Pelvic organ prolapse (POP) is a common clinical condition affecting postmenopausal women. It is defined as an inward and downward bulging of one or more vaginal walls, such as anterior and/or posterior vaginal wall, uterine cervix, or vaginal vault.1,2 About 75% of women aged 45 to 85 years had some degree of POP, of these 3% to 12% present symptoms such as seeing or feeling a vaginal bulge and urinary incontinence.3,4
As women age, postural balance may deteriorate due to the decreased functional capacity of several organs, as eyes and vestibular organs, and poorer postural balance responses.5 The aging process changes the systems responsible for balance, motor strategies, reactive and anticipatory postural control, and limits of stability.6
When women are in the standing position, the trunk, abdominal, and pelvic floor muscles move to compensate any disturbance of balance. Among the active and passive structures of the pelvis, the pelvic floor muscles help to support the pelvic organs, contributing to the continence and voiding of the bladder and bowel. These muscles are also responsible for helping to maintain trunk stability.7
Recent studies have suggested that young women with pelvic floor disorders, such as stress urinary incontinence (SUI), have greater postural instability because of the increased activity of the pelvic floor muscles.8,9 However, the same condition has not been demonstrated in older women.
In our clinical practice, we have been observing an increased incidence of body imbalance in older women with advanced POP. In addition, many of these older women related their balance deficiency with the fact that the POP hinders the act of standing.
Therefore, the aim of this study was to determine the effects of advanced POP on older women's body balance.
This was a cross-sectional study. All consecutive older women with POP evaluated by the Department of Urogynecological Physical Therapy at a single academic institution from November 2012 to January 2014 were initially included. Older women were those who were at least 60 years old as defined by the Brazilian Ministry of Health.10
To avoid external factors that could affect body balance, we excluded all patients with cognitive impairment (detectable by the Mini-Mental State Examination <18 for illiterates; <24 for 1 year or more of schooling)11; neurological injuries; claudication, use of assistive devices; fractures in the lower limbs; vestibular and limbic disorders; vertigo evaluated using Romberg's test12; retinopathy, strabismus, or severe eye disorders13; peripheral occlusive disease or altered sensitivity in the feet,14 respiratory disorders,15 crossbite,16 use of systemic or inhaled corticosteroids, muscle relaxants, and nonsteroidal anti-inflammatories, history of abdominal or pelvic surgical procedures, but c-section.
The study population was initially evaluated by a staff gynecologist with special interest on pelvic floor disorders and was classified according to the Pelvic Organ Prolapse Quantification (POP-Q) (Table 1).17
The data collected included demographics, number of pregnancies, number of vaginal deliveries, previous abdominal and pelvic surgeries, urinary incontinence (UI), diabetes mellitus, level of physical activity, and educational level. The level of physical activity was evaluated by the Human Activity Profile18 and UI was defined as any urinary leakage according to the International Continence Society.1
Body balance was assessed through the following measurements commonly used in previous studies5,7,8,13: the Berg Balance Scale (BBS)19 and the following stabilometric measures (SM): center of pressure displacement range (COPd-range), center of pressure mediolateral displacement (COPd-ML), center of pressure anteroposterior displacement (COPd-AP), and center of pressure displacement speed (COPd-speed). SM assessment was performed using a force plate (AM 3 Foot Work Pro, electronic baropodometry model, featuring 4096 sensors, covered with polycarbonate, size 645 mm, 520 mm, 25 mm, frequency of 200 Hz, Italy). Patients were asked to void their bladder before the SM assessment. For the first SM evaluation, patients were asked to stand up on both feet in a comfortable position looking directly at an imaginary point in front of them.20 One minute later, patients were asked to close their eyes and measures were taken again, as described by Doyle et al.21 The investigator in charge for acquiring the SM was blinded to the patient prolapse stage group.
The study population was divided into 2 groups according to the POP degree: advanced POP versus nonadvanced POP (Table 1). Groups were compared with respect to demographics, collected clinical data, BBS, and SM. Associations between advanced POP and body balance were also evaluated by a univariate analysis.
This study was approved by the Research Ethics Committee of the University of Brasilia School of Medicine (protocol no. 070/2012) and by the Brazilian Clinical Trials Registry (RBR-85693t). All women signed an informed consent form before taking part in the study.
Continuous variables were summarized within the “advance POP” and “nonadvanced POP” groups as medians and interquartile ranges with the Wilcoxon rank sum test for comparison. Categorical data were summarized by frequency within each group, and the comparison was performed using the χ2 and Fisher exact test.
Body balance variables that were significantly different between groups in the distribution comparisons were selected as dependent variables for the univariate analysis that used advanced POP as an independent variable. The body balance variables selected for the univariate analysis were dichotomized using the lower limit of the third quartile as cut-off.
All tests were 2 tailed and a P < .05 was considered statistically significant.
A sample size calculation was made considering the COPd-speed as a primary outcome. Based in a pilot study, calculated sample size was of 17 patients in each group based on the following assumptions: (i) expect difference of 20% between the groups found in previous data,22 (ii) type I and II errors of 0.05 and 0.18, respectively.
A total of 48 patients were initially selected for this study. Of these 10 patients filled the exclusion criteria, resulting in 38 patients for analysis who were classified according to the POP-Q (Table 2).
Seventeen patients with POP III and IV were grouped in the advanced POP group. The remaining 21 patients were allocated in the nonadvanced POP group (Figure 1).
The population median age was 64 years (interquartile ranges 62-67) and median body mass index was 26 kg/m2 (25-29). Advanced POP and nonadvanced POP were statistically similar with respect to demographics, level of physical activity, history of pregnancies and surgeries, and type of pelvic floor dysfunction (Table 3).
When the study groups were compared with respect to the BBS, no significant difference could be observed. However, when SMs were acquired with eyes closed, the advanced POP group had significantly higher COPd-speed (Table 4).
The eyes closed COPd-speed measurement was then selected for the univariate analysis and dichotomized using the 6.4 mm/s as cut-off, because this was the third quartile lower limit. The univariate analysis failed to demonstrate the association between the advanced POP and higher eyes closed COPd-speed (Table 5).
This study was designed to evaluate the impact of advanced POP on body balance in older women, who were demographically homogeneous and had comparable clinical characteristics. The idea of performing this study was driven by occasional advanced POP patients' complaints of body imbalance and also by the fact that some patients stated that their POP increased difficulty in the act of standing. We assessed body balance through SM and BBS, and advanced POP did not affect them.
There are few studies investigating the impact of pelvic floor disorders, mainly SUI, on body balance,9,23,24 and to the best of our knowledge, this is the first one regarding the body balance effects of advanced POP in older women.
The data about pelvic floor dysfunctions on body balance are conflicting. Smith et al9 compared 16 women with UI to 13 continent women performing 6 different tasks in the standing position. They found that women with SUI had increased COPd-AP. On the other hand, a larger American study from Brown et al,24 including 6049 community-dwelling women, failed to demonstrate any association between SUI and impaired body balance by questionnaire evaluations. Perhaps, the different methodology used on those studies might be the key to understand their conflicting results.
Similar to Brown's study, we failed to demonstrate a relationship between impaired body balance and a pelvic floor dysfunction, in our case advance POP. However, it is possible that patients' adaptation to a new condition could have prevented us to identify the advance POP effects on body balance. In fact, one could argue that patients with advanced POP could have used their increased pelvic floor and trunk muscle electrical activity to compensate potential body instability.7,25,26 Perhaps, a future study utilizing pelvic floor and trunk electromyography could provide deeper knowledge about the trunk muscle activity and possible postural adaption of this population.
Our study presents some drawbacks. First of all, it is possible that our population of 38 patients, while relatively large when compared with the other studies examining this issue, still lacks the statistical power to detect more clinically meaningful differences. Also, our study population belongs to a Brazilian public hospital, where the vast majority patients have lower income and educational level, increased number of pregnancies and vaginal deliveries.27,28 Therefore, one could argue that our study subjects might not properly represent other populations. However, the number of pregnancies and vaginal deliveries was not significantly different between the POP groups; therefore, we think that it is unlike that this increased number of pregnancies could have favored one group over the other.
Also, it could be argued that the presence of the POP itself, instead its occurrence, affects body balance in older women population, and therefore if we had used as control group of older women without POP, our results could had been different. However, the effects of aging on pelvic floor almost always will result in some degree of POP; indeed, in older women, grade I POP is considered by some authors as being physiologic.29 As a result, comparing older women with POP to those without POP would not be representative of the population observed in clinical practice.
We chose to study the age of 60 or older, considered aging initial stage, according to the United Nations (UN, 1982) for developing countries, such as Brazil.10 Oscillations in these population are correlated to changes in the base of support or unexpected displacements such as articular instability30 and muscle weakness31; however, other studies present that there are disturbances of balance even in patients without impaired muscular strength.32 In the present study these correlations were not investigated preventing the potential examination of these correlations; however, we eliminated several confounding factors that could potentially impair body balance, such as vestibular disorders, impaired mental status, and history of lower limbs fractures, body mass index, and retinopathy.12,33 Finally, the BBS may not have been effective in detecting the balance deficit in community-dwelling elderly, enabling the occurrence of the “ceiling effect” observed.34
There are several strengths in our data. The investigator retrieving the SM was blinded to the patient POP group, increasing the reliability of our findings. Moreover, we assessed body balance by 2 different methods, through SM, the gold standard for postural sway and body balance assessment, and BBS, which is an instrument validated in Portuguese language. Finally, all SMs were retrieved with patients having their eyes open and closed, as the last might be more reliable in the older population.35 This study has also merit for provoking further questions concerning postural control in advanced POP in older women.
Future studies with larger sample size investigating similar aims and using different body balance evaluation techniques, such as electromyographic studies, are needed to better define the effects of POP in older women.
Advanced POP does not cause body balance impairment or increases falling risk in older women.
1. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21:5–26.
2. Swift S, Woodman P, O'Boyl A, et al. Pelvic Organ Support Study (POSST)—the distribution, clinical definition and epidemiology of pelvic organ support defects. Am J Obs Gynecol. 2005;192:795–806.
3. Wu JM, Visco AG, Grass EA, et al. Matrix metalloproteinase-9 genetic polymorphisms and the risk for advanced pelvic organ prolapse
. Obstet Gynecol. 2012;120(3):587–593.
4. Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, Steegers-Theunissen RP, Burger CW, Vierhout ME. The prevalence of pelvic organ prolapse
symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20:1037–1045.
5. Holbein-Jenny MA, McDermott K, Shaw C, Demchak J. Validity of functional stability limits as a measure of balance in adults aged 23-73 years. Ergonomics. 2007;50(5):631–646.
6. Cavalheiro GL, Almeida MF, Pereira AA, Andrade AO. Study of age-related changes in postural control during quiet standing through linear discriminant analysis. Biomed Eng. 2009;8:35.
7. Hodges PW, Sapsford R, Pengel LHM. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362–371.
8. Smith MD, Coppieters MW, Hodges PW. Postural activity of the pelvic floor muscles is delayed during rapid arm movements in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(8):901–911.
9. Smith MD, Coppieters MW, Hodges PW. Is balance different in women with and without stress urinary incontinence? Neurourol Urodyn. 2008;27(1):71–78.
10. Organizac[COMBINING CEDILLA]a[Combining Tilde]o das Nac[COMBINING CEDILLA]o[Combining Tilde]es Unidas - ONU. Assemble[Combining Acute Accent]ia Mundial Sobre Envelhecimento: Resoluc[COMBINING CEDILLA]a[Combining Tilde]o 39/125. Viena, Áustria: Organizac[COMBINING CEDILLA]a[Combining Tilde]o das Nac[COMBINING CEDILLA]o[Combining Tilde]es Unidas; 1982.
11. Laks J, Baptista EMR, Contino ALB, de Paula EO, Engelhart E. Mini-mental state examination norms in a community-dwelling sample of elderly with low schooling in Brazil. CAD Saúde Publica. 2007;23(2):315–319.
12. Fujimoto C, Murofushi T, Chihara Y, et al. Assessment of diagnostic accuracy of foam posturography for peripheral vestibular disorders: analysis of parameters related to visual and somatosensory dependence. Clin Neurophysio. 2009;120:1408–1414.
13. Bellizzi M, Rizzo G, Bellize G, et al. Electronic baropodometry in patients affected by ocular torticollis. Strabismus. 2011;19(1):21–25.
14. Palma FH, Antigual DU, Martínez SF, Monrroy MA, Gajardo RE. Static balance in patients presenting diabetes mellitus type 2 with and without diabetic polyneuropathy. Arq Bras Endocrinol Metabol. 2013;57(9):722–726.
15. Janssen L, Brumagne S, McConell AK, et al. Proprioceptive changes impair balance control in individuals with chronic obstructive pulmonary disease. PLoS One. 2003;8(3):e57949.
16. Moon HJ, Lee YK. The Relationship between dental occlusion/temporomandibular joint status and general body health: Part 1. Dental occlusion and TMJ status exert an influence on general body health. J Altern Complement Med. 2011;17(11):995–1000.
17. Bump RC, Mattiasoon A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse
and pelvic floor dysfunction. Am J Obstetr Gynecol. 1996;175(1):10–17.
18. Souza AC, Magalhães LC, Teixeira-Salmela LF. Cross-cultural adaptation and analysis of the psychometric properties in the Brazilian version of the Human Activity Profile. Cad Saude Publica. 2006;22(12):2623–2636.
19. Berg KO, Maki BE, Williams JI, Holliday PJ, Wood-Dauphinee SL. Clinical and laboratory measures of postural balance
in an elderly population. Arch Phys Med Rehabil. 1992;73(11):1073–1080.
20. De Noronha RDF, de Souza RGV, Giani TS, et al. Correlation between static balance and functional autonomy in elderly women. Arch Gerontol Geriatr. 2011;52(1):111–114.
21. Doyle RJ, Hsiao-Wecksler ET, Ragan BG, Rosengren KS. Generalizability of center of pressure measures of quiet standing. Gait Posture. 2007;25(2):166–167.
22. Pasma JH, Bijlsma AY, van der Bij MD, Arendzen JH, Meskers CG, Maier AB. Age-related differences in quality of standing balance using a composite score. Gerontology. 2014;60:306–314.
23. Kaercher CW, Genro VK, Souza CA, Alfonsin M, Berton G, Cunha-Filho JS. Baropodometry on women suffering from chronic pelvic pain—a cross-sectional study. BMC Womens Health. 2011;11:51.
24. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary incontinence: does it increase risk for falls and fractures? J Am Geriatr Soc. 2000;48(7):721–725.
25. Smith MD, Coppieters MW, Hodges PW. Postural response of the pelvic floor and abdominal muscles in women with and without incontinence Neurourol Urodyn. 2007;26(3):377–385.
26. Halski T, Słupska L, Dymarek R, et al. Evaluation of bioelectrical activity of pelvic floor muscles and synergistic muscles depending on orientation of pelvis in menopausal women with symptoms of stress urinary incontinence: a preliminary observational study. Biomed Res Int. 2014;2014:274938.
27. Rodrigues AM, de Oliveira LM, Martins KF, et al. Risk factors for genital prolapse in a Brazilian population. Rev Bras Ginecol Obstetri. 2009;31(1):17–21.
28. de faria RM, Sayd JD. A socio-historical approach to the evolution of childbirth assistance in a medium-sized city in Minas Gerais (1960-2001). Cien Saude Colet. 2013;18(8):2421–2430.
29. Nygaard I, Bradley C, Brand D. Pelvic organ prolapse
in older women: prevalence and risk factors. Obstet Gynecol. 2004;104:489–497.
30. Perracine MR, Ramos LR. Fall-related factors in a cohort of elderly community residents. Rev Saúde Pública. 2002;36:709–716.
31. Wiacek M, Hagner W, Hagner-Derengowska M, et al. Correlations between postural stability and strength of lower body extremities of women population living in long-term care facilities. Arch Gerontol Geriatr. 2009;48:346–349.
32. Bird ML, Pittaway JK, Cuisick I, Rattray M, Ahuja KD. Age-related changes in physical fall risk factors: results from a 3 year follow-up of community dwelling older adults in Tasmania, Australia Int. J Environ Res Public Health. 2003;10:5989–5997.
33. Pothula VB, Chew F, Lesser THJ, Sharma K. Falls and vestibular impairment. Clin Otolaryngol Allied Sci. 2004;29(2):179–182.
34. Scott V, Votova K, Scanlan A, Close J. Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings. Age Ageing. 2007;36(2):130–139.
35. Bauer C, Groger I, Rupprecht R, Gassmann KG. Reliability of static posturography in elderly persons. Z Gerontol Geriatric. 2010;43(4):245–248.