Pelvic organ prolapse in nulliparae.

BACKGROUND: Pregnancy and childbirth are thought to be the strongest environmental risk factors for pelvic organ prolapse, but prolapse does occur in nulliparae. AIM: To characterise prolapse in vaginal nulliparae. MATERIAL AND METHODS: This was a retrospective study using archived clinical and imaging data of 368 vaginally nulliparous women seen between 2006 and 2017 at two tertiary urogynaecological centres. Patients underwent a standardised interview, clinical examination and 3D/4D translabial ultrasound. Volume datasets were analysed by the second author, blinded against all clinical data, using post-processing software on a personal computer. Significant prolapse was defined as Pelvic Organ Prolapse Quantification system stage ≥2 for the anterior and posterior compartment, and stage ≥1 for the central compartment. On imaging, significant prolapse was defined as previously described. RESULTS: Of 4297 women seen during the inclusion period, 409 were vaginally nulliparous, for whom 368 volume data sets could be retrieved. Mean age was 50 years (17-89) and mean body mass index 29 (16-64). Eighty-one (22%) presented with prolapse symptoms. On clinical examination, 106 women (29%) had significant prolapse, mostly of the posterior compartment (n = 70, 19%). On imaging 64 women showed evidence of significant prolapse (17%), again mostly posterior (n = 47, 13%). Rectovaginal septal defects were even more common in 69 (19%). On multivariate analysis we found no differences between true nulliparae (n = 184) and women delivered exclusively by caesarean section (n = 184). CONCLUSIONS: Prolapse occurs in vaginal nulliparae, but it has distinct characteristics. Rectocele predominates, while cystocele and uterine prolapse are uncommon. Pregnancy and caesarean delivery seem to have little effect.

Prevalence of Maternal Birth Trauma in Nepali Women.

OBJECTIVES: Pelvic organ prolapse is very common among women in Nepal, especially uterine prolapse. This would suggest a high rate of levator trauma, which is a strong predictor of such prolapse in the Western world. Hence, we decided to study the prevalence of maternal birth trauma in Nepali women. METHODS: In November 2016, we offered an interview, clinical examination, and 4-dimensional translabial sonography to women attending a gynecology clinic. Of 129 women seen, 5 were excluded due to previous pelvic surgery. Translabial sonography volume data sets were obtained and analyzed by tomographic imaging for levator ani and anal sphincter trauma at a later date, blinded against all clinical data. RESULTS: Mean age was 39 (21-74) years, median vaginal parity was 2 (0-9), mean age at first delivery 21 (14-40). Seventeen (14%) had not given birth vaginally; of these, 14 (11%) delivered by cesarean only, and 3 (2%) were nulliparous. Tomographic assessment for levator avulsion and anal sphincter trauma was possible in 124 women and performed as previously described. We found 2 (2%) unilateral avulsions and significant external anal sphincter defects in another 2 women. CONCLUSIONS: Levator and anal sphincter trauma are significantly less prevalent in Nepali women in comparison to Western populations. This is intriguing, especially in view of the high prevalence of prolapse in Nepali women.

Functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic.

INTRODUCTION AND HYPOTHESIS: Limited existing evidence suggests that there is a high prevalence of female pelvic organ prolapse (POP) amongst Nepali women. However, to date, no comprehensive assessment of pelvic floor functional anatomy has been undertaken in this population. Our study aimed to determine functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic. METHODS: One hundred and twenty-nine consecutive women attending the clinic were offered an interview, clinical examination [International Continence Society Pelvic Organ Prolapse Quantification system (ICS/POP-Q)] and 4D translabial ultrasound (TLUS). Most presented with general gynaecological complaints. Five were excluded due to previous pelvic surgery, leaving 124. RESULTS: A POP-Q exam was possible in 123 women, of whom 29 (24%) were diagnosed with a significant cystocele, 50 (41%) significant uterine prolapse and seven (6%) significant posterior compartment prolapse. Evaluation of 4D TLUS data sets was possible in 120 women, of whom 25 (21%) had a significant cystocele, 45 (38%) significant uterine prolapse and ten (8%) significant descent of the rectal ampulla. In 13 cases, there was a rectocele with a mean depth of 14 (10-28) mm. Of 114 women in whom uterine position could be determined, 68 (60%) had a retroverted uterus associated with significant uterine prolapse (P 0.038). CONCLUSIONS: POP is common in Nepali women attending a general gynaecology clinic, with a high prevalence of uterine prolapse (40%). Uterine retroversion was seen in 60% and was associated with uterine prolapse. Patterns of POP in Nepal seem to be different from patterns observed in Western populations.

Digitation to Void: What Is the Significance of This Symptom?

OBJECTIVE: Digitation to void is defined as the need to apply manual pressure on the perineum or the vagina to assist with voiding. It has been associated with prolapse; however, there is little objective data concerning this symptom. Our aim was to determine the correlation between digitation to void, symptoms and signs of pelvic organ prolapse (POP), and urodynamic data. METHODS: This was a retrospective study that included a total of 1174 patients seen at a tertiary urogynecological unit. A standardized history was obtained from all patients followed by multichannel urodynamic testing, Pelvic Organ Prolapse Quantification scoring and 3-D/4-D translabial ultrasound. Stored 4-D translabial ultrasound volumes were obtained and analyzed at a later date. RESULTS: Digitation to void was present in 7% (n = 83) of our population. It is associated with primary symptoms of POP (odds ratio [OR], 25.75; confidence interval [CI], 8.08-82.05), clinically significant POP (OR, 5.62; CI, 2.25-14.02), and POP on ultrasound (OR, 5.39; CI, 2.67-10.88). Cystocele presented the strongest association, clinically (OR, 3.45; CI, 1.98-6.03) and on ultrasound (OR, 4.04; CI, 2.46-6.64). Digitation to void was also associated with symptoms of voiding dysfunction (OR, 6.38 [3.83-10.64]) and slower maximum urine flow rate centile (18.4 vs 24.9, P = 0.017). CONCLUSIONS: Digitation to void is strongly associated with primary symptoms of prolapse and of voiding dysfunction, clinically significant POP, and pelvic organ descent on ultrasound. It is also associated with objective voiding dysfunction. The strongest associations were found with cystocele, both clinically and on imaging.