Introduction

Pelvic organ prolapse (POP) is a symptom arising from pelvic floor dysfunction. Other common symptoms are stress and urge incontinence, sexual dysfunction and fecal incontinence, which are often found in various combinations [1, 2].

Patients suffering from POP should be assessed with a generalized focus on all compartments as well as pelvic floor function, as one-third of the patients undergoing prolapse surgery seem to require a second operation [3]. Before the introduction of the POP-Q staging, proposed by the International Continence Society [4], clinical examination of patients with prolapse lacked uniformity and reliability. A recurrent prolapse could be a true recurrence at the same site, a de novo prolapse at a new site [5], or an 'overlooked' prolapse at a site not evaluated specifically in the first place [6].

Many women hesitate to bring symptoms of pelvic organ prolapse and incontinence to their doctors. Often these patients have had their symptoms for years [7], and the delay is attributed to their reluctance to talk about the subject, and to low expectations of the health system [8]. Very little is known about the effect of pelvic organ prolapse and related pelvic floor dysfunction on quality of life for these women, who might have adapted their lifestyle and physical activities to their symptoms.

The aim of this study was to evaluate patients with pelvic organ prolapse by relating type and severity of symptoms from the bladder, mechanical, sexual and bowel domains to bother from the symptoms, and to type and grade of prolapse measured by the POP-Q system.

Materials and methods

One hundred and ten consecutive women referred from general practice with pelvic organ prolapse were included in the study. The patients completed a validated questionnaire with 34 questions in four domains concerning mechanical symptoms (see Table 2), lower urinary tract symptoms (LUTS) (see Table 3), bowel symptoms (see Table 4), and sexual symptoms. The severity of each symptom was graded according to frequency: 1. never or less than once per month, 2. less than once per week, 3. once or more per week, and 4. daily. As a measure of effect on quality of life for each symptom, the woman filled in a 4-point bother score, as follows: 1= none, 2 = mild, 3 = moderate or 4 = severe bother. Finally, the patients were asked why they consulted their doctor, and how much their symptoms affected their daily life at home, at work, during shopping, and during social activities. The questionnaire was tested for content validity by discussing the questions with specialists in the field and with patients operated on for prolapse. The construct validity was tested by 20 controls without urogynecologic complaints or objective prolapse. They all filled in the questionnaire with the lowest grade of frequency and bother in all domains except the questions concerning sexual life. The test–retest reliability was tested in 20 patients, who filled in the questionnaire twice, 2–3 weeks apart.

Before pelvic examination, the patients were asked to empty their bladders. The participants were examined in the supine position with the hips and knees flexed at 90°. The prolapse was brought into vision by coughing and Valsalva maneuvre until the patient agreed on the maximal size (by 'how it felt', or with the help of a handheld mirror). Each compartment was evaluated separately while the other compartments were retracted with a single-bladed speculum. The supine position was chosen for the convenience of the examiner.

The prolapse was graded visually from 1 to 4, in the anterior, middle and posterior compartments of the vagina, respectively. Cervical elongation >3 cm was noted as well as the presence of an enterocele. The nine POP-Q measurement points were determined by a ruler. The accuracy of the measurements was 0.5 cm.

For statistical analysis, the severity of the symptoms was grouped in two: present less than once per week versus once or more per week. The bother scores were also grouped in two: none or mild bother versus moderate or severe bother. The grading of prolapse in each compartment was grouped into low grade: 0 and 1 versus grades 2, 3 and 4, according to the present indication for operative treatment in the two hospitals. The χ2 test was used for categorical variables and the Kruskal–Wallis test for numerical variables. The level of significance was chosen as P<0.05.

The study was approved by the local ethical comitees of the County of Copenhagen and Storestrom, respectively.

Results

Symptoms and POP grade

The median age of the 110 patients was 66.5 years (range 38–85), 23% had had a hysterectomy, and 63% were either premenopausal or receiving hormone replacement therapy. The distribution in age groups versus prolapsed compartment is shown in Table 1. Only patients with prolapse greater than grade 1 in one or more compartments were analyzed, and only 5 women had prolapse of grade 1 or less in all three compartments. There was no difference between the involved compartments in the four age groups.

Table 1. Age-group versus prolapsed compartment (≥grade 2) in 110 women

A prolapse of grade 2 or more of the middle compartment or cervix elongation 3 cm or more was found in 36% of the patients. Prolapse of the middle compartment was combined with prolapse in the anterior compartment in 36%, with prolapse in the posterior compartment in 21%, and with prolapse in both the posterior and anterior compartment in 50%. More women with the combined anterior–posterior compartment prolapse also had prolapse in the middle compartment (P=0.05).

The symptoms had been present for more than a year in 58%, and for more than 2 years in 38%. The delay in presenting symptoms to healthcare providers was independent of age group.

The answers to the mechanical domain questions versus the prolapsed compartment is shown in Table 2. Only patients with symptoms once or more per week are displayed. Vaginal pain is not a typical complaint with prolapse. Significantly more patients with combined anterior–posterior prolapse complained of a lump at or outside the introitus. The other mechanical symptoms were independent of the involved compartment. Whether the middle compartment was also involved or not did not affect the mechanical symptoms.

Table 2. Mechanical symptoms (≥1/week) versus prolapsed compartment (≥grade 2)

The distribution of LUTS more than once per week versus the prolapsed compartment is shown in Table 3. LUTS were very common in women referred with pelvic organ prolapse, 8%–47% complaining of one or more bladder symptoms at least once per week. There was no difference in the frequency of LUTS according to which compartment was prolapsed, except for the symptom of stress incontinence, which was significantly less frequent in the group with combined anterior–posterior prolapse (P=0.04).

Table 3. LUTS (≥1/week) versus prolapsed compartment (>grade 1)

The type and frequency of problems in passing stool and fecal incontinence versus the prolapsed compartment is shown in Table 4. Significantly (P=0.01) more patients with prolapse in the posterior compartment with or without anterior or middle involvement had evacuation problems, and had to strain excessively and use vaginal, perineal or rectal digitation to empty their bowels. Fecal incontinence symptoms were reported by 12%–35% of the patients. There was no difference in the frequency of fecal incontinence according to which compartment was prolapsed.

Table 4. Bowel symptoms (≥1/week) versus prolapsed compartment (≥grade 2)

Significantly (P=0.04) more women complaining of urinary stress incontinence than continent patients also complained of incontinence for liquid stool.

Urinary urge incontinence was significantly related to symptoms of fecal incontinence of all three types. Incontinence for liquid and solid stool was significantly interrelated. Flatus incontinence was not significantly related to incontinence for solid and liquid stool, but as mentioned to urinary incontinence.

Sixty-one women (55%) had not had sexual intercourse within the last year. The reasons given were: no partner (36%), or a partner with disease or impotence (21%). Of the 43% sexually inactive women with a potent partner, one or more of the following reasons were given: prolapse 18%, dyspareunia 15%, and lack of libido 20%.

Forty-nine women were sexually active, 29% had coitus at least once per week, 36% at least once per month, and 35% less than once per month. Low frequency of coitus was significantly related to old age (P<0.001). Most of these sexually active women (92%) complained of one or more problems during sexual intercourse: 57% had mechanical or psychological problems because of their prolapse, and 35% complained of dyspareunia or vaginal dryness. Five women were afraid that intercourse might worsen their prolapse, one woman complained of urinary incontinence during coitus, and 36% complained of diminished libido.

Symptoms and POP-Q measurements

The mean POP-Q values of the anterior compartment versus the tested LUTS did not disclose any significant differences in the symptomatic versus the non-symptomatic patients. Considering the posterior compartment, patients with symptomatic stress incontinence once or more per week had a significantly smaller Ap: −1.4 cm, compared to −0.5 cm in patients without incontinence. No other differences of the posterior compartment measurements were found according to LUTS.

The mean POP-Q measurements in the posterior compartment were significantly larger in patients with frequent bowel evacuation problems than in those with normal bowel evacuation: Ap: −0.1, Bp:+ 0.68 cm in the symptomatic group versus Ap: −1.1 and Bp: −0.5 in the asymptomatic group. Furthermore, patients with incontinence for liquid stool once or more per week had a significantly larger Bp: +1.1 cm versus −0.4 cm in patients without this symptom.

The measured size of the genital hiatus was compared to the subjective impression of introital size in the sexually active women. Three patients found their introitus too narrow, 40 patients felt it was sufficient, and 24 felt it was too wide, the corresponding mean gh-measurement being: 4.7 cm, 4.2 cm and 4.0 cm, respectively.

Symptoms and bother score

For analysis, the bother score was divided into two grades of severity: those with no or little bother (Figs. 13, left column), and those with moderate or severe bother (Figs. 13, right column). The frequency of symptoms was divided into patients with the symptom less than once per week versus those with the symptom more than once per week. The bother score versus the frequency of mechanical symptoms and sexual problems is shown in Fig. 1. Bother score versus LUTS is shown in Fig. 2, and versus bowel symptoms in Fig. 3.

Fig. 1.
figure 1

Frequency of mechanical and sexual problems versus bother of the symptom

Fig. 2.
figure 2

Frequency of bowel symptoms versus bother of the symptom

Fig. 3.
figure 3

Frequency of LUTS versus bother of the symptom

In all cases the 'severe bother' group was significantly related to having symptoms more than once per week, except for the use of laxatives, which was not a significant problem. In the case of sexual problems, these were so frequent in both the severe and the mild bother groups that there was no difference.

The domain with the most severe bother was the mechanical symptoms. The main problem was a lump outside the introitus, which was a severe bother in 75%, followed by the feeling of pelvic heaviness, a severe bother in 72%. Urge incontinence was a severe bother to 65% of the affected.

The symptoms affected the quality of life to a moderate or severe degree in 75% of patients.

The main reason for seeing their doctor was symptoms from the prolapse in 77%, and worries about what the lump was (a tumor?) in 36%. Only 7% saw their doctor for other reasons, meaning that the diagnosis of prolapse was partly incidental.

Discussion

When assessing pelvic floor dysfunction, the ideal would be to identify each symptom and each defect in the pelvic support system. The POP-Q system is a clinical step on the way to systematically describing each compartment, and not only the most apparent defect.

In the future, magnetic resonance imaging (MRI) will hopefully improve the evaluation of women with pelvic organ prolapse. The POP-Q system can be applied in MRI diagnostics [6], which can facilitate communication between radiologists and clinicians. Most MRI studies find defects in all three compartments, even if defects were not found on pelvic examination [9, 10, 11, 12]. Most MRI studies use a grading system relative to the pubococcygeal line, and define prolapse of an organ as being when it is below this 'pelvic muscle floor' line. This is probably a more sensitive definition than the hymen or the midpubic line used in POP-Q and at MRI [6]. Until clinical and MRI definitions come into agreement, we will not really know whether patients are under- or overdiagnosed by either of the two systems.

Another important task is to relate symptoms to defects: when this can be done a more realistic prognosis for postoperative results can be given. First, LUTS are very common in older women. In a study of 4000 40–60-year-old Danish women the prevalence of LUTS was 27.8%, and 16.1% complained of urinary incontinence [13]. In our study of women with pelvic organ prolapse, the prevalence of the various LUTS ranged from 8% to 45%, with 27% complaining of stress incontinence and 21% of urge incontinence. The mean age of our study population was 66.5 years. Because the prevalence of LUTS, especially urge incontinence, frequency and nocturia, increases with age, some of the LUTS in our patients may be explained more by old age than by prolapse. An epidemiologic study of women with/without LUTS and corresponding POP-Q is needed to evaluate the association of symptoms with POP.

Several studies [1, 14, 15, 16] have found LUTS, and especially urinary incontinence, very prevalent in patients with cystocele. In our study stress incontinence was less prevalent in the more 'severe' prolapse group with involvement of both the anterior and the posterior compartments. A pronounced prolapse (grade III–IV) may cause kinking or obstruction of the urethra, as shown in the studies of both Yalcin [1] and Gardy [15], who concluded that a severe cystocele may mask stress incontinence. When vaginal packing or a pessary test is applied, even more cases with stress incontinence are unmasked, though the diagnostic sensitivity and specificity of a pessary test seem low [17].

Traditionally, urinary symptoms are related to cystoceles and bladder neck hypermobility, i.e. defects in the anterior compartment. In this study, LUTS had the same prevalence in patients with defects in the anterior and posterior compartments. Furthermore, Aa, as a measure of bladder neck mobility, was not significantly different in patients with urinary incontinence than in continent patients. Urinary incontinence and prolapse in any compartment seem to represent different aspects of a global pelvic floor weakness.

It is a shortcoming of the POP-Q system that it does not differentiate between lateral and central defects in the anterior compartment. As lateral defects are more often related to urinary incontinence [18], the prevalence of incontinence in a coincident prolapse population will depend on the unregistered representation of lateral versus central defects. Both MRI and the New York classification [19] differentiate between the two types of defect. Furthermore, anterior vaginal wall relaxation, diagnosed by ultrasonography, is related to stress incontinence [20].

Hardly any studies address the question of LUTS in patients with defects in the posterior compartment or, vice versa, of bowel symptoms in patients with defects in the anterior compartment. Glavind and Madsen [21] remarked that 9 of 67 women were cured of LUTS after fascial defect rectocele repair. A postoperative follow-up of all types of symptoms is ongoing for the patients in our study group.

Flatus incontinence was significantly related to urinary incontinence, but not to incontinence for liquid and solid stool. No relation was found between fecal incontinence and the involved compartment. The POP-Q system does not measure pelvic floor muscle function, which could explain flatus and urinary incontinence, nor does it measure anal sphincter function, which could explain incontinence for liquid and solid stool.

Stool entrapment in a large rectocele frequently necessitates digital manipulation of the posterior vaginal wall or the perineum to initiate defecation. Problems with evacuation were significantly related to defects it the posterior compartment, and were found in 36% with posterior defects. Evacuation problems were also found by Glavind and Madsen [21] in 40% of patients before discrete fascial repair.

Constipation is a common finding in patients with rectocele [22, 23], usually around 50% having this complaint. In our study the definition of constipation was strict – bowel movement twice or less per week—and constipation was only found in 6%, unrelated to which compartment was prolapsed. One cannot conclude anything concerning cause and effect from epidemiologic studies, and it might be that continuous straining is more the cause than the effect of prolapse [24].

Only half of these elderly women were sexually active, and sexual problems were common in this group. The most studied single sexual dysfunction in the literature is dyspareunia, which is reported in 6%–67% [21, 22, 23, 25, 26, 27]. Dyspareunia being the only subject of sexual life to be studied gives very little information about the causes of the symptom. According to other studies, some of the 57% with mechanical or psychological problems from their prolapse found in this study might have been registered in the dyspareunia group, as exact definitions of dyspareunia are seldom given.

Mechanical symptoms from the prolapse were the most troublesome to patients' daily lives. The more frequent a symptom the more troublesome. All in all, 75% thought that their symptoms had a moderate or severe impact on their quality of life. In spite of this, 58% waited more than a year to consult their doctor.

In conclusion, problems with emptying the bladder and bowels, and problems with urinary and fecal incontinence as well as sexual problems, are common in patients with pelvic organ prolapse, and quality of life is affected accordingly. The symptoms are reported generally and with little relation to prolapse in a specific compartment or POP-Q value.

Because of the paucity of informations in the medical literature, further clinical and epidemiologic studies are needed to evaluate the relation of symptoms generally attributed to POP, and the degree and site of the POP before as well as after surgical repair.