Gunilla Tegerstedt

Prevalence of symptomatic pelvic organ prolapse in a Swedish population.

Our aim was to estimate the prevalence of symptomatic pelvic organ prolapse (POP) in a Swedish urban female population. The cross-sectional study design included 8,000 randomly selected female residents in Stockholm, 30–79-year old. A postal questionnaire enquired about symptomatic POP, using a validated set of five questions, and about urinary incontinence and demographic data. Of 5,489 women providing adequate information, 454 (8.3%, 95% confidence interval 7.3–9.1%) were classified as having symptomatic POP. The prevalence rose with increasing age but leveled off after age 60. In a logistic regression model that disentangled the independent effects, parity emerged as a considerably stronger risk factor than age. There was a ten-fold gradient in prevalence odds of POP with parity, the steepest slope (four-fold) being between nulliparous and primiparous women. The prevalence of frequent stress urinary incontinence was 8.9% and that of frequent urge incontinence 5.9%. Out of the 454 women with prolapse, 37.4% had either or both types of incontinence.

Nonobstetric risk factors for symptomatic pelvic organ prolapse.

OBJECTIVE: To identify possible nonobstetric risk factors for symptomatic pelvic organ prolapse in the general female population. METHODS: This was a population-based, cross-sectional study derived from a sample of 5,489 Stockholm women, 30 to 79 years old, who answered a validated questionnaire for the identification of symptomatic prolapse. The 454 women whose answers indicated the presence of such prolapse and the 405 randomly selected control participants with answers that gave no indication of prolapse received a 72-item questionnaire, which probed into a priori suspected risk factors. Only those women with intact uteri and no prior surgery for incontinence or prolapse were included. Multivariable logistic regression models estimated prevalence odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: In addition to age and parity, overweight (prevalence OR for body mass index [kg/m2] 26–30 compared with 19–25 was 1.9, 95% CI 1.2–3.1), history of conditions suggestive of deficient connective tissue (varicose veins/hernia/hemorrhoids, prevalence OR for positive history compared with no history 1.8, 95% CI 1.2–2.8), family history of prolapse (prevalence OR for positive history compared with no history 3.3, 95% CI 1.7–6.4), heavy lifting at work (prevalence OR for 10 kg or more compared with no heavy lifting 2.0, 95% CI 1.1–3.6), and presence of constipation, hard stools, or difficult evacuation (prevalence OR relative to normal bowel habits 2.1, 95% CI 1.4–3.3) all were linked independently, significantly, and positively to the presence of symptomatic prolapse. CONCLUSION: In this nonconsulting population, age and parity were the dominating risk factors, but significant independent associations with markers suggestive of congenital susceptibility (family history and conditions signaling weak connective tissue) and nonobstetric strain on the pelvic floor (overweight/obesity, heavy lifting, and constipation) imply that individual predisposition and lifestyle/environment also may play an important role. The causal direction of the association with bowel habits remains uncertain, and the link to family history could be partly because of information bias. LEVEL OF EVIDENCE: II

Sexual dysfunction after trocar-guided transvaginal mesh repair of pelvic organ prolapse.

OBJECTIVE: To estimate sexual dysfunction before and after trocar-guided transvaginal mesh surgery for pelvic organ prolapse. METHODS: Sexually active women participating in a prospective multicenter study were recruited at 26 centers. All participants underwent a standardized surgical procedure and were evaluated before (n=105) and 1 year after (n=84) surgery using the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Nonparametric statistics were used for comparisons. RESULTS: Mean age at surgery was 61.5 years (standard deviation [SD] 7.6), median parity was 2 (range, 1–6), and mean body mass index was 26.8 (SD 4.3) (body mass index is calculated as weight (kg)/[height m]2). Anterior transvaginal mesh repair was performed in 46 patients (44%), posterior in 26 patients (25%), and combined anterior and posterior in 33 patients (31%). Overall sexual function scores worsened from 15.5 (SD 8.0) at baseline to 11.7 (SD 6.9) 1 year after surgery (P<.001). The trend toward deteriorating sexual function scores was similar for all three surgical procedures. There was an overall worsening of all symptoms in the behavioral–emotive and partner-related items, whereas improvements were observed in physical function. Overall rates and severity of dyspareunia in specific neither improved nor worsened. CONCLUSION: Sexual function scores deteriorate 1 year after trocar-guided transvaginal mesh surgery. The worsening was attributed primarily to a worsening in behavioral–emotive and partner-related items. Anatomical cure after surgery was not associated with improved PISQ scores. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00402844 LEVEL OF EVIDENCE: II

A 5-year prospective follow-up study of vaginal surgery for pelvic organ prolapse

The objective of this study was to evaluate anatomic, functional, short- and long-term outcome of vaginal surgery for pelvic organ prolapse. This was a prospective observational study of 185 consecutive women planned for vaginal prolapse reconstructive surgery. Stage of prolapse, urinary incontinence (UI), bowel and mechanical symptoms were assessed preoperatively and at 1, 3 and 5xa0years postoperatively. The mean follow-up time was 53xa0months. The anatomic recurrence rate was 41.1% but less than half of them were symptomatic. Anterior compartment was most prone for recurrence and the majority of the recurrences took place within the first year. UI remained at the same level at 1-year follow-up. De novo urge occurred in 22.6% and de novo stress incontinence in 6.0%. An improvement was seen in difficulty in emptying bowel 1xa0year after surgery (54%). Patients were primarily cured from mechanical symptoms. Re-operation rate was 9.7%; if additional operation for incontinence was included, it was13.5%.

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. LEVEL OF EVIDENCE: II

Urodynamic assessment of anterior vaginal wall surgery: a randomized comparison between colporraphy and transvaginal mesh.

To investigate the urodynamic effects of anterior vaginal wall prolapse surgery using either trocar guided transvaginal mesh or colporraphy.

Operation for pelvic organ prolapse: a follow-up study

Objective.u2002 Long‐term results of surgery for pelvic organ prolapse in terms of objective and subjective cure rates, postoperative complications and side‐effects were studied retrospectively.

Short-term natural history in women with symptoms indicative of pelvic organ prolapse

Introduction and hypothesisInformation about the natural history of pelvic organ prolapse (POP) is scarce.MethodsThis was a prospective cohort study of 160 women (mean age 56xa0years), whose answers in a population-based survey investigation indicated presence of symptomatic prolapse (siPOP), and 120 women without siPOP (mean age 51xa0years).ResultsFollow-up questionnaire was completed by 87%, and 67% underwent re-examination according to pelvic organ prolapse quantification (POP-Q) system after 5xa0years. Among re-examining siPOP women, 47% had an unchanged POP-Q stage, 40% showed regression, and 13% showed progression. The key symptom “feeling of a vaginal bulge” remained unchanged in 30% of women with siPOP, 64% improved by at least one step on our four-step rating scale, and 6% deteriorated. Among control women, siPOP developed in 2%. No statistically significant relationship emerged between changes in anatomic status and changes in investigated symptoms.ConclusionOnly a small proportion of women with symptomatic POP get worse within 5xa0years.

Effects of anterior trocar guided transvaginal mesh surgery on lower urinary tract symptoms.

To assess the effects of trocar guided transvaginal mesh on lower urinary tract symptoms after anterior vaginal wall prolapse repair.

Clinical outcome or abdominal urethropexy-colposuspension: a long-term follow-up.

Abstract: The aim of this study was to investigate the long-term results of abdominal urethropexy–colposuspension in terms of cure rate of stress urinary incontinence, complications and side effects. Between 1985 and 1992, 169 women between 27 and 79 years old underwent abdominal urethropexy–colposuspension at Stockholm So¨der Hospital. In 1997 they were invited to participate in a long-term follow-up study, 5–11 years after the operation. One hundred and thirty-one women (78%) were willing to attend for a clinical review; 38 were lost to follow-up. At the follow-up visit all women were assessed with medical history, symptoms of incontinence, and their satisfaction and problems after the operation, following a predefined protocol. Peri- and postoperative data were retrieved from the files. The patients underwent a gynecological examination, measurement of residual urine volume and a provocative leakage test. One hundred and nine women (83%) were satisfied with the results of the operation and 22 (17%) were not. Seventy-one (54%) were subjectively completely dry, 48 (35%) had a little leakage and 14 (11%) had frequent leakage; 122 women were continent in the provocation test, and only 9 (7%) demonstrated leakage. The cure rate for stress incontinence was 93%. According to their medical histories 63 (48%) women had mixed incontinence before their operation. At the follow-up examination 43 of these 63 women still had symptoms of urgency. Twenty-six women with genuine stress incontinence before the operation had developed urgency or urge incontinence during the follow-up period. Urge symptoms before operation was 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. The cure rate for stress incontinence was high but still there were women who were not satisfied with the operation. Most of these complained of urge incontinence. There were few serious complications. The objective cure rate was better than the subjective cure rate.