Overall, 158 women (6.0%) were considered to have past or present symptomatic POP. Characteristics associated with it were high BMI and the number of vaginal deliveries (Table 4). The one-variable model that used mode of delivery to predict a history of symptomatic POP had an R2=0.008 (data not shown). The multivariable model for women with children, which also tested age at first delivery, episiotomy, a third-degree anal tear, and birth weight of the largest child, found no other obstetric variable to be significant (data not shown).
In our population of women in their 50s, POP symptoms were associated with a significant impairment of quality of life. Factors associated with past or present symptomatic POP were high BMI and vaginal delivery.
The principal limitation of our study was that POP was not clinically confirmed. Prolapse is a sign observed during clinical examinations, and epidemiologic surveys about this disease are difficult because of the indirectness of its study by questionnaires. Nonetheless, what matters from a practical point of view is symptomatic prolapse that motivates the woman to seek care. That is, women see their doctors for a functional disease and not for an anatomic defect. Moreover, a study of quality of life and the risk factors associated with POP symptoms requires the availability of a sample of women recruited outside of a medical practice. It thus seems useful from a public health perspective to look at the prevalence of prolapse symptoms in the general population.
A major advantage of our sample is that the women participating were not recruited because they had symptoms. Their status as volunteers probably explains the excellent response rate (85%). At the time we began this study, there were no questionnaires validated in a population at low risk for POP.15 Unfortunately, the question we used (Have you experienced a sensation of bulging from your vagina?) could not be combined with clinical examination. Seeing or feeling a vaginal bulge is considered a specific symptom of POP, but the sensitivity of this symptom is mediocre in low-risk populations.16 Barber et al17 showed that the question Do you usually have a bulge or something falling out that you can see or feel in your vaginal area? had a specificity of 99% but a sensitivity of 35% for prolapse at or beyond the hymen (grades II and III) in a population at low risk. The question used by Rortveit et al18 in their study (Has there been a visible bulging or protrusion from your vagina?) had a sensitivity of only 16% for grade II or III prolapse. Symptoms increased with the severity of prolapse; they were frequent for stages III and IV and usually absent at stages I or 0.19 Tan et al20 examined 1,912 women who answered the question: Do you ever feel a bulge or that something is falling out of the vagina? The response was positive in 79–85% of women who had a stage III or IV prolapse compared with 6–11% of women with a stage I or 0. It is therefore probable that those who responded positively in our survey were those with the most serious prolapse. In our study, the bulging symptom was correlated with pelvic pain and difficulties in voiding and defecation (Table 2), which serves as evidence supporting the clinical relevance of the question. Ellerkmann et al21 showed that POP documented by a standardized clinical examination is often associated with these symptoms. Finally, the more frequent the prolapse symptoms, according to this question, the greater the impairment of quality of life in all Nottingham Health Profile dimensions. This graded association between the frequency of prolapse symptoms and quality of life is additional evidence of the question’s clinical relevance.
The relatively rare character of this condition necessarily means that in a general population sample we find few symptomatic women, thus statistical power is limited and significant risk factors more difficult to show. Only 2.7% of our participants had a history of surgery for prolapse and 3.7% had symptoms suggestive of prolapse. These figures are close to those of studies based on clinical examination, which have found only a 0–2.1% prevalence of prolapse beyond the introitus (stage III or IV) in women aged 50–59 years.22,23 The cumulative risk of surgery for POP or urinary incontinence is estimated at 4.7% to 5.1% for women in their 50s.3,24
Another limitation is that our population sample is not exactly representative of middle-aged French women, because women enrolled in the GAZEL cohort were recruited from a work setting and volunteered to participate in medical research. We know, for example, that the women who agreed to participate in GAZEL had a higher education level and were in better health than nonparticipating employees.6–8 From our point of view, that is not likely to affect the quality of life impairment observed or the risk factors identified.
Few studies have examined the effect of POP on quality of life with a generic quality-of-life tool. We showed that the more frequent the prolapse symptoms, the greater the impairment of quality of life in all of the Nottingham Health Profile dimensions. Even in multivariable analysis taking numerous factors likely to be associated with quality of life into account, the symptoms of POP remained associated with a significant impairment in overall quality of life. In the case–control study by Jelovsek et al,25 the Short Form Health Survey (SF-12) physical scale showed impairment in women with prolapse, whereas the mental scale was similar in both groups; this study did not include multivariable analysis. We have previously shown that impairment of quality of life in the Nottingham Health Profile dimensions of physical mobility and pain is proportional to the severity of urinary incontinence.9 A similar result appears for POP symptoms (Fig. 1). This suggests that symptomatic POP can have an important effect on general health-related quality of life and interfere as a disability with physical mobility, pain, emotional reaction, social isolation, energy, and sleep.
We still know very little about its causes. A congenital or acquired tissue factor is probable26–28; the position of the pelvis or the spine may play a role29,30; and physical effort, constipation, a chronic cough, and obesity (BMI is a significant factor in our study) weighing on the pelvic floor may also be involved.31–34 The most frequently suggested hypothesis is that of obstetric trauma. Mant et al33 found a risk of hospitalization for POP proportional to parity. Clinical examination shows that prolapse is more frequent in women with children.22,23 Several other cross-sectional surveys have shown that symptoms of POP are more frequent in women with vaginal deliveries.1,35–37 Nonetheless, the role of vaginal delivery in the natural history of prolapse must be slight, for in our population it explains less than 1% of the symptomatic prolapses. Other mechanisms probably play a role in onset, but we are limited by the cross-sectional nature of our study, which makes it impossible to record the risk factor when it occurs. Only a longitudinal survey can identify traumatic events to the perineum as they occur. In the same GAZEL population, severe stress incontinence (15% prevalence) and fecal incontinence (9.5%) were not associated with mode of delivery.8,10 It is therefore probable that even though these pelvic floor disorders are often associated, they do not share the same pathophysiologic mechanisms. This is consistent with the work by DeLancey et al,38 who showed that stress urinary incontinence is linked more to an aging sphincter than to the impairment of urethral support.
In conclusion, although their prevalence is relatively slight, POP symptoms have a significant effect on the quality of life of the women who have them. Even if it is probable that vaginal delivery plays a role in the genesis of POP, it is an incidental factor that explains only a very small part of it.
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