 25.0% and, in the studies, used the physical examination was 41.8%.

Conclusion

Studies carried out in different parts of the world have examined the prevalence of pelvic organ prolapse using different tools. Since some cases are asymptomatic, especially in the low stage of prolapse, physical examination of pelvic organ prolapse should be considered an essential tool in evaluating pelvic organ prolapse.

A situation analysis on postmenopausal women's self-care needs and priorities in Tehran: a population-based study

BACKGROUND

Women need special care during and after menopause. Due to the emphasis of the World Health Organization on promoting self-care in postmenopausal women, this study aims to analyze the situation and prioritize the self-care needs of postmenopausal women in the Tehran-Iran.

METHODS

This was a descriptive-analytical study on 486 postmenopausal women aged 46-85 years living in Tehran in 2021. The Subjects were recruited using a multi-stage sampling method. Data were collected using a socio-demographic and a valid and reliable questionnaire to assess postmenopausal women's self-care status with four domains including physical health, psychosocial health, reproductive-sexual health, and screening tests. The data were analyzed by SPSS-24.

RESULTS

The mean age of the participants was 62.58 ± 7.75 years. The mean score of self-care was 44.63 ± 21.64% in the postmenopausal women. The lowest score and highest scores were related to psychosocial health (25.12 ± 28.21%) and periodic tests (50.62 ± 24.40%) respectively. There were significant positive correlations between self-care with women's education level (r = 0.277; p < 0.001), husband's education level (r = 0.258; p < 0.001), as well as monthly income (r = 0.153; p = 0.001). There was a negative correlation between self-care with the number of children (r = - 0.215; p < 0.001). The level of self-care was higher in employed women (p = 0.001) and also, in women whose husbands were employed (p = 0.012). Multiple linear regression test showed the level of education of the husband (B = 2.72, p = 0.038) and the family size (B = -1.54, p = 0.023) are predictors of the self-care of postmenopausal women.

CONCLUSION

The findings showed more than 55% of challenges in the self-care behaviors of postmenopausal women in Tehran. The most and least challenging self-care behaviors were related to psychosocial health and performing periodic tests. The priorities were in psychosocial health and reproductive-sexual health dimensions. Self-care promotion is necessary, especially in postmenopausal women, who need special care due to various physical, psychological, and social changes.

Pelvic Organ Prolapse and its Associated Factors Among Women: A Facility Based Cross-sectional Study

Pelvic organ prolapse is the downward descent of female organs, including the bladder, small bowel, and large bowel, resulting in the protrusion of the vagina, uterus, or both. This disorder, exclusive to women, causes psychological trauma and social withdrawal, leading to an increased rate of gynecologic surgery. To assess the Pelvic Organ Prolapse and its associated factors among Women Visiting public Hospitals in south west Ethiopia. An institution-based cross-sectional study was conducted among gynecologic patients. A total sample size of 408 was allocated to the institutions proportional to their previous month's case load. Data were collected using an interviewer-administered structured questionnaire. The collected data were coded and entered into EpiData version 3.1, then exported to SPSS version 20 for descriptive and inferential analysis. Adjusted odds ratios (AOR) along with a 95% confidence level were estimated, and a P-value < .05 was considered statistically significant. Out of the intended sample size, 393 women participated in the study, resulting in a response rate of 96.3%. The overall magnitude of pelvic organ prolapse among the study participants was 19.8% (95% CI: 16.0, 24.1). Factors significantly associated with pelvic organ prolapse were place of residence (AOR = 2.21, 95% CI: 1.11, 4.40), parity (AOR = 2.82, 95% CI: 1.39, 5.72), age at first pregnancy (AOR = 2.32, 95% CI: 1.27, 4.26), and place of delivery of the first child (AOR = 4.18, 95% CI: 1.97, 8.85). The prevalence of pelvic organ prolapse is high. Place of residence, parity, age at first pregnancy, and place of delivery of the first child were factors significantly associated with pelvic organ prolapse. Therefore, different stakeholders, programmers, and implementers should take aggressive steps to prevent early pregnancy, train health professionals to encourage women to use family planning, and promote institutional delivery.

One in ten ever-married women who visited health facilities for various reasons have pelvic organ prolapse in Harari regional state, Eastern Ethiopia

Background

Pelvic organ prolapse remains a neglected public health problem in developing countries. The burden of pelvic organ prolapse varies by region and ranges from 9 to 20%. It poses an impact on women’s quality of life and affects their role at the community and family level. Although it has negative consequences and extensive burden, the true feature of pelvic organ prolapse is not well known among ever-married women attending health facilities for various reasons in the study area. Therefore, this study was aimed to assess the magnitude of pelvic organ prolapse and associated factors among ever-married women attending health care services in public Hospitals, Eastern Ethiopia.

Methods

A facility-based cross-sectional study design was conducted from March 4th to April 5th, 2020 among 458 ever-married women attending public Hospitals in Harar town, Eastern Ethiopia. The study subjects were selected through systematic sampling. The data were collected using a structured questionnaire through face-to-face interviews. Data were analyzed using SPSS version 22 (IBM SPSS Statistics, 2013). The prevalence was reported by proportion and summary measures. Predictors were assessed using a multivariable logistic regression analysis model and reported using an adjusted odds ratio with 95% CI. Statistical significance was declared at p-value < 0.05.

Result

Of 458 women enrolled in the study, 10.5% of them had pelvic organ prolapse based on women’s reporting of symptoms. History of lifting heavy objects [AOR = 3.22, 95% CI (1.56, 6.67)], history of chronic cough [AOR = 2.51, 95% CI (1.18, 5.31)], maternal age of greater than or equal to 55 years [AOR = 3.51, 95% CI (1.04, 11.76)], history chronic constipation (AOR = 3.77, 95% CI (1.54, 9.22) and no history of contraceptive utilization [AOR = 2.41, 95% CI (1.13, 5.05)] were significantly associated with pelvic organ prolapse.

Conclusion

In this study, one in ten ever-married women who visited health facilities for various reasons have pelvic organ prolapse. Modifiable and non-modifiable risk factors were identified. This result provides a clue to give due consideration to primary and secondary prevention through various techniques.

International Urogynecology Consultation: Patient Reported Outcome Measures (PROs) use in the evaluation of patients with pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Patient-reported outcome measure instruments include patient-reported outcomes (PROs) and patient-reported goals (PRGs), which allow practitioners to measure symptoms and determine outcomes of treatment that matter to patients.

METHODS

This is a structured review completed by the International Urogynecology Consultation (IUC), sponsored by the International Urogynecological Association (IUGA). The aim of this working group was to evaluate and synthesize the existing evidence for PROs and PRGs in the initial clinical work-up/evaluation and research arena for patients with pelvic organ prolapse (POP).

RESULTS

The initial search generated 3589 non-duplicated studies. After abstract review by 4 authors, 211 full texts were assessed for eligibility by 2 writing group members, and 199 studies were reviewed in detail. Any disagreements on abstract or full-text articles were resolved by a third reviewer or during video meetings as a group. The list of POP PROs and information on PRGs was developed from these articles. Tables were generated to describe the validation of each PRO and to provide currently available, validated translations.

CONCLUSIONS

All patients presenting for POP should be evaluated for vaginal, bladder, bowel and sexual symptoms including their goals for symptom treatment. This screening can be facilitated by a validated PRO; however, most PROs provide more information than needed to provide clinical care and were designed for research purposes.

Global burden and trends of pelvic organ prolapse associated with aging women: An observational trend study from 1990 to 2019

Purpose

Worldwide, about 40% of women will experience pelvic organ prolapse (POP), and this proportion is expected to increase with the aging of the population. We investigated the global, regional and national influenza burden in the past 30 years through the age and sociodemographic index (SDI).

Patients and methods

Data were extracted from the Global Burden of Disease (GBD) 2019 database for 195 countries and territories between 1990 and 2019. Estimated annual percentage changes (EAPCs) were used to explore the age-standardized incidence rate (ASIR) and age-standardized disability adjusted life years (AS-DALYs) trends, and the corresponding 95% uncertainty intervals (UI). In addition, the time cut-off points of 1990 and 2019 were used to separately analyze the incidence rate and DALYs.

Results

In 2019, the global ASIR and AS-DALYs for POP were 316.19 (95%UI: 259.84-381.84) and 10.37 (95%UI: 5.79-17.99) per 100,000 population, respectively. Moreover, from 1990 to 2019, the ASR of both showed a downward trend, and EAPCs were -0.46 (95%CI: -0.52 to -0.4) and -0.53 (95%CI: -0.58 to -0.47), respectively. In addition, DALYs of POP also showed a downward trend in most regions and countries with high SDI. From 1990 to 2019, the global incidence rate and DALYs rate were highest in the 65-75 and ≥60 age groups, respectively.

Conclusion

Over the past three decades, the incidence and DALY of POP have been decreasing from 1990 to 2019. However, POP remains a major health problem, especially among females in less developed countries. Primary and secondary prevention measures of POP should be integrated into the practice of healthcare professionals dealing with aging women.

Development and initial validation of a pictorial survey to assess for symptomatic pelvic organ prolapse and urinary incontinence in western Kenya

Introduction and hypothesis

Visual tools are a valuable tool for ascertaining patient symptoms, especially in populations with low literacy rates. The objective was to develop and validate a pictorial scale for assessing symptomatic pelvic organ prolapse (POP) and urinary incontinence among women in western Kenya.

Methods

Illustrations of POP, stress urinary incontinence (SUI), and urgency urinary incontinence (UUI) were developed by an artist. Virtual Zoom interviews were conducted with gynecology providers in Kisumu soliciting feedback on the illustrations. Cognitive interviews with patients were then conducted. Validation of the illustrations was performed against the gold standard of clinical history and examination amongst patients presenting for outpatient care at three Kisumu hospitals.

Results

Sixteen provider interviews were conducted. The illustrations were revised to reflect each disorder more clearly, and performed well during cognitive interviews with 8 patients (aged 21 to 76). One hundred patients were included in the validation study. Nine patients had symptomatic POP, whereas 32 had UUI and 25 had SUI. Sensitivity and specificity for the SUI illustration was 80% (95% CI 61–91%) and 97% (95% CI 72–98%) and for UUI they were 81% (95% CI 65–91%) and 99% (95% CI 92–100%) respectively. POP illustrations had lower sensitivity and specificity, with the best performing illustration having sensitivity of 67% (95% CI 35–88%) and specificity of 99% (95% CI 94–100%), which improved when only bulge or pressure symptoms were included.

Conclusions

We present a newly developed pictorial scale to assess for clinical urinary incontinence and POP that may be adapted and evaluated in other settings for clinical and research purposes.

Supplementary information

The online version contains supplementary material available at 10.1007/s00192-022-05214-5

Success and failure are dynamic, recurrent event states after surgical treatment for pelvic organ prolapse

BACKGROUND

The ideal measure of success after surgery for pelvic organ prolapse has long been debated. Historically, strict definitions based on anatomic perfection have dominated the literature. However, the importance of patient-centered perception of outcomes is equally or more important when comparing the success of various prolapse surgeries. Understanding the limitations of existing outcome definitions will guide surgical outcome reporting and comparisons of pelvic organ prolapse surgeries.

OBJECTIVE

This study aimed to describe the relationships and overlap among the participants who met the anatomic, subjective, and retreatment definitions of success or failure after pelvic organ prolapse surgery; demonstrate rates of transition between success and failure over time; and compare scores from the Pelvic Organ Prolapse Distress Inventory, Short-Form Six-Dimension health index, and quality-adjusted life years among these definitions.

STUDY DESIGN

Definitions of surgical success were evaluated at 3 or 6, 12, 24, 36, 48, and 60 months after surgery for ≥stage II pelvic organ prolapse in a cohort of women (N=1250) from 4 randomized clinical trials conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Surgical failure was defined by a composite measure requiring 1 or more of (1) anatomic failure (Pelvic Organ Prolapse Quantification point Ba, Bp, or C of >0), (2) subjective failure (presence of bothersome vaginal bulge symptoms), or (3) pessary or surgical retreatment for pelvic organ prolapse. Pelvic Organ Prolapse Distress Inventory, Short-Form Six-Dimension health index, and quality-adjusted life years were compared among participants who met a variety of definitions of success and failure including novel "intermittent" success and failure over time.

RESULTS

Among the 433 of 1250 women (34.6%) who had surgical failure outcomes at ≥1 time point, 85.5% (370 of 433) met only 1 component of the composite outcome at the assessment of initial failure (anatomic failure, 46.7% [202 of 433]; subjective failure, 36.7% [159 of 433]; retreatment, 2.1% [9 of 433]). Only 12.9% (56 of 433) met the criteria for both for anatomic and subjective failure. Despite meeting the criteria for failure in primary study reporting, 24.2% of these (105 of 433) transitioned between success and failure during follow-up, of whom 83.8% (88 of 105) met the criteria for success at their last follow-up. There were associations between success or failure classification and the 1- and 2-year quality-adjusted life years and a time-varying group effect on Pelvic Organ Prolapse Distress Inventory and Short-Form Six-Dimension health index scores.

CONCLUSION

True failure rates after prolapse surgery may be overestimated in the current literature. Only 13% of clinical trial subjects initially met both subjective and objective criteria for failure. Approximately one-quarter of failures were intermittent and transitioned between success and failure over time, with most intermittent failures being in a state of "surgical success" at their last follow-up. Current composite definitions of success or failure may result in the overestimation of surgical failure rates, potentially explaining, in part, the discordance with low retreatment rates after pelvic organ prolapse surgery.

Burden of pelvic organ prolapse in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Pelvic organ prolapse can significantly affect a woman's quality of life by compromising physical, social, psychological and sexual function. Pelvic organ disorders and its consequences have higher economic burden to the patient as well to the country. Therefore, this systematic review and met- analysis aimed to estimate the burden of POP in Ethiopia.

METHODS

International databases (MEDLINE/Pub Med, Hinari, Scopus, Google scholar, African journals and literatures were searched and seven eligible cross sectional and two case control studies were included in this systematic review and meta-analysis. Eggers test and funnel plot were computed to check publication bias across the studies. Publication bias was computed using a funnel plot and eggers test. Heterogeneity of the studies was checked using Cochrane Q-test and I2 statistic. Subgroup analysis was computed for the evidence of heterogeneity.

RESULTS

This systematic review and meta-analysis revealed that the overall national prevalence of pelvic organ prolapse in Ethiopia was 23.52% (95% CI: 61.04, 80.24). Being rural resident (AOR = 3.29; 95% CI: 1.38-7.85), I2 = 47.5%, P = 0.167), having < 18.5 BMI (AOR = 2.59; 95% CI: 1.53-4.4), I2 = 59.9%, P = 0.64), and age > 40(AOR = 7.43; 95% CI: 2.27-24.29), I2 = 75.9%, P = 0.016) were the associated risk factors for pelvic organ prolapse.

CONCLUSIONS

The pooled prevalence of pelvic organ prolapse was high. Residence, body mass index and age of the women were the predictors of pelvic organ prolpase. Creating awareness and identifying the modifiable and non modifiable risk factors for pelvic organ prolpase is a crucial strategy to prevent further complications and risk of operation.

Validation of the Pelvic Organ Prolapse Simple Screening Inventory (POPSSI) in a population of Ethiopian women

Background

The incidence of Pelvic Organ Prolapse (POP) in the developing world is not known. A nonclinical screening tool for prolapse is needed in the resource poor setting. In this study, we aim to determine the validity of the Pelvic Organ Prolapse Simple Screening Inventory (POPSSI) for detection of POP in a population of women at two academic hospitals in Addis Ababa, Ethiopia.

Methods

Women from two teaching hospitals in Addis Ababa, Ethiopia were recruited to complete the POPSSI questionnaire as well as a Pelvic Organ Prolapse Quantification (POP-Q) exam. Descriptive data on exam findings were collected. Questionnaire responses were then correlated to exam findings and data analyzed to determine the validity of this test as a screening tool for prolapse in our patient population.

Results

Majority of the women with POP had advanced stage. The sensitivity and specificity of the POPSSI for identifying pelvic organ prolapse in our study patient population was 91.7 and 60.6% respectively.

Conclusion

The POPSSI has a high sensitivity for detecting women with POP. “Feeling or seeing bulge” had a higher sensitivity and specificity.

Immunohistochemical expression of hypoxia-inducible factor-1α in stromal cells of vaginal tissue in post-menopausal women with pelvic organ prolapse

Background & objectives:

Pelvic organ prolapse (POP) is a common medical condition that affects adult women of different ages. The support of a normal pelvic floor is the result of complex interactions between ligaments, muscles, connective tissue and vaginal walls. Hypoxia and oxidative stress can reduce protein synthesis in the pelvic muscles that may contribute to muscular atrophy. Hypoxia-inducible factor-1α (HIF-1α) is a transcriptional activator which, expressed in response to hypoxia, activates a number of genes involved in cellular response to hypoxia. However, a potential role of hypoxia and oxidative stress in pathogenesis of POP is not known. This study was aimed to compare the level of HIF-1α immunohistochemical expression in the vaginal stromal cells of postmenopausal women with and without POP.

Methods:

Samples of the vaginal tissue from 120 menopausal women were obtained during surgery, and immunohistochemical expression of HIF-1α was assessed. There were 60 women with POP while 60 women in the control group were without prolapse but with benign gynaecological diseases.

Results:

In post-menopausal women with prolapse, significant differences were observed in the number of HIF-1α-positive stromal cells in the vaginal tissue compared to the control group. There was a significant increase in the number of HIF-1α in the stromal cells of the vaginal tissue in women with prolapse.

Interpretation & conclusions:

Difference in expression of HIF-1α in stromal cells of the vaginal tissue in the post-menopausal women with and without POP suggests that prolonged hypoxia probably has an important role in the aetiopathogenesis of POP.

The Annual Gynecologic Examination Updated for the 21st Century

The concept of an annual gynecologic screening visit to identify disease at an early stage has long been an established component of women's health care. Women and their health care providers have historically accepted the schedule of an annual gynecologic examination with cervical cancer screening and a pelvic examination. Recently, researchers questioned the value of the annual breast and pelvic examinations in asymptomatic women and re-established the intervals for Pap test screening with the addition of human papillomavirus co-testing to establish cervical cancer risk. The updated well woman examination is now an opportunity to engage women in health education, screening for chronic disease risks, and health care concerns such as depression and violence.

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.