|Year : 2015 | Volume
| Issue : 1 | Page : 36-40
Determinants and treatment modalities of uterovaginal prolapse: A retrospective study
E Sujindra, N Himabindu, P Sabita, A Bupathy
Department of Obstetrics and Gynecology, Indira Gandhi Medical College and Research Institute, Puducherry, India
|Date of Web Publication||5-Jun-2015|
Dr. E Sujindra
Department of Obstetrics and Gynecology, Indira Gandhi Medical College and Research Institute, Puducherry
Source of Support: None, Conflict of Interest: None
Introduction: Prevalence of uterovaginal prolapse is increasing with increase in life expectancy of women. The reported prevalence of uterovaginal prolapse is different in different countries. Various studies have been reported on the prevalence, determinants, clinical manifestations and treatment modalities of uterovaginal prolapse.
Objectives: Determine the prevalence of uterovaginal prolapse, identify determinants of uterovaginal prolapse, its clinical manifestations and describe different treatment options.
Study Design: Retrospective study done on uterovaginal prolapse at Indira Gandhi Medical College and Research Institute in Puducherry in India from January 1, 2014 to December 31, 2014.
Results: The mean age of the patients in our study was 57.5. 87.3%belonged to the Hindu religion. 77% of women with prolapse were post-menopausal. 86.2% of women were multiparous. The predominant presenting complaint was history of mass protruding out of vagina. Non-surgical treatment was offered for 33.7%. Vaginal hysterectomy with pelvic floor repair was the predominant surgical treatment offered.
Conclusion: Prolonged labor and vaginal delivery involving sphincter and vaginal tear are the main determinants of uterovaginal prolapse. Modifiable risk factors warrant health programs to develop interventions targeting the prevention of uterovaginal prolapse.
Keywords: Determinants, treatments, uterovaginal prolapse
|How to cite this article:|
Sujindra E, Himabindu N, Sabita P, Bupathy A. Determinants and treatment modalities of uterovaginal prolapse: A retrospective study. Indian J Health Sci Biomed Res 2015;8:36-40
|How to cite this URL:|
Sujindra E, Himabindu N, Sabita P, Bupathy A. Determinants and treatment modalities of uterovaginal prolapse: A retrospective study. Indian J Health Sci Biomed Res [serial online] 2015 [cited 2020 Jun 4];8:36-40. Available from: http://www.ijournalhs.org/text.asp?2015/8/1/36/158221
| Introduction|| |
Uterovaginal prolapse is an abnormal protrusion or herniation of pelvic organs from its normal anatomical position in the pelvis, due to the failure of anatomical supports.  Prevalence of uterovaginal prolapse is increasing with increase in life expectancy of women. The reported prevalence of uterovaginal prolapse is different in different countries. In fact, the exact prevalence of uterovaginal prolapse is difficult to be determined because many women are asymptomatic, and many women feel shy or do not reveal the presence of uterovaginal prolapse due to social reasons. 
In a population-based survey, the prevalence of uterovaginal prolapse has been reported to be 4-10%. , The lifetime risk of requiring at least one operation for prolapse has been reported as 11%.  The development of uterovaginal prolapse is multifactorial. Many factors have been attributed to the development of uterovaginal prolapse.
Parity and mode of delivery have long been described as important causative factors for uterovaginal prolapse as women following vaginal delivery had significantly higher prevalence of pelvic floor disorders, when compared to nulliparous or those delivered by cesarean section.  Overweight has also been attributed to increase the prevalence of uterovaginal prolapse. Weight loss studies indicate that both bariatric and nonsurgical weight loss lead to significant improvements in pelvic floor disorder symptoms.  Postmenopausal state due to hypoestrogenemia and genital atrophy also play an important contributing role in the pathogenesis of uterine prolapse. 
Patients with uterovaginal prolapse present with various symptoms like vaginal heaviness or protrusion of mass through the vagina, urinary symptoms, vaginal discharge, vaginal itching, ulceration, alteration in bowel movements, and impaired sexual function. Protrusion of mass or heaviness in the vagina has been reported as the predominant presenting symptom, next being urinary complaints. 
Based on the clinical scenario, age of the patient, parity, desire for preservation of reproductive function, desire for preservation of coital function, general medical status and previous correction surgery, the management of uterovaginal prolapse varies. Conservative surgery like Manchester repair is offered for those who like to preserve their reproductive function. Vaginal hysterectomy with pelvic floor repair is done for those who have completed their family and pessary treatment for, those who are not fit for surgery.
Various studies have been reported on the prevalence, determinants, clinical manifestations and treatment modalities of uterovaginal prolapse. But studies are very limited among Indian women. The aim of this study was to determine the prevalence of uterovaginal prolapse from our hospital statistics, identify determinants of uterovaginal prolapse, its clinical manifestations and also describe the different treatment options available in our setting. Evaluation of these factors associated with uterovaginal prolapse in our representative sample will highlight potentially modifiable risk factors, which we may be able to target for prevention efforts.
| Materials and Methods|| |
The study was a retrospective study done on uterovaginal prolapse at Indira Gandhi Medical College and Research Institute in Puducherry. Indira Gandhi Medical College and Research Institute is a tertiary care hospital and medical college catering health needs to the people of the union territory, Puducherry and also to a huge percentage of people from various districts of the neighboring state, Tamil Nadu. The study population in our setting hence serves as a representative population of the South Indian women.
The study was conducted by reviewing the medical records of 196 patients with pelvic organ prolapse in our hospital from January 1, 2014 to December 31, 2014. Institute Ethics Committee approval was taken to review the patient records. Data was collected from the gynecological case entry register, gynecological ward admission register, case files, and theater records. The medical records were reviewed by trained staff and data entered into data extraction forms. Information collected were sociodemographic characteristics (age, parity, occupation, and religion), determinants of uterovaginal prolapse, presenting complaints, degree of prolapse, and treatment modalities. The data were analyzed using statistical package for social science (SPSS)version 20, and results were entered as percentage and frequency tables.
| Results|| |
The study period was 1-year from January 1, 2014 to December 31, 2014. Within the study period, 10,825 patients were seen at the gynecological clinic. Of these, 196 patients had uterovaginal prolapse, thus giving a prevalence of 1.8%.
The sociodemographic profiles of patients are shown in [Table 1]. The mean age of the patient in our study was 57.5. The age range was between 29 and 75 years. Nearly 50% of the study population was above the age of 55 years. Eight patients (4%) presented with prolapse in the age group below 35 years. Only 5% of the patients with prolapsed were nulliparous. 20.9% were grand multiparous. Nearly two-third of the study population was employed in hard manual work involving strenuous activities, farmers (39.3%) and laborers (32.1%). Only 13.3% were housewives. Majority of our women belonged to the Hindu religion (87.3%).
The analysis of determinants and risk factors for uterovaginal prolapse are shown in [Table 2]. 77% of women with prolapse were postmenopausal. 86.2% of women were multiparous (two or more children) and nearly 80% had some cause attributing to chronic increase in intra-abdominal pressure (constipation, chronic cough, and strenuous physical activities including farmers and laborers). Distribution of risk factors is also shown in [Table 2]. 66.8% of women had more than two risk factors.
Clinical symptomatology and presentation of patients are shown in [Table 3]. The predominant presenting complaint was a history of mass protruding out of vagina (82.2%). Next common complaint was urinary symptoms (69.4%). Other symptoms were vaginal discharge, itching, and ulceration. Only three women complained of impaired sexual function. The predominant type of prolapse was uterine prolapse, 91.8%. Cystocele, rectocele, and enterocele were present in 72.4%, 61.7%, and 41.8%, respectively. Of the 180 patients who presented with uterine prolapse, 7.7% had procidentia (complete prolapse), 61.1% had third degree, 6% had second degree, and 25% had first degree uterine prolapse.
Treatment modalities are shown in [Table 4]. Nonsurgical treatment was offered as the only modality of treatment for 66 patients (33.7%). Five patients received pessary treatment as they were not fit for surgical intervention due to co-morbid medical problems. Sixty-one patients (31%), (45 patients with first degree prolapse and 16 patients with very minimal cystocele without prolapse), were advised to do Kegel's exercise. 66.3% were offered surgical treatment. Vaginal hysterectomy with pelvic floor repair was the predominant surgical treatment offered (47.9%). Only vaginal hysterectomy in 12.2%, Manchester repair in 55.6% and sacrospinous colpopexy in one patient.
| Discussion|| |
Uterovaginal prolapse forms 1.8% percentage of the gynecological case attendance in the outpatient department of our hospital. A study in United States by Okonkwo et al. reported an incidence of 2.1%. Eleje et al., reported 6.5% incidence of pelvic organ prolapsed in a teaching hospital in Nigeria. Though the total number of prolapse cases in 1 year reported in our study is more when compared to other studies, the percentage attendance among the gynecological cases is less. This is due to dilution of the gynecological case load by other nonspecific complaints like discharge per vaginum and low back ache. Differences in incidence among different studies might be due to cultural differences, type of population studied, ignorance due to lack of education, attitude of people toward illness, influence of health facilities available like newer treatment modalities, increasing skills, and availability of various diagnostic equipment such as ultrasound and laparoscopy.  The obesity epidemic has also influenced the prevalence of pelvic floor disorders.  The mean age of our patients was 57.5 years. Indicating the fact that uterovaginal prolapse is more common in the postmenopausal age group. Nearly, two-third of our patients were either farmers or laborers, involving themselves in heavy and strenuous physical activities.
Symptomatic prolapse is less common among African-American women and more common among women with 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.  Our study gives a note on the major determinants of uterovaginal prolapse in our population. Being a well-established cause, excessive stretching and tearing during multiple deliveries can be attributed as main predisposing obstetric factors for symptomatic pelvic organ prolapse.  This was actually supported by our study also with almost 86% having delivered two or more children. Tegerstedt et al., also showed that abdominal delivery presents as a comparably strong protective factor.  Glazener et al., reported that compared with women whose births were all spontaneous vaginal deliveries, women who had all births by caesarean section were the least likely to have prolapse and there was a reduced risk after forceps or a mixture of spontaneous vaginal delivery and caesarean section.  There is a significant association between number of vaginal deliveries, duration of labor, vagina tear, and sphincter damage in previous childbirth.  77% of women in our study were postmenopausal. This result is supported by a study from Italy on menopausal women.  There is evidence that the process of aging results in loss of collagen and weakness of fascia and connective tissue, which is further accentuated during the postmenopausal period due to estrogen deficiency leading to prolapse. Thus, the damage to the pelvic floor muscle during childbirth often only becomes more evident when age-related changes are superimposed. Increasing body mass index was associated with a higher prevalence of pelvic floor disorder in a study by Greer et al. 23% of our women were overweight. Being a modifiable risk factor, it is important to evaluate the impact of being overweight and obese on pelvic floor disorders so as to reduce the prevalence of uterovaginal prolapse. 66.8% of women had more than two risk factors which highlights the need for health programs for the prediction and prevention of prolapse.
"Bulging" is the principle symptom that correlates with prolapse severity.  This was supported by our study as the predominant presenting complaint was a history of mass protruding out of vagina in 82.2% of patients. Vaginal support defects in older women are associated with obstructive urinary symptoms and the symptom of seeing or feeling a bulge.  69.4% of our women had urinary symptoms. Voiding dysfunction was characterized by urinary hesitancy, prolonged or intermittent flow and a need to reduce the prolapse for the sake of voiding. Impairment of sexual relations was reported by three patients, and it has been reported that this symptom is strongly associated with worsening uterovaginal prolapse.  Uterine prolapse was the most common pelvic organ prolapse, and 72% had anterior compartment defect. Majority of our women had third degree uterovaginal prolapse. This could be because of the fact that women with prolapse usually do not present to the health care facility early as they are shy and worried about its social implications.
Various treatment options are available for management of uterovaginal prolapse, both surgical and nonsurgical options. Nonsurgical treatment in the form of pessary or Kegel's exercise was offered to 33.7%. Patients who received pessary were not fit for surgery and those who were advised Kegel's exercise had a very minimal cystocele or first degree prolapse. The most common surgery done in our setting was vaginal hysterectomy and pelvic floor repair. These treatment options were comparable with a previous study by Eleje et al. Thus, the current conventional approach to uterine prolapse when a woman no longer wishes to have children is a vaginal hysterectomy with any additional repair to the vaginal walls. Manchester repair was done for those who wanted to conserve their uterus. Sacrospinous colpopexy was done in one patient. Studies have shown that sacrospinous colpopexy is associated with the longer postoperative recovery period and is more expensive. 
Limitations of the present study also need to be addressed. The main weakness is that this is a retrospective study where some data could get lost or missed due to improper case record entry. Further, psychosocial factors like ignorance and socioeconomic factors such as education, income, and social class could not be assessed due to inadequate data.
| Conclusion|| |
Prolonged labor and vaginal delivery involving sphincter and vaginal tear are the main determinants of uterovaginal prolapse. The presence of many modifiable risk factors warrants health programs to strongly consider these issues and to develop interventions targeting the prevention of uterovaginal prolapse.
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[Table 1], [Table 2], [Table 3], [Table 4]