|Year : 2022 | Volume
| Issue : 1 | Page : 32-36
Prevalence and risk factors associated with the development of severe pelvic organ prolapse in the University of Maiduguri teaching hospital, Nigeria
Ado Danazumi Geidam1, Danladi Joseph Goje2
1 Department of Obstetrics and Gynaecology, College of Medical Sciences, University of Maiduguri, Maiduguri, Borno, Nigeria
2 Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital Maiduguri, Maiduguri, Borno, Nigeria
|Date of Submission||01-Sep-2021|
|Date of Decision||19-Nov-2021|
|Date of Acceptance||20-Nov-2021|
|Date of Web Publication||23-Jun-2022|
Prof. Ado Danazumi Geidam
Department of Obstetrics and Gynaecology, College of Medical Sciences, University of Maiduguri, PMB 1069, Maiduguri, Borno
Source of Support: None, Conflict of Interest: None
Background and Aim: Pelvic organ prolapse (POP) is a common gynecological disorder that negatively affects women's quality of life, especially if it is severe. Its burden has increased because of increased in life expectancy. The aim of this study is to determine the prevalence, risk factors, and the factors associated with the development of severe POP in our environment. Materials and Methods: A retrospective review of cases of POP managed at the University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria, over 10 years (January 2010–December 2019). Information including sociodemographic and risk factors were obtained from the gynecological ward register, case files, and theater records using a pro forma designed for the study. Data analysis was done using the Statistical Package for the Social Sciences. Multinomial regression analysis was used to determine factors that are independently associated with severe POP. Results: The prevalence of POP is 1.8%. The majority of the patients, 73% (54/74) were grand multipara and 64.9% (48/74) were postmenopausal. Home delivery 83.8% (62/74) and difficult labor 73.0% (54/74) were found to be the common risk factors. In 41.9% (31/74) of the cases, the POP was severe. Multivariate analysis showed postmenopausal status OR 10.7 (95% CI 1.39–82.56, P = 0.023), heavy lifting OR 13.7 (95% CI 1.73–108.75, P = 0.013), age ≥50 years OR 22.4 (95% CI 1.26–397.08, P = 0.034), and being unmarried OR 16.2 (95% CI 2.22–118.64, P = 0.006) to be independently associated with severe POP. Conclusion: POP is not uncommon in our environment with about half of the patients having severe disease. Postmenopausal status, heavy lifting, age ≥50 years, and being unmarried were independently associated with severe POP.
Keywords: Pelvic organ prolapse, risk factors, severe pelvic organ prolapse, UMTH
|How to cite this article:|
Geidam AD, Goje DJ. Prevalence and risk factors associated with the development of severe pelvic organ prolapse in the University of Maiduguri teaching hospital, Nigeria. Arch Med Health Sci 2022;10:32-6
|How to cite this URL:|
Geidam AD, Goje DJ. Prevalence and risk factors associated with the development of severe pelvic organ prolapse in the University of Maiduguri teaching hospital, Nigeria. Arch Med Health Sci [serial online] 2022 [cited 2023 Feb 9];10:32-6. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/32/347954
| Introduction|| |
Pelvic organ prolapses (POPs) defined as the descent of a pelvic organ into or outside the vaginal canal, is a common gynecological condition that causes significant morbidity among women. This is because it can result in bothersome symptoms that affect the woman's quality of life. The burden of POP is even more with the current increasing life expectancy. The recent global prevalence of POP is reported to be around 9% and in sub-Saharan Africa, studies from Ghana, Gambia, and Ethiopia report prevalence rates that vary from 12% to 55%.,,
In Nigeria, the reported prevalence ranges from 7.55 to 39.1 per 1000 gynecological patients.,
The risk factors for POP include high parity, increasing age, difficult labor, lifting of heavy objects, postmenopausal status, and obesity.,
Treatment modalities for POP include conservative measures such as the use of pelvic exercise and pessaries, especially in mild cases, but severe POP usually requires surgical treatment.
The lifetime risk of surgery for POP in the general female population is 11.1%, and the surgery for POP is known to have a high reoperation rate because of reoccurrence of the prolapse after the surgery, especially if the POP is severe. Furthermore, surgery for severe POP represents a major challenge and is not without complication as it requires a lot of reconstruction of the multicompartmental defects that lead to the development of the severe POP., Knowledge of the risk factors for the development of severe POP will be important in the overall management of this gynecological condition as it can help in the formulation of strategies that can help to reduce the occurrence of severe POP and therefore the need for its surgical treatment. For example, those identified as at-risk can be educated on preventive strategies. They can also be closely followed up to enhance detection of early disease and institute appropriate conservative management which is known to reduce the risk of the development of severe POP.
Therefore, this study aims to determine the prevalence, risk factors, and factors associated with the development of severe POP in our environment.
| Materials and Methods|| |
This was a review of the cases of POP managed at the University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria, over 10 years (January 2010 to December 2019).
Information was retrieved from the gynecological ward admission and discharge register, case files, and theater records using a pro forma designed for the study.
The data obtained included sociodemographic characteristics (age, parity, occupation, and marital status), presenting symptoms, and risk factors. Other information obtained was the type of POP, grading of the POP which was done on vaginal examination using the POP quantification system (by ICS-1996).
Data analysis was done using the statistical package for the social sciences (SPSS) IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA), and the results were expressed as simple percentages in a frequency table. Multinomial regression analysis was used to determine factors that are independently associated with severe POP after controlling for possible confounders. Factors included in the regression model were those found to have a statistically significant association with severe POP in the bivariate analysis conducted. A P < 0.05 was considered statistically significant.
Ethical clearance was obtained from the ethical committee of the University of Maiduguri Teaching Hospital, Maiduguri.
Severe POP is considered POP stage 3 and above, while employment is defined as being engaged in an income-generating venture. Difficult labor is having had prolonged labor and/or prolonged second stage and/or instrumental vaginal delivery.
| Results|| |
During the study, there were 86 cases of POP of 4678 gynecological consultations for a prevalence of 1.8%. Of the 86 cases of the POP, only 79 case folders were retrieved; of which 74 have complete data giving a retrieval rate of 86%.
[Table 1] shows the sociodemographic characteristics of the study population. The majority of the patients, 73% (54/74) were grand multipara, 83.8% (62/74) were unemployed, and 64.9% (48/74) were postmenopausal.
Postmenopausal status 64.9% (48/74), home delivery 83.8% (62/74), and difficult labor 73.0% (54/74) were the common risk factors of POP in the study population as shown in [Table 2].
|Table 2: Identified risk factors of pelvic organ prolapse in the study population|
Click here to view
In this study, the most common type of POP was uterovaginal prolapse representing 67.6% (50/74) of the cases and 41.9% (31/74) of the patients had severe POP [Table 3].
There was a statistically significant association between severe POP and home delivery (P = 0.05), postmenopausal status (P < 0.001), heavy lifting (P = 0.03), 50 years (P < 0.001), unemployment (P = 0.01), grandmultiparity (P = 0.001), and unmarried status (<0.001). After multivariate analysis to control for confounders postmenopausal status odds ratio (OR) 10.7 (95% confidence interval [CI] 1.39–82.56, P = 0.023), heavy lifting OR 13.7 (95% CI 1.73–108.75, P = 0.013), age ≥50 years OR 22.4 (95% CI 1.26–397.08, P = 0.034), and being unmarried OR 16.2 (95% CI 2.22–118.64, P = 0.006) were found to be independently associated with severe POP [Table 4] and [Table 5].
|Table 4: Univariate analysis showing factors associated with severe pelvic organ prolapse in the study population|
Click here to view
|Table 5: Multinomial logistic regression analysis showing factors associated with severe pelvic organ prolapse in the study population|
Click here to view
| Discussion|| |
Our study showed that POP is not uncommon in our environment with about half of the patients having severe disease. Furthermore, postmenopausal status, heavy lifting, age ≥50 years, and being unmarried were found to be independently associated with severe POP.
Although the prevalence of POP of 1.8% in this study was below the reported global ranges of 3%–68%, it is similar to the prevalence reported by Obinna et al., in Umuahia, Southeastern Nigeria. This low prevalence maybe because our women hardly complain of genital symptoms to their doctors because of cultural values, and we seldom screen women for POP during a typical gynecological evaluation.
About half of our patients had severe POP. This was higher than the report of Pang H et al. but similar to the report of Masenga et al. This high prevalence of severe prolapse might not be unrelated to the majority of our patients (73%) being grand multipara as increasing parity was found to be associated with the severity of POP.
Although POP is not life-threatening, it significantly affects women's quality of life more, especially if it is severe as women with severe POP (stages III and above) usually experience burdensome symptoms. The treatment of severe POP significantly improves woman's quality of life and social well-being. However, the treatment is normally a challenging surgical procedure that is not without complications including a reoccurrence of prolapse and reoperation.,,, Therefore, the prevention of the development of severe POP will be of enormous benefit to the quality of life in women, especially with increasing life expectancy as the occurrence of severe POP was especially pronounced among women aged 55 years and above. Knowing the risk factors associated with the development of severe POP is therefore very important as it can allow the formulation of strategies that can help to reduce the occurrence of severe POP and therefore the need for its surgical treatment. In this study, the age of 50 years or above was found to be independently associated with severe POP. This is similar to the finding of Tegerstedt et al. This association of severe POP with the age of 50 years and above might be a representation of the menopausal status of the patients as 64.7% were postmenopausal and postmenopausal status was found to be independently associated with severe POP. During menopause, the lack of estrogen causes atrophy of the genital tract musculature and reduces the strength of the connective tissue supporting it leading to the development of POP.
Traditional weight lifting put excessive strain on the pelvic floor, which can cause or aggravate an existing POP. In this study, severe POP was independently associated with carrying heavyweight. This was similar to the findings of other studies, although the findings of Lori Forner et al. is not in agreement with this.
The positive association of severe POP with sexual dysfunction found in this study is more likely an effect rather than a cause. POP is usually associated with restrictive sexual activity and sexual dysfunction including loss of libido, infrequent orgasm, and dyspareunia. This is a result of a perceived loss of attractiveness and fear of incontinence. Similar to our finding, Ellerkmann RM also found that increasing severity of POP is associated with symptoms related to sexual dysfunction, although Fatton B et al. reported that the effect of POP on sexual function does not correlate with its anatomical stage.
The relevance of this study is the fact that the factors found to be associated with severe POP can be used to identify those at-risk women who have early-stage disease and commence them on conservative treatments even if asymptomatic as this was found to prevent aggravation of the condition thereby reducing the need for surgery. Moreover, although POP surgery is associated with improved quality of life, it represents a major challenge, especially with severe disease. It is also associated with complications including reoperation.,
| Conclusion|| |
POP is not uncommon in our environment with about half of the patients having severe disease. Postmenopausal status, heavy lifting, age ≥50 years, and being unmarried were found to be independently associated with severe POP.
The possible limitations of this study are the small sample size and it being retrospective and therefore prone to misclassification bias. Furthermore, only patients seeking care for pelvic floor problems were included in the study, which is not necessarily representative of the whole population of women with POP. However, the use of multivariate analysis to tease out factors that are independently associated with severe POP and the proportion of patients with severe is a strength as previous studies have reported less number of patients with severe disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gunasekera P, Sazaki J, Walker G. Pelvic organ prolapse: Don't forget developing countries. Lancet 2007;369:1789-90.
Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al.
Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: A systematic analysis for the global burden of disease study 2010. Lancet 2012;380:2163-96.
Scherf C, Morison L, Fiander A, Ekpo G, Walraven G. Epidemiology of pelvic organ prolapse in rural Gambia, West Africa. BJOG 2002;109:431-6.
Wusu-Ansah OK, Opare-Addo HS. Pelvic organ prolapse in rural Ghana. Int J Gynaecol Obstet 2008;103:121-4.
Megabiaw B, Adefris M, Rortveit G, Degu G, Muleta M, Blystad A, et al.
Pelvic floor disorders among women in Dabat district, northwest Ethiopia: A pilot study. Int Urogynecol J 2013;24:1135-43.
Ojiyi EC, Dike EI, Anolue FC, Nzewuihe AC, Ejikem CC. Uterovaginal prolapse at a university teaching hospital in South-Eastern Nigeria. Orient J Med 2013;25:107-12.
Balogun OR. Genital prolapse in Ilorin – A seven-year review. Niger J Med 1997;6:77-82.
Akmel M, Segni H. Pelvic organ prolapse in Jimma university specialized hospital, southwest Ethiopia. Ethiop J Health Sci 2012;22:85-92.
Masenga GG, Shayo BC, Rasch V. Prevalence and risk factors for pelvic organ prolapse in Kilimanjaro, Tanzania: A population based study in Tanzanian rural community. PLoS One 2018;13:e0195910.
Sujindra E, Himabindu N, Sabita P, Bupathy A. Determinants and treatment modalities of uterovaginal prolapse: A retrospective study. Indian J Health Sci 2015;8:36-40.
Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501-6.
Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: A systematic review. Int Urogynecol J 2015;26:1559-73.
Delancey JO, Kane Low L, Miller JM, Patel DA, Tumbarello JA. Graphic integration of causal factors of pelvic floor disorders: An integrated life span model. Am J Obstet Gynecol 2008;199:5.e1-5.
Oraekwe OI, Udensi MA, Nwachukwu KC, Okali UK. Genital prolapse: A 5-year review at federal medical centre Umuahia, Southeastern Nigeria. Niger Med J 2016;57:286-9.
] [Full text]
Pang H, Zhang L, Han S, Li Z, Gong J, Liu Q, et al.
A nationwide population-based survey on the prevalence and risk factors of symptomatic pelvic organ prolapse in adult women in China – A pelvic organ prolapse quantification system-based study. BJOG 2021;128:1313-23.
Doshani A, Teo RE, Mayne CJ, Tincello DG. Uterine prolapse. BMJ 2007;335:819-23.
Digesu GA, Chaliha C, Salvatore S, Hutchings A, Khullar V. The relationship of vaginal prolapse severity to symptoms and quality of life. BJOG 2005;112:971-6.
Nygaard I, Bradley C, Brandt D; Women's Health Initiative. Pelvic organ prolapse in older women: Prevalence and risk factors. Obstet Gynecol 2004;104:489-97.
Tegerstedt G, Maehle-Schmidt M, Nyrén O, Hammarström M. Prevalence of symptomatic pelvic organ prolapse in a Swedish population. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:497-503.
Forner L, Beckman EM, Smith M. Symptoms of pelvic organ prolapse in women who lift heavy weights for exercise: A cross-sectional survey. Int Urogynecol J 2020;31:1551-8. [doi: 10.1007/s00192-019-04163-w].
Fatton B, de Tayrac R, Letouzey V, Huberlant S. Pelvic organ prolapse and sexual function. Nat Rev Urol 2020;17:373-90.
Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA, Leffler K, Bent AE. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001;185:1332-7.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]