- Email: [email protected]
Pelvic Organ Support and Prevalence by Pelvic Organ Prolapse-Quantification (POP-Q) in Korean Women
Voiding Dysfunction Pelvic Organ Support and Prevalence by Pelvic Organ Prolapse-Quantification (POP-Q) in Korean Women Ju Tae Seo* and Joo Myung Kim From the Departments of Urology and Obstetrics and Gynecology (JMK), Samsung Cheil Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
Purpose: We evaluated pelvic organ support and the prevalence of pelvic organ prolapse in Korean women using the Pelvic Organ Prolapse-Quantification system as the assessment tool. Materials and Methods: The study population consisted of 713 women 18 to 72 years old who were seen for annual Papanicolaou testing and pelvic examinations. Pregnant patients and patients who had delivered within the previous 6 weeks were not recruited. All pelvic examinations were performed by a single examiner. The patient was examined in the dorsal lithotomy position in a pelvic examination chair positioned at a 15-degree angle. All 9 measurements except total vaginal length were taken with the patient performing the maximal Valsalva maneuver. Results: Mean patient age was 41.6 years (range 18 to 72), mean weight ⫾ SD was 55.8 ⫾ 7.4 kg (range 40 to 83), mean height was 158.7 ⫾ 5.4 cm (range 138 to 177), mean body mass index was 22.3 ⫾ 8.1 kg/m2 (range 15.7 to 32) and median parity was 2 (range 0 to 6). Mean scores for the position of the cervix and posterior fornix, and total vaginal length were ⫺5.0, ⫺6.6 and 7.0 cm, respectively. In the 713 women with a uterus the incidence of anterior vaginal, uterine and posterior vaginal prolapse was 27.6%, 2.0% and 25.4%, respectively. The overall distribution of pelvic organ prolapse quantification system stage was stages 0 to 4 in 68.3%, 19.9%, 11.2%, 0.6% and 0.0% of patients, respectively. Conclusions: Vaginal size in Korean women differs from that in Western women. The prevalence of any degree of prolapse was approximately 31.7%. Korean women were at relatively higher risk for anterior and posterior vaginal prolapse than for uterine prolapse. Key Words: female, prolapse, vagina, Korea, uterus
OP is a common condition, of which the risk is expected to increase with increasing age. The lifetime risk of undergoing a single surgery for POP or urinary incontinence by age 80 years is 11.1% in Americans.1 The annual incidence of hospital admission with prolapse before age 60 years in a British region was 2/1,000 person-years.2 Because of this demographic trend coupled with the growing interaction among medical centers, the need for standardization of the terminology of POP has been made evident. Standardization of the terminology used to describe POP would provide a common language in which clinicians and researchers may communicate the anatomical position of the pelvic organs. Many systems for grading and describing disorders of pelvic floor support have been advocated in the medical literature and in gynecologic texts. In 1996 Brubaker and Norton presented the results of a review of more than 100 articles and 15 textbooks.3 They found no consensus regarding a standard system for the description of POP. The International Continence Society, Society for Gynecologic Surgeons and American Urogynecologic Society have recognized this need and have supported a standardized method for evaluating and reporting POP.4 This system
P
Submitted for publication July 7, 2005. * Correspondence: Department of Urology, Samsung Cheil Hospital, Sungkyunkwan University School of Medicine, 1-19, Mukjeongdong, Jung-gu, Seoul, 100-380, Korea (telephone: 82-2-2000-7585; FAX: 82-2-2000-7787; e-mail: [email protected]).
0022-5347/06/1755-1769/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
has been shown to have good intraobserver and interobserver reliability.5,6 Currently the POP-Q system is the only POP classification system to attain international acceptance and recognition. Many women have signs of POP on gynecologic examination. Despite these circumstances little is known about its prevalence in a general population because previous studies have only been done in women with symptomatic prolapse who were hospitalized for surgery. Research in the area of POP has focused primarily on aspects of treatment, whereas less attention has been focused on understanding the normal support of prolapse or its natural history. To our knowledge there exist little published data regarding the prevalence of prolapse in a broader age range of women in the general population.7–9 We evaluated pelvic organ support and prevalence by POP-Q in 713 Korean women. METHODS This study group consisted of 713 women 18 to 72 years old who were seen at our institution for annual Papanicolaou testing and pelvic examination. Subjects were eligible for inclusion if they were seeking annual gynecologic examinations or had any gynecologic complaints that required a pelvic examination and Papanicolaou test as part of the visit. Pregnant subjects and subjects who had delivered within the previous 6 weeks were excluded. Women with hysterectomy or who had been treated for POP were excluded from study.
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Vol. 175, 1769-1772, May 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(05)00993-6
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Various biographical and historical data were collected using a questionnaire, interview and physical examination, including patient age, gravidity, parity, the number of vaginal deliveries, height, weight, waist circumference, menopausal status, hormone therapy, surgical history and medical history. All pelvic examinations were performed by a single examiner with the subject in the dorsal lithotomy position in a pelvic examination chair positioned at a 15degree angle. One examiner experienced in the POP-Q technique performed all evaluations and he was blinded to data analysis. All patients were asked to empty the bladder before examination. Measurements were obtained with a wooden cotton swab marked in 1 cm increments. The POP stating system measurements includes 9 sites, namely Aa—3 cm proximal to the urethral meatus on the anterior vaginal wall, Ba—the most distal position of the upper anterior wall, C—the most distal edge of the cervix or vaginal cuff, D—the location of the posterior vaginal fornix, Ap—3 cm proximal to the hymen on the posterior vaginal wall, Bp—the most distal position of the upper portion of the posterior vaginal wall, gh—the genital hiatus measured from the midline of the external urethral meatus to the posterior midline hymen, tvl—total vaginal length and pb—the perineal body measured from the posterior margin of the genital hiatus to the mid anal opening.4 All points except tvl were recorded with the subject performing maximal Valsalva maneuvers. If the subject was judged not to perform an adequate Valsalva maneuver, measurements were taken with the subject coughing forcefully after being coached by the examiner. The first measurements obtained were genital hiatus and perineal body measurements using a plastic ruler. A bivalve speculum was then placed into the vagina to allow the introduction of the wooden cotton swab and the measurement of total vaginal length. The speculum was slowly withdrawn as the patient strained downward. The points of maximal descent of the cervix (point C) and posterior fornix (point D) were measured. Finally, points Aa, Ba, Ap and Bp were measured. All measurements were recorded and are expressed in cm. If POP-Q staging was greater than POP-Q 1, it was considered a form of prolapse. After this procedure 2 finger vaginal palpation was performed with the pelvic floor muscles relaxed. The woman was then asked to contract the pelvic floor muscles around the examiner finger as hard and for as long as she could. Pelvic floor muscle strength was rated as absent—1 or no detectable muscular contractility around the examiner fingers, weak—2 or contractility detectable but not all around the fingers, moderate—3 or contractility around the fingers
TABLE 1. POP-Q scores according to age Mean Score ⫾ SD Site
Enrollment
18–29
No. pts 713 105 Aa ⫺2.6 ⫾ 0.79 ⫺3.0 ⫾ 0.35 Ba ⫺2.6 ⫾ 0.75 ⫺3.0 ⫾ 0.31 C ⫺5.0 ⫾ 0.75 ⫺5.1 ⫾ 0.61 gh 2.4 ⫾ 0.77 1.8 ⫾ 0.43 pb 2.9 ⫾ 0.54 2.8 ⫾ 0.48 tvl 7.0 ⫾ 0.90 6.8 ⫾ 0.71 Ap ⫺2.7 ⫾ 0.69 ⫺3.0 ⫾ 0.20 Bp ⫺2.7 ⫾ 0.69 ⫺3.0 ⫾ 0.24 D ⫺6.6 ⫾ 0.95 ⫺6.5 ⫾ 0.73
30–39
40–49
50 or Older
189 ⫺2.8 ⫾ 0.51 ⫺2.8 ⫾ 0.47 ⫺5.1 ⫾ 0.85 2.2 ⫾ 0.63 2.9 ⫾ 0.62 7.0 ⫾ 0.92 ⫺2.9 ⫾ 0.41 ⫺2.9 ⫾ 0.41 ⫺6.7 ⫾ 0.83
266 ⫺2.6 ⫾ 0.78 ⫺2.6 ⫾ 0.81 ⫺5.0 ⫾ 0.93 2.5 ⫾ 0.71 3.0 ⫾ 0.50 7.1 ⫾ 0.89 ⫺2.6 ⫾ 0.73 ⫺2.7 ⫾ 0.75 ⫺6.7 ⫾ 0.97
153 ⫺2.1 ⫾ 1.03 ⫺2.2 ⫾ 0.94 ⫺4.9 ⫾ 1.01 2.8 ⫾ 0.88 3.1 ⫾ 0.53 6.7 ⫾ 0.95 ⫺2.3 ⫾ 0.92 ⫺2.4 ⫾ 0.90 ⫺6.2 ⫾ 1.08
TABLE 2. POP-Q scores in Korean and Western women Mean Score ⫾ SD Site
Present Series
Bland et al11
Present Series
O’Boyle et al12
No. pts Age Aa Ba C gh pb tvl Ap Bp D
204 45–55 ⫺2.3 ⫾ 0.91 ⫺2.4 ⫾ 0.84 ⫺5.0 ⫾ 0.99 2.7 ⫾ 0.84 3.1 ⫾ 0.60 7.0 ⫾ 0.93 ⫺2.5 ⫾ 0.88 ⫺2.5 ⫾ 0.83 ⫺6.6 ⫾ 1.06
241 45–55 ⫺2.9 ⫾ 0.19 ⫺2.7 ⫾ 0.04 ⫺6.5 ⫾ 1.3 2.8 ⫾ 0.05 3.5 ⫾ 0.04 8.6 ⫾ 0.07 ⫺3.0 ⫾ 0.01 ⫺2.9 ⫾ 0.02 ⫺7.8 ⫾ 1.1
105 18–29 ⫺3.0 ⫾ 0.35 ⫺3.0 ⫾ 0.31 ⫺5.1 ⫾ 0.61 1.8 ⫾ 0.43 2.8 ⫾ 0.48 6.8 ⫾ 0.71 ⫺3.0 ⫾ 0.20 ⫺3.0 ⫾ 0.24 ⫺6.5 ⫾ 0.73
21 18–29 ⫺2.5 ⫾ 0.5 ⫺2.5 ⫾ 0.5 ⫺5.7 ⫾ 1.3 2.7 ⫾ 0.7 3.1 ⫾ 0.5 9.8 ⫾ 0.8 ⫺2.8 ⫾ 0.3 ⫺2.8 ⫾ 0.3 ⫺8.2 ⫾ 1.4
but no pelvic floor elevation, or good— 4 or powerful contractility around the fingers and pelvic floor elevation. Data were entered into dBSTAT, version 4.0 (DBSTAT, Chunchon, Korea). Standard descriptive statistics were calculated according to the POP-Q system stage to develop normative data on pelvic organ support. Univariate analyses of categorical data were performed with the chi-square test. Statistical significance was considered at p ⬍0.05. RESULTS A total of 713 women underwent pelvic organ support evaluation with POP-Q scoring. No subjects were excluded from analyses. No subjects refused the request of entry to the study. Mean study subject age ⫾ SD was 41.6 ⫾ 10.2 years (range 18 to 72), mean weight was 55.8 ⫾ 7.4 kg (range 40 to 83), mean height was 158.7 ⫾ 5.4 cm (range 138 to 177) mean BMI was 22.3 ⫾ 8.1 kg/m2 (range 15.7 to 32) and median parity was 2 (range 0 to 6). The women were a single ethnic group. Table 1 lists the mean values of each POP staging system point at enrollment and subject age. Mean scores describing the position of the cervix and posterior fornix, and total vaginal length were ⫺5.0, ⫺6.6 and 7.0 cm, respectively. Tables 2 and 3 show comparisons of POP-Q scores and total vaginal length in Korean and Western women. Total vaginal length in Korean women was shorter than in Western women. In the 713 women with a uterus the rate of anterior vaginal, uterine and posterior vaginal prolapse was 27.6%, 2.0% and 25.4%, respectively. The overall distribution of POP-Q system stages was stages 0 to 3 in 68.3%, 19.9%, 11.2% and 0.6% of cases, respectively. None of the subjects examined had stage 4 prolapse. Korean women had a relatively higher rate of anterior and posterior vaginal prolapse than of uterine prolapse. The prevalence of any form of prolapse was 2.0% in women 20 to 29 years old and 57.5% in those older than 50 years with an overall prevalence of 31.7%. Prolapse occurred
TABLE 3. Total vaginal length in Korean and Western women References
No. Pts
Mean Age
Mean TVL
Weber et al13 Barber et al14 Visco et al15 Dannecker et al16 Kearney and DeLancey17 Present series
73 189 131 26 76 713
53 61 60 29 65 42
10.8 9.0 8.7 11.0 9.7 7.0
PELVIC ORGAN SUPPORT AND PREVALENCE IN KOREAN WOMEN TABLE 4. POP risk factors in Korean women (p ⬍0.001) % POP-Q Stage
Age: 19–29 30–39 40–49 50 or older Parity (No.): 0 1 2 3 or greater BMI (kg/m2): 18.5 or less 18.6–22.9 23–24.9 25.0 or greater Waist circumference (cm): 70 or Less 70–75 76–80 Greater than 80 Pelvic floor muscle score: 4 3 1–2 Menopause: No Yes Delivery: Cesarean Vaginal
No. Pts
0
1
2 or Greater
105 189 266 153
98.0 85.2 59.4 42.5
1.0 12.2 27.4 29.4
1.0 2.6 13.2 28.1
157 123 316 117
98.1 75.6 61.7 38.4
1.9 18.7 23.1 36.8
0 5.7 15.2 24.8
58 387 146 122
91.4 75.2 58.2 47.5
6.9 17.6 23.3 29.5
1.7 7.2 18.5 23.0
260 243 111 99
80.8 69.6 53.2 49.5
15.0 19.3 28.8 24.2
4.2 11.1 18.0 26.3
407 242 64
72.9 53.2 61.0
18.7 26.9 17.1
8.4 19.9 21.9
552 161
74.6 46.6
17.4 28.6
8.0 24.8
75 481
82.7 57.0
13.3 26.4
4.0 16.6
in 40.1% of parous women. The corresponding prevalence among nonparous women was 1.9%. Table 4 shows the effects of age, parity, BMI, waist circumference, pelvic floor muscle score, menopausal status and delivery mode on the stage of pelvic organ support. All of these variables showed a statistically significant trend toward increased POP-Q system stage (each p ⬍0.01). DISCUSSION This study presents normative data on pelvic organ support and prevalence obtained after application of the POP-Q staging system in 713 Korean women. Although POP is one of the most common indications for gynecologic surgery, there are little epidemiological data on this condition. To our knowledge the number of women with POP who are treated without hospitalization and surgery as well as the number with POP who never seek medical attention is unknown. Incidence and prevalence estimates based on surgical procedure rates almost certainly underestimate the magnitude of POP. Clinically POP does not seem to regress, although some improvement may be seen with chronic retention of a pessary.10 Because prolapse often does not become symptomatic until the descending segment is through the introitus, POP is frequently not recognized until end stage disease exists. Some women progress rapidly from mild to advanced stages of POP, whereas others seem to remain stable for many years. It has been reported that total vaginal length by POP-Q score in Western women is approximately 10 cm.11–17 However, total vaginal length by POP-Q score in Korean women is different from that in Western women. The mean total vaginal length score in Korean women is 7 cm. There is no difference between height and total vaginal length. Height
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in 83 women was above 165 cm and their mean total vaginal length was 7 cm. Total vaginal length is different in ethnic groups. There are reports of the incidence of surgical correction of POP in large populations but the degree and stage of prolapse in subjects undergoing surgical correction were not objectively reported according to a standardized, reproducible staging system. These reports also did not account for subjects in whom prolapse was managed nonsurgically.1,2 Although such studies yield information on the lifetime incidence of surgery for the correction of POP, they do not provide any information on what represents normal vs abnormal support in women of various ages. Few publications in the gynecologic literature provide normative data on large groups of women with the various classifications of POP. In 1997 Samuelsson et al reported their findings in 487 Swedish women 20 to 59 years old to find the prevalence of prolapse in that general population.7 Without assigning a severity score they reported only the presence or absence of prolapse during the Valsalva maneuver. The overall prevalence of any form of prolapse was 30.8% with no prolapse in 69.2% of cases. In 1999 Bland et al reported prolapse stage by the POP-Q staging system at the time of initial examination and 1 year later in 241 women 45 to 55 years old who registered to receive perimenopausal gynecologic care and a soybean supplement as treatment for menopausal symptoms.11 Of interest are the stages of prolapse in those women at initial examination, namely stages 0 to 2 in 73%, 23% and 4%, respectively. No patients were classified at stage 3 or greater. In 2000 Swift reported the distribution of pelvic organ support stages in a general population of women 18 to 82 years old.8 The overall distribution of POP-Q stages was stages 0 to 3 in 6.4%, 43.3%, 47.7% and 2.6% of cases, respectively. In 2002 Hendrix et al reported their findings of the prevalence of prolapse in a population of 50 to 79-year-old women enrolled in the Women’s Health Initiative Hormone Replacement Therapy Clinical Trial.18 Prolapse assessment was performed with direct visualization of the external genitalia during the Valsalva maneuver. Of the 16,616 women with a uterus 41.1% had some form of prolapse. In 2004 Nygaard et al reported the prevalence of POP in 279 women 57 to 84 years of age who enrolled in the Women’s Health Initiative Hormone Replacement Therapy Clinical Trial.19 By applying the POP-Q staging system to the study group 2.3% of the cases were classified as stage 0, whereas 33.0%, 62.9% and 1.9% were stages 1 to 3, respectively. There appears to be a significant difference in the number of women in the general population with stage 0 support in the study of Swift (6.4%)8 compared to that in the study of Samuelsson et al (69.2%).7 Also, there appears to be a significant difference in the number of perimenopausal and postmenopausal women with stage 0 support observed by Bland et al (73%)11 compared to those observed by Hendrix et al (48.9%)18 and Nygaard et al (2.3%).19 In our study the prevalence of stage 0 was 68.3% in the general population and 42.5% in women older than 50 years. Three studies show similarity to our study. However, 2 studies are different from our study. It is difficult to explain the differences between other observations and ours except to state the possibility that patients in other studies performed a more forceful Valsalva maneuver during examination and were of a different ethnicity. Existing data suggest that ethnicity is associated
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PELVIC ORGAN SUPPORT AND PREVALENCE IN KOREAN WOMEN
with POP.18,20 The results of the current study correspond with the earlier study showing that Asian women show relatively higher risks of anterior and posterior vaginal prolapse but not of uterine prolapse. Additionally, our study shows a statistically significant trend toward increased POP-Q stage in women with many of the historically quoted etiological factors for POP (table 4). To our knowledge there are no published data regarding pelvic organ support and the prevalence of prolapse using the POP-Q staging system in the general Asian population. We are hopeful that the normative data presented in this study may provide a useful reference for physicians as they evaluate prolapse in an attempt to restore normal pelvic anatomy.
Abbreviations and Acronyms BMI ⫽ body mass index POP ⫽ pelvic organ prolapse POP-Q ⫽ POP-Quantification REFERENCES 1. Olsen, A. L., Smith, V. J., Bergstrom, J. O., Colling, J. C. and Clark, A. L.: Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol, 89: 501, 1997 2. Mant, J., Painter, R. and Vessey, M.: Epidemiology of genital prolapse observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol, 104: 579, 1997 3. Brubaker, L. and Norton, P.: Current clinical nomenclature for description of pelvic organ prolapse. J Pelvic Surg, 2: 257, 1996 4. Bump, R. C., Mattiasson, A., Bö, K., Brubaker, L. P., DeLancey, J. O. L., Klarskove, P. et al: The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol, 175: 10, 1996 5. Hall, A. F., Theofrastous, J. P., Cundiff, G. W., Harris, R. L., Hamilton, L. F., Swift, S. E. et al: Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system. Am J Obstet Gynecol, 175: 1467, 1996 6. Koback, W. H., Rosenberger, K. and Walters, M. D.: Interobserver variation in the assessment of pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct, 7: 121, 1996 7. Samuelsson, E. V., Arne Victor, F. T., Tibblin, G. and Svardsudd, K. F.: Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol, 180: 299, 1999
8. Swift, S. E.: The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol, 183: 277, 2000 9. Slieker-ten Hove, M. C. P., Vierhout, M., Bloembergen, H. and Schoenmaker, G.: Distribution of pelvic organ prolapse (POP) in the general population; prevalence, severity, etiology and relation with the function of the pelvic floor muscles. Neurourol Urodyn, 23: 401, abstract, 2004 10. Bump, R. C. and Norton, P. A.: Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am, 25: 723, 1998 11. Bland, D. R., Earle, B. B., Bitolins, M. Z. and Burke, G.: Use of the pelvic organ prolapse staging system of the International Continence Society, American Urogynecologic Society, and Society of Gynecologic Surgeons in perimenopausal women. Am J Obstet Gynecol, 181: 1324, 1999 12. O’Boyle, A. L., Woodman, P. J., O’Boyle, J. D., Davis, G. D. and Swift, S. E.: Pelvic organ support in nulliparous pregnant and nonpregnant women: a case control study. Am J Obstet Gynecol, 187: 99, 2002 13. Weber, A. M., Walters, M. D., Schover, L. R. and Mitchinson, A.: Vaginal anatomy and sexual function. Obstet Gynecol, 86: 946, 1995 14. Barber, M. D., Lambers, A. R., Visco, A. G. and Bump, R. C.: Effect of patient position on clinical evaluation of pelvic organ prolapse. Obstet Gynecol, 96: 18, 2000 15. Visco, A. G., Wei, J. T., McClure, L. A., Handa, V. L. and Nygaard, I. E.: Effects of examination technique modifications on pelvic organ prolapse quantification (POP-Q) results. Int Urogynecol J, 14: 136, 2003 16. Dannecker, C., Lienemann, A., Fischer, J. and Anthuber, C.: Influence of spontaneous and instrumental vaginal delivery on objective measures of pelvic organ support assessment with the pelvic organ prolapse quantification (POP-Q) technique and functional cine magnetic resonance imaging. Euro J Obstet Gynecol Reprod Biol, 114: 32, 2004 17. Kearney, R. and DeLancey, J. O. L.: Selecting suspension points and excising the vagina during Michigan four-wall sacrospinous suspension. Obstet Gynecol, 101: 325, 2003 18. Hendrix, S. L., Clark, A. C., Nygaard, I., Aragki, A., Barnabei, V. and McTiernan, A.: Pelvic organ prolapse in the Women’s Health Initiative gravity and gravidity. Am J Obstet Gynecol, 186: 1160, 2002 19. Nygaard, I., Bradley, C. and Brandt, D.: Pelvic organ prolapse in older women: prevalence and risk factors. Obstet Gynecol, 104: 489, 2004 20. Bump, R. C.: Racial comparisons and contrasts in urinary incontinence and pelvic organ prolapse. Br J Obstet Gynaecol, 81: 421, 1993
Purpose: We evaluated pelvic organ support and the prevalence of pelvic organ prolapse in Korean women using the Pelvic Organ Prolapse-Quantification system as the assessment tool. Materials and Methods: The study population consisted of 713 women 18 to 72 years old who were seen for annual Papanicolaou testing and pelvic examinations. Pregnant patients and patients who had delivered within the previous 6 weeks were not recruited. All pelvic examinations were performed by a single examiner. The patient was examined in the dorsal lithotomy position in a pelvic examination chair positioned at a 15-degree angle. All 9 measurements except total vaginal length were taken with the patient performing the maximal Valsalva maneuver. Results: Mean patient age was 41.6 years (range 18 to 72), mean weight ⫾ SD was 55.8 ⫾ 7.4 kg (range 40 to 83), mean height was 158.7 ⫾ 5.4 cm (range 138 to 177), mean body mass index was 22.3 ⫾ 8.1 kg/m2 (range 15.7 to 32) and median parity was 2 (range 0 to 6). Mean scores for the position of the cervix and posterior fornix, and total vaginal length were ⫺5.0, ⫺6.6 and 7.0 cm, respectively. In the 713 women with a uterus the incidence of anterior vaginal, uterine and posterior vaginal prolapse was 27.6%, 2.0% and 25.4%, respectively. The overall distribution of pelvic organ prolapse quantification system stage was stages 0 to 4 in 68.3%, 19.9%, 11.2%, 0.6% and 0.0% of patients, respectively. Conclusions: Vaginal size in Korean women differs from that in Western women. The prevalence of any degree of prolapse was approximately 31.7%. Korean women were at relatively higher risk for anterior and posterior vaginal prolapse than for uterine prolapse. Key Words: female, prolapse, vagina, Korea, uterus
OP is a common condition, of which the risk is expected to increase with increasing age. The lifetime risk of undergoing a single surgery for POP or urinary incontinence by age 80 years is 11.1% in Americans.1 The annual incidence of hospital admission with prolapse before age 60 years in a British region was 2/1,000 person-years.2 Because of this demographic trend coupled with the growing interaction among medical centers, the need for standardization of the terminology of POP has been made evident. Standardization of the terminology used to describe POP would provide a common language in which clinicians and researchers may communicate the anatomical position of the pelvic organs. Many systems for grading and describing disorders of pelvic floor support have been advocated in the medical literature and in gynecologic texts. In 1996 Brubaker and Norton presented the results of a review of more than 100 articles and 15 textbooks.3 They found no consensus regarding a standard system for the description of POP. The International Continence Society, Society for Gynecologic Surgeons and American Urogynecologic Society have recognized this need and have supported a standardized method for evaluating and reporting POP.4 This system
P
Submitted for publication July 7, 2005. * Correspondence: Department of Urology, Samsung Cheil Hospital, Sungkyunkwan University School of Medicine, 1-19, Mukjeongdong, Jung-gu, Seoul, 100-380, Korea (telephone: 82-2-2000-7585; FAX: 82-2-2000-7787; e-mail: [email protected]).
0022-5347/06/1755-1769/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
has been shown to have good intraobserver and interobserver reliability.5,6 Currently the POP-Q system is the only POP classification system to attain international acceptance and recognition. Many women have signs of POP on gynecologic examination. Despite these circumstances little is known about its prevalence in a general population because previous studies have only been done in women with symptomatic prolapse who were hospitalized for surgery. Research in the area of POP has focused primarily on aspects of treatment, whereas less attention has been focused on understanding the normal support of prolapse or its natural history. To our knowledge there exist little published data regarding the prevalence of prolapse in a broader age range of women in the general population.7–9 We evaluated pelvic organ support and prevalence by POP-Q in 713 Korean women. METHODS This study group consisted of 713 women 18 to 72 years old who were seen at our institution for annual Papanicolaou testing and pelvic examination. Subjects were eligible for inclusion if they were seeking annual gynecologic examinations or had any gynecologic complaints that required a pelvic examination and Papanicolaou test as part of the visit. Pregnant subjects and subjects who had delivered within the previous 6 weeks were excluded. Women with hysterectomy or who had been treated for POP were excluded from study.
1769
Vol. 175, 1769-1772, May 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(05)00993-6
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PELVIC ORGAN SUPPORT AND PREVALENCE IN KOREAN WOMEN
Various biographical and historical data were collected using a questionnaire, interview and physical examination, including patient age, gravidity, parity, the number of vaginal deliveries, height, weight, waist circumference, menopausal status, hormone therapy, surgical history and medical history. All pelvic examinations were performed by a single examiner with the subject in the dorsal lithotomy position in a pelvic examination chair positioned at a 15degree angle. One examiner experienced in the POP-Q technique performed all evaluations and he was blinded to data analysis. All patients were asked to empty the bladder before examination. Measurements were obtained with a wooden cotton swab marked in 1 cm increments. The POP stating system measurements includes 9 sites, namely Aa—3 cm proximal to the urethral meatus on the anterior vaginal wall, Ba—the most distal position of the upper anterior wall, C—the most distal edge of the cervix or vaginal cuff, D—the location of the posterior vaginal fornix, Ap—3 cm proximal to the hymen on the posterior vaginal wall, Bp—the most distal position of the upper portion of the posterior vaginal wall, gh—the genital hiatus measured from the midline of the external urethral meatus to the posterior midline hymen, tvl—total vaginal length and pb—the perineal body measured from the posterior margin of the genital hiatus to the mid anal opening.4 All points except tvl were recorded with the subject performing maximal Valsalva maneuvers. If the subject was judged not to perform an adequate Valsalva maneuver, measurements were taken with the subject coughing forcefully after being coached by the examiner. The first measurements obtained were genital hiatus and perineal body measurements using a plastic ruler. A bivalve speculum was then placed into the vagina to allow the introduction of the wooden cotton swab and the measurement of total vaginal length. The speculum was slowly withdrawn as the patient strained downward. The points of maximal descent of the cervix (point C) and posterior fornix (point D) were measured. Finally, points Aa, Ba, Ap and Bp were measured. All measurements were recorded and are expressed in cm. If POP-Q staging was greater than POP-Q 1, it was considered a form of prolapse. After this procedure 2 finger vaginal palpation was performed with the pelvic floor muscles relaxed. The woman was then asked to contract the pelvic floor muscles around the examiner finger as hard and for as long as she could. Pelvic floor muscle strength was rated as absent—1 or no detectable muscular contractility around the examiner fingers, weak—2 or contractility detectable but not all around the fingers, moderate—3 or contractility around the fingers
TABLE 1. POP-Q scores according to age Mean Score ⫾ SD Site
Enrollment
18–29
No. pts 713 105 Aa ⫺2.6 ⫾ 0.79 ⫺3.0 ⫾ 0.35 Ba ⫺2.6 ⫾ 0.75 ⫺3.0 ⫾ 0.31 C ⫺5.0 ⫾ 0.75 ⫺5.1 ⫾ 0.61 gh 2.4 ⫾ 0.77 1.8 ⫾ 0.43 pb 2.9 ⫾ 0.54 2.8 ⫾ 0.48 tvl 7.0 ⫾ 0.90 6.8 ⫾ 0.71 Ap ⫺2.7 ⫾ 0.69 ⫺3.0 ⫾ 0.20 Bp ⫺2.7 ⫾ 0.69 ⫺3.0 ⫾ 0.24 D ⫺6.6 ⫾ 0.95 ⫺6.5 ⫾ 0.73
30–39
40–49
50 or Older
189 ⫺2.8 ⫾ 0.51 ⫺2.8 ⫾ 0.47 ⫺5.1 ⫾ 0.85 2.2 ⫾ 0.63 2.9 ⫾ 0.62 7.0 ⫾ 0.92 ⫺2.9 ⫾ 0.41 ⫺2.9 ⫾ 0.41 ⫺6.7 ⫾ 0.83
266 ⫺2.6 ⫾ 0.78 ⫺2.6 ⫾ 0.81 ⫺5.0 ⫾ 0.93 2.5 ⫾ 0.71 3.0 ⫾ 0.50 7.1 ⫾ 0.89 ⫺2.6 ⫾ 0.73 ⫺2.7 ⫾ 0.75 ⫺6.7 ⫾ 0.97
153 ⫺2.1 ⫾ 1.03 ⫺2.2 ⫾ 0.94 ⫺4.9 ⫾ 1.01 2.8 ⫾ 0.88 3.1 ⫾ 0.53 6.7 ⫾ 0.95 ⫺2.3 ⫾ 0.92 ⫺2.4 ⫾ 0.90 ⫺6.2 ⫾ 1.08
TABLE 2. POP-Q scores in Korean and Western women Mean Score ⫾ SD Site
Present Series
Bland et al11
Present Series
O’Boyle et al12
No. pts Age Aa Ba C gh pb tvl Ap Bp D
204 45–55 ⫺2.3 ⫾ 0.91 ⫺2.4 ⫾ 0.84 ⫺5.0 ⫾ 0.99 2.7 ⫾ 0.84 3.1 ⫾ 0.60 7.0 ⫾ 0.93 ⫺2.5 ⫾ 0.88 ⫺2.5 ⫾ 0.83 ⫺6.6 ⫾ 1.06
241 45–55 ⫺2.9 ⫾ 0.19 ⫺2.7 ⫾ 0.04 ⫺6.5 ⫾ 1.3 2.8 ⫾ 0.05 3.5 ⫾ 0.04 8.6 ⫾ 0.07 ⫺3.0 ⫾ 0.01 ⫺2.9 ⫾ 0.02 ⫺7.8 ⫾ 1.1
105 18–29 ⫺3.0 ⫾ 0.35 ⫺3.0 ⫾ 0.31 ⫺5.1 ⫾ 0.61 1.8 ⫾ 0.43 2.8 ⫾ 0.48 6.8 ⫾ 0.71 ⫺3.0 ⫾ 0.20 ⫺3.0 ⫾ 0.24 ⫺6.5 ⫾ 0.73
21 18–29 ⫺2.5 ⫾ 0.5 ⫺2.5 ⫾ 0.5 ⫺5.7 ⫾ 1.3 2.7 ⫾ 0.7 3.1 ⫾ 0.5 9.8 ⫾ 0.8 ⫺2.8 ⫾ 0.3 ⫺2.8 ⫾ 0.3 ⫺8.2 ⫾ 1.4
but no pelvic floor elevation, or good— 4 or powerful contractility around the fingers and pelvic floor elevation. Data were entered into dBSTAT, version 4.0 (DBSTAT, Chunchon, Korea). Standard descriptive statistics were calculated according to the POP-Q system stage to develop normative data on pelvic organ support. Univariate analyses of categorical data were performed with the chi-square test. Statistical significance was considered at p ⬍0.05. RESULTS A total of 713 women underwent pelvic organ support evaluation with POP-Q scoring. No subjects were excluded from analyses. No subjects refused the request of entry to the study. Mean study subject age ⫾ SD was 41.6 ⫾ 10.2 years (range 18 to 72), mean weight was 55.8 ⫾ 7.4 kg (range 40 to 83), mean height was 158.7 ⫾ 5.4 cm (range 138 to 177) mean BMI was 22.3 ⫾ 8.1 kg/m2 (range 15.7 to 32) and median parity was 2 (range 0 to 6). The women were a single ethnic group. Table 1 lists the mean values of each POP staging system point at enrollment and subject age. Mean scores describing the position of the cervix and posterior fornix, and total vaginal length were ⫺5.0, ⫺6.6 and 7.0 cm, respectively. Tables 2 and 3 show comparisons of POP-Q scores and total vaginal length in Korean and Western women. Total vaginal length in Korean women was shorter than in Western women. In the 713 women with a uterus the rate of anterior vaginal, uterine and posterior vaginal prolapse was 27.6%, 2.0% and 25.4%, respectively. The overall distribution of POP-Q system stages was stages 0 to 3 in 68.3%, 19.9%, 11.2% and 0.6% of cases, respectively. None of the subjects examined had stage 4 prolapse. Korean women had a relatively higher rate of anterior and posterior vaginal prolapse than of uterine prolapse. The prevalence of any form of prolapse was 2.0% in women 20 to 29 years old and 57.5% in those older than 50 years with an overall prevalence of 31.7%. Prolapse occurred
TABLE 3. Total vaginal length in Korean and Western women References
No. Pts
Mean Age
Mean TVL
Weber et al13 Barber et al14 Visco et al15 Dannecker et al16 Kearney and DeLancey17 Present series
73 189 131 26 76 713
53 61 60 29 65 42
10.8 9.0 8.7 11.0 9.7 7.0
PELVIC ORGAN SUPPORT AND PREVALENCE IN KOREAN WOMEN TABLE 4. POP risk factors in Korean women (p ⬍0.001) % POP-Q Stage
Age: 19–29 30–39 40–49 50 or older Parity (No.): 0 1 2 3 or greater BMI (kg/m2): 18.5 or less 18.6–22.9 23–24.9 25.0 or greater Waist circumference (cm): 70 or Less 70–75 76–80 Greater than 80 Pelvic floor muscle score: 4 3 1–2 Menopause: No Yes Delivery: Cesarean Vaginal
No. Pts
0
1
2 or Greater
105 189 266 153
98.0 85.2 59.4 42.5
1.0 12.2 27.4 29.4
1.0 2.6 13.2 28.1
157 123 316 117
98.1 75.6 61.7 38.4
1.9 18.7 23.1 36.8
0 5.7 15.2 24.8
58 387 146 122
91.4 75.2 58.2 47.5
6.9 17.6 23.3 29.5
1.7 7.2 18.5 23.0
260 243 111 99
80.8 69.6 53.2 49.5
15.0 19.3 28.8 24.2
4.2 11.1 18.0 26.3
407 242 64
72.9 53.2 61.0
18.7 26.9 17.1
8.4 19.9 21.9
552 161
74.6 46.6
17.4 28.6
8.0 24.8
75 481
82.7 57.0
13.3 26.4
4.0 16.6
in 40.1% of parous women. The corresponding prevalence among nonparous women was 1.9%. Table 4 shows the effects of age, parity, BMI, waist circumference, pelvic floor muscle score, menopausal status and delivery mode on the stage of pelvic organ support. All of these variables showed a statistically significant trend toward increased POP-Q system stage (each p ⬍0.01). DISCUSSION This study presents normative data on pelvic organ support and prevalence obtained after application of the POP-Q staging system in 713 Korean women. Although POP is one of the most common indications for gynecologic surgery, there are little epidemiological data on this condition. To our knowledge the number of women with POP who are treated without hospitalization and surgery as well as the number with POP who never seek medical attention is unknown. Incidence and prevalence estimates based on surgical procedure rates almost certainly underestimate the magnitude of POP. Clinically POP does not seem to regress, although some improvement may be seen with chronic retention of a pessary.10 Because prolapse often does not become symptomatic until the descending segment is through the introitus, POP is frequently not recognized until end stage disease exists. Some women progress rapidly from mild to advanced stages of POP, whereas others seem to remain stable for many years. It has been reported that total vaginal length by POP-Q score in Western women is approximately 10 cm.11–17 However, total vaginal length by POP-Q score in Korean women is different from that in Western women. The mean total vaginal length score in Korean women is 7 cm. There is no difference between height and total vaginal length. Height
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in 83 women was above 165 cm and their mean total vaginal length was 7 cm. Total vaginal length is different in ethnic groups. There are reports of the incidence of surgical correction of POP in large populations but the degree and stage of prolapse in subjects undergoing surgical correction were not objectively reported according to a standardized, reproducible staging system. These reports also did not account for subjects in whom prolapse was managed nonsurgically.1,2 Although such studies yield information on the lifetime incidence of surgery for the correction of POP, they do not provide any information on what represents normal vs abnormal support in women of various ages. Few publications in the gynecologic literature provide normative data on large groups of women with the various classifications of POP. In 1997 Samuelsson et al reported their findings in 487 Swedish women 20 to 59 years old to find the prevalence of prolapse in that general population.7 Without assigning a severity score they reported only the presence or absence of prolapse during the Valsalva maneuver. The overall prevalence of any form of prolapse was 30.8% with no prolapse in 69.2% of cases. In 1999 Bland et al reported prolapse stage by the POP-Q staging system at the time of initial examination and 1 year later in 241 women 45 to 55 years old who registered to receive perimenopausal gynecologic care and a soybean supplement as treatment for menopausal symptoms.11 Of interest are the stages of prolapse in those women at initial examination, namely stages 0 to 2 in 73%, 23% and 4%, respectively. No patients were classified at stage 3 or greater. In 2000 Swift reported the distribution of pelvic organ support stages in a general population of women 18 to 82 years old.8 The overall distribution of POP-Q stages was stages 0 to 3 in 6.4%, 43.3%, 47.7% and 2.6% of cases, respectively. In 2002 Hendrix et al reported their findings of the prevalence of prolapse in a population of 50 to 79-year-old women enrolled in the Women’s Health Initiative Hormone Replacement Therapy Clinical Trial.18 Prolapse assessment was performed with direct visualization of the external genitalia during the Valsalva maneuver. Of the 16,616 women with a uterus 41.1% had some form of prolapse. In 2004 Nygaard et al reported the prevalence of POP in 279 women 57 to 84 years of age who enrolled in the Women’s Health Initiative Hormone Replacement Therapy Clinical Trial.19 By applying the POP-Q staging system to the study group 2.3% of the cases were classified as stage 0, whereas 33.0%, 62.9% and 1.9% were stages 1 to 3, respectively. There appears to be a significant difference in the number of women in the general population with stage 0 support in the study of Swift (6.4%)8 compared to that in the study of Samuelsson et al (69.2%).7 Also, there appears to be a significant difference in the number of perimenopausal and postmenopausal women with stage 0 support observed by Bland et al (73%)11 compared to those observed by Hendrix et al (48.9%)18 and Nygaard et al (2.3%).19 In our study the prevalence of stage 0 was 68.3% in the general population and 42.5% in women older than 50 years. Three studies show similarity to our study. However, 2 studies are different from our study. It is difficult to explain the differences between other observations and ours except to state the possibility that patients in other studies performed a more forceful Valsalva maneuver during examination and were of a different ethnicity. Existing data suggest that ethnicity is associated
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PELVIC ORGAN SUPPORT AND PREVALENCE IN KOREAN WOMEN
with POP.18,20 The results of the current study correspond with the earlier study showing that Asian women show relatively higher risks of anterior and posterior vaginal prolapse but not of uterine prolapse. Additionally, our study shows a statistically significant trend toward increased POP-Q stage in women with many of the historically quoted etiological factors for POP (table 4). To our knowledge there are no published data regarding pelvic organ support and the prevalence of prolapse using the POP-Q staging system in the general Asian population. We are hopeful that the normative data presented in this study may provide a useful reference for physicians as they evaluate prolapse in an attempt to restore normal pelvic anatomy.
Abbreviations and Acronyms BMI ⫽ body mass index POP ⫽ pelvic organ prolapse POP-Q ⫽ POP-Quantification REFERENCES 1. Olsen, A. L., Smith, V. J., Bergstrom, J. O., Colling, J. C. and Clark, A. L.: Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol, 89: 501, 1997 2. Mant, J., Painter, R. and Vessey, M.: Epidemiology of genital prolapse observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol, 104: 579, 1997 3. Brubaker, L. and Norton, P.: Current clinical nomenclature for description of pelvic organ prolapse. J Pelvic Surg, 2: 257, 1996 4. Bump, R. C., Mattiasson, A., Bö, K., Brubaker, L. P., DeLancey, J. O. L., Klarskove, P. et al: The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol, 175: 10, 1996 5. Hall, A. F., Theofrastous, J. P., Cundiff, G. W., Harris, R. L., Hamilton, L. F., Swift, S. E. et al: Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system. Am J Obstet Gynecol, 175: 1467, 1996 6. Koback, W. H., Rosenberger, K. and Walters, M. D.: Interobserver variation in the assessment of pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct, 7: 121, 1996 7. Samuelsson, E. V., Arne Victor, F. T., Tibblin, G. and Svardsudd, K. F.: Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol, 180: 299, 1999
8. Swift, S. E.: The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol, 183: 277, 2000 9. Slieker-ten Hove, M. C. P., Vierhout, M., Bloembergen, H. and Schoenmaker, G.: Distribution of pelvic organ prolapse (POP) in the general population; prevalence, severity, etiology and relation with the function of the pelvic floor muscles. Neurourol Urodyn, 23: 401, abstract, 2004 10. Bump, R. C. and Norton, P. A.: Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am, 25: 723, 1998 11. Bland, D. R., Earle, B. B., Bitolins, M. Z. and Burke, G.: Use of the pelvic organ prolapse staging system of the International Continence Society, American Urogynecologic Society, and Society of Gynecologic Surgeons in perimenopausal women. Am J Obstet Gynecol, 181: 1324, 1999 12. O’Boyle, A. L., Woodman, P. J., O’Boyle, J. D., Davis, G. D. and Swift, S. E.: Pelvic organ support in nulliparous pregnant and nonpregnant women: a case control study. Am J Obstet Gynecol, 187: 99, 2002 13. Weber, A. M., Walters, M. D., Schover, L. R. and Mitchinson, A.: Vaginal anatomy and sexual function. Obstet Gynecol, 86: 946, 1995 14. Barber, M. D., Lambers, A. R., Visco, A. G. and Bump, R. C.: Effect of patient position on clinical evaluation of pelvic organ prolapse. Obstet Gynecol, 96: 18, 2000 15. Visco, A. G., Wei, J. T., McClure, L. A., Handa, V. L. and Nygaard, I. E.: Effects of examination technique modifications on pelvic organ prolapse quantification (POP-Q) results. Int Urogynecol J, 14: 136, 2003 16. Dannecker, C., Lienemann, A., Fischer, J. and Anthuber, C.: Influence of spontaneous and instrumental vaginal delivery on objective measures of pelvic organ support assessment with the pelvic organ prolapse quantification (POP-Q) technique and functional cine magnetic resonance imaging. Euro J Obstet Gynecol Reprod Biol, 114: 32, 2004 17. Kearney, R. and DeLancey, J. O. L.: Selecting suspension points and excising the vagina during Michigan four-wall sacrospinous suspension. Obstet Gynecol, 101: 325, 2003 18. Hendrix, S. L., Clark, A. C., Nygaard, I., Aragki, A., Barnabei, V. and McTiernan, A.: Pelvic organ prolapse in the Women’s Health Initiative gravity and gravidity. Am J Obstet Gynecol, 186: 1160, 2002 19. Nygaard, I., Bradley, C. and Brandt, D.: Pelvic organ prolapse in older women: prevalence and risk factors. Obstet Gynecol, 104: 489, 2004 20. Bump, R. C.: Racial comparisons and contrasts in urinary incontinence and pelvic organ prolapse. Br J Obstet Gynaecol, 81: 421, 1993