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Symptoms differ for anterior and posterior prolapse

Key clinical point: Women with stage II posterior pelvic organ prolapse are more likely to have symptoms such as a loss of gas from the rectum and a sensation of bulge than are women with similar stage anterior pelvic organ prolapse.

Major finding: Obstetric risk factors for stage II anterior and posterior pelvic organ prolapse were similar, but women with posterior prolapse were more likely to report having symptoms and having sought medical help for them.

Data source: A cohort study of 1,497 women assessed 5-10 years after a first delivery

Disclosures: Dr. Wilbur disclosed no relevant conflicts of interest.


 

AT SGS 2014

SCOTTSDALE, ARIZ. – Obstetric risk factors for stage II anterior and posterior pelvic organ prolapse are essentially the same, but symptoms differ, according to a cohort study reported at the annual meeting of the Society of Gynecologic Surgeons.

Investigators led by Dr. MaryAnn Wilbur of the department of obstetrics and gynecology at Johns Hopkins University, Baltimore, analyzed data from women who were 5-10 years out from a first delivery, comparing 85 women with posterior prolapse (with or without concomitant anterior prolapse), 334 women with isolated anterior prolapse, and 1,078 women with no prolapse.

The results showed that having had a vaginal delivery was a risk factor for both posterior and anterior prolapse. But the women with posterior prolapse were significantly more likely to report a loss of gas from the rectum, having to push on the vagina to complete a bowel movement, having a sensation of bulge, and having asked a physician for help because of their symptoms.

"Not surprisingly, prolapse was associated with vaginal delivery, but when we compare anterior versus posterior prolapse, there were no differences in terms of obstetric risk factors, at least that we could perceive in this study," Dr. Wilbur commented. "But the symptomatology was different between those two groups," although the reasons for this difference were not readily apparent.

The investigators analyzed data collected at enrollment, 5-10 years after a first delivery, from women in the Mothers’ Outcomes After Delivery cohort. Most had had their delivery at Greater Baltimore Medical Center, a large community hospital.

The women’s obstetric history was reviewed, they underwent examination including the pelvic organ prolapse quantification (POP-Q) system assessment, and they completed validated measures of symptoms, including the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and the Colorectal-Anal Impact Questionnaire (CRAIQ).

The investigators categorized the women as having posterior prolapse (with a point A posterior value on the POP-Q greater than or equal to –1) with or without anterior prolapse, isolated anterior prolapse (with a point A anterior value greater than or equal to –1), or no prolapse.

It was not possible to study isolated posterior prolapse because only 20 women had posterior prolapse without concomitant anterior prolapse, Dr. Wilbur explained at the meeting, which was jointly sponsored by the American College of Surgeons.

Compared with the no-prolapse group, both the posterior and anterior prolapse groups were more likely to have completed the first stage of labor (85% and 76% vs. 53%) and to have had a vaginal delivery (79% and 70% vs. 40%), she reported.

The two prolapse groups were similar with respect to these and a variety of other obstetric factors, such as having a prolonged second stage of labor, having an infant weighing at least 4,000 g, having an operative delivery, having an episiotomy, and experiencing perineal tears.

But relative to their counterparts with anterior prolapse, women with posterior prolapse were more likely to report a loss of gas from the rectum (odds ratio, 1.79), having to push on the vagina to complete a bowel movement (1.72), having a sensation of bulge (2.58), and having asked a physician for help because of prolapse symptoms (3.24).

Women with anterior prolapse were similar to women with no prolapse on most of these measures. The exception was that women without prolapse were, not surprisingly, less likely to have asked a physician for help (odds ratio, 0.27).

"We are following these women over time. So those 1,497 women came in for the first visit, but as of today we have 3,840 person-visits, and in the final manuscript, we did do generalized estimating equations where we followed those trends over time," Dr. Wilbur commented. "They are actually very similar to the enrollment data."

The study’s main shortcoming is its potential lack of generalizability, she said. "Greater Baltimore Medical Center does deliver women who are mostly white and relatively affluent in comparison to the general American population."

Dr. Wilbur disclosed no relevant conflicts of interest

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