Pelvic organ prolapse : aspects of etiology, symptomatology and outcome after surgery

Abstract

The objective of this thesis was to increase the understanding of symptoms related to pelvic support defects, to study the influence of non-obstetric risk factors for pelvic organ prolapse, to describe short-term natural history in women with symptomatic prolapse and to evaluate outcome after surgery.

In a cross-sectional survey investigation of the age-specific prevalence of prolapse in Stockholm 8,000 women, 30-79 years of age, were randomly selected from the Swedish Population Register. All women were mailed a validated 5-item questionnaire for identification of symptomatic prolapse and 454 (8.3%) women gave self-reports that were consistent with symptomatic prolapse.

Two hundred and six women, randomly selected among the 454 women whose self-reports were consistent with POP, and 206 randomly selected women among the 5035 whose questionnaire answers did not indicate presence of POP, were invited to a standardized gynaecological examination. Two hundred eighty women, 160/206 women classified as having symptomatic prolapse and 120/206 as not having symptomatic prolapse were examined according to POP-Q by two gynecologists blinded to symptom reports. Anatomical findings were correlated to symptom reports (Paper I). Pelvic floor related symptoms could not predict the anatomical location of the prolapse. The feeling of a vaginal bulge was significantly associated with prolapse but a non-compartment specific symptom, stress urinary incontinence had a stronger association with posterior wall prolapse and no convincingly associations between bowel symptoms and prolapse were observed.

To investigate possible risk factors for symptomatic prolapse (Paper II) a 72-item questionnaire was mailed to all 454 cases classified in the initial survey investigation as having symptomatic prolapse and 405 control subjects. All of the 280 women who had undergone gynecological examination were included. Age, parity and family history of prolapse were the dominating risk factors but significant independent associations were found with conditions suggestive of deficient connective tissues (varicose veins, hernia, hemorrhoids) and non-obstetric strain on the pelvic floor (overweight/obesity, heavy lifts, and constipation) implying that individual predisposition and lifestyle may also play an important role.

To study short term natural history of prolapse (Paper III), a cohort consisting of the 160 examined women whose scores had been indicative of symptomatic prolapse and the 120 examined control women were followed up after 5 years with the same 5- item questionnaire and invited for reexamination according to POP-Q. Most symptomatic women reported a reduction of the key symptom vaginal bulging (64%; 95%CI 56-72%). Among the control women symptomatic prolapse developed in 2%. For the re-examined women, (n=188) few had an anatomical progression, asymptomatic women fared worse than the women classified with symptomatic prolapse.

Finally, in a prospective study (Paper IV) of women who underwent vaginal reconstructive surgery for pelvic organ prolapse (n=185) during a 3 -year period, anatomical and functional outcome was evaluated 1, 3 and 5 years postoperatively. Anatomical recurrences in operated compartment were 40.0% and prolapse in new compartment was 8.6%. Anterior compartment was most prone for recurrence. Urinary incontinence remained at the same level at one-year follow up. De novo urge occurred in 22.6 % and de novo stress incontinence 6.0 %. An improvement was seen in difficulty emptying bowel one year after surgery (54%). Patients were primarily cured from mechanical symptoms.