Auditory passage of vaginal air, also known as vaginal wind, is not well characterized in the medical literature. Case series and cross-sectional studies have provided some insight into this symptom.1–4 Nevertheless, the etiology of vaginal wind remains unknown. One potential mechanism involves air ingress at the introitus with resultant air trapping in the vagina. This trapped air is later expelled with changes in vaginal volume, creating vibration of the vaginal walls at the introitus.
A larger genital hiatus or vaginal caliber could potentially facilitate vaginal air trapping. Air could also become trapped behind the leading edge of anterior or posterior vaginal wall prolapse. Changes in vaginal volume may occur with increases in intraabdominal pressure or as the vagina returns to its normal length and caliber after sexual activity.
The optimal treatment of vaginal wind is also unknown. Different treatment options include posterior colporrhaphy, pelvic floor physical therapy, tampon insertion, and pessary use.1,2,5,6 Nevertheless, evaluation of the effectiveness of these options remains limited to case series.
Our primary objective was to estimate the prevalence of vaginal wind among women with and without pelvic organ prolapse (POP) in a population of women with pelvic floor disorders. We hypothesized that a greater proportion of women with POP would experience vaginal wind compared with women without POP. Our secondary objectives were to identify other potential risk factors for vaginal wind and to evaluate whether vaginal wind resolves in the subset of women with vaginal wind who underwent pelvic reconstructive surgery.
MATERIALS AND METHODS
We conducted a prospective cohort study of English-speaking women 18 years of age or older with pelvic floor disorders who sought care at a single academic urogynecology clinic between December 2012 and August 2013. Women with urinary or POP symptoms as their chief complaint were included. We excluded women who had rectovaginal fistula, a history of prior surgery for POP or incontinence, or who were pregnant or unable to complete study forms. Women were approached for participation at the time of their initial clinic visit if time permitted. This study was approved by the MedStar Health Research Institute institutional review board.
After informed consent was obtained, all participants completed a questionnaire about vaginal wind, the Pelvic Floor Distress Inventory Short Form, and the revised Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire.7,8 During the informed consent process, participants were told that vaginal wind refers to passage of air from the vagina beyond one's control, usually associated with a sound. The vaginal wind questionnaire was composed by the authors. The items included in the vaginal wind questionnaire are displayed in Box 1. The categories of available responses for symptom frequency with activity and degree of symptom bother were based on the response choices of other validated questionnaires assessing symptom bother and quality of life in women with pelvic floor disorders.7,9
Box 1 Vaginal Wind Questionnaire Cited Here
The Pelvic Floor Distress Inventory Short Form consists of three subscales: the Urinary Distress Inventory, Pelvic Organ Prolapse Distress Inventory, and Colorectal–Anal Distress Inventory. Each subscale is scored from 0 to 100 with higher scores indicating a greater degree of symptom bother. The revised Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire consists of 29 questions, which assess sexual function in both sexually active and inactive women. Neither the Pelvic Floor Distress Inventory Short Form nor the revised Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire contain specific questions about vaginal wind.
Demographic information and clinical characteristics were collected for all participants. Pelvic organ prolapse quantification (POP-Q) data and midvaginal width at rest and with levator contraction were recorded.10 Participants who underwent pelvic reconstructive surgery completed the same questionnaires at 6 months postoperative. Postoperative POP-Q data were also collected. Pelvic organ prolapse quantification data were used to determine the stage or degree of POP severity. Pelvic organ prolapse quantification stages range from 0 to 4 with stage 0 indicating perfect vaginal support and stage 4 indicating complete vaginal eversion.10 In stage 1 POP, the most distal portion of the POP is greater than 1 cm above the hymen. In stage 2 POP, the most distal portion of the POP is within 1 cm above or below the hymen, while in stage 3 POP, the most distal portion of the POP extends greater than 1 cm below the hymen but does not protrude more than 2 cm less than the total vaginal length.
We defined POP as POP-Q stage 2–4. Normal support was defined as POP-Q stage 0–1. Our primary outcome was the proportion of women with POP (POP-Q stage 2–4) who experienced vaginal wind compared with the proportion of women with normal support (POP-Q stage 0–1) who had vaginal wind. Our secondary outcomes included demographic and clinical characteristics associated with vaginal wind and the proportion of women in whom vaginal wind resolved after pelvic reconstructive surgery. Resolution was defined as no recurrence of vaginal air passage at 6 months postoperative.
Data analysis included summary statistics such as means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Differences in baseline characteristics and outcome measures between women with and without vaginal wind were analyzed using two-sample t tests or nonparametric tests based on ranks for continuous variables and χ2 and Fisher's exact tests for categorical variables. The association between potential risk factors and vaginal wind was assessed by bivariate and multivariate logistic regression. P values <.05 were considered statistically significant. All statistical analyses were performed with Intercooled Stata 11.
Our sample size calculation was based on the assumption from our own clinical experience that 15% of patients with POP experience vaginal wind. A total sample size of 92 (46 in each group) was required to detect a 13-percentage point difference in the prevalence of vaginal wind between women with POP and normal support with a one-sided α of 0.05 and a power of 80%. Approximately 1,600 new patients present for care at our urogynecology clinic annually, the majority of whom (greater than 75%) present with POP, urinary incontinence, or both. We attempted to recruit an equal number of women with and without POP for participation.
One hundred thirty-two patients were approached for participation. One hundred twenty-three (93%) agreed to participate, of whom 110 (83%) completed initial study questionnaires. Of these 110, 51 (46%) had normal support and 59 (54%) had POP (Fig. 1).
The majority of participants were white (71/110 [65%]) and had at least a college education (84/110 [76%]). Seventy-six (69%, 95% confidence interval [CI] 60–78%) experienced vaginal wind. There was no difference in the prevalence of vaginal wind between women with POP and women with normal support (39/59 [66%], 95% CI 54–78% compared with 37/51 [73%], 95% CI 60–85%, P=.47, respectively).
Women with vaginal wind were younger than women without vaginal wind (mean age 52±12 compared with 62±11, P<.001; Table 1). Thirty-nine of the 76 women with vaginal wind (51%, 95% CI 40–63%) were postmenopausal compared with 29 of 34 women (85%, 95% CI 73–97%) without vaginal wind (P=.001). The majority of women with vaginal wind (63/76 [83%], 95% CI 74–83%) were sexually active compared with only 15 of 34 (44%, 95% CI 27–61%) women without vaginal wind (P<.001). Fewer women with vaginal wind had diabetes and chronic obstructive pulmonary disease compared with women without vaginal wind (5/76 [7%], 95% CI 1–12% compared with 9/34 [27%], 95% CI 12–41% and 0/76 [0%] compared with 5/34 [15%], 95% CI 3–27%, respectively, P≤.01 for both). There were no differences in other medical comorbidities, body mass index, parity, or number of vaginal or cesarean deliveries between women with and without vaginal wind (P≥.05 for all). Mean Pelvic Floor Distress Inventory Short Form and revised Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores did not differ between groups (P≥.05 for both; Table 1).
Women with vaginal wind had a longer mean vaginal length (9.45±1.0 cm compared with 8.84±1.1 cm, P=.004) and better apical support (C-point −5.07±3.9 cm compared with −3.03±5.2 cm, P=.02) than those without vaginal wind (Table 1). There was no difference in midvaginal width or other POP-Q points including genital hiatus size between groups (P>.05 for all; Table 1). In the subgroup of women with stage 0–1 POP, midvaginal width and genital hiatus size were not significantly different between those who experienced vaginal wind and those who did not.
A subanalysis of those with vaginal wind did not reveal a specific POP-Q point, which predicted the presence or absence of bothersome symptoms. However, more women with POP at or above the hymen, including women with stage 1 POP, experienced vaginal wind compared with women with POP below the hymen (48/63 [76%], 95% CI 66–87% compared with 16/31 [52%], 95% CI 34–70%, P=.02). Nevertheless, this analysis is limited by the fact it was conducted post hoc.
Vaginal wind occurred an average of 2.1±8.7 times per week (range 0.02–70.2) and this frequency did not differ between women with and without POP. The majority of women with vaginal wind (65/75 [87%], 95% CI 77–93%) experienced it during intercourse. However, only 17 of 75 (23%, 95% CI 14–34%) reported a negative effect on sexual satisfaction. One of the 76 women with vaginal wind did not respond to these items on the questionnaire.
Other activities associated with vaginal wind included digital stimulation in 13 of 76 (17%, 95% CI 9–28%), cunnilingus and jogging in 22 of 76 (28%, 95% CI 43–77%), and sit-ups in 33 of 75 (44%, 95% CI 33–56%). Sixty-four percent of women with vaginal wind (49/76, 95% CI 53–75%) were at least somewhat bothered by it and 17 of 76 (22%, 95% CI 14–33%) reported a negative effect on quality of life. A subanalysis of those with vaginal wind revealed a significant trend between vaginal wind frequency and degree of symptom bother, in which women who experienced vaginal wind more frequently expressed a greater degree of symptom bother (P=.005 using nonparametric trend test).
More women with POP were at least moderately bothered by vaginal wind and reported a negative effect on quality of life compared with women without POP (15/39 [39%], 95% CI 23–55% compared with 4/37 [11%], 95% CI 3–25% and 15/39 [39%], 95% CI 23–55% compared with 2/37 [5%], 95% CI 1–18%, respectively, P≤.02 for both). In addition, more women with than without POP (14/23 [61%], 95% CI 39–80% compared with 5/22 [23%], 95% CI 8–45%) reported that they would like their gynecologist to ask about vaginal wind (P=.01). However, only 45 of 76 women responded to this question.
Bivariate and multivariate logistic regression analyses revealed that sexual activity was a significant risk factor for vaginal wind (odds ratio [OR] 6.14, 95% CI 2.49–15.14; P≤.01, and adjusted OR 3.15, 95% CI 1.14–8.72; P≤.05). Both older age and postmenopausal status were associated with decreased odds of vaginal wind (OR 0.92, 95% CI 0.88–0.96; P≤.01 and OR 0.18, 95% CI 0.06–0.52; P≤.01, respectively). Longer total vaginal length increased the odds of vaginal wind even after adjusting for menopausal status (adjusted OR 1.63, 95% CI 1.01–2.62; P≤.05). However, this effect was no longer significant after adjusting for other confounding variables (adjusted OR 1.32, 95% CI 0.80–2.16). Worsening apical support, denoted by an increasing C-point, also decreased the odds of vaginal wind (OR for C-point 0.90, 95% CI 0.82–0.99, P≤.05). However, this effect was also no longer significant after adjusting for confounding variables (adjusted OR 0.93, 95% CI 0.82–1.06).
Forty women who completed initial study questionnaires underwent pelvic reconstructive surgery for POP, urinary incontinence, or both. Of these 40, 30 (75%) completed postoperative questionnaires and 10 were lost to follow-up (Fig. 1). The breakdown of surgeries performed for the 30 participants who completed postoperative questionnaires is provided in Table 2. Three of the 30 participants, all of whom had stage 0–1 POP preoperatively, had midurethral slings without concomitant POP repairs. The remainder had POP repairs with and without concomitant anti-incontinence procedures.
Twenty of the 27 women who underwent POP repair and completed postoperative questionnaires reported vaginal wind before surgery. Vaginal wind resolved in 13 of these 20 (65%, 95% CI 41–85%) women after surgery. Preoperative and postoperative POP-Q data for 12 of the 13 in whom vaginal wind resolved are presented in Table 3. All 12 had stage 0–1 POP at a median of 8 weeks postoperative (range 7–52 weeks).
In this study, we demonstrate that vaginal wind is a common problem affecting 69% (76/110) of women with pelvic floor disorders. Additionally, we found no difference in the prevalence of vaginal wind between women with and without POP. The rate of vaginal wind in our study was much higher than previously reported rates, which vary between 12.8% and 20%.3,4 One possible explanation for this discrepancy is that we assessed the prevalence of vaginal wind in a population of women with pelvic floor dysfunction, whereas other authors assessed the prevalence of vaginal wind in general gynecologic populations.3,4 Our results suggest that vaginal wind may be related to pelvic floor dysfunction, but not necessarily to POP.
The majority of women who experienced vaginal wind in our study reported it was at least somewhat bothersome and women with POP reported a greater degree of symptom bother. These results are consistent with those previously reported by other authors who also found that vaginal wind was associated with distress and embarrassment.2,4 One main reason why vaginal wind may be bothersome is due to the auditory nature of this condition and the potential for confusion with anal flatulence.
In our study, vaginal wind occurred most commonly with intercourse but was also associated with exercise and other sexual activities. Veisi et al4 also found that vaginal wind occurred most frequently with intercourse. Vaginal elongation during sexual arousal increases vaginal volume, which may enable air that is introduced with penetration to be potentially stored or trapped in the vagina during intercourse. After intercourse, this air may be expelled as the vagina returns to its normal length and caliber.
A wider vaginal caliber at baseline or increased vaginal laxity could also potentially increase the risk of air trapping. Nevertheless, we found no difference in genital hiatus measurements or midvaginal width between those who experienced vaginal wind and those who did not. Although women with vaginal wind had longer vaginal length and better apical support than women without vaginal wind, these anatomic characteristics were not associated with increased odds of vaginal wind on multivariate logistic regression.
Women who experienced vaginal wind were younger than those who did not experience vaginal wind. This age difference may explain why fewer women with vaginal wind had diabetes and chronic obstructive pulmonary disease. Additionally, more premenopausal women reported vaginal wind compared with postmenopausal women. It is possible that vaginal estrogenization, lubrication, or both may play a role in the development of vaginal wind. Estrogen, which helps maintain the elasticity and rugae of the vagina, may provide for air trapping, vibration of the vaginal walls with release of trapped air, or both.
Our finding that vaginal wind may resolve after pelvic reconstructive surgery corroborates other authors' results.1,4 In a case series of six premenopausal women, vaginal wind resolved in all after posterior colporrhaphy.1 Eighty-seven percent of women in our study who underwent surgery had posterior colporrhaphies. It is possible that tightening the posterior vaginal wall results in less air trapping, decreases vibration of the vaginal walls at the introitus when trapped air is released, or both. Veisi et al4 also reported resolution of vaginal wind in a subset of women who underwent pelvic floor repair. However, the exact number who experienced resolution was not specified.
Because our study population consisted of women with pelvic floor disorders, our results may not be generalizable to the population of women at large. Furthermore, although participants completed validated quality-of-life instruments, the questionnaire about vaginal wind was not validated. Twenty-five percent of participants who completed initial study questionnaires and underwent pelvic reconstructive surgery were lost to follow-up, and many participants who completed 6-month postoperative questionnaires did not follow-up after 8 weeks postoperative for repeat POP-Q examinations. Finally, because follow-up questionnaires were completed at 6 months postoperative, it is unknown whether women who had resolution of vaginal wind experienced recurrence of symptoms after this time.
Although our study did not detect a significant difference in the prevalence of vaginal wind between women with POP and normal support, it provides important data on the characterization of vaginal wind and level of symptom bother in women with pelvic floor disorders. In addition, our results substantiate previously published case series data suggesting vaginal wind may resolve after pelvic reconstructive surgery. Larger cohort studies of women with pelvic floor disorders are needed to determine how vaginal wind and pelvic floor dysfunction might be related and to further investigate the effect of pelvic reconstructive surgery on vaginal wind.
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