Predictors of advanced pelvic organ prolapse in Asian women.

OBJECTIVE: To investigate risk factors for advanced pelvic organ prolapse (POP) in Asian women. STUDY DESIGN: This was a case-control study of Asian women referred for POP or incontinence over a 10-year period at San Francisco General Hospital. Details of a structured pelvic examination and demographic information were abstracted from medical records. Cases were women with advanced (beyond the hymenal remnant) POP, while patients with a lesser degree of prolapse served as controls. Categorical variables were analyzed using chi2 or Fisher's exact test (where appropriate), while continuous variables were analyzed with Student's t test. Logistic regression was used for multivariate analysis. RESULTS: One hundred thirty Asian women were identified. Sixty-six women had advanced prolapse of some portion of their vagina. Increasing parity was associated with advanced prolapse of the anterior compartment of the vagina (adjusted OR 1.56, 95% CI 1.22-2.00). Previous hysterectomy appears to be protective of advanced prolapse of the anterior vagina (adjusted OR 0.09, 95% CI 0.01-0.81). CONCLUSION: Similar to the Caucasian population, Asian women with higher parity are at increased risk for prolapse of the anterior compartment of the vagina. However, previous hysterectomy appears to be protective of future prolapse in Asian women.

Validation of the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) in a Turkish population.

OBJECTIVE: To validate the Turkish translated version of short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). STUDY DESIGN: After the test-retest reliability and internal consistency were established in a pilot study, 270 patients were enrolled and general and subscale scores of the questionnaire were calculated. All participants underwent the International Continence Society (ICS) prolapse score (POP-Q) and urodynamic assessment. Main scores and scores of Prolapse Quality of Life questionnaire (PQoL) and Incontinence Impact Questionnaire (IIQ-7) were compared between patients with incontinence+/-prolapse and asymptomatic women. RESULTS: 62.24% of the participants showed urodynamic abnormality and/or leakage with or without prolapse. 28.91% had prolapse stage 3 or higher diagnosed by the POP-Q system. PISQ-12 showed a high internal consistency (Cronbach's alpha was 0.89). For test-retest reliability Spearman's rho was 0.72-0.79 for all domains. The mean scores of PISQ-12 were significantly better in asymptomatic women compared with the incontinence+/-prolapse group. Sexual function was negatively affected by prolapse and/or incontinence as assessed with PQoL and IIQ-7 questionnaires. CONCLUSION: The Turkish translated version of the PISQ-12 is a reliable, consistent and valid instrument to evaluate sexual functioning in women with urinary incontinence and/or pelvic organ prolapse. It is easy to understand that it may be easily administered and self-completed by the women.

Racial differences in women who have a hysterectomy for benign conditions.

OBJECTIVE: To evaluate if there are racial differences between African-American and Caucasian women who have hysterectomy for benign conditions in terms of (1) presenting symptoms (prolapse, vaginal bleeding, pain, and known history of leiomyomas), (2) serum estradiol and testosterone levels at the visit before hysterectomy, and (3) uterine weight. METHODS: A multi-ethnic, multisite, community-based longitudinal cohort study of 3,302 women ages 42-52 at enrollment was conducted. During 9 years of follow-up, 203 African-American and Caucasian women reported a hysterectomy, 90 with evidence of uterine leiomyomas. Women were surveyed regarding their overall perceived health before and after hysterectomy, presenting symptoms, and their motivations for surgery. Serum estradiol and testosterone levels were measured. Uterine weight at time of hysterectomy and clinical pathology were determined via medical record abstraction. RESULTS: Previously diagnosed leiomyomas were presenting symptoms more frequently in African-American women than Caucasian women (85% vs. 63%; p = .02). African-American women had less prolapse than Caucasian women (0% vs. 10%; p = 0.04). Chronic pain was a more frequent reason for hysterectomy in African-American women than in Caucasian women (49% vs. 29%; p = .05). There were no differences between the groups in levels of estradiol or testosterone. African-American women had almost twice the uterine weight as that of Caucasian women (448 vs. 240 g; p = .0005). CONCLUSION: Racial differences in frequency of hysterectomy for benign conditions are consistent with differences in presenting symptoms, where African-American women seemingly have larger, more symptomatic fibroids.

Pelvic floor disorders among indigenous women living in Xingu Indian Park, Brazil.

INTRODUCTION AND HYPOTHESIS: Current assessment for pelvic floor disorders (PFDs) allows comparison between different communities. METHODS: A total of 377 indigenous women living in Xingu Indian Park were evaluated. The pelvic organ prolapse quantification (POP-Q) was the system used to quantification the staging of pelvic support. The pelvic floor muscle strength was assessed by a perineometer. Logistic regression analysis was used to determine risk factors that were associated with prolapse. RESULTS: Only 5.8% of women reported urinary incontinence. The overall distribution of POP-Q stage system was the following: 15.6% stage 0, 19.4% stage I, 63.9% stage II and 0.8% stage III. Parity and age were the risk factors for pelvic organ prolapse (p < 0.0001). CONCLUSIONS: Urinary incontinence was uncommon in Xingu indigenous women. Like non-indigenous communities, age and parity were the most important risk factors to the genital prolapse.

Do racial differences in knowledge about urogynecologic issues exist?

The objective of this study is to assess knowledge about urinary incontinence and pelvic organ prolapse in white versus nonwhite women. We hypothesize that there are racial differences in patient knowledge about these issues. One hundred twenty-six women presenting to our institution's gynecology clinic completed a two-scale, validated questionnaire assessing knowledge about incontinence and prolapse. Responses were compared for white versus nonwhite women using nonparametric statistical methods. Logistic regression was used to control for confounding variables. Mean score for white women exceeded that for nonwhite women for the incontinence (p = 0.019) but not the prolapse scale (p = 0.354). Of the white patients, 37.9% versus 19.1% of the nonwhite patients scored > or =80% on the incontinence scale (p = 0.019). This difference remained significant after controlling for potential confounders using logistic regression (p = 0.039). White women may have improved tested urinary incontinence knowledge as compared to nonwhite women.

Surgery for stress urinary incontinence in the United States: does race play a role?

The objective of this study was to evaluate the prevalence, demographics and complications of stress urinary incontinence (SUI) surgery across races in the United States (US) in 2003. We hypothesized that there would be racial differences in surgical rates. Data from the 2003 National Census and National Hospital Discharge Survey were used. Continuous variables were tested for statistical significance by one-way analysis of variance and categorical variables by chi2 analysis. 129,778 women underwent SUI surgery in the US in 2003, a rate of 12 surgical procedures per 10,000 women (95% CI 10-14). By race, rates (per 10,000 women, 95% CI) of SUI surgery were: ten (7-12) in white women, three (0-9) in black women, and six (0-13) in women of other races. Racial disparities in the receipt of SUI surgery may exist.

Prevalence of genital prolapse in 3 ethnic groups.

OBJECTIVE: To compare the prevalence of genital prolapse stratified by Asian American, black and white ethnic groups in women presenting for routine gynecologic examinations and to screen them for symptoms of pelvic floor problems. STUDY DESIGN: This was a descriptive study of women presenting for annual examinations. Demographic information on age, weight, gravidity, parity, weight of largest vaginally delivered infant, gynecologic surgery, medical problems (including hypertension, diabetes, pulmonary disease, smoking) and menopausal status were obtained from the patient and chart. Pelvic organ prolapse was assessed using the quantitative pelvic organ prolapse system. Subjects completed the Pelvic Floor Distress Inventory, which was graded along the 3 scales of Urinary Distress Inventory, Pelvic Organ Prolapse Distress Inventory and Colorectal-Anal Distress Inventory. RESULTS: One hundred sixty-seven women completed the study, including 73 whites, 60 Asian Americans and 34 blacks. The populations differed in that black women had higher body weight and were more likely to smoke, while white patients had lower parity and more use of hormone replacement therapy. Sixty-seven percent of Asian American patients had stage 2 or higher prolapse as compared to 26% of black and 28% of white patients. Multiple logistic regression showed that Asian American ethnicity independently correlated with higher rates of pelvic organ prolapse. There was no difference in survey results by race. CONCLUSION: There may be significant racial differences in the incidence of pelvic floor prolapse, with higher rates of stage 2 prolapse in asymptomatic Asian American women.

Validation of the prolapse quality of life questionnaire (P-QOL) in a Turkish population.

OBJECTIVE: To validate the Turkish translated version of the prolapse quality of life questionnaire (P-QOL). STUDY DESIGN: After establishing the test-retest reliability and internal consistency in a pilot study, 310 patients were enrolled in the study and general and subscale scores of the questionnaires were calculated. All participants underwent the International Continence Society (ICS) prolapse score (POP-Q). RESULTS: One hundred and forty-five (49.7%) women were symptomatic and 147 (50.3%) were asymptomatic. The level of missing data ranged from 0 to 2.2%. For the test-retest reliability, Spearman's rho was from 0.91 to 1.00 for all domains (p<0.001). The severity of P-QOL was strongly correlated with the vaginal examination findings among the symptomatic group (p<0.001). Items correlated with the objective vaginal examination findings. The total and domain scores for P-QOL of symptomatic and asymptomatic women were found to be statistically significant (p<0.001). CONCLUSION: The Turkish translated version of the P-QOL is reliable, consistent and valid instrument for assessing symptom severity, impact on quality of life in women with uterovaginal prolapse. It is easy to understand may be easily administered and self-completed by the women.

Racial characteristics of women undergoing surgery for pelvic organ prolapse in the United States.

OBJECTIVE: This study was undertaken to compare the prevalence, demographics, and complications of pelvic organ prolapse surgery across races in the United States. STUDY DESIGN: Data from the 2003 National Census and the 2003 National Hospital Discharge Survey were used to determine rates of prolapse surgery, demographic characteristics, morbidity, and mortality across races. RESULTS: In 2003, 199,698 women underwent prolapse surgery. Rates of prolapse surgery per 10,000 women were 14.8, 5.6, and 8.7 in women of white, black, and other races. By geographic region, surgical rates per 10,000 white vs black women differed most in the West (16.0 vs 0.8). Of black women, 27% were on public assistance, compared with 5.9% and 9.6% women of white and other races. Complications occurred in 19.4%, 34.1%, and 27.4% of women of white, black, other races. Mortality was uncommon for all races. CONCLUSION: Racial disparities between white and black women undergoing prolapse surgery appear to exist.

Symptomatic pelvic organ prolapse: prevalence and risk factors in a population-based, racially diverse cohort.

OBJECTIVE: To estimate the prevalence of and identify risk factors associated with symptomatic pelvic organ prolapse and level of distress in racially diverse women aged older than 40 years. METHODS: The Reproductive Risks for Incontinence Study at Kaiser is a population-based study of 2,001 randomly selected women. Symptomatic prolapse was determined by self-report of a feeling of bulge, pressure, or protrusion or a visible bulge from the vagina. Risk factors were assessed by self-report, interview, physical examination, and record review. Distress was assessed by self-report. Multivariable logistic regression analysis was used to identify independent risk factors. RESULTS: Symptomatic prolapse was reported by 118 (6%) women. Almost 50% of these women reported moderate or great distress, and 35% reported that the symptoms affected at least one physical, social or sexual activity. In multivariable analysis, the risk of prolapse was significantly increased in women with one (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.1-7.2), two (OR 4.1, 95% CI 1.8-9.5), and three or more (OR 5.3, 95% CI 2.3-12.3) vaginal deliveries compared with nulliparous women. Irritable bowel syndrome, constipation, and self-reported fair or poor health status were strongly associated with prolapse, with ORs of 2.8 (95% CI 1.7-4.6), 2.5 (95% CI 1.7-3.7), and 2.3 (95% CI 1.1-4.9), respectively. African-American women were significantly less likely to report symptomatic prolapse compared with white women (OR 0.4, 95% CI 0.2-0.8). CONCLUSION: Symptomatic prolapse is less common among African-American women and more common among women with a prior vaginal delivery, poor health status, constipation, or irritable bowel syndrome. Nearly one half of women with symptomatic prolapse are substantially bothered by their symptoms.

Magnetic resonance imaging of uterine version in a multiethnic, nulliparous, healthy female population.

OBJECTIVE: To determine measurement and topography of uterine position in asymptomatic women with different ethnicity. STUDY DESIGN: The angle and direction of uterine version were measured using magnetic resonance imaging in nulliparous, young volunteers from 5 ethnic groups (Emiratis, other Arabs, Indians/Pakistanis, Filipinos and Europeans/ Caucasians; N=55) and compared using Europeans/Caucasians as the reference group. RESULTS: The uterus was anteverted on the vagina in 46 (83.6%) and retroverted in 9 (16.4%) women, with no significant difference between Europeans/Caucasians and non-Caucasians. The angle of uterine version was significantly less (i.e., the cervix was more anteverted or retroverted on the vagina) in Europeans/Caucasians as compared to other women (p=0.002), particularly Indians/Pakistanis (p < 0.00001). CONCLUSION: The degree of uterine version is different in healthy, nulliparous European/Caucasian and non-Caucasian women.

Percentage of hysterectomy for pelvic organ prolapse in five ethnic groups.

The aim of this study was to determine whether there are differences in the percentage of hysterectomies performed for pelvic organ prolapse between five ethnic groups. Using archived data from January 1984 to January 2000, multiple logistic regression was used to adjust for age and the age-adjusted percentages were compared to Caucasians as odds ratios. A total of 6401 hysterectomies were identified, and 832 (13%) were performed for pelvic organ prolapse. The differences in the age-adjusted percentages were significant. The Japanese (P<0.001), Chinese (P<0.001) and Hawaiian (P<0.05) percentages were lower and those of the Filipinos were not significantly different from those of Caucasians below age 60. The age-adjusted odds ratios of hysterectomy for pelvic organ prolapse relative to Caucasians for Japanese, Chinese and Hawaiians were from 0.5 to 0.7. The differences begin to disappear after age 60. A significantly lower percentage of hysterectomies for pelvic organ prolapse were done in Japanese, Hawaiian and Chinese women. The odds ratios in Filipino women increased after age 60.

Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity.

OBJECTIVE: The purpose of this study was to describe the prevalence of and correlates for pelvic organ prolapse. STUDY DESIGN: This was a cross-sectional analysis of women who enrolled in the Women's Health Initiative Hormone Replacement Therapy Clinical Trial (n = 27,342 women). Baseline questionnaires ascertained demographics and personal habits. A baseline pelvic examination assessed uterine prolapse, cystocele, and rectocele. Descriptive statistics and logistic regression models were used to investigate factors that were associated with pelvic organ prolapse. RESULTS: In the 16,616 women with a uterus, the rate of uterine prolapse was 14.2%; the rate of cystocele was 34.3%; and the rate of rectocele was 18.6%. For the 10,727 women who had undergone hysterectomy, the prevalence of cystocele was 32.9% and of rectocele was 18.3%. After controlling for age, body mass index, and other health/physical variables, African American women demonstrated the lowest risk for prolapse. Hispanic women had the highest risk for uterine prolapse. Parity and obesity were strongly associated with increased risk for uterine prolapse, cystocele, and rectocele. CONCLUSION: Pelvic organ prolapse is a common condition in older women. The risk for prolapse differs between ethnic groups, which suggests that the approaches to risk-factor modification and prevention may also differ. These data will help address the gynecologic needs of diverse populations.

Pelvic organ prolapse and connective tissue abnormalities in Korean women.

OBJECTIVE: To evaluate the relationship between pelvic organ prolapse in Korean women and joint hypermobility, which suggests a metabolic collagen fiber abnormality. STUDY DESIGN: Between March 1998 and March 2000, we investigated 55 patients with prolapse. The prevalence of joint hypermobility, by measuring finger extension angle, and the proportion of patients with joint hypermobility were measured in patients with pelvic organ prolapse and benign gynecologic patients (control group). RESULTS: In middle-aged women (40-59 years), the average finger extension angles were higher in the POP group than in the control group (50.04 +/- 9.70 degrees vs. 39.50 +/- 12.19 degrees, respectively; P < .05), but in older women there was no significant difference between the two groups (42.84 +/- 13.05 degrees vs. 43.00 +/- 13.34 degrees, respectively; P > .05). CONCLUSION: The prevalence of joint hypermobility was higher in the POP group and with advanced POP stage (III, IV) than in the control group and early POP stage (I, II). Our results suggest that intrinsic connective tissue abnormality is related to the development of pelvic organ prolapse. Further study involving more patients with pelvic organ prolapse is warranted, and molecular studies to determine the genetic basis of pelvic organ prolapse are also required to further elucidate this abnormality.

Genital prolapse: a legacy of the West?

A retrospective study was undertaken to determine if there has been a change in the incidence of genital prolapse and urinary stress incontinence in Chinese women in Hong Kong. The medical records of 2,312 consecutive patients admitted for major gynaecological surgery for benign conditions in 5 out of 7 major public teaching hospitals in Hong Kong for the calendar year of 1993 were reviewed by way of an audit of all gynaecological operations performed in these hospitals. A total of 578 cases (25%) were identified as having genital prolapse and or urinary problems.

Clinical features of urinary incontinence and urogenital prolapse in a black inner-city population.

OBJECTIVE: Our purpose was to describe the clinical features and urodynamic findings of a black female inner-city population with urinary incontinence and uterovaginal prolapse. STUDY DESIGN: A retrospective review of the urogynecoloy records of 159 black female patients was performed. RESULTS: Genital prolapse was common. A cystocele was identified in 116 patients, a rectocele in 88 patients, and uterine or vaginal vault prolapse in 41 patients. Subtracted multichannel cystometry revealed detrusor overactivity in 58 patients, genuine stress incontinence in 44 patients, and mixed incontinence in 30 patients. Sixteen patients had normal urodynamic studies. The presence of a cystocele and the physical sign of stress incontinence at initial examination were found equally in patients with genuine stress incontinence, detrusor instability, and mixed incontinence at cystometry. There was no correlation between other commonly associated clinical factors (such as age, parity, and obesity) and the urodynamic diagnosis. CONCLUSIONS: Many of the factors commonly assumed to predispose women to the development of incontinence and prolapse may not apply to the black inner-city population. Urodynamic testing to establish the correct diagnosis is required, because the correlation between symptoms, physical examination, and urodynamic findings is relatively poor in this population.

Racial comparisons and contrasts in urinary incontinence and pelvic organ prolapse.

OBJECTIVE: To compare black and white women with regard to urinary incontinence and prolapse. METHODS: Two hundred consecutive women referred for evaluation of urinary incontinence or severe prolapse, 54 of whom were black, were evaluated. Each had a comprehensive standardized evaluation. Qualitative and quantitative data were analyzed for significant differences between the groups. RESULTS: The symptoms of pure stress, pure urge, and mixed incontinence were described by 7, 56, and 37% of black subjects, respectively, compared to 31, 28, and 41% of white subjects (P = .001). The conditions of pure genuine stress incontinence (GSI), pure motor incontinence, and mixed incontinence were diagnosed in 27, 56, and 17% of black subjects, respectively, compared to 61, 28, and 11% of whites (P = .0008). Black women with mixed symptoms were significantly less likely than white women to have pure GSI (47 versus 74%; P = .05). Blacks with GSI were significantly heavier, had higher parity, more often took a diuretic, were more often diabetic, and had better passive urethral closure pressure but greater urethral axis mobility than whites. Blacks with motor incontinence were significantly younger, heavier, less likely to have had prior continence surgery or hysterectomy, and had better passive urethral closure pressure but smaller bladder capacities than whites. The prevalence of severe prolapse in this referral population was the same for blacks and whites (24 and 23%), although blacks had significantly more vaginal deliveries. No other significant racial differences were noted in the prolapse group. CONCLUSIONS: Black women with urinary incontinence have a different distribution of symptoms, different conditions causing their incontinence, and different risk profiles for these conditions than do whites. The significantly lower prevalence of pure GSI in black women compared to white women makes the clinical evaluation for GSI appreciably less accurate in the individual black patient. Until further epidemiologic information regarding incontinence in black women is available, such women should be considered candidates for more accurate, sophisticated urodynamic testing before continence surgery.