incidence of pelvic organ prolapse in - NCBI

INCIDENCE OF PELVIC ORGAN PROLAPSE IN NIGERIAN WOMEN J.E.N. Okonkwo, FACOG, FICS, N.J.A. Obiechina, FWACS, C. N. Obionu, FWACP, FMCPH Nnewi, Nigeria

Objective: To establish the incidence and types of utero-vaginal prolapse. Methods: Retrospective medical records analyses of women who were subjected to reconstructive pelvic surgery for various types of pelvic relaxation at the Nnamdi Azikiwe University Teaching Hospital, Nnewi and the University Of Nigeria Teaching Hospital, Enugu, Nigeria was carried out. The study was conducted from January 1996 to December 1999 during which there were 7515 surgical admissions. The inclusion criteria were those women who complained of feeling a mass in the vagina with demonAstrable descent of the anterior and/or posterior and/or apical vaginal walls and/or perineal descent. Excluded were patients who had other symptoms other than utero-vaginal prolapse and those whose grades and sites of prolapse were not determinable from the clinical or surgical notes. Also excluded were patients with nerve injury or disease, connective tissue disorders and neuromuscular diseases. The subjects were divided into two groups. Group I consisted of 54 women (age < 40 years), and group 11 included 105 women (age . 40 years). The findings between those two groups were compared with reference to sites, types and degree of prolapse. Also, coexistence of pelvic relaxation and underlying medical conditions were evaluated. Results: A total of 159 subjects out of 492 charts studied met the inclusion criteria for the study. In group 1, mean age was 32.839 with a standard deviation (SD) of ± 6.012 years; and in group 11 the mean age was 56.543 with a SD of 8.094. Hypertrophic (elongated) cervix was determined in 15 (6.3%) subjects in group I for an incidence of 1.58% per year, cystocele (vaginal anterior wall descent) was present in 21 (8.9%) women for an incidence of 2.2% per year; rectocele (posterior vaginal wall descent) was identified in 15 (6.3%) women for an incidence of 1.58% per year; vaginal cough prolapse (apical descent) was present 21 (8.9%) women for an incidence of 2.2% per year. Perineal descent was absent in this group. In group 11, there was no hypertrophic cervix; cystocele was present in 39 (16.5%) cases for an incidence of 4.13% per year; rectocele was identified in 27 (11.4%) women, amounting to an incidence of 2.85% per year; vaginal cough prolapse was present in 36 (15.%) women, an incidence of 3.75% per year; perineal descent was present in 63 (25.6%) women, for an incidence of 6.4% per year. Conclusion: (1) The incidence of hypertrophic cervix without any other abnormality amounted to 1.58% per year. This medical entity can present as uterine prolapse and was noted only in group 1. (2) The annual incidence for hospital admission with a diagnosis of uterine prolapse was 2.1%. (3) The incidence of cystocele, and rectocele was not statistically different in the two groups; but the incidence of perineal descent and uterine prolapse were significantly more in group 11 than group 1. (4) The etiology of hypertrophic cervix is not known, but it is of importance especially in the childbearing age when it may be related to prolonged pregnancy, cervical dystocia, etc. (J Natl Med Assoc. 2003;95:132-136.) 2003. From the Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria, and the Department of Community Medicine, University of Nigeria Teaching Hospital, Nnewi, Nigena. Address correspondence to: Dr J.E.N. Okonkwo, P.O. Box 8282, Enugu, Nigeria; direct e-mail to [email protected]; or phone 234-42-550272.

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Key words: prevalence * pelvic organ prolapse * Nigerian women The overall incidence of genital prolapse in the Nigerian population is difficult to ascertain. This is mainly because many women with this problem tend to live with it for as long as they VOL. 95, NO. 2, FEBRUARY 2003

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PELVIC ORGAN PROLAPSE

can tolerate it. This, however, is not peculiar to Nigeria as others have pointed to this attitude in other countries and estimated that approximately 10 to 15% of hysterectomies are performed for genital proplapse. 1-3 In Nnamdi Azikiwe University Teaching Hospital, hysterectomies performed for genital prolapse form 5.3% of our gynecologic surgery.4 In the United States, prolapse has been reported as the most common reason for hysterectomy in women over 50 years of age.5 In Quebec, Canada, one report accounted for 13% of hysterectomies in all age groups.6 Olsen and co-workers7 assessed the age-specific incidence and risk of surgery for prolapse in a large managed care population in Oregon, US, and noted that the incidence increased with advancing age.

pelvic surgery for various types of pelvic relaxation at the Nnamdi Azikiwe University Teaching Hospital, Nnewi, and the University of Nigeria Teaching Hospital, Enugu, was carried out. The study was conducted from January 1996 to December 1999, during which time there were 7515 surgical admissions. The inclusion criteria were those women who complained of feeling a mass in the vagina and with demonstrable descent of the anterior and/or posterior and/or apical vaginal walls and/or perineal descent. Excluded were patients who had other symptoms other than uterovaginal prolapse and those whose grades and sites of prolapse were not determinable from the clinical or surgical records. Also excluded were patients with nerve injury or disease, connective tissue disorders and neuromuscular diseases.

Table 1. GRADES OF PROLAPSE IN THE TWO GROUPS (Percent [%] is of each group) Grades of prolapse Group I (. 40) Group It (> 40) First degree 15 (27.8%) 9 (8.6%) Second degree 33 (31.4%) 27(50%) Third degree 12(22.2%) 63(60%) Total 54(100%) 105(100%) Birth trauma, increased parity, age, and/or postmenopausal states play major roles in the development of genital prolapse,8 but these factors have been determined mainly in the white population and affluent, well-nourished populations in the western world.5 There is paucity of information on this subject about their less-affluent black counterparts. The objective of this study is, therefore, to determine the incidence of prolapse in Nigerian women. It also aims to compare the incidence in the two groups: young women below the age of 40 and older women above 40 with a view to highlighting other factors (other than age) that contribute to vaginal prolapse.

The subjects were divided into two groups. The findings between those two groups were compared with reference to sites, types and degree of prolapse. Also, coexistence of pelvic relaxation and underlying medical conditions were evaluated. The precise grading system of Bump et al.9 was not used because it applies only in a prospective study. Using the introitus as a reference point, a grade was assigned to the defects. First degree equals prolapse present and extended to the introitus; second degree is when the prolapse exceeded the introitus at straining, and third degree is complete prolapse outside the introitus.

RESULTS MATERIAL AND METHODS Analysis of retrospective medical records of women who were subjected to reconstructive 133 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

Over the four-year study period, there were 7514 surgical admissions. A total of 159 subjects out of 492 charts studied met the inclusion criteria VOL. 95, NO. 2, FEBRUARY 2003


for the study. This forms 32.3% of pelvic reconstructive surgery. In group I, the mean age was 32.839 with a standard deviation (SD) of ± 6.012 years; and in group lI the mean age was 56.543 with SD 8.094. Hypertrophic (elongated) cervix was determined in 15 (6.3%) subjects in group I for an incidence of 1.58% per year, cystocele (vaginal anterior wall descent) was present in 21 (8.9%) women for an incidence of 2.2% per year; rectocele (posterior vaginal wall descent) was identified in 15 (6.3%) women for an incidence of 1.58% per year; vaginal cough prolapse (apical descent) was present in 21 (8.9%) women for an incidence of 2.2% per year. Perineal descent was absent in this group. In group II, there was no hypertrophic cervix, cystocele was present in 39 (16.5%) women, for an incidence of 4.13% per year; rectocele was identified in 27 (11.4%) women, having an incidence of 2.85% per year; vaginal cough prolapse was present in 36 (15.%) women, with an incidence of 3.75% per year; perineal descent was present in 63 (25.6%) women, for an incidence of 6.4% per year. These were of higher grades than in group I (Table 1). Group II had a higher mean parity of 4, compared to 2 in group I (Table 2). There were more medical conditions in group II, such as chronic cough, back and waist pain, diabetes and hypertension, and this group also manifested a greater number of urinary disorders like frequency and urgency. Surgery done in group I included anterior and posterior colporrhaphy (10), trachelloraphy (10), vaginal hysterectomy, and posterior repair (4). In group II there was a combination of vaginal hysterectomy, anterior and posterior repair (24), and abdominal hysterectomy (2).

DISCUSSION Genital prolapse was responsible for 32.3% of our reconstructive pelvic surgery in groups I and II. This is much higher than the 19.89% observed by B. Dao et al. in Burkina Faso, Africa.10 In their prospective study of 285 menopausal patients referred to a menopause clinic, E. Versi et al.11 observed anterior wall prolapse in 51%, posterior prolapse in 27%, and apical prolapse in JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

20% of their patients. Comparable figures for our group II women are 16.5%, 11.4% and 15%, respectively. Noted in this group is the existence of perineal descent in 25.6% and higher grades of prolapse (Table 1). Observations by Carey MP and Dwyer PL12 concluding that we could expect to see a dramatic increase in the incidence of genital prolapse in the presence of an aging population is substantiated by our study, as 69.6% of the prolapses occurred in our older population. Olsen et al.7 documented the same observation in their study of a large managed care population. We found an incidence of 1.58% per year of cervical hypertrophy (cervical elongation without any other anatomical defect) in the younger age group. We also recorded a higher incidence of medical conditions in the older group, versus the reverse by Strohbehn et al.1 Damage to the pelvic support system is thought to be the result of a combination of factors, including childbirth, connective tissue disorders, pelvic neuropathies, congenital factors, pelvic surgery, and miscellaneous factors such as obesity, respiratory disorders, occupational and recreational stress and hypoestrogenism. Most recorded cases of prolapse have been secondary to damage to the pelvic organ support,13 or due to the aging processes. Within our two age groups were nulliparous women: four in group I and three in group II. Of the four in group I, all had hypertrophy of the cervix without any other anatomic defect; but the three in group II had only cystoceles. In this nulliparous group, the pathogenesis of pelvic organ prolapse may be different from those occurring after childbirth. The etiology of hypertrophy of the cervix in the younger group is unknown. Answers may be found in the congenital and neuromuscular causes of pelvic organ prolapse. A study is necessary to determine the site of this hypertrophy of the cervix-supravaginal or portio vaginalis. Although vaginal childbirth has a significant effect on the innervations and strength of the pelvic floor muscles, women studied before delivery and nine to 15 months VOL. 95, NO. 2, FEBRUARY 2003

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Table 2. PARITY IN THE GROUPS

Parity 0 1 2 3 4

Group I (. 40) No.

Group 11 (>40) No.

12 6

9 18

5

6 6 6 3

9 12 15 18

6 7 8 Total

9

12

0 6 54

0 0 105

after vaginal childbirth showed no significant decrease in the strength of the pelvic floor muscles. Pescheu et al.14 has shown that any impairment in muscular strength seen immediately postpartum was transient, with recovery occurring within the first postpartum months. We observed, however, that the older group had a higher mean parity of 4 versus 2 in the younger group (Table II). This compares with the study by B. Dao et al.,10 whose patients had a mean age of 38 years and mean parity of 5. The complexity of the prolapse was different in our two groups. The older group had more incidences of multifocal sites of prolapse than did the younger group. Apical and perineal descents were not existent in our younger group. Also, there was no vault prolapse since none in this group had had a hysterectomy. In contrast to this situation is the higher grade of prolapse found in the older group and the occurrence of urinary symptoms prevalent in this group. The presence of the cervix protruding through the introitus without any demonstrable anatomical defect is a new feature we encountered in this study. The other differences may be due to the progression of the prolapse with aging. The presence of some chronic medical conditions in the older group may reflect the pathogenesis of the 135 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

prolapse in this group. A study is required to investigate further the site (vaginal or supravaginal) and etiology of hypertrophic cervix in our population using perhaps the contrast ultrasonographic method of Ostrzenski et al.15

REFERENCES 1. Strohbehn K, Jakary JA, DeLancey JOL. Pelvic organ prolapse in young women. Obstet Gynecol. 1997;90: 33-36. 2. Luoto R, Rutamen EM Kaprio J. Five gynecologic diagnoses associated with hysterectomy-trends in incidence of hospitalization in Finland 171-86. Maturitas. 1994;141:32. 3. Carlson KJ, Nichols DH, Schiff 1: Indications for hysterectomy. N Engl J Med. 1993;328:856-60. 4. Department of Obstetrics & Gynecology Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria. Information handbook presented to the West African College of Surgeons for accreditation of the department, 1988. 5. Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Clin Obstet Gynecol. 1998;25: 723-746. 6. Allard P, Roshette L. The descriptive epidemiology of hysterectomy, province of Quebec, 1981-1988. Ann Epidemiol. 1991;1:541-549. 7. Olsen AL. Smith VJ, Bergstrom JO et al; Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence Obstet Gynecol. 1997; 89:501-506. 8. DeLancey JOL: Anatomy and biomechanics of genital prolapse. Clin Obstet Gynecol. 1993; 36:897-909. 9. Bump RC, Mattiason A, Bok et al. The standardization of terminology of female pelvic floor dysfunction. Am J Obstet Gynecol. 1996; 175:10-17. 10. Dao B, Toure B, Sano D et al. Hysterectomies in tropical

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zones: experience of one African maternal health service; 141 cases in Burkina Faso. Tunis Med. January 2001;79:47-50. 11. Versi E,Harvey MA, Cardoso L et al. Urogenital prolapse and atrophy at menopause: a prevalence study. Int Urolgynecol J Pelvic Floor Dysfunct. 2001 ;12: 107-110. 12. Carey MP, Dwyer PL Genital prolapse: vaginal versus abdominal route of repair. Curr Opin Obstet Gynecol. 2001; 13:499-505. 13. Gill EJ. Hurt WG Pathophysiology of pelvic organ prolapse. Clin Obstet Gynec. 1998;24:757-769. 14. Pascheu UM, Schaes GN, DeLancey JOL et al. Levator anti function before and after childbirth. Br J Obstet Ggyn 1997;104: 1004. 15. Ostrzenski A, Osborne NG, Ostrzenska K. Method for diagnosing paravaginal defects using contrast ultrasonographic technique.

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