The natural history of pelvic organ prolapse (POP) is poorly understood. We investigated the prevalence and risk factors of postnatal POP in premenopausal primiparous women and the associated effect of mode of delivery.
We conducted a prospective cohort study in a tertiary teaching hospital attending 9,000 deliveries annually. Collagen-diseases history and clinical assessment was performed in 202 primiparae at ≥1 year postnatally. Assessment included Pelvic Organ Prolapse Quantification (POP-Q) system, Beighton mobility score, 2/3D-transperineal ultrasound (US) and quantification of collagen type III levels. Association with POP was assessed using various statistical tests, including logistic regression, where results with p < 0.1 in univariate analysis were included in multivariate analysis.
POP had a high prevalence: uterine prolapse 89 %, cystocele 90 %, rectocele 70 % and up to 65 % having grade two on POP-Q staging. The majority had multicompartment involvement, and 80 % were asymptomatic. POP was significantly associated with joint hypermobility, vertebral hernia, varicose veins, asthma and high collagen type III levels (p < 0.05). In multivariate logistic regression, only levator ani muscle (LAM) avulsion was significant in selected cases (p < 0.05). Caesarean section (CS) was significantly protective against cystocele and rectocele but not for uterine prolapse.
Mild to moderate POP has a very high prevalence in premenopausal primiparous women. There is a significant association between POP, collagen levels, history of collagen disease and childbirth-related pelvic floor trauma. These findings support a congenital contribution to POP etiology, especially for uterine prolapse; however, pelvic trauma seems to play paramount role. CS is significantly protective against some types of prolapse only.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Elenskaia K et al (2013) Effect of childbirth on pelvic organ support and quality of life: a longitudinal cohort study. Int Urogynecol J 24(6):927–937
Sze EH, Hobbs G (2011) A prospective cohort study of pelvic support changes among nulliparous, multiparous, and pre- and post-menopausal women. Eur J Obstet Gynecol Reprod Biol 160:232–235
Jackson SR et al (1996) Changes in metabolism of collagen in genitourinary prolapse. Lancet 347(9016):1658–1661
Ewies AA, Al-Azzawi F, Thompson J (2003) Changes in extracellular matrix proteins in the cardinal ligaments of post-menopausal women with or without prolapse: a computerized immunohistomorphometric analysis. Hum Reprod 18(10):2189–2195
Norton PA et al (1995) Genitourinary prolapse and joint hypermobility in women. Obstet Gynecol 85(2):225–228
Lammers K et al (2012) Pelvic organ prolapse and collagen-associated disorders. Int Urogynecol J 23(3):313–319
Buchsbaum GM, Duecy EE (2008) Incontinence and pelvic organ prolapse in parous/nulliparous pairs of identical twins. Neurourol Urodyn 27(6):496–498
Twiss C, Triaca V, Rodriguez LV (2007) Familial transmission of urogenital prolapse and incontinence. Curr Opin Obstet Gynecol 19(5):464–468
Dietz HP, Simpson JM (2008) Levator trauma is associated with pelvic organ prolapse. BJOG 115(8):979–984
Durnea CM, Khashan AS, Kenny LC, Tabirca SS, O’Reilly BA (2013) An insight into pelvic floor status in nulliparous women. Int Urogynecol J 25:337–345
Baessler K et al (2009) Australian pelvic floor questionnaire: a validated interviewer-administered pelvic floor questionnaire for routine clinic and research. Int Urogynecol J Pelvic Floor Dysfunct 20(2):149–158
Remvig L, Jensen DV, Ward RC (2007) Epidemiology of general joint hypermobility and basis for the proposed criteria for benign joint hypermobility syndrome: review of the literature. J Rheumatol 34(4):804–809
Dietz HP, Lekskulchai O (2007) Ultrasound assessment of pelvic organ prolapse: the relationship between prolapse severity and symptoms. Ultrasound Obstet Gynecol 29(6):688–691
Orejuela FJ, Shek KL, Dietz HP (2012) The time factor in the assessment of prolapse and levator ballooning. Int Urogynecol J 23(2):175–178
Dietz HP, Abbu A, Shek KL (2008) The levator-urethra gap measurement: a more objective means of determining levator avulsion? Ultrasound Obstet Gynecol 32(7):941–945
Zou GY (2004) A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol 159(7):702–706
Dietz HP et al (2012) Avulsion injury and levator hiatal ballooning: two independent risk factors for prolapse? An observational study. Acta Obstet Gynecol Scand 91(2):211–214
Swift S (2005) Pelvic organ prolapse: is it time to define it? Int Urogynecol J Pelvic Floor Dysfunct 16(6):425–427
Martin HDA (2013) What is ‘significant’ pelvic organ prolapse? Int Urogynecol J 24(1 Supplement):S65–S66
Kerkhof MH, Hendriks L, Brolmann HA (2009) Changes in connective tissue in patients with pelvic organ prolapse—a review of the current literature. Int Urogynecol J Pelvic Floor Dysfunct 20(4):461–474
Edwall L, Carlstrom K, Jonasson AF (2007) Endocrine status and markers of collagen synthesis and degradation in serum and urogenital tissue from women with and without stress urinary incontinence. Neurourol Urodyn 26(3):410–415
Knuuti E et al (2011) Genitourinary prolapse and joint hypermobility are associated with altered type I and III collagen metabolism. Arch Gynecol Obstet 283(5):1081–1085
Rosenquist C et al (1998) Serum CrossLaps One Step ELISA. First application of monoclonal antibodies for measurement in serum of bone-related degradation products from C-terminal telopeptides of type I collagen. Clin Chem 44(11):2281–2289
Bailey AJ (2001) Molecular mechanisms of ageing in connective tissues. Mech Ageing Dev 122(7):735–755
Gabriel B et al (2005) Uterosacral ligament in postmenopausal women with or without pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 16(6):475–479
Strohbehn K, Jakary JA, Delancey JO (1997) Pelvic organ prolapse in young women. Obstet Gynecol 90(1):33–36
DeLancey JO (1992) Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 166(6 Pt 1):1717–1724, discussion 1724–8
Nichols DH, Randall CR (1989) Vaginal surgery. Williams & Wilkins, Baltimore
Knuutinen A et al (2002) Smoking affects collagen synthesis and extracellular matrix turnover in human skin. Br J Dermatol 146(4):588–594
Thom DH et al (2006) Differences in prevalence of urinary incontinence by race/ethnicity. J Urol 175(1):259–264
We thank all SCOPE Ireland participants, Continence Foundation Ireland and Irish Centre for Fetal and Neonatal Translational Research (INFANT) for their input into this research project.
SCOPE Ireland is funded by Health Research Board of Ireland (grant reference CSA 2007/2). The study was supported by Continence Foundation Ireland and INFANT Centre, UCC.
This work was funded in part by Science Foundation Ireland.
Conflicts of interest
Electronic supplementary material
Below is the link to the electronic supplementary material.
Online Appendix A1
STARD flowchart indicating recruited numbers (BMP 1594 kb)
Online Appendix A2
Medical conditions potentially associated with collagen disorders (DOCX 12 kb)
Online Appendix 3
A POP-Q assessment and ultrasound estimate of POP-Q coordinates (XLSX 100 kb)
Rights and permissions
About this article
Cite this article
Durnea, C.M., Khashan, A.S., Kenny, L.C. et al. Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal primiparous women. Int Urogynecol J 25, 1463–1470 (2014). https://doi.org/10.1007/s00192-014-2382-1
- Pelvic organ prolapse