Paper 33: Vaginal Descensus and Pelvic Floor Symptoms in Older Women

Abstract

OBJECTIVE: To better understand the clinical significance of early pelvic organ prolapse, we studied the association between vaginal descensus and pelvic floor symptoms in older community-dwelling women not seeking care for pelvic floor disorders. METHODS: This cross-sectional study included women with an intact uterus enrolled at 1 site of the WHI Hormone Therapy clinical trial. Subjects underwent a Pelvic Organ Prolapse Quantification (POP-Q) exam and completed a questionnaire of 30 bladder, bowel and prolapse symptom items, modified from the Pelvic Floor Distress Inventory (PFDI). Symptoms were grouped and simple additive scores were calculated (presence of symptom = 1, absence = 0). We tested associations between individual symptoms, as well as symptom group scores and anterior, posterior, apical and maximal vaginal descensus (measured in centimeters in relation to the hymen) and also compared rates of symptoms and symptom group scores using a dichotomous definition of prolapse (defined as the most distal POP-Q point at or beyond the hymen). Statistical tests included Chi-square or Fisher exact, Cochrane-Armitage test for trend and Wilcoxon rank sum. RESULTS: Two hundred seventy women were enrolled with mean age 68 years (range 57–84). On exam, 96% had POP-Q stages I or II. Of bladder symptoms, only certain obstructive symptoms (difficulty emptying, incomplete emptying, weak stream, intermittent stream, pushing on abdomen to urinate and changing positions to urinate) were associated with increasing descensus in at least 1 vaginal compartment (P<0.05 for all); all 3 vaginal compartments were associated with obstructive symptoms. Obstructive urinary symptom group scores increased as anterior, posterior and maximal vaginal descensus increased (P<0.05 for all). Weak stream and position change to urinate were more common in women with prolapse at or beyond the hymen (both P=0.01), but the majority of women reporting these symptoms did not have prolapse using this definition. Bowel symptoms were not associated with increasing descensus of any vaginal compartment. “See or feel a bulge,” endorsed by 11 women (4%), was associated with descensus in all compartments (P<0.05) and was also strongly associated with the dichotomous definition of prolapse (P<0.0001). This symptom alone was highly specific (100%), but not sensitive (16%) for the presence of prolapse at or beyond the hymen. The obstructive urinary and prolapse group symptom scores were not associated with prolapse by this definition. CONCLUSION: “Milder” support defects in older women are associated with obstructive urinary symptoms and the symptom of seeing or feeling a bulge, but in general, these symptoms are not helpful in discriminating between women with and without prolapse. For the most part, symptoms and symptom group scores were not helpful in identifying a cut-point in vaginal descensus that might indicate normal or abnormal support in these women with largely POP-Q Stage I and II prolapse.