Clinical and epidemiological aspects of pelvic floor dysfunction

Abstract

The overall objective of this thesis was to estimate the prevalence of symptomatic pelvic floor disorders, to study associations with putative risk factors and to evaluate surgical procedures for this condition.

Methods: Thirteen questions for identifying POP were constructed, and from these five questions were identified to in combination have a sensitivity of 92.5 % and a specificity of 94.5 % for POP. The final questionnaire was further tested and used in a cross-sectional study with 8000 randomly selected women, 30-79 years old, from the Swedish Population Register. Two hundred and eighty-two of these women underwent a gynaecological examination of the pelvic floor anatomy. Specificity and sensitivity in the survey were 66.5 and 94.2 % respectively for the short questionnaire. A case-control study was conducted with 454 women with self-reported symptomatic POP and 405 controls without symptoms randomly selected from the survey. All the women received a mailed questionnaire with 72 questions about factors suspected to be linked to risk, including obstetric history. To investigate long-term results of surgery we invited women, who underwent surgery for stress urinary incontinence or pelvic organ prolapse in 1985-92 for a follow-up visit.

Results: Of 5489 women providing adequate information in the cross-sectional study, 454 (8.3%) were classified as having symptomatic POP. The prevalence rose with increasing age but leveled off after menopause. Parity seems to be more important than age as indicator of pelvic organ prolapse prevalence. The prevalence of frequent genuine stress incontinence (GSI) was 8.9 % and that of frequent urge incontinence 5.9%. Urinary incontinence frequently co-occurs with pelvic organ prolapse. In the case-control study the response rate was 77 %. Indices of excessive stretching and tearing during labour (vaginal lacerations or/and episiotomies) were associated with increased risk of symptomatic POP. Instrumental delivery with forceps or vacuum did not seem to increase the risk of symptomatic POP, nor did length of delivery or maternal age at time for delivery. Abdominal delivery appeared to be protective for symptomatic POP. Abdominal colposuspension is an effective method for treatment of GSI. The objective cure rate for correcting GSI was higher (93 %) than the subjective cure rate (54 %). Urge symptoms before operation were a negative prognostic factor for a good outcome in terms of subjective cure of incontinence, but had no impact on objective cure rate or satisfaction of the operation. Subjective cure rate at follow-up visit for women operated on for POP, with curing of all symptoms of pelvic organ prolapse was 46%. Objective cure rate with satisfactory anatomical outcome was 56%. An unsatisfactory anatomical outcome was not necessarily associated with symptoms.

Conclusion: The prevalence of symptomatic POP was 8.3 %. The increase in prevalence with age halts after childbearing ages. Parity seems to be more important than age as an indicator of symptomatic POP prevalence. Excessive stretching and tearing during labour and multiple deliveries seem to be the main predisposing obstetric factors for symptomatic POP. Abdominal delivery emerged as a comparably protective strong factor. Objective outcome after surgery was higher than subjective outcome both for incontinence and prolapse surgery.