Prevalence of anal incontinence in women with symptoms of urinary incontinence and genital prolapse

OBJECTIVE: To investigate risk factors and prevalence of anal incontinence among women with pelvic floor dysfunctions. METHODS: We evaluated 881 women with symptoms of urinary incontinence and/or genital prolapse. Each completed a bowel questionnaire and underwent a detailed medical, surgical, obstetric, and gynecologic history, and a pelvic examination. Additional testing, when indicated, included office cystometry or multichannel urodynamic evaluation. Multivariable analysis using logistic regression was used to test the overall significance of all variables significantly associated with anal incontinence, using univariate analysis. RESULTS: A total of 178 women had anal incontinence (20%). These patients were on average older, had a greater body mass index, and had larger birth weight infants than their anal-continent counterparts; 511 were diagnosed with urinary incontinence, and 122 (24%) also had anal incontinence. Women with urinary incontinence were more likely to report anal incontinence events than women continent of urine (24% versus 15%, P =.002). The following associations were found with anal incontinence: infant with birth weight 3800 g or greater (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1, 2.2), rectocele greater than grade 2 (OR 1.9, 95% CI 1.1, 3.3), urinary incontinence (OR 1.9, 95% CI 1.3, 2.8), hemorrhoidectomy (OR 2.7, 95% CI 1.1, 7.0), irritable bowel syndrome (OR 6.3, 95% CI 3.5, 11.5). CONCLUSION: Among women with symptoms of urinary incontinence and pelvic organ prolapse, the prevalence of anal incontinence was 20%. Urinary incontinence and severe rectocele were found to be associated with anal incontinence.     

Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders

OBJECTIVE: To evaluate the psychometric properties of the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ). METHODS: The PFDI and PFIQ are based on the structure and content of two previously validated questionnaires (the Urinary Distress Inventory [UDI] and the Incontinence Impact Questionnaire [IIQ]) and have additional questions regarding pelvic organ prolapse and colorectal dysfunction. The PFDI assesses symptom distress in women with pelvic floor disorders and has 3 scales: UDI (28 items), Colorectal-anal Distress Inventory (17 items), and Pelvic Organ Prolapse Distress Inventory (16 items). The PFIQ assesses life impact and also has 3 scales: IIQ, Colorectal-anal Impact Questionnaire, and the Pelvic Organ Prolapse Impact Questionnaire (31 items each). One hundred women with pelvic floor symptoms were enrolled and completed both the PFDI and PFIQ at baseline and again 1 week later. Patients underwent a comprehensive evaluation that included a structured history, Pelvic Organ Prolapse Quantitation, and a 1-week prospective bowel/bladder diary. Patients with urinary incontinence and stage III or IV pelvic organ prolapse also had a urodynamic evaluation. RESULTS: Each scale of the PFDI and PFIQ proved to be internally consistent (alphas: PFDI.82-.89; PFIQ.96-.97) and reproducible (interclass correlations: PFDI.86-.87; PFIQ.77-.92). Both the UDI and the IIQ significantly correlated with the number of urinary incontinence episodes per week (rho =.26, P <.05; rho =.46, P <.0001, respectively) and the number of pads used per week (rho =.26, P <.05; rho =.40, P <.0001, respectively). The Pelvic Organ Prolapse Distress Inventory and the Pelvic Organ Prolapse Impact Questionnaire significantly correlated with the stage of prolapse (rho =.32 and rho =.33, P <.01 each), and the Colorectal-anal Distress Inventory and Colorectal-anal Impact Questionnaire significantly correlated with the number of fecal incontinence episodes per month (rho =.49, P <.0001 and rho =.30, P <.01) and a diagnosis of defecatory dysfunction (rho =.47, P <.0001 and rho =.29, P <.01). The total time taken to complete both instruments averaged 23 minutes (range, 9-55). CONCLUSION: The PFDI and the PFIQ are reliable, valid, condition-specific quality of life instruments for women with pelvic floor disorders.     

Anal incontinence in women with and those without pelvic floor disorders

OBJECTIVE: To compare the prevalence of anal incontinence and anal sphincter injury in women with pelvic floor disorders (cases) with those in a group of normal control subjects and to evaluate the relationship between sphincter injury and anal incontinence in each group. METHODS: We previously reported the results of a cross-sectional study of 100 women with pelvic floor disorders (> or = stage II pelvic organ prolapse and/or urinary incontinence). In this study, we compared those cases with 90 controls (stage 0 or I pelvic organ prolapse and no urinary incontinence) who completed the Rockwood-Thompson fecal incontinence severity index, in which scoring (0-61) is based on the frequency and type of anal incontinence. All women underwent endoanal ultrasonography, and the internal and external anal sphincters were reported as intact versus disrupted. Chi-square test, Student t test, and logistic regression were used for statistical analysis. RESULTS: Women with pelvic floor disorders were significantly more likely to report anal incontinence (54% versus 17.8%, odds ratio [OR] 5.4, 95% confidence interval [CI] 2.8-10.6, P < .001) and had higher mean fecal incontinence severity index scores (22.3 +/- 13 versus 12.7 +/- 6.3, P = .006) than controls. Cases demonstrated higher rates of anal sphincter defects on ultrasound examination than did controls (52% versus 30%, P = .007). Anal incontinence was significantly associated with anal sphincter injury in women with pelvic floor disorders (OR 36.4, 95% CI 12-114, P < .001) and in controls (OR 5.9, 95% CI 3-11, P = .002). CONCLUSION: Anal incontinence was more common in women with pelvic floor disorders than normal controls and may be due to higher rates of anatomic anal sphincter disruption in this group.     

Determinants of urinary incontinence in a population of young and middle-aged women

BACKGROUND: Urinary incontinence and genital prolapse are prevalent conditions in the female population. The aim of this study was to study possible determinants of female urinary incontinence in a population-based sample of young and middle-aged women. METHODS: Of 641 eligible women aged 20-59 years in a primary health care district, 487 (76%) responded to a questionnaire and accepted an invitation to a gynecological examination. The examination included digital assessment of the pelvic floor muscle strength (PFMS). Genital prolapse presence (cystocele, rectocele, uterine prolapse or absence of the urethrovesical crease) was graded in relation to the vaginal introitus. RESULTS: The prevalence of urinary incontinence was 28%, 3.5% having daily leakage. Stress urinary incontinence was the dominant type. The odds ratio (OR) of having incontinence increased from 1 to 3.5 with increasing age and from 1 to 2.7 with increasing parity. The OR also increased with decreasing PFMS; from 1 in the group with the best PFMS to 3.4 in the group unable to contract their pelvic musculature. In addition, women with cystocele and/or absence of the urethrovesical crease had a 2.5-fold increased OR of incontinence (95% CI 1.5-4.2), smoking increased the OR 1.9 times (95% CI 1.1-3.2) and estrogen replacement therapy (ERT) increased the OR 2.9 times (95% CI 1.4-5.9). There were no significant correlations with the presence of chronic disease, episiotomy or the birth weights of children but small non-significant correlations with performed hysterectomy and the woman's weight. CONCLUSIONS: Urinary incontinence is a frequent symptom in the female general population and related to age, pelvic floor muscle strength, genital prolapse, smoking, parity and estrogen replacement therapy.     

Sexual function in women with urinary incontinence and pelvic organ prolapse

OBJECTIVE: To compare sexual function in women with urinary incontinence and pelvic organ prolapse and to determine the effects of therapy on sexual function. METHODS: 343 community-dwelling women older than 45 years with urinary incontinence or advanced prolapse were recruited into a multi-armed clinical trial. Women with incontinence were stratified to receive estrogen therapy, behavioral therapy, or surgical therapy. Women with prolapse were enrolled in a randomized surgical trial. All women completed a standardized urogynecologic evaluation and a sexual function questionnaire at baseline and after therapy. RESULTS: Women with prolapse or detrusor instability were more likely to cite pelvic floor symptoms as a reason for sexual inactivity than were women with other conditions. One third of patients with prolapse reported that their pelvic floor condition affected their ability to have sexual relations "moderately" or "greatly" significantly more than did other groups. Patients with genuine stress incontinence who underwent surgical or behavioral therapy were less likely to report being worried about urine leakage during intercourse after therapy than at baseline. After surgery, women with prolapse were less likely to report that their symptoms affected their ability to have sexual relations compared with baseline. Overall sexual satisfaction was the same at baseline and remained unchanged in all therapeutic groups at 6 months. CONCLUSION: Prolapse is more likely than urinary incontinence to result in sexual inactivity and to be perceived as affecting sexual relations. However, overall sexual satisfaction appears to be independent of diagnosis of or therapy for urinary incontinence or prolapse.     

Prevalence of urinary and fecal incontinence and symptoms of genital prolapse in women

BACKGROUND: Urinary incontinence is common in women. How often incontinence occurs has been only briefly investigated. Studies on the prevalence of fecal incontinence are few. The epidemiology of genital prolapse symptoms is unknown. This epidemiological study describes a general population of women aged 40 and 60 years with regard to the prevalence and frequency of urinary and fecal incontinence and the prevalence of genital prolapse symptoms. METHODS: A questionnaire on medical background, urinary and fecal incontinence, and genital prolapse symptoms was sent to 1000 40-year-old and 1000 60-year-old randomly selected women. RESULTS: Sixty-seven per cent answered: 53% were continent for urine; 9% of the 40-year-olds and 19% of the 60-year-olds had urinary incontinence weekly or more often. Detrusor instability score was significantly higher in the 60-year-olds. Incontinence of flatus, weekly or more often, was reported by 9% and 19%, loose feces by 5% and 8%, and solid feces by 0.3% and 1.7% according to the 40- and 60-year-olds, respectively. Fifty-three per cent reported no flatus incontinence. Of the prolapse symptoms investigated, 15% of the females reported pelvic heaviness, 4% genital bulge, and 12% use of fingers in the vagina or perineum by defecation. CONCLUSIONS: Incontinence of urine is common in this population. Flatus incontinence is as common, but the concept must be operationalized if used as an endpoint in research. The International Continence Society's (ICS) definition of urinary incontinence is unpractical for use in epidemiological research. We suggest leakage weekly or more often as a criterion for significant incontinence in epidemiological research.     

Parity, mode of delivery, and pelvic floor disorders

OBJECTIVE: This study aimed to assess the associations between parity, mode of delivery, and pelvic floor disorders. METHODS: The prevalence of pelvic organ prolapse, stress urinary incontinence, overactive bladder, and anal incontinence was assessed in a random sample of women aged 25-84 years by using the validated Epidemiology of Prolapse and Incontinence Questionnaire. Women were categorized as nulliparous, vaginally parous, or only delivered by cesarean. Adjusted odds ratios and 95% confidence intervals (CIs) for each disorder were calculated with logistic regression, controlling for age, body mass index, and parity. RESULTS: In the 4,458 respondents the prevalence of each disorder was as follows: 7% prolapse, 15% stress urinary incontinence, 13% overactive bladder, 25% anal incontinence, and 37% for any one or more pelvic floor disorders. There were no significant differences in the prevalence of disorders between the cesarean delivery and nulliparous groups. The adjusted odds of each disorder increased with vaginal parity compared with cesarean delivery: prolapse = 1.82 (95% CI 1.04-3.19), stress urinary incontinence = 1.81 (95% CI 1.25-2.61), overactive bladder = 1.53 (95% CI 1.02-2.29), anal incontinence = 1.72 (95% CI 1.27-2.35), and any one or more pelvic floor disorders = 1.85 (95% CI 1.42-2.41). Number-needed-to-treat analysis revealed that 7 women would have to deliver only by cesarean delivery to prevent one woman from having a pelvic floor disorder. CONCLUSION: The risk of pelvic floor disorders is independently associated with vaginal delivery but not with parity alone. Cesarean delivery has a protective effect, similar to nulliparity, on the development of pelvic floor disorders when compared with vaginal delivery. LEVEL OF EVIDENCE: II-2.     

Fecal and urinary incontinence in primiparous women

OBJECTIVE: To prospectively investigate the relationship between anal sphincter tears and postpartum fecal and urinary incontinence. METHODS: The Childbirth and Pelvic Symptoms study was a prospective cohort study performed by the Pelvic Floor Disorders Network to estimate the prevalence of postpartum fecal and urinary incontinence in primiparous women: 407 with clinically recognized anal sphincter tears during vaginal delivery, 390 without recognized sphincter tears (vaginal controls), and 124 delivered by cesarean before labor. Women were recruited postpartum while hospitalized and interviewed by telephone 6 weeks and 6 months postpartum. We assessed fecal and urinary incontinence symptoms using the Fecal Incontinence Severity Index and the Medical, Epidemiological, and Social Aspects of Aging Questionnaire, respectively. Odds ratios were adjusted for age, race, and clinical site. RESULTS: Compared with the vaginal control group, women in the sphincter tear cohort reported more fecal incontinence (6 weeks, 26.6% versus 11.2%; adjusted odds ratio [AOR] 2.8, 95% confidence interval [CI] 1.8-4.3; 6 months, 17.0% versus 8.2%; AOR 1.9, 95% CI 1.2-3.2), more fecal urgency and flatal incontinence, and greater fecal incontinence severity at both times. Urinary incontinence prevalence did not differ between the sphincter tear and vaginal control groups. Six months postpartum, 22.9% of women delivered by cesarean reported urinary incontinence, whereas 7.6% reported fecal incontinence. CONCLUSION: Women with clinically recognized anal sphincter tears are more than twice as likely to report postpartum fecal incontinence than women without sphincter tears. Cesarean delivery before labor is not entirely protective against pelvic floor disorders. LEVEL OF EVIDENCE: II-3.     

Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse

OBJECTIVE: To prospectively evaluate the effects of vaginal pessaries on symptoms associated with pelvic organ prolapse and identify the risk factors for failure. METHODS: All women referred to a specialist urogynecology unit with symptomatic pelvic organ prolapse who elected to use a pessary were included in this study. All completed the Sheffield pelvic organ prolapse symptom questionnaire before use and after 4 months of use. The primary outcome measure was change of symptoms from baseline to 4 months. RESULTS: Of 203 consecutive women fitted with a pessary, 153 (75%) successfully retained the pessary at 2 weeks, and 97 completed the questionnaires at 4 months. Multivariate logistic regression analysis showed that failure to retain the pessary was significantly associated with increasing parity (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14-2.02, P = .004) and hysterectomy (OR 4.57, 95% CI 1.71-12.25, P = .002). In the success group at 4 months (n = 97), a significant improvement in voiding was reported by 39 participants (40%, P = .001), in urinary urgency by 37 (38%, P = .001), in urge urinary incontinence by 28 (29%, P = .015), in bowel evacuation by 27 (28%, P = .045), in fecal urgency by 22 (23%, P = .018), and in urge fecal incontinence by 19 (20%, P = .027), but there was no significant improvement in stress urinary incontinence in 22 participants (23% P = .275). Of the 26 (27%) who were sexually active, 16 (17%, P = .001) reported an increase in frequency of sexual activity, and 11 (11%, P = .041) had improved in sexual satisfaction. CONCLUSION: A vaginal pessary is an effective and simple method of alleviating symptoms of pelvic organ prolapse and associated pelvic floor dysfunction. Failure to retain the pessary is associated with increasing parity and previous hysterectomy. LEVEL OF EVIDENCE: II-3.     

Fecal incontinence after high-risk delivery

OBJECTIVE: To investigate the prevalence of and factors associated with fecal incontinence and its precursors among high-risk women at 12 months postpartum. METHODS: A survey of women in the immediate and later postpartum was conducted. Participants were 568 women at higher risk of anal sphincter damage, namely those who had an instrumental delivery and/or delivered a high birth weight infant (4000 g or more) at tertiary teaching hospitals in Australia. Women participated in a baseline hospital-based interview and a 12-month follow-up telephone interview. The main outcome measures were frank fecal incontinence (solid and/or liquid stool) and precursor symptoms (flatal incontinence, soiling, and/or fecal urgency) at 12 months postpartum. RESULTS: Prevalence rates were 2.6% for solid stool incontinence and 4.9% for liquid stool incontinence. Overall, 6.9% women had either one or both of these symptoms of frank fecal incontinence. Prevalence rates were 24.4% for flatal incontinence, 10.9% for soiling, and 14.8% for fecal urgency. Overall, 32.4% women had at least one of these precurser symptoms. Concurrent urinary incontinence and postpartum constipation were significantly associated with both frank fecal incontinence and precursor symptoms. In addition, joint hypermobility and older maternal age were associated with frank fecal incontinence, whereas inability to stop the urine flow and multiparity was associated with precursor symptoms. CONCLUSION: The present findings suggest that older and multiparous women, and women with joint hypermobility are at increased risk of postpartum anal incontinence symptoms after a high-risk delivery. Concurrent urinary incontinence, flow-stopping inability, and constipation are also associated with postpartum anal incontinence symptoms after high-risk deliveries.     

Anal sphincter injury in women with pelvic floor disorders

OBJECTIVE: 1) To estimate the rate of anal incontinence and anal sphincter injury in a group of women with pelvic floor disorders; 2) to evaluate the relationship between anal incontinence and anal sphincter injury as demonstrated by endoanal ultrasonography; 3) to explore any associations between operative vaginal delivery and anal sphincter injury in this population. METHODS: A cohort of 100 women with stage II or greater pelvic organ prolapse and/or urinary incontinence completed the Rockwood-Thompson Fecal Incontinence Severity Index Questionnaire (FISI). Pelvic organ prolapse was recorded using the Pelvic Organ Prolapse Quantification system. Multichannel cystometry and endoanal ultrasonography were performed. Categorical data were compared using the chi(2) statistic. The FISI scores were correlated with degree of anal sphincter injury using the Pearson correlation coefficient (r). RESULTS: Fifteen women with pelvic organ prolapse only, 28 with urinary incontinence only, and 57 with both were evaluated. Mean age (+/- standard deviation) and body mass index were 57.1 +/- 13.2 years and 29.8 +/- 6.8 kg/m(2), respectively. Median parity was 3. Fifty-four percent of those studied had anal incontinence, and 52% had anal sphincter defects. Anal incontinence was significantly associated with sphincter injury (odds ratio 36.4, 95% confidence interval 12-114, P <.001). The FISI scores were positively correlated with increasing degrees of anal sphincter disruption (r = 0.81, P <.001). A history of operative vaginal delivery was significantly associated with anal sphincter injury (P =.023). CONCLUSION: Anal incontinence and anal sphincter injury are common in women with other pelvic floor disorders and are significantly related. Operative vaginal delivery may contribute to unrecognized anal sphincter trauma in this population. LEVEL OF EVIDENCE: III     

Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse

OBJECTIVE: Our purpose was to estimate, in women after 2 months of pessary use, patient satisfaction and the percentage of prolapse and urinary symptoms that improve or worsen. STUDY DESIGN: In a prospective study, 100 consecutive women with symptomatic pelvic organ prolapse were fitted with a pessary, and 73 women had a successful 2-week pessary fitting trial. Prolapse and urinary symptoms were assessed at baseline and at 2 months. Patient satisfaction was assessed at 2 months. Risk factors for patient dissatisfaction were assessed. RESULTS: Nearly all prolapse symptoms resolved from baseline to 2 months, respectively: bulge (90% to 3%; P<.001), pressure (49% to 3%; P<.001), discharge (12% to 0%; P=.003), and splinting (14% to 0%; P=.001). Among women with concurrent urinary symptoms at baseline, stress incontinence improved in 45%, urge incontinence improved in 46%, and voiding difficulty improved in 53%, after 2 months. However, among women without urinary symptoms at baseline, occult (de novo) stress incontinence occurred in 21%, de novo urge incontinence occurred in 6%, and de novo voiding difficulty occurred in 4%. At 2 months, 92% of the women were satisfied with their pessary. Six women (8%) were dissatisfied and discontinued use of the pessary. Dissatisfaction was associated with occult stress incontinence (odds ratio, 17.1; 95% CI, 1.9, 206; P=.004). CONCLUSION: After 2 months, 92% of women with a successful pessary fitting trial were satisfied. Nearly all prolapse symptoms resolved after 2 months; 50% of urinary symptoms improved, but occult stress incontinence was a common side effect.     

Pelvic floor dysfunction after Burch colposuspension--a comprehensive study. Part II

OBJECTIVE: To evaluate the prevalence of pelvic floor dysfunction (PFD) concerning bowel function at long-term follow-up after Burch colposuspension (Bc) in relation to the bowel function in an age-matched sample of women in the general population. METHODS AND MATERIAL: This is a follow-up study of a cohort of 190 patients who underwent Bc in 1980-1988 and 305 age-matched control women without urinary anti-incontinence surgery, randomly selected from the general population. The participants answered a postal questionnaire with detailed questions about the pelvic floor function in 1998. Univariate and multivariate analyses were performed. RESULTS: The patients showed considerable signs of bowel dysfunction compared with the general population in the following aspects: they used the fingers to help emptying the bowel [odds ratio (OR) 3.25 (1.35-7.86)]; had feeling of incomplete emptying of the bowel [OR 2.29 (1.11-4.73)]; felt no warning before passing a motion [OR 3.04 (1.20-7.71)]; had gas incontinence [OR 1.98 (1.17-3.37); had loose stool incontinence [OR 3.67 (1.43-9.42)]; used protection against fecal leakage during daytime [OR 3.22 (1.30-7.95)]; and experienced that the bowel function affected the general well-being adversely [OR 2.15 (1.30-3.56)]. CONCLUSION: The patients who have undergone colposuspension for stress urinary incontinence have more symptoms of PFD concerning the bowel function than women without urinary anti-incontinence surgery in the general population. This affects the general well-being. A comprehensive concept of multidisciplinary assessment and treatment of PFD should be encouraged.     

Vaginal wall descensus and pelvic floor symptoms in older women

OBJECTIVE: To understand the clinical significance of early pelvic organ prolapse in older women, we studied associations between vaginal descensus and pelvic floor symptoms. METHODS: In this cross-sectional study, 270 women enrolled at one site of the Women's Health Initiative clinical trial completed a questionnaire modified from the Pelvic Floor Distress Inventory on pelvic floor symptoms and underwent a Pelvic Organ Prolapse Quantification (POP-Q) examination. We tested associations between symptoms (individual and grouped) with anterior, posterior, uterine, and maximum vaginal descensus. RESULTS: Mean age was 68 years. Ninety-six percent had POP-Q stages I or II. Only obstructive urinary symptoms and feeling a bulge were associated with vaginal descensus. Obstructive urinary symptom scores increased as anterior (P = .04), posterior (P < .01), and maximal (P = .01) vaginal descensus increased. Urinary incontinence or bowel symptoms were not associated with descensus of any vaginal compartment. 'See or feel a bulge,' reported by 11 women (4%), was associated with descensus in all compartments (P < or = .04 for all) and with prolapse at or beyond the hymen (P < .001). This symptom was specific (100%), but not sensitive (16%) for prolapse, defined as descensus at or beyond the hymen. CONCLUSION: Vaginal support defects in older women are associated with obstructive urinary symptoms and the symptom of seeing or feeling a bulge. However, symptoms are not useful in discriminating between women with and without milder vaginal wall descensus. Based on these results, we suggest that other etiologies for bothersome bladder or bowel complaints be considered before performing surgery for early pelvic organ prolapse.     

Symptoms and pelvic support defects in specific compartments

OBJECTIVE: To investigate whether the nature of the anatomic defects in pelvic organ prolapse (POP) correlates with the character of the symptoms. METHODS: This study was a cross-sectional investigation within a population-based sample. Two hundred eighty women who had completed a symptom questionnaire were examined according to POP quantification by two gynecologists blinded to symptom reports. RESULTS: An age- and parity-adjusted logistic regression model, controlling for POP in other compartments, revealed that the feeling of vaginal bulge was specific to prolapse but not to any particular compartment, although the association was strongest with anterior-wall prolapse (odds ratio [OR] for the symptom among women with stage II-IV relative to stage 0 was 5.8, 95% confidence interval [CI] 2.5-13.3). Urge urinary incontinence tended to be linked to POP in either the anterior or posterior wall, but the association was stronger with anterior-wall prolapse. Stress urinary incontinence was strongly linked to posterior-wall prolapse (stage II-IV OR 5.4, 95% CI 1.9-15.2). Self-reports of hard/lumpy stool and difficult or painful defecation tended to be associated with anterior-wall prolapse but without consistent relationships with stage. Painful defecation was the only bowel symptom significantly linked to posterior-wall prolapse (P=.05). CONCLUSION: Pelvic floor-related symptoms do not predict the anatomic location of the prolapse in women with mild to moderate prolapse.     

Idiopathic fecal incontinence.

Pelvic floor dysfunction is related to neuropathic injury to the pelvic floor musculature. Clinically, the patient may present with genital prolapse or urinary or fecal incontinence. For a successful outcome, the physician must consider all pelvic compartments in the evaluation and treatment of patients with these disorders. Disorders of the posterior compartment are the least familiar to the gynecologist. Idiopathic fecal incontinence, a posterior compartment defect, is defined as a progressive deterioration of anal sphincter function in patients with no history of sphincter damage. This review discusses the latest findings about idiopathic fecal incontinence within the context of pelvic floor dysfunction and neuropathy.     

Correlation of symptoms with location and severity of pelvic organ prolapse

OBJECTIVE: The purpose of this study was to compare the symptoms that are related to pelvic floor dysfunction with the location and severity of the coexisting prolapse. STUDY DESIGN: Two hundred thirty-seven consecutive patients with symptomatic pelvic organ prolapse came to Johns Hopkins Medicine during a 24-month period beginning in July 1998 and completed a symptom-specific Likert scale questionnaire that included standardized questions that were compiled from commonly used validated instruments. All questionnaires were completed by the patients before they were seen by a physician. Further evaluation included a standardized physical examination that included the International Continence Society's system for grading uterovaginal prolapse. Symptoms were categorized according to both severity and associated anatomic compartment. Symptoms that were related to urinary and anal incontinence and voiding, defecatory, sexual, and pelvic floor dysfunction were analyzed with respect to location and severity of pelvic organ prolapse with the use of the nonparametric correlation coefficient, Kendall's tau-b. RESULTS: The mean age of the women was 57.2 years (range, 23-93 years); 109 of the women (46%) had undergone hysterectomy. Overall, stage II was the most common pelvic organ prolapse (51%) that was encountered. In 77 patients (33%), anterior compartment pelvic organ prolapse predominated; 46 patients (19%) demonstrated posterior compartment prolapse, whereas 26 patients (11%) had apical prolapse. In 88 patients (37%), no single location was more severe than another. Voiding dysfunction that was characterized by urinary hesitancy, prolonged or intermittent flow, and a need to change position was associated with the increasing severity of anterior and apical pelvic organ prolapse. Pelvic pressure and discomfort along with visualization of prolapse were strongly associated with worsening stages of pelvic organ prolapse in all compartments. Defecatory dysfunction characterized by incomplete evacuation and digital manipulation was associated with worsening posterior compartment pelvic organ prolapse. Impairment of sexual relations and duration of abstinence were strongly associated with worsening pelvic organ prolapse. An inverse correlation was observed between increasing severity of pelvic organ prolapse and urinary incontinence and enuresis. CONCLUSION: Women with pelvic organ prolapse experience symptoms that do not necessarily correlate with compartment-specific defects. Increasing severity of pelvic organ prolapse is weakly to moderately associated with several specific symptoms that are related to urinary incontinence and voiding, defecatory, and sexual dysfunction.     

The Effect of Pelvic Organ Prolapse on Sexual Function in a General Cohort of Women

IntroductionThis is a report about the effects of pelvic organ prolapse on sexual function in women.AimTo determine the effect of pelvic organ prolapse on sexual function in women.MethodsThe study group consisted of 1,267 sexually active women. Baseline characteristics, medical and obstetric history of the patients were recorded. All women underwent vaginal examination to determine the degree of prolapse by pelvic organ prolapse quantification (POPQ) system. Of 1,267 women, 342 (27.0%) had prolapse stage ≥2.Main Outcome Measure(s)The Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire short form (PISQ-12) scores of the women were recorded.Result(s)Women with genital prolapse had lower PISQ-12 scores than women without it. The difference resulted mainly from urinary incontinence during sexual activity, fear of incontinence and avoidance of intercourse due to prolapse. Multivariate analyses showed that genital prolapse was one of the confounding factors for sexual function.Conclusion(s)Pelvic floor dysfunction is a multi-faceted problem because it has both anatomical and functional aspects. Although pelvic organ prolapse had an effect on some aspects of sexuality, it has no effect on certain aspects of sexual function such as orgasm and sexual satisfaction. Tok EC, Yasa O, Ertunc D, Savas A, Durukan H, and Kanik A. The effect of pelvic organ prolapse on sexual function in a general cohort of women.     

Effect of pessary use on genital hiatus measurements in women with pelvic organ prolapse

OBJECTIVE: To compare the size of the genital hiatus in women wearing a pessary for pelvic organ prolapse after consistent pessary use, describe characteristics of patients who continue use, and assess change in pelvic floor symptoms. METHODS: This was an observational cohort study of 90 women seeking nonsurgical management of symptomatic prolapse. Our primary outcome was change in genital hiatus (in centimeters) after 3 months of consistent pessary use. Pelvic floor symptoms were assessed with the Pelvic Floor Distress Inventory. Change in genital hiatus measurements and Pelvic Floor Distress Inventory scores were assessed using a paired Student t test. Between-group differences were evaluated using the Student t, Mann Whitney U, and Fisher exact tests, where appropriate. Logistic regression was used to assess baseline characteristics predictive of continued pessary use. RESULTS: The average (+/-standard deviation) age of participants enrolled was 62.8 +/-13.2 years. Median parity was 3, and 87.7% were postmenopausal. Forty-two (47%) continued pessary use at 3 months. After 2 weeks, there was a decrease in the size of the genital hiatus measured with strain from 4.8+/-1.6 cm to 4.1+/-1.2 cm, P<.001, which persisted at 3 months (3.9+/-1.1 cm, P<.001). The greatest change occurred with the Gellhorn pessary. Baseline Pelvic Organ Prolapse Quantification system point Aa was positively associated with continued pessary use at 3 months, and perineal body at rest was negatively associated. CONCLUSION: After 3 months of pessary use, genital hiatus size decreased significantly. Pessary use results in significant anatomic changes to the genital hiatus in patients with pelvic organ prolapse.     

Is Pelvic Floor Dysfunction an Independent Threat to Sexual Function? A Cross-Sectional Study in Women With Pelvic Floor Dysfunction

IntroductionPrior studies have reported an association of sexual dysfunction with pelvic floor dysfunction (PFD), but without defining causation.AimTo investigate predictors of sexual function in women with PFD, including pelvic organ prolapse, stress urinary incontinence, overactive bladder, obstructed defecation, and fecal incontinence.MethodsThis retrospective cross-sectional study included 755 women (mean age = 56 years, 68% postmenopausal) referred for PFD (2008–2013). Subjects underwent standardized history and examination, including demographics and assessment of pelvic floor function and sexual function using validated quality-of-life instruments. The physical examination included body mass index, Pelvic Organ Prolapse Quantification measurements, and pelvic muscle strength (Oxford scale). Proportional odds regression analysis tested patient characteristics, PFD, and other determinants of sexual dysfunction as predictors of sexual function.Main Outcome MeasuresThe Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) to assess PFD and the Short Personal Experiences Questionnaire to assess sexual function.ResultsThe prevalence of PFD included pelvic organ prolapse (72%), stress urinary incontinence (66%), overactive bladder (78%), fecal incontinence (41%), and obstructed defecation (70%). Most subjects (74%) had a sexual partner and most (56%) reported recent sexual intercourse. Participants reported a low level of sexual desire and sexual enjoyment and moderate levels of sexual arousal and orgasm. When stratified by sexual enjoyment, 46% enjoyed sex and this group had lower PFDI and PFIQ scores, reflecting less quality-of-life burden. Pelvic organ prolapse, obstructed defecation, and fecal incontinence were associated with not enjoying sex. However, when adjusted for other determinants of sexual dysfunction (eg, aging, dyspareunia, atrophy, and partner issues), these associations disappeared.ConclusionWomen with PFD also have a large burden of sexual dysfunction, although this appears to be mediated by factors not unique to PFD.