Sexual Function in Women with and without Urinary Incontinence and/or Pelvic Organ Prolapse

The sexual function of women with and without urinary incontinence and/or pelvic organ prolapse (UI/POP) was compared using a condition-specific validated questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). Eighty-three women with UI/POP and 56 without agreed to participate. PISQ scores were significantly lower among women with UI/POP than in those without (P = 0.003). No differences in the stages of sexual excitement were noted between groups. The frequency of intercourse was less with UI/POP than without (P = 0.04). Women with UI/POP restricted sexual activity for fear of losing urine more frequently than did those without (P= 0.005). No differences were reported in patients’ or partners’ sexual satisfaction. This study found that women with UI/POP have poorer sexual functioning than those without, as measured by the PISQ, and report less frequent sexual activity. In addition, women with UI/POP are more likely to restrict sexual activity for fear of incontinence, although they report similar levels of satisfaction with their sexual relationships as do women without UI/POP.     

LOX family enzymes expression in vaginal tissue of premenopausal women with severe pelvic organ prolapse

Introduction and Hypothesis  

The extracellular matrix proteins collagen and elastin provide tissue strength and resilience, whereas lysyl oxidase enzymes play a major role in their stabilization. This study examines the expression and tissue localization of lysyl oxidase family proteins in the anterior vaginal wall of premenopausal women with advanced pelvic organ prolapse (POP, n = 15) and asymptomatic controls (n = 11). All women were in the proliferative phase of menstrual cycle.     

Comparison of the main body of the external anal sphincter muscle cross-sectional area between women with and without prolapse

The aim of the study was to compare the main body of the external anal sphincter (EAS) cross-sectional area (CSA) of women with and without pelvic organ prolapse. Pelvic magnetic resonance imaging (MRI) scans of 40 women were selected for analysis. Of these women, 20 had pelvic organ prolapse and 20 had normal support. Of the women with normal support, 10 had known major levator ani (LA) muscle defects and 10 had normal LA muscles. The same was true for the women with pelvic prolapse: half had major LA defects and half had no LA defects. All patients had previously completed pelvic MRI in the supine position. 3-D models of the EAS were made and CSA of the EAS perpendicular to the fiber direction were measured circumferentially at 30° intervals. Univariable and multivariable analyses were performed. The mean CSA did not significantly differ between women with prolapse and normal support regardless of LA defect status (normal/−LA defect = 1.13 cm², prolapse/−LA defect = 0.86 cm², p = 0.065; normal/+LA defect = 1.08 cm², prolapse/+LA defect = 1.28 cm², p = 0.28). Women with prolapse and LA defects had a 49% larger mean muscle CSA compared to prolapse patients without LA defects (p = 0.01). This difference associated with defect status in prolapse patients was not seen in women with normal support. Women with prolapse alone had external anal sphincter CSAs that were comparable to women with normal support. However, women with both prolapse and a major levator ani defect had larger external anal sphincter CSAs compared to prolapse patients without levator ani defects.     

Comparative histological analysis of anterior vaginal wall in women with pelvic organ prolapse or control subjects. A pilot study

The purpose of this study was to compare smooth muscle content of anterior vaginal wall in women with pelvic organ prolapse (POP) and control subjects. Specimens were taken in the midline from the apex of anterior vaginal cuff from eleven women with POP and eight control subjects operated for hysterectomy without prolapse. Masson’s trichrome stain was used to determine the distribution of collagen in the extracellular matrix of the vaginal muscularis and to quantify the collagen in area of interest. Slides of alpha smooth muscle actin were detected using antibodies. Morphometric analysis was used to compare and to quantify the smooth muscle content of the vaginal muscularis. Fractional area of nonvascular vaginal smooth muscle of women with POP was significantly decreased in comparison to control subjects (41.9 vs 61.9%, p = 0.005). Fractional area of connective tissue was significantly increased (56.8 vs 35%, p = 0.004). Fractional area of blood vessels was similar (2.2 vs 3.4%, p = 0.20).     

Complications of transvaginal monofilament polypropylene mesh in pelvic organ prolapse repair

Introduction and hypothesis  This study aimed to document intraoperative and postoperative complications associated with the use of transvaginal polypropylene mesh in the repair of pelvic organ prolapse (POP). Methods  This is a retrospective review of 127 cases of transvaginal repair of POP using synthetic mesh. Results  Mean postoperative value (±SD) for pelvic organ prolapse quantification (POPQ) measurements Aa, Ap, and C were: −2.4 ± 1.1 (cm), −2.4 ± 0.9 (cm), and −7.7 ± 1.2 (cm), respectively. The difference between preoperative and postoperative values of these points was significant (p < 0.0001). Mesh erosion rate was 13/127 (10.2%) with significant correlation between mesh erosion and concurrent vaginal hysterectomy (p = 0.008). Combined anterior and posterior vaginal mesh surgery increased the risk of intraoperative bleeding and blood transfusion (p < 0.05). Conclusions  Concurrent vaginal hysterectomy is associated with increased risk of vaginal mesh erosion. Combined anterior and posterior vaginal mesh repair is an increased risk factor for intraoperative bleeding and blood transfusion.     

Does COLIA1 SP1-binding site polymorphism predispose women to pelvic organ prolapse?

Introduction and hypothesis  COLIA1 polymorphism is associated with increased risk for stress urinary incontinence. We hypothesize that a similar association exists with pelvic organ prolapse (POP). Methods  Patients with advanced prolapse and healthy controls were evaluated by interview, validated questionnaires, and pelvic examination. DNA was extracted from peripheral blood, and polymerase chain reaction was performed to determine the presence or absence of the polymorphism. Power calculation indicated the need for 36 patients in each arm. Results  The prevalence of the polymorphic heterozygous genotype (GT) in the study and control groups was 33.3% and 19.4%, respectively, leading to an odds ratio of 1.75. This difference, however, did not reach statistical significance (p = 0.27). Conclusions  The COLIA1 polymorphism was not significantly associated with increased risk for POP.     

The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population

Introduction and hypothesis  In selected populations, pelvic organ prolapse (POP) was associated with bladder/bowel symptoms, but data on the general female population are lacking. Our aim was to obtain normative data on the prevalence of POP and pelvic floor dysfunction (PFD) symptoms and signs and to identify associations. Methods  Validated questionnaires on POP and PFD (urogenital distress inventory, (UDI) and defaecation distress inventory (DDI)) were sent to a general population of 2,979 women (aged 45–85 years). Data were analysed using the Kruskal–Wallis test, chi square test and Spearman’s rank correlation coefficient. Results  Response rate was 62.7%. Associations between POP stage and parity (0.002) and vaginal bulging (<0.001) are significant. Anatomical locations of POP and PFD symptoms correlated significantly with incontinence of flatus, feeling anal prolapse, manual evacuation of stool, vaginal bulging, constipation and pain during faecal urge (p ≤ 0.005). Conclusions  Strategies should be developed to alleviate obstructive bowel disorders associated with POP. Summary  POP was strongly associated with obstructive bowel disorders. Therefore, preventive strategies should be developed.     

Case of longitudinal vaginal septum with pelvic organ prolapse

Longitudinal vaginal septum is a rare mullerian anomaly and its association with pelvic organ prolapse (POP) is unusual. A case of longitudinal vaginal septum with stage IV POP in a 35-year-old multiparous woman is being reported. Examination revealed an incomplete longitudinal vaginal septum (9 × 6 × 2 cm) with stage IV POP. Vaginal hysterectomy with repair and reconstruction was done along with excision of the longitudinal vaginal septum which was technically challenging due to proximity to rectum. This is the only case report of stage IV pelvic organ prolapse associated with a thick longitudinal vaginal septum in a multiparous woman without any obstetric complications. Surgery required increased caution per operatively while dissecting the septum from the vaginal wall and the adjacent organs.     

Magnetic resonance assessment of pelvic anatomy and pelvic floor disorders after childbirth

To compare pelvic anatomy, using magnetic resonance imaging, between postpartum women with or without pelvic floor disorders. We measured postpartum bony and soft tissue pelvic dimensions in 246 primiparas, 6–12-months postpartum. Anatomy was compared between women with and without urinary or fecal incontinence, or pelvic organ prolapse; P < 0.01 was considered statistically significant. A deeper sacral hollow was significantly associated with fecal incontinence (P = 0.005). Urinary incontinence was marginally associated with a wider intertuberous diameter (P = 0.017) and pelvic arch (P = 0.017). There were no significant differences in pelvimetry measures between women with and without prolapse (e.g., vaginal or cervical descent to or beyond the hymen). We did not detect meaningful differences in soft tissue dimensions for women with and without these pelvic floor disorders. Dimensions of the bony pelvis do not differ substantially between primiparous women with and without postpartum urinary incontinence, fecal incontinence and prolapse.     

Assessment of sexual function in women with pelvic floor dysfunction

Forty-seven women participated in a pilot study for a multi-centre randomized controlled trial of the effectiveness of pelvic floor muscle training (PFMT) for women with prolapse. Women with symptomatic stage I or II prolapse [measured by Pelvic Organ Prolapse Quantification (POP-Q)] were randomized to a 16-week physiotherapy intervention (PFMT and lifestyle advice; n = 23) or a control group receiving a lifestyle advice sheet (n = 24). Symptom severity and quality of life were measured via postal questionnaires. Blinded POP-Q was performed at baseline and follow-up. Intervention women had significantly greater improvement than controls in prolapse symptoms (mean score decrease 3.5 versus 0.1, p = 0.021), were significantly more likely to have an improved prolapse stage (45% versus 0%, p = 0.038) and were significantly more likely to say their prolapse was better (63% versus 24%, p = 0.012). The data support the feasibility of a substantive trial of PFMT for prolapse. A multi-centre trial is underway.     

Follow-up of prolapse surgery in rural Nepal

Pelvic organ prolapse (POP) is a significant problem in Nepal. Surgical treatment is scarcely available and little is known of the results of POP surgery on women living under burdensome circumstances. The aim of our study was to set up a follow-up program in rural Nepal and evaluate POP surgery. In 2004 and 2006, 74 women with a POP from remote areas around Dhulikhel Hospital underwent prolapse surgery. Together with local contacts men, a plan was made to implement a follow-up program. All the operated patients were invited to a follow-up visit in March 2007. Thirty-three (45%) patients attended the follow-up: 85% (n = 28) found the effect of the procedure an improvement. A satisfactory anatomic outcome was found in 93% (n = 32). A remarkable finding was the reduction in physical labour after the surgical procedure in 50% of the follow-up cases. Some adjustments in the follow-up program may contribute to a higher participation.     

Biomechanical properties of vaginal tissue: preliminary results

The aim of this study is to characterise the biomechanical properties of vaginal tissue to develop an accurate cure of pelvic organ prolapse (POP). Prolapsed vaginal tissues were extracted during the prolapse cure of five patients (POP) and on five cadavers without noticed pelvic floor dysfunction (non-pelvic organ prolapse) with agreement of the ethics committee. Uni-axial tension was performed, and the results were analysed. Individual reproducibility of experimental results was good, and the results highlight the non-linear relationship between stress (force per unit of surface) and strain (l − l ₀ / l ₀) and very large deformation before rupture appearance. This experimental study has proven for the first time that the mechanical behaviour of vaginal tissue has to be defined as hyperelastic with a large deformation. This response has to be taken into account to develop accurate synthetic prostheses for POP cure and in the numerical simulation of the pelvic floor. The authors thank the Foundation for Medical Research for financing this study and the ethics committee for their approval.     

Does bladder neck descent increase with age?

It is assumed that pelvic organ descent and prolapse increase with age. Epidemiological studies support this assumption. We aimed to define the relationship between age and bladder neck descent (BND) in a retrospective observational study on 790 women referred for evaluation of pelvic floor disorders. Bladder neck descent, cystocele descent and urethral rotation were evaluated on maximal Valsalva manoeuvre, using trans-labial ultrasound. There was a weak negative correlation between bladder neck descent on Valsalva and age (r = −0.154, p < 0.001), which was absent in nulliparous women (n = 107) and stronger (r = −0.213, p < 0.001) in parous women (n = 683). This relationship was evident from the age of 50 years onwards and may be explained by increased tissue stiffness after menopause. The difference observed between parous and nulliparous women is intriguing and raises the issue of obstetric confounders such as historical changes in the likelihood of significant pelvic floor trauma.     

Vaginal noise: prevalence, bother and risk factors in a general female population aged 45–85 years

Introduction and hypothesis  Vaginal noise (VN) is a symptom of pelvic floor (PF) dysfunction and has been described in a few studies. No other risk factors have been described besides parity and pelvic organ prolapse (POP). Underlying mechanisms of VN are unclear. Aims of this study were to describe prevalence, bother and relation between VN and PF (muscle)(dys)function. Methods  A cross-sectional study was performed on a general population of 2,921 women (aged 45–85 years). Questionnaires were filled in by 1,397 women, and 800 were selected at random to undergo vaginal examination for POP Quantification and PF muscle function assessment. Chi-square tests, Student's t test and multivariate logistic regression were performed (P < 0.05). Results  Response rate was 62.7%. Prevalence of VN was 12.8%; 72.1% reported only a little bother. Odds ratios for parity and solid stool were high. Conclusions  VN was strongly related to many symptoms of pelvic floor dysfunction, but it was only causing a little bother.     

Fibulin-5 expression is decreased in women with anterior vaginal wall prolapse

The aim of this study was to compare fibulin-5 expression in women with and without anterior vaginal wall prolapse. Vaginal tissues were sampled in a standardized fashion from women with (n = 12) or without (n = 10) anterior vaginal wall prolapse. Quantitative real-time polymerase chain reaction was performed to measure mRNA levels of fibulin-5 (FIB-5). FIB-5 protein expression was assessed by immunohistochemistry. There were no significant differences in demographic data between the two groups. FIB-5 mRNA expression was significantly decreased in women with anterior vaginal wall prolapse compared to women without prolapse [(FIB-5 mean ± SD mRNA expression in relative units) 0.01 ± 0.01 vs. 0.09 ± 0.14, P = 0.04]. Fibulin-5 staining intensity was diminished in women with prolapse compared to women without prolapse [intensity score, median (range), 1 (1–2) vs. 3 (2–3), P = 0.04]. Fibulin-5 expression is decreased in vaginal biopsies from women with prolapse. Changes in fibulin expression may play a role in the development of pelvic organ prolapse.     

Pelvic prolapse and urinary incontinence in nulliparous college women in relation to paratrooper training

The objective of this study was to determine whether paratrooper training is associated with pelvic support defects or urinary incontinence. Nulliparous women at The United States Military Academy were examined using the Pelvic Organ Prolapse Quantification System and completed a questionnaire regarding incontinence and exercise prior to undergoing summer military training. The exam and questionnaire were repeated following training. One hundred sixteen women completed the study (80.6%), 37 of whom had attended paratrooper training. Women who attended paratrooper training were significantly more likely to have stage II prolapse (RR = 2.72, 1.37 < RR < 5.40; p = 0.003). Additionally, women who attended paratrooper training were significantly more likely to have worsening in their pelvic support regardless of initial prolapse stage (RR = 1.57, 1.12 < RR < 2.20; p = 0.01). Twenty-four women complained of urinary incontinence; however, this was not associated with paratrooper training. The forces transmitted to the female pelvis during paratrooper training are significant and cause pelvic support defects. Presented at the combined AUGS/SGS Joint Scientific Meeting, July 2004.     

The impact of pelvic organ prolapse on sexual function in women with urinary incontinence

The aim of the study is to evaluate the impact of pelvic organ prolapse (POP) on sexual function in women with urinary incontinence (UI). In this retrospective, case-cohort study, we reviewed the medical records of all women evaluated for UI between March and November 2003. All patients completed the short forms of the Urogenital Distress Inventory, Incontinence Impact Questionnaire, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. Women with stage two or greater POP, as determined by the pelvic organ prolapse quantification (POPQ) system, were compared to women with stage 0 or 1 POP. Sixty-nine women with POP and 47 women without POP were included. Patient demographics did not differ between the two groups. Women with POP were significantly more likely to report absence of libido (53% versus 30%, P=0.02), lack of sexual excitement during intercourse (46% versus 27%, P=0.05), and that they rarely experienced orgasm during intercourse (49% versus 30%, P=0.05). In conclusion, women with POP in addition to UI are more likely to report decreased libido, decreased sexual excitement, and difficulty achieving orgasm during intercourse when compared to women with UI alone.     

Pelvic floor disorders among indigenous women living in Xingu Indian Park, Brazil

Introduction and hypothesis  Current assessment for pelvic floor disorders (PFDs) allows comparison between different communities. Methods  A total of 377 indigenous women living in Xingu Indian Park were evaluated. The pelvic organ prolapse quantification (POP-Q) was the system used to quantification the staging of pelvic support. The pelvic floor muscle strength was assessed by a perineometer. Logistic regression analysis was used to determine risk factors that were associated with prolapse. Results  Only 5.8% of women reported urinary incontinence. The overall distribution of POP-Q stage system was the following: 15.6% stage 0, 19.4% stage I, 63.9% stage II and 0.8% stage III. Parity and age were the risk factors for pelvic organ prolapse (p < 0.0001). Conclusions  Urinary incontinence was uncommon in Xingu indigenous women. Like non-indigenous communities, age and parity were the most important risk factors to the genital prolapse.     

Magnetic resonance imaging of pelvic organ prolapse: comparing pubococcygeal and midpubic lines with clinical staging

Introduction and hypothesis  The aim of the study was to determine which magnetic resonance imaging (MRI) reference line for staging pelvic organ prolapse, the pubococcygeal line (PCL) vs. the midpubic line (MPL), has the highest agreement with clinical staging. Methods  A retrospective study of women with pelvic floor complaints who underwent dynamic pelvic MRI from January 2004 to April 2007 was conducted. Two radiologists staged descent on MRI for each pelvic compartment (anterior, apical, posterior) by consensus, using PCL and MPL reference lines. Agreement between MRI and clinical staging was estimated using weighted kappas. Results  Twenty women were included. Agreement between clinical and PCL staging was fair in the anterior (κ = 0.29) and poor in the apical (κ = 0.03) and posterior (κ = 0.08) compartments. Agreement between clinical and MPL staging was fair in the anterior (κ = 0.37), apical (κ = 0.31), and posterior (κ = 0.25) compartments. Conclusions  The MPL has higher agreement with clinical staging than the PCL. However, neither reference line has good agreement with clinical staging.