European Journal of Obstetrics & Gynecology and Reproductive Biology 190 (2015) 52–57

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Pelvic organ prolapse and stress urinary incontinence, do they share the same risk factors? Nu´ria. L. Rodrı´guez-Mias a,*, Eva Martı´nez-Franco b, Jaume Aguado c, Emilia Sa´nchez d, Lluis Amat-Tardiu a a

Department of Obstetrics and Gynaecology, Hospital Sant Joan de De´u, University of Barcelona, Spain Department of Obstetrics and Gynaecology, Parc Sanitari Sant Joan de De´u, Sant Boi del Llobregat, Spain Research and Development Unit, Parc Sanitari Sant Joan de De´u, Sant Boi del Llobregat, Spain d Blanquerna School of Health Sciences, Universitat Ramon Llull, Barcelona, Spain b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 27 March 2015 Received in revised form 21 April 2015 Accepted 27 April 2015

Objective: To determine whether there are differences in the etiologies of two of the most common pelvic floor disorders (PFD), pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Study design: This cross-sectional descriptive study included 1042 women, referred to a pelvic floor unit in a tertiary Spanish hospital, between 2008 and 2012. Subjects at their fist visit were interviewed and examined generally and specifically (medical and urogynecological history). Collected parameters included: age, weight, height, medical and surgical background (including in-depth obstetrical and gynecological characteristics). The participants were classified into 3 different groups (POP, SUI, and mixed pathology). Descriptive analyses of each variable and multinomial logistic regression were performed to determine factors associated with POP and SUI. Results: Patients with POP were older, thinner, with greater parity and their newborns tended to be heavier. Furthermore, forceps, vaginal tears and vaginal surgeries were more common in the POP group. In contrast, family history was an important factor for the development of SUI, with a 6.45-fold increase (95% CI: 3.69–11.24). Two protective factors were identified for POP, cesarean section reduces the risk by 3 fold (OR = 0.33) (95% CI: 0.13–0.85) whereas pelvic floor rehabilitation produces a 2 fold reduction (OR = 0.49) (95% CI: 0.31–0.76). Conclusions: Our data study demonstrates differences in potential triggers and risk factors for POP and SUI. Cesarean section and pelvic floor rehabilitation have a protective effect on preventing the development of POP. Bringing up that a personal medical care and a specific urogynecological follow-up should be developed for those who are more susceptible or at risk of PFD. ß 2015 Elsevier Ireland Ltd. All rights reserved.

Keywords: Epidemiology Pelvic floor dysfunction Pelvic organ prolapse Risk factor Urinary incontinence

Introduction As the elderly population is increasing, pelvic floor disorders (PFD), which include urinary incontinence (UI), pelvic organ prolapse (POP), fecal incontinence, sexual dysfunction and pelvic pain, are becoming a highly prevalent health problem that affects the quality of life of the patients and places a financial burden on the health system [1,2]. There is a significant association between

Abbreviations: BMI, body mass index; PFD, pelvic floor disorders; POP, pelvic organ prolapse; SUI, stress urinary incontinence; UI, urinary incontinence. * Corresponding author at: Department of Obstetrics and Gynaecology, Hospital Sant Joan de De´u, University of Barcelona, Passeig St. Joan de De´u, 2, 08950 Esplugues, Barcelona, Spain. Tel.: +34 93 253 21 00; fax: +34 93 203 39 59. E-mail address: [email protected] (Nu´ria. L. Rodrı´guez-Mias). http://dx.doi.org/10.1016/j.ejogrb.2015.04.015 0301-2115/ß 2015 Elsevier Ireland Ltd. All rights reserved.

presenting symptoms of lower urinary tract dysfunction and POP, two of the most common PFD [3–6]. Although the mortality related to these disorders is low, the quality of life and perception of the patient’s own body are severely affected [7,8]. In accordance with this, the number of reports devoted to investigation of these diseases has been steadily increasing. Nevertheless, there is paucity of epidemiological studies of the natural history of pelvic disorders, making it difficult to understand deeply their pathophysiology [3,6,9,10]. POP is a common condition defined as the descent of the pelvic organs (bladder, urethra, vagina, uterus, small bowel or rectum) due to deficiencies in the pelvic support system [3,6,11–14]. It has been estimated that over 50% of women who had vaginal birth have some degree of POP, but only 10–20% of them seek medical care for their symptoms [15]. Olsen et al. reported that 11% of

N.L. Rodrı´guez-Mias et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 190 (2015) 52–57

women at 80 years of age will require a surgery for POP, and additional 30% will need a reoperation [9,16]. Stress urinary incontinence (SUI) is defined as the involuntary leakage on effort or exertion, or on sneezing or coughing [1,17]. De Lancey states that it is a symptom that arises from damage to the muscles, nerves, and connective tissue of the pelvic floor [18]. The estimated prevalence in middle-aged or older women is 30–60%, and it increases with age, although women in their fifties are affected the most [3–6,19–24]. The association between POP and SUI has been explained based on the holistic view of the pelvic floor anatomy and the comprehensive ‘‘integral theory’’ of Petros and Ulmsten [7,12,20,24]. Because of the shared relationship of the physiological mechanisms involved in the preservation of the normal pelvic floor function, an injury and weakness to any of these pelvic structures would lead to multiple symptomatologies and a combination of PFD. Considering this common pathophysiological process, the development of these disorders is multi-faceted and likely to be influenced or triggered by several similar factors. Some common intrinsic components (genetics, age, postmenopausal period or race [2,3,6,9–12,16,17,25]) and extrinsic risk factors like obstetric history, pelvic floor surgery, comorbidities as well as obesity or physical activity [3,6,11,12,19–24] have been described in the genesis of POP and SUI. This study aimed to assess whether there are differences in epidemiological factors involved in the development of POP and SUI as well as to identify possible causal and protective factors for each disease. Materials and methods This cross-sectional descriptive study, based on STROBE guidelines [26], includes a total of 1256 women referred to the PFD unit of the Gynaecology and Obstetrics department of a tertiary University Hospital in Barcelona (Spain) for any urogynecological pathology from January 2008 to December 2012. As the exclusion criteria accepted were PFD other than POP and/or SUI or even urgency and/or functional UI. Out of the 1256 women

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evaluated to be included in this study only 1042 participants were subjected to include them for the analysis. We excluded 105 women for presenting pure urgency UI and 109 for complaining of other urogynecological pathology other than UI or POP. All epidemiological data were acquired at once during the first visit to the unit. Patients were interviewed in the hospital and after an explanation about the nature (non experimental procedures) and objectives of the study, and an informed consent was obtained from all them conforming to the principles outlined in the Declaration of Helsinki. Three trained interviewers asked and examined all women about general medical and specific urogynecological history. A standardized Microsoft Access1 database (Microsoft Office Access, Microsoft Corporation, Redmond, WA, USA) specifically designed for this study was used to collect all data, based on specialized POP and UI questionnaires (such as the International Consultation on Incontinence Questionnaire short form (ICIQ-SF), Pelvic Floor Distress Inventory (PFDI-20) or incontinence severity index of Sandvik [14]). The same gynecologist at the same day collected all variables shown in Tables 1–3. A standardized pelvic evaluation of pelvic organs and pelvic floor support was done in the dorsal supine lithotomy position, with an empty bladder and after explaining to the patient about the procedure. The exam included an inspection of the vulvar, vagina and cervical appearance and position after the placement of a speculum. After that, a disarticulated speculum was inserted in the vagina to observe if any vaginal wall (anterior, posterior or apical) was prolapsed and the degree of the protrusion in relation to hymeneal ring with strain or cough, accordingly to the simplified Pelvic Organ Prolapse Quantification (S-POPQ) [27]. For the assessment of the SUI, the cough stress test was performed and the visualization of fluid loss from the urethra simultaneous with a cough it was classified as SUI; meanwhile, if it appeared or worsen when POP was reduced with a nonobstructing pessary then it was considered as hidden SUI. Finally, a bimanual examination for determines abdominal and pelvic mass was performed. Based on the examination and the interview, we define the POP as the presence of vaginal bulge; the SUI as the involuntary leakage

Table 1 Clinical characteristics of the study population. All (n = 1029)

POP (n = 474)

UI (n = 272)

POP/UI (n = 277)

p-value

Population characteristics Mean age Mean weight Mean BMI Smokers Daily physical exercise >1500 cc fluid intake daily Stimulating drinks Chronic constipation

59.6 (SD 12.2) 68.6 (SD 11.8) 27.5 (SD 4.5) 110 (10.7%) 279 (27.1%) 393 (38.2%) 613 (59.6%) 330 (32.1%)

61.9 (SD 11.3) 66.3 (SD 9.9) 26.7 (SD 3.8) 49 (44.5%) 120 (43%) 172 (43.8%) 273 (44.5%) 149 (45.2%)

55.5 (SD 13.1) 71.3 (SD 13.8) 28.4 (SD 5.4) 41 (37.3%) 78 (28%) 112 (28.5%) 161 (26.3%) 93 (28.2%)

59.8 (SD 11.8) 69.9 (SD 12.2) 28.0 (SD 4.5) 20 (18.2%) 81 (29%) 109 (27.7%) 179 (29.2%) 88 (26.7%)

Pelvic organ prolapse and stress urinary incontinence, do they share the same risk factors?

To determine whether there are differences in the etiologies of two of the most common pelvic floor disorders (PFD), pelvic organ prolapse (POP) and s...
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