Indian Journal of Obstetrics and Gynecology Research

Print ISSN: 2394-2746

Online ISSN: 2394-2754

CODEN : IJOGCS

Indian Journal of Obstetrics and Gynecology Research (IJOGR) open access, peer-reviewed quarterly journal publishing since 2014 and is published under auspices of the Innovative Education and Scientific Research Foundation (IESRF), aim to uplift researchers, scholars, academicians, and professionals in all academic and scientific disciplines. IESRF is dedicated to the transfer of technology and research by publishing scientific journals, research content, providing professional’s membership, and conducting conferences, seminars, and award more...

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Get Permission Gupta: To evaluate the predisposing factors of uterovaginal prolapse in women admitted in gynaecology ward


Introduction

According to Novak’s textbook of gynaecology, 16th edition, Pelvic organ prolapse is defined as, “descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus(cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy),” correlating with symptoms, assisted by any relevant imaging.1

It is the progressive herniation of the pelvic organs through the urogenital diaphragm that most commonly leads to vaginal bulge symptoms. Women with prolapse beyond the hymen may also report lower urinary tract incontinence, urgency, frequency or voiding difficulty and bowel symptoms like obstructed defecation, fecal incontinence.1 POP is multifactorial in etiology with combination of anatomical, physiological, genetic, lifestyle and reproductive factors.2 Data from the Women’s Health Initiative revealed anterior POP in 34.3%, posterior wall prolapse in 18.6% and uterine prolapse in 14.3% of women.1 It has a detrimental effect on women’s psychological, social, emotional and physical well being.3 As the women age advance, pelvic floor dysfunction becomes more and more troublesome as it effects quality of life, workforce productivity and cost to the individual as well as whole healthcare system.4 The recognition of determinants for development of pelvic organ prolapse will help physician to target at risk women for professional counseling on preventive behavior and life style changes.

The pelvic organ prolapse determinants will aid in building a risk model for identification of low and high risk women. Since this condition is considered a social taboo, women suffering often do not tell their problems even to the closest kin and continue to suffer which in turn effects their quality of life. Hence, it can be called a “Silent Epidemic”.

Owing to the fact that this condition is very much preventive by better counseling in antenatal and postnatal period, the prevalence of this condition can be curtailed, and thereby quality of life can be improved.

Materials and Methods

Type of study

Hospital based observational retrospective study.

Study population

Patients of IPD, department of OBG, IIMSR, Lucknow.

The study was conducted by reviewing the medical records of 206 patients with pelvic organ prolapse in Integral Institute of Medical Sciences and Research between January 2019 to January 2021 for a period of two year.

The hospital is a tertiary care hospital and medical college catering health needs of rural and urban population of Dasauli, Kursi Road, Lucknow. Data was collected from gynaecological case entry register, gynaecological ward admission register, case files and operation theatre records. The medical records were reviewed by trained staff and data entered into proforma. The information collected were sociodemographic characteristics (age, parity, occupation) determinants of uterovaginal prolapse, presenting complaints, degree of prolapse and treatment modalities. The data were analyzed using SPSS version 20 and results were entered as percentage and frequency table.

Inclusion criteria

Included all women diagnosed with

  1. Cystocele

  2. Cystourethrocele

  3. Uterine prolapse

  4. Vault prolapse

  5. Rectocele and enterocele

  6. Pregnancy with prolapse

Exclusion criteria

  1. Nerve injury or disease

  2. Neuromuscular disease

  3. Genital tract malignancy

  4. Intra-abdominal tumours

Study duration

January 2019 to January 2021.

Data collection

All the patients who were admitted to gynaecology department, IIMSR and diagnosed with uterovaginal prolapse after clinical evaluation between January 2019 to January 2021 will be included in the study and data will be retrieved from Medical Records Department.

  1. Case files as per the inclusion and exclusion criteria will be identified and included in the study.

  2. Information regarding the risk factors will be collected.

  3. Pelvic Organ Prolapse Quantification System(POPQ) approved by the International Continence Society will be used for categorizing uterovaginal prolapse.

Data analysis will be done using SPSS version 20. The frequency, percentage and mean will be computed to describe the variables of the study. The statistical significance P<0.05 will be considered significant.

Result

The period of study was from January 2019 to January 2021. During this period 11256 patients were seen at the gynaecological clinic, out of which 206 patients had uterovaginal prolapse. The prevalence was 1.8%.

The sociodemographic profile of patients is shown in Table 1. The mean range of patient in our study was 52.84years. The range was between 25years and 74 years. Nearly 35.9% of study population was above 55 years. 4.3% presented with prolapse in the age group below 35 years. 3.8% presented with prolapse in nulliparous age group and 22.8%women were grand muliparous. 33.4% were farmers, 28.6% were labourers.19.9% were well-educated and employed while 17.9% were housewives.

In Table 2, the analysis of determinants and risk factors for uterovaginal prolapse were done. The uterovaginal prolapse was present in multiparous women 84.4% of cases and 74.4% in post menopausal women. 80% of cases were due to chronic intraabdominal pressure like constipation, chronic cough and strenuous physical work. While overweight was in 33.9% of cases and abdominal mass in 0.97% of cases. 62.1% of women had more than 2 risk factors, 77.6% had 2 risk factors and 88.8% had 1 risk factors.

The clinical symptomatology and presentation of patients were done in Table 3. 97% of cases presented with protrusion of mass per vagina, 88% presented with urinary symptoms, 85.4% presented with vaginal discharge, 38.8% presented with vaginal itching, 27.1% presented with ulceration and 4.8% presented with impaired sexual function. The uterine prolapse was present in 94.1% of cases, cystocele in 67.9%, rectocele in 58.2% of cases and enterocele in 41.2% of cases. Further 2.9% had procidentia, 67.9% had third degree prolapse, 7.2% had second degree prolapse and 21.8% had first degree prolapse.

The treatment modalities offered was shown in Table 4. The surgical treatment was given in 77.1% of cases, Vaginal hysterectomy in 7.2% of cases, Vaginal hysterectomy with pelvic floor repair in 69.9% of cases. Non surgical modalities were offered in 22.8% of cases like pessary in 0.97% and kegels exercise in 21.8% of cases.

Table 1

Sociodemographic profiles

Variable

Number of patients

Percentage

Age

25-34

9

4.3

35-44

43

20.8

45-54

52

25.2

55-64

74

35.9

>65

28

13.6

Parity

0

8

3.8

1

14

6.8

2

21

10.2

3

48

23.3

4

68

33.0

>/=5

47

22.8

Occupation

Farmer

69

33.4

Labourer

59

28.6

Educated/employed

41

19.9

Housewife

37

17.9

Table 2

Determinants of uterovaginal prolapse

Variables

Number of patient

Percentage

Overweight

70

33.9

Postmenopausal state

154

74.7

Multiparity

174

84.4

Abdominal mass

2

0.97

Chronic intraabdominal pressure

165

80.0

Distribution of risk factors

1

183

88.8

2

160

77.6

>2

128

62.1

Table 3

Clinical presentation

Symptoms

Patients

Percentage

Mass per vagina

200

97

Urinary symptoms

176

85.4

Vaginal discharge

80

38.8

Vaginal itching

25

12.13

Ulceration

56

27.18

Impaired sexual function

10

4.8

Types of Prolapse

Type

Patients

Percentage

Uterine prolapse

194

94.1

Cystocele

140

67.9

Rectocele

120

58.2

Enterocele

85

41.2

Degree of Prolapse

Degree

Patients

Percentage

First degree

45

21.8

Second degree

15

7.2

Third degree

140

67.9

Procidentia

6

2.9

Table 4

Treatment modalities for uterovaginal prolapse

Variable

Patients

Percentage

Nonsurgical

47

22.8

Pessary

2

0.97

Kegels exercise

45

21.8

Surgical

159

77.1

VH

15

7.2

VH with PFR

144

69.9

Discussion

The uterovaginal prolapse accounts for 1.8% of prevalence in gynaecological OPD. The incidence in Okankuo et al. is 2.1%.1 The incidence according to Eleji et al. is 6,5%.2 The difference in incidence may be due to ethnicity, awareness among the patients, social stigma and hesitancy to show to the doctors, ignorance and lack of education and health facilities. The mean age of patients was 52.84 years. The study shows it is more common in postmenopausal age group due to estrogen deficiency and its complications.1, 2

There is significant association with the parity.89.3% of women had 2 or more children. 22.8% of women were grand multipara. Hence, multiple pregnancy and delivery can be attributed as a predisposing factor for symptomatic uterovaginal prolapse.3, 4 There is significant association between number of vaginal deliveries, duration of labour, vaginal tear and sphincter damage in previous childbirths.4, 5, 6 The process of aging and resultant estrogen deficiency causes loss of collagen and weakness of fascia and connective tissue which results in uterine prolapse.7

Regarding the occupation, 28.6% were labourers, 33.4% were farmers and 17.9% were housewives. 62% of the patients were farmers and labourers, involved in heavy and strenuous physical activities.8

The major determinants for uterovaginal prolapse is postmenopausal state (74.7%) and multiparity (84.4%). The chronic intraabdominal pressure contributed to 80%of cases. The study showed excessive stretching and tearing during multiple deliveries attributed to pelvic organ prolapse. Also, postmenopausal state which leads to estrogen deficiency and weakness of fascia and connective tissue contributed to the uterovaginal prolapse.9 70% of women had more the two risk factors.

97% of patients were symptomatic to mass per vagina. The bulging or mass protruding out of vagina was a predominant presenting symptom.10

The other symptoms were obstructive symptoms like urinary symptoms like hesitancy, incomplete voiding, digital reposition before voiding. The impaired sexual function was present in 4.8% of cases. Some patients were worried about social stigma and were hesitant to share the sexual history.11

The posterior compartment defects caused pressure symptoms and constipation. The treatment modalities available are both surgical and non-surgical. About 22.8% were treated nonsurgically and 77.1% were treated surgically in our setup. The women with anaemia, postpartum period, pregnancy, elderly women with comorbidities were offered vaginal pessary. The patients who had first degree prolapse and minimal cystocele were taught kegels exercise. 69.9% of patients underwent vaginal hysterectomy with pelvic floor repair and 7.2% underwent vaginal hysterectomy. This treatment is in accordance to some studies.12, 13

The vaginal hysterectomy with pelvic floor repair still remains treatment of choice for patient with prolapse who have completed family.14, 15

The limitation with the study could be some data may not have been retrieved as it is a retrospective study. The elaborate history on socioeconomic factors, educational status, access to health care, cultural factors may not have been taken in the history.

Source of Funding

None.

Conflict of Interest

None.

References

1 

JE Okonkwo NJ Obiechina CN Obionu Incidence of pelvic organ prolapse in Nigerian womenJ Natl Med Assoc20039521326

2 

G Eleje O Udegbunam C Ofojebe C Adichie Determinants and management outcomes of pelvic organ prolapse in a low resource settingAnn Med Health Sci Res201445796801

3 

E Sujindra N Himabindu P Sabita A Bhupathy Determinants and treatment modalities of uterovaginal prolapse. A retrospective studyIndian J Health Sci201583640

4 

N Sumathi CC Nandini Uterovaginal Prolapse-A Study in South Indian WomenSch J Appl Med Sci201754F16981704

5 

C Ghetti WT Gregory SR Edwards LN Otto AL Clark Pelvic organ descent and symptoms of pelvic floor disordersAm J Obstet Gynecol20051931537

6 

CS Bradley IE Nygaard Vaginal wall descensus and pelvic floor symptoms in older womenObstet Gynecol2005106475966

7 

AV Ballard I Meyer RE Varner JL Gleason HE Richter Jonathan S. Berek Pelvic Organ ProlapseBerek & Novak’s Gynaecology20206th edWolters KluwerPhiladelphia15921649

8 

JO Delancey LK Low JM Miller DA Miller JA Tumbarello Graphic integration of causal factors of pelvic floor disorders: An integrated life span modelAm J Obstet Gynaecol20081996610

9 

M Abdel-Fattah A Familusi S Fielding J Ford S Battacharya Primary and repeat surgical treatment for female pelvic organ prolapse and incontinence in parous women in the UK: a register linkage studyBMJ Open201112e00020610.1136/bmjopen-2011-000206

10 

JM Wu AF Hundley RG Fulton ER Myers Forecasting the prevalence of pelvic floor disorders in US Women:2010 to 2050Obstet Gynaecol20091146127883

11 

BD Mekonnen Prevalence and Factors Associated with Uterine Prolapse among Gynecologic Patients at University of Gondar Comprehensive Specialized Hospital, Northwest EthiopiaJ Women’s Health Care202094492

12 

U Mishra Poonam U Prasad Pelvic Organ Prolapse-Four years review from IGIMS, Patna Int J Contemp Med Res201961014

13 

C Ghetti W T Gregory S R Edwards L N Otto A L Clark Pelvic organ descent and symptoms of pelvic floor disordersAm J Obstet Gynecol20051935360

14 

CS Bradley IE Nygaard Vaginal wall descensus and pelvic floor symptoms in older womenObstet Gynecol2005106475966

15 

AR Smith DK Edmonds Pelvic floor dysfunction I: Uterovaginal prolapseDewhursts’s Textbook of Obstetrics and Gynecology7th edBlackwell Publishing IncLondon20074979



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Article type

Original Article


Article page

185-188


Authors Details

Bhavana Gupta*


Article History

Received : 17-11-2022

Accepted : 14-03-2023


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