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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONAPPENDIX: SHORT LIST OF...REFERENCES |
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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 
.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.
LEVEL OF EVIDENCE: II-2
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In our clinical experience, patients often assume that surgically correcting their early pelvic support defects will alleviate a myriad of pelvic floor symptoms (such as urinary urgency, frequency, incontinence, and constipation). Gynecologic references also suggest that prolapse and symptoms are related. For example, one gynecologic textbook notes "symptoms...of cystocele consist of a sensation of fullness or pressure and at times a feeling that organs are falling out, stress incontinence, occasional urgency, and often a feeling of incomplete emptying with voiding."11 The most recent American College of Obstetricians and Gynecologists (ACOG) technical bulletin on pelvic organ prolapse states "Anterior vaginal wall prolapse has a strong association with urinary urgency and frequency, urinary incontinence, incomplete emptying, and voiding dysfunction."12
Women with advanced pelvic organ prolapse often complain of a bulge that they can see or feel.13 Surgery generally alleviates this symptom. However, this scenario represents the end of the spectrum of pelvic floor support. Because both mild pelvic support defects and pelvic floor symptoms are common, particularly in older women, a better understanding of how these two are related will help us counsel patients. To add to the limited information about this relationship in women not seeking care for specific urogynecologic complaints,9,14 our study objective was to measure the association between symptoms (individual and grouped) and vaginal wall descensus in older women.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONAPPENDIX: SHORT LIST OF...REFERENCES |
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At the time this study was initiated, there was no validated tool to assess pelvic floor symptoms in women without known pelvic floor disorders. Therefore, as previously reported,15 we modified the Pelvic Floor Distress Inventory, a validated quality of life instrument that is condition-specific for women with pelvic floor disorders.16 Because our main purpose was to determine whether specific symptoms were present or absent in our group of non–care-seeking women, we modified the Pelvic Floor Distress Inventory stem so that each item functioned as a yes/no symptom-screening question. We also constructed symptom groups, similar to the subscale groupings described by Barber et al16 as follows: stress urinary incontinence, overactive bladder, bladder pain, obstructive urinary, prolapse, obstructive colorectal, anal incontinence, and colorectal pain. To identify possible associations between pelvic organ prolapse and symptom groups, we calculated simple additive scores for each group by assigning a score of 0 to the absence and 1 to the presence of each symptom within a group.
The women also provided information about obstetric, medical, and surgical histories in the written questionnaire. Other demographic and background data were abstracted from the WHI database.
The POP-Q examinations were performed by 2 experienced urogynecology research nurses while the subject was in dorsal lithotomy position. All measurements, except total vaginal length, were taken during maximal Valsalva maneuver. In the POP-Q system, each vaginal compartment (anterior, apical, and posterior) is described in reference to its distance in centimeters from the hymen. Negative values denote location above or proximal to the hymeneal ring, and positive values indicate location below or distal to the hymeneal ring. A zero value indicates that the area of vagina being measured is located at the level of the hymen. Measurement points used in the POP-Q system and definitions of the International Continence Society stages of pelvic organ prolapse using the POP-Q measurement points are provided in Figure 1 and Table 1.
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Analyses were performed separately for descensus in each vaginal compartment and for the maximum point of descensus. POP-Q points Ba and Bp, which indicate the most dependent portions of the anterior and posterior vaginal walls, were used to represent anterior and posterior vaginal descensus, respectively. Because we had relatively few subjects with POP-Q points of less than –2 or greater than +1 cm, we created categorical prolapse variables with 4 levels for anterior prolapse and for the maximum descensus overall (POP-Q point of interest at –2, –1, 0 and 
+1 cm from the hymen). For posterior vaginal descensus, we used a variable with 3 levels (Bp at –2, –1 and 0 cm) because only 3 women had Bp of +1 or greater. Apical descensus was also categorized into 4 levels by grouping the result of (total vaginal length + D) as less than or equal to 1, 2, 3 and greater than or equal to 4 cm. We defined apical descensus using the POP-Q point D (posterior fornix), rather than C (cervix), to avoid including subjects with cervical elongation in the absence of true apical descensus.
We also studied a dichotomous definition of prolapse based on our previous work, in which prolapse was considered present when the POP-Q point of interest (Ba, Bp, or the maximum point of descensus) was measured at or past the hymen ( 0 cm).4 Apical prolapse was dichotomized into groups with (total vaginal length + D) less than 3 cm or 3 cm or more.
We studied the association between individual symptoms and vaginal descensus by using 
2 or Fisher exact tests and the Cochran-Armitage test for trend.17 Median symptom scores were compared in women with varying levels of vaginal descensus by using Wilcoxon rank-sum tests and a nonparametric test for trend across ordered groups.18 We repeated our analyses of associations between symptoms and symptom group scores and prolapse after excluding 14 women who reported a history of surgery for incontinence or prolapse or current treatment of incontinence or prolapse with medication, a pessary, or bladder training.
In a previous study that focused on lifestyle factors and pelvic floor symptoms in this population, age and coffee drinking were independently associated with various pelvic floor symptoms, including obstructive bladder symptoms.15 Vaginal parity and body mass index (BMI) were not associated with any symptoms on multivariable analysis. Based on these results, the associations between symptoms and symptom scores and prolapse were re-examined after adjusting for age (in quartiles) and coffee drinking (yes/no) by using multiple logistic regression models. All statistical analyses were performed with SAS 8.0 (SAS Institute Inc, Cary, NC). Associations were considered significant at a P < .05 level.
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RESULTS |
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Women reported a median of 4 (range 0–19) symptoms from a total of 30. At least 25% of women reported stress urinary incontinence (53%), urge urinary incontinence (49%), urinary frequency (29%), urgency (29%), intermittent urinary stream (26%), straining for bowel movements (25%), a sense of incomplete bowel movements (35%), and involuntary loss of gas (35%). Of the 8 symptom groups (see Table 2 for a list of the symptoms in each group), women most commonly reported symptoms from overactive bladder (62%), stress urinary incontinence (53%), obstructive colorectal (49%), and obstructive urinary (43%).
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Pelvic Organ Prolapse Quantification measurements for the study group are summarized in Figure 1 and POP-Q stages in Table 1. Table 2 presents individual bladder, prolapse, and bowel symptoms at each level of anterior and posterior vaginal wall descensus. (Results by the level of apical and maximum vaginal descensus are available on request. Only statistically significant results are summarized below.)
Stress urinary incontinence and overactive bladder symptoms were not associated with vaginal descensus, nor were most other bladder symptoms, with the following exceptions: various obstructive urinary symptoms and anterior or posterior vaginal wall descensus (Table 2); difficulty emptying the bladder and apical descensus (P = .04); weak urinary stream (P = .02), intermittent urinary stream (P = .03), position change to urinate (P < .01), and need to push abdomen to urinate (P = .02); and descensus of the most distal (that is, maximum) POP-Q point.
Women with greater anterior (P = .03) or overall descensus (P < .01) were more likely to report a sensation of bulging. Women with greater descensus of all compartments were more likely to report the symptom "see or feel a bulge" (P = .04 for posterior and P < .01 for all others). No bowel symptom was associated with increasing descensus of any vaginal compartment (including posterior).
In terms of symptom scores, the number of obstructive urinary symptoms increased as anterior, posterior, and maximum descensus overall increased (P = .04, P < .01, and P = .01, respectively), and the number of prolapse symptoms increased as anterior vaginal wall (but not posterior or apical) and maximum descensus increased (P = .04 for both). Other symptom groups were not associated with vaginal descensus of any compartment. Interestingly, even in women with minimal anterior vaginal descensus (Ba –1), greater posterior vaginal descensus was associated with a higher obstructive urinary score.
Figure 2 graphically displays the distributions of urinary obstructive scores by the level of anterior vaginal descensus and prolapse scores by the maximal vaginal descensus using box-and-whisker plots.19 As seen in this figure, even when associations are statistically significant, the median scores are low and the differences small.
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With the dichotomous definition, in which prolapse is defined as descensus to or beyond the hymen, only the following symptoms were associated with prolapse: for anterior vaginal prolapse, changing position to urinate and seeing/feeling a bulge (P = .01 and P < .001, respectively); for posterior vaginal prolapse, incomplete bladder emptying, weak stream, and intermittent stream (P .01 for all); and for apical prolapse, difficulty emptying the bladder and seeing/feeling a bulge (P .01 for both).
Of 270 women, 11 reported seeing or feeling a bulge, and on examination all 11 had the maximal point of prolapse at the hymen or beyond. The specificity and positive predictive value of this symptom for the presence of prolapse were both 100% (95% confidence intervals [CIs] 98.2–100 and 71.5–100, respectively), and its negative predictive value was 78% (95% CI 72.4–82.9). The sensitivity was only 16% (95% CI 8.4–27.1) because 57 women with this level of descensus on examination did not report this symptom. Although other symptoms were associated with prolapse (namely, the obstructive urinary symptoms), they were not discriminating. In fact, the majority of the women reporting each of these symptoms did not have prolapse at or beyond the hymen.
After excluding the 14 participants who had prior surgery or currently used medication, pessary, or bladder training to treat incontinence or prolapse, associations between symptoms or symptom scores and vaginal wall descensus were unchanged with the following exceptions: difficulty emptying, weak stream, and intermittent stream were associated with anterior vaginal descensus (P < .05 for all) and difficulty emptying was associated with the maximum vaginal descensus (P = .01). Associations between symptoms and symptom group scores and prolapse were also re-examined while controlling for age and coffee drinking, and no significant changes to our results were noted.
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DISCUSSION |
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Anatomic pelvic support is a continuum. We found no point at which vaginal descensus was clearly symptomatic. Similar to our findings in older women, younger and middle-aged women not seeking urogynecologic care also have no symptom cut point that yields a clear definition of normal or abnormal support.9,14 Further, even women referred for treatment of pelvic floor disorders have few correlations between symptoms and prolapse.13,20,21 The point at which vaginal descensus becomes a clinical disorder in women with early stage prolapse may depend more on individual care-seeking behavior or physician input than on symptoms or anatomy.
Strengths of our study include our population of older women (the age group most likely to have surgery for pelvic organ prolapse) recruited from the community and our use of standardized anatomy and symptom-based outcomes. Our results are not necessarily generalizable to all women of this age. The group's mean BMI is higher than the average BMI for American white women in the same age group,22 but BMI was not associated with prolapse in this population.4 In addition, the group had minimal racial or regional diversity. We specifically limited our study population to women with a uterus so that we could better understand the natural history of pelvic organ support. It is possible that symptoms and findings differ among women who have undergone surgery. We tested numerous associations between symptoms and prolapse. Given the exploratory nature of this work, we reported our results at the P < .05 significance level, rather than correct for multiple analyses, and some of these associations may have occurred by chance.
Our results tell one part of the larger story of the association between symptoms and anatomic levels of pelvic support. As investigators add to this story, it is remarkable in its consistency: with the exception of seeing or feeling a bulge, most other pelvic floor symptoms do not predict pelvic organ prolapse. Because our study design is cross-sectional, we don't know whether a specific symptom in a specific woman may have begun as the vagina prolapsed. However, given that many women have both early pelvic support defects and various pelvic floor symptoms, physicians should evaluate other etiologies for their symptoms before considering surgical repair of the prolapse. Patients should be counseled that it is unclear whether their symptoms either result from vaginal descensus or will improve following surgical treatment. Prospective studies are needed to sort out both of these issues.
Based on these data, we recommend that the diagnosis of the condition of pelvic organ prolapse be restricted to women with anterior or posterior vaginal wall descensus to or below the hymen. Apical prolapse should be analyzed separately and may need to be defined differently from prolapse of the anterior and posterior walls. Assessing symptoms is important for clinical care but does not seem to help refine the definition of pelvic organ prolapse. Although this proposed dichotomous definition of pelvic organ prolapse would improve communication, it is important that researchers and clinicians continue to measure all levels of vaginal support. Only by continued careful observation and analysis will we begin to understand the risk factors that lead to progression from minimal vaginal descensus to the clinical condition of pelvic organ prolapse.
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APPENDIX: SHORT LIST OF WHI INVESTIGATORS |
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(National Heart, Lung, and Blood Institute, Bethesda, MD) Barbara Alving, Jacques Rossouw, Linda Pottern.
Clinical Coordinating Center
(Fred Hutchinson Cancer Research Center, Seattle, WA) Ross Prentice, Garnet Anderson, Andrea LaCroix, Charles L. Kooperberg, Ruth E. Patterson, Anne McTiernan; (Wake Forest University School of Medicine, Winston-Salem, NC) Sally Shumaker; (Medical Research Labs, Highland Heights, KY) Evan Stein; (University of California at San Francisco, San Francisco, CA) Steven Cummings.
Clinical Centers
(Albert Einstein College of Medicine, Bronx, NY) Sylvia Wassertheil-Smoller; (Baylor College of Medicine, Houston, TX) Jennifer Hays; (Brigham and Women's Hospital, Harvard Medical School, Boston, MA) JoAnn Manson; (Brown University, Providence, RI) Annlouise R. Assaf; (Emory University, Atlanta, GA) Lawrence Phillips; (Fred Hutchinson Cancer Research Center, Seattle, WA) Shirley Beresford; (George Washington University Medical Center, Washington, DC) Judith Hsia; (Harbor-UCLA Research and Education Institute, Torrance, CA) Rowan Chlebowski; (Kaiser Permanente Center for Health Research, Portland, OR) Evelyn Whitlock; (Kaiser Permanente Division of Research, Oakland, CA) Bette Caan; (Medical College of Wisconsin, Milwaukee, WI) Jane Morley Kotchen; (MedStar Research Institute/Howard University, Washington, DC) Barbara V. Howard; (Northwestern University, Chicago/Evanston, IL) Linda Van Horn; (Rush-Presbyterian St. Luke's Medical Center, Chicago, IL) Henry Black; (Stanford Prevention Research Center, Stanford, CA) Marcia L. Stefanick; (State University of New York at Stony Brook, Stony Brook, NY) Dorothy Lane; (The Ohio State University, Columbus, OH) Rebecca Jackson; (University of Alabama at Birmingham, Birmingham, AL) Cora E. Lewis; (University of Arizona, Tucson/Phoenix, AZ) Tamsen Bassford; (University at Buffalo, Buffalo, NY) Jean Wactawski-Wende; (University of California at Davis, Sacramento, CA) John Robbins; (University of California at Irvine, Orange, CA) Allan Hubbell; (University of California at Los Angeles, Los Angeles, CA) Howard Judd; (University of California at San Diego, La Jolla/Chula Vista, CA) Robert D. Langer; (University of Cincinnati, Cincinnati, OH) Margery Gass; (University of Florida, Gainesville/Jacksonville, FL) Marian Limacher; (University of Hawaii, Honolulu, HI) David Curb; (University of Iowa, Iowa City/Davenport, IA) Robert Wallace; (University of Massachusetts/Fallon Clinic, Worcester, MA) Judith Ockene; (University of Medicine and Dentistry of New Jersey, Newark, NJ) Norman Lasser; (University of Miami, Miami, FL) Mary Jo O'Sullivan; (University of Minnesota, Minneapolis, MN) Karen Margolis; (University of Nevada, Reno, NV) Robert Brunner; (University of North Carolina, Chapel Hill, NC) Gerardo Heiss; (University of Pittsburgh, Pittsburgh, PA) Lewis Kuller; (University of Tennessee, Memphis, TN) Karen C. Johnson; (University of Texas Health Science Center, San Antonio, TX) Robert Brzyski; (University of Wisconsin, Madison, WI) Gloria E. Sarto; (Wake Forest University School of Medicine, Winston-Salem, NC) Denise Bonds; (Wayne State University School of Medicine/Hutzel Hospital, Detroit, MI) Susan Hendrix.
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Footnotes |
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Supported by grants K12 RR01770001 (C.S.B.) from the National Center for Research Resources and R01 HD4 1131-01 (I.E.N.) and K24 HD42469-01 (I.E.N.) from the National Institute of Child Health and Human Development. The Women's Health Initiative study is funded by the National Heart, Lung and Blood Institute, U.S. Department of Health and Human Services.
Accepted for a paper presentation at the 26th Annual Meeting of the American Urogynecologic Society, Atlanta, Georgia, September 15–17, 2005.
Corresponding author: Catherine S. Bradley, MD, MSCE, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242; e-mail: catherine-bradley{at}uiowa.edu. 
doi:10.1097/01.AOG.0000180183.03897.72
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REFERENCES |
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2. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;186:1160–6.[Medline]
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6. Sze EH, Sherard GB, 3rd, Dolezal JM. Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol 2002;100:981–6.
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14. Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol 2003;189:372–7; discussion 7–9.
15. Bradley CS, Kennedy CM, Nygaard IE. Pelvic floor symptoms and lifestyle factors in older women. J Womens Health (Larchmt) 2005;14:128–36.
16. Barber MD, Kuchibhatla MN, Pieper CF, Bump RC. Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. Am J Obstet Gynecol 2001;185:1388–95.[Medline]
17. Margolin BH. Test for trend in proportions. In: Klotz S, Johnson NL, editors. Encyclopedia of statistical sciences. New York (NY): John Wiley & Sons; 1988. p. 334–6.
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20. Burrows LJ, Meyn LA, Walters MD, Weber AM. Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol 2004;104:982–8.
21. Mouritsen L, Larsen JP. Symptoms, bother and POPQ in women referred with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:122–7.[Medline]
22. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002;288:1723–7.
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