Clinical
Question
Since it is known that pelvic
floor trauma (PFMT) is associated with prolapse (POP) and symptoms of prolapse
(sPOP) and POP-Q>2 in patient populations, the aim was to establish
prevalence and possible associations between PFMT, sPOP, and POP > 2
in healthy women twenty years after their first delivery.
Introduction
PFMT is commonly defined as
levator avulsion injury or increased levator hiatal area. Evidence of PFMT is
diagnosed by ultrasoundography and magnetic resonance imagery. Levator avulsion
injury may occur during vaginal delivery, and vacuum and normal vaginal
delivery carries less risk than forceps. Hiatal area is much larger after
vaginal birth versus cesarean section. Association between hiatal dimensions
and POP is demonstrated, but often increased with avulsion. POP usually occur
many years after delivery versus a few months post-delivery.
Methods
Cross sectional study of 847
women who were recruited from June 2013 to February 2014. All subjects
delivered at the same hospital in Norway between 1990-1997. Women responded to
9 questionnaires included a Norwegian version of the Pelvic Distress Inventory.
PFDI-20, BMI, menopausal state, hysterectomy, previous prolapse surgery
information were also collected. Norwegian Birth Registry supplied data and
delivery mode, parity, birth weight, and years post first birth. A positive
response to the question, “Do you usually see or feel a bulge in your vagina?” was
used as a diagnostic of symptoms.
Chi-squared test to calculate the
odds ratio (OR) for the association between PFMT and POP-Q > 2 and
sPOP and for the association between sPOP and POP-Q > 2. Fisher’s
exact test for calculations of when numbers were small with 95% confidence
interval. Multi-variable logistic regression analysis was then performed for
association between compounding factors (age, BMI, parity, infant birth weight,
hysterectomy). A p-value <0 .05="" considered="" o:p="" significant.="" statistically="" was="">
Discussion
1.
PFMT
associated POP-Q > 2 and sPOP.
2.
Levator
avulsion and area >40
more associated than POP-Q > 2 than sPOP
3.
Most
symptoms were pain free at POP-Q > 2 but at risk for sPOP.
4.
More
anterior and middle compartment problems.
5.
PMFT
risk for surgery and risk of reoccurrence s/p surgery.
6.
Only
21 at POP-Q > 2 were symptomatic.
7.
17%
had symptoms of prolapse.
8.
21%
with POP-Q > 2 were symptomatic
9.
Lifetime
risk in Western countries 20%.
10. Mean age at hospital for first
surgery was 63.
11. Eligible women who attended an
examination more frequently had sPOP
Conclusion
A
cross sectional study design examined possible associations between PMFT, sPOP,
and POP-Q > 2, but arousal link between PFMT and POP not established.
Strength of the study was the time passed between birth and assessment, but
even a longer time (maybe post-menopausal) would establish more sPOP and need
for surgery. From the study, a large population of healthy women from a
population do have signs of POP 20 years post-delivery. Obstetricians should
avoid delivery methods associated with PFMT to avoid POP in later life.
Other Considerations
1.
Pelvic
floor muscle strength at first prenatal visit, six months of pregnancy, and 6
months post-delivery.
This
is the site that might be interesting for people to review.
Do
Ultrasound Findings of Levator Ani ‘‘Avulsion’’ Correlate
With
Anatomical Findings: A Multicenter Cadaveric Study
http://www.ncbi.nlm.nih.gov/pubmed/25982354
ICS
Wiki on POPQ
http://wiki.ics.org/Pelvic+organ+prolapse+quantification
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