The urinary and fecal incontinence and utero-vaginal prolapse (UFIUVP) study was a population based investigation of the prevalence of sub-types of pelvic floor disorders in women, their risk factors and impact on women’s quality of life to assess the burden of these diseases in a rural population in Pakistan. The aim was to assess the prevalence of the different disorders in a rigorous manner, including pelvic organ prolapse symptoms reported by women with signs confirmed by clinical examination, as reported in this paper.
The detailed study design, subjects, sample size, settings, data collection and other methods are described elsewhere12–13. Briefly, all women aged 15 and above in the study areas were eligible and a structured questionnaire was administered by trained Lady Health Workers (LHWs) through face to face home based interviews. Getting consent from the study participant was paramount and it was obtained from the subject, or from her parent or guardian of any participants under the age of 18 years. Demographic, socio-economic and the obstetric characteristic details were also recorded. An appointment for a clinical examination was offered for symptomatic women.
The entry question to assess POP was; ‘do you experience a feeling of bulging or protrusion coming down from or in the vaginal area?’ (Yes/No). To enhance the understanding of the first question and likelihood of reporting, a second question was asked; ‘do you experience bulging or protrusion or something you can see in the vaginal area?’ (Yes/No). If the response to either question was positive the woman was asked for further information to assess the stage of bulging or protrusion (comes and goes back at strain; partially out but need to push it up back into vagina; or completely hanging out from the vagina), the duration of symptoms and when they first occurred? The women were asked “how much does bulging or protrusion bother you” to rate the impact of symptoms on their overall quality of life in general (not at all, slightly, moderately or greatly) (answer one only); and then they were asked “how much does bulging or protrusion interfere with your everyday life to rate the impact on specific aspects of their everyday: hygiene, home life, work life and social life (not at all, slightly, moderately or greatly) (answer one only). Finally, they were asked if they had ever consulted a doctor because of their symptoms (Yes/No).
A urogynaecologist, expert in pelvic floor disorders and part of the study team then reviewed all the questionnaires and from the responses, women were categorized as having POP (any of the symptoms of interest) or not. The women whose answers indicated the presence of POP symptoms were invited to attend the local health facilities to have a gynecological examination conducted by qualified local female gynecologists, expert and experienced in clinical practice to verify and assign the diagnosis. These gynecologists were provided training on how to examine and assess POP with Baden-Walker system of classification as they were not familiar with POP-Q staging system. The gynecologist took a standardized obstetric and gynecological history followed by clinical examination of the pelvic region and abdomen. A speculum and bimanual examination were performed with the patient in the left lateral position to assess the vaginal walls and cervix asking the patient to perform maximum straining or coughing. The Baden-walker classification system was used to grade POP considering posterior urethral descent, lowest part and other sites as: Grade 0 indicated normal position for each respective site, Grade I indicated descent halfway to hymen, Grade II indicated descent to the hymen, Grade III indicated descent half way past the hymen and Grade IV indicated maximum possible descent for each site. Women with POP were offered referral for clinical management.
Statistical analysis was conducted using SPSS software version 19.0 (IBM corporation Armonk, NY, USA). The prevalence estimates were calculated by considering those women in the numerator with POP verified by clinical examination as a proportion of all women interviewed. Summary statistics were calculated using frequencies, percentages for categorical variables like grades of POP and means, medians, standard deviations and ranges for continuous variables such as age. The chi-square test was used to evaluate relationship between the various categorical variables and continuous variables using the Student’s t-test for the presence or absence of POP. The socio-demographic variables were then entered into logistic regression model to see statistical significance at p<0.05. Odds ratios, p values and 95% confidence intervals were calculated for the relationships between the variables and the presence or absence of prolapse. No exposure was treated as main exposure for the POP (outcome) in this cross-sectional study so, we did not have any confounder and as well as any plausible interaction for the study.
Ethical approval was granted by the Ethical Review Committee of Aga Khan University, Karachi, Pakistan, (vide no. 741-CHS/ERC–07, dated 27 June 2007).