Prevalence and management of pelvic organ prolapse. A retrospective cohort study

doi:10.21203/rs.3.rs-5227800/v1

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Prevalence and management of pelvic organ prolapse. A retrospective cohort study

https://doi.org/10.21203/rs.3.rs-5227800/v1

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Background: Pelvic organ prolapse (POP) is a major public health problem. It corresponds to the descent of female pelvic organs, such as the bladder, uterus or post-hysterectomy vaginal cuff, and the small or large bowel, resulting in protrusion of the vagina, uterus, or both.

The objective of this study was to determine the incidence, socio-demographic profile of patients, the management and outcomes of POP in a maternity hospital with limited resources in Niger.

Methodology: This was an eight-year retrospective cohort study involving the analysis of medical records from patients who underwent management of POP between 1 January 2015 and 31 December 2022 at the Mother and Child Health Centre (MCHC) in Maradi, Niger. The epidemiological data, treatment, and outcomes of POP were collated and subjected to analysis using the statistical software package Epi infos 7.2.5. Comparisons were made using the Chi-squared test. A p-value of less than 0.05 was considered statistically significant.

Results: During the study period, 358 cases of POP were recorded out of a total of 12536 patients treated in the department, representing a frequency of 2.8%. The mean age of the patients was 46.14 years (range: 17–90 years). The patients were identified as married (307 cases, 85.75%), unemployed (353 cases, 98.6%) and not attending school (332 cases, 92.74%). The largest number of cases were observed in large multiparous women (i.e., those with more than five children), representing 60.05% of the total number of cases (215 patients). The average parity among this group was 6.5 children. The vast majority of patients (269 cases, 75.14%) lived in rural areas. The most frequent motif for consultation were the sensation of mass in the vagina (146 acs,40.78%) and vulvar swelling (138 cas, 38.55%). The most frequent genital prolapses type was middle, made of the hysterocele essentially (150 cases, 41,90%). The stage III of genital prolapses was the most frequent in 76.51% (274 cases). All patients underwent surgical treatment (100%), and the vaginal access was most used in 57.55% (206 cases) of cases. Conservative treatment was performed in the majority of patients (197 cases, 55.02%). The most frequent intraoperative complications were the vesical lesions in 0.56% (2 cases) and ureteral and vascular lesion in 0,28% (1 case). The post-therapeutical evolution was marked by the disappearance of genital prolapses in 100% of cases, no cases of recurrence of prolapse have been observed.

Conclusion: Our findings are in close alignment with those previously documented in the literature. POP is a common occurrence in our region. Surgical treatment is the most practiced and hysterectomy by vaginal surgical approach is the most practiced. Treatment by transvaginal polypropylene prostheses is not available in our region.

Pelvic organ prolapse

genital prolapse

pelvic floor dysfunction

maternal health

Niger

Pelvic organ prolapse is downward descent of female pelvic organs, such as the bladder, uterus or post-hysterectomy vaginal cuff, and the small or large bowel, resulting in protrusion of the vagina, uterus, or both [1]. This is an anatomical and clinical entity corresponding to the failure of the support and suspension systems of the female pelvic organs, which protrude through the vulvovaginal orifice [2]. This situation is favoured by obstetrical trauma which leads to direct pelvic floor muscle and connective tissue injury, hence the high frequency in our countries where patients are generally multiparous and deliveries are generally unassisted medicaly [1, 3–6]. Other risk factors reported in the literature include obstetric manoeuvres, foetal macrosomia, menopause, congenital damage to the supporting fascial tissues, and conditions associated with sustained episodes of increased intra-abdominal pressure, such as obesity, chronic cough, constipation, significant or repeated physical effort [1, 4, 6, 7]. POP is a common but benign condition. In fact, around 50% of women develop urogenital prolapse in the course of their lives. However, only 10–20% of them seek treatment, as the majority of patients are asymptomatic [1, 8]. However, women with symptomatic POP suffer from physical and emotional distress which has a great negative impact on women’s social, physical, and psychological wellbeing. Patients generally present with several complaints, such as bladder, bowel, and pelvic symptoms [1, 9]. Diagnosis of POP rest on the clinical and paraclinical exams as perineal ultrasound, cysto-defecography (CDG) and magnetic resonance imaging (MRI) [3, 10]. Treatment depends on the type of POP, the degree of functional discomfort, the patient's age, the desire to become pregnant in the future or to maintain a normal sexual activity. Therapeutic options include surgery and conservative treatments. Although surgical management of POP is currently adopted, non-surgical treatments such as pessaries, pelvic floor muscle training, or both can be useful in symptomatic improvement as well as weight loss in case of obesity [1, 11, 12]. The lack of epidemiological data on pelvic organ prolapse in our region justifies this study, the objective of which is to determine the epidemiological, clinical, and therapeutic profile of pelvic organ prolapse in a secondary health care hospital in Niger.

Study design and setting

This was a retrospective descriptive and analytical study conducted over 8 years from 1 January 2015 to 31 December 2022 at the Mother and Child Health Centre of Maradi (MCHC). The MCHC of Maradi is a secondary healthcare facility that offers medical education, clinical care, and research to a population of over 5 million in habitants of the city of Maradi and its environs. The Obstetrics and Gynaecology department has 8 obstetricians, 45 paramedical staff (comprising of midwives, nurses and assistant nurses), 3 outpatient consultation rooms, 1 delivery room, 4 delivery beds with an annual average of 3300 deliveries.

Study population and sampling

The study involved all patients admitted directly or after transfer to the department and who diagnosis and treated for POP during the period, 2015 to 2022.

Inclusion criteria

The study included all patients diagnosed with genital prolapse and managed in our department during the study period.

Non-inclusion criteria

The study not included patients seen for consultations and/or hospitalised in the department for other reasons. Furthermore, patients who had undergone POP outside the specified study period were non included from the study.

Exclusion criteria

We excluded all unusable records with missing data.

Data collection

Data were collected from gynecologic records and various registers (consultation register, operative reports) using a pre-established survey form.

Variables studied

The variables under investigation encompassed socio-demographic characteristics and a range of clinical, paraclinical, therapeutic and prognostic data pertaining to patients.

Statistical analysis

The data were entered, processed and analysed using the statistical software package Epi infos 7.2.5. The results are presented as mean values and proportions, expressed as percentages. Comparisons were made using the Chi-squared test, continuity correction of Yates and, Fisher test, with a significance level of P = 0.05. Tables and figures were generated using Microsoft Word and Excel 2016.

Out of a total of 12536 patients treated in the gynaecology department, 358 were treated for POP, representing a frequency of 2.8%. The mean age of the patients was 46.14 years (ranging from 17 to 90 years). The age group with the highest representation was that of 50–90 years old, with a total of 160 patients (44.69%). Six patients (1.68%) were under the age of 20. The majority of patients were married (307 cases, 85.75%), unemployed (353 cases, 98.6%) and not schooling (332 cases, 92.74%). The mean parity was 6.5, with a range from 0 to 14 children. The majority of women were large multiparous (i.e., had given birth to more than five children), with 215 patients (60.05%) falling into this category. Conversely, three patients (0.84%) were nuliparous. Of the total number of patients, 6 (1.68%) had a history of POP, 2 (0.56%) had a history of POP during pregnancy. The patients were postmenopausal in 41.34% (148 cases). Only one patient (0.28%) had a history of chronic cough. The vast majority of patients (269 cases, 75.14%) lived in rural areas. Table 1 provides a summary of the socio-demographic characteristics of the patients.

Table 1

Socio-demographic characteristics of patients with POP at Mother and Child Health Centre in Maradi, 2024
Variables Numbers of cases(N = 358) Percentage (%)
Age(year)
< 20	6	1,68
20–29	49	13,69
30–39	74	20,67
40–49	69	19,27
≥ 50	160	44,69
Parity
0	3	0,84
1	0	0
2–3	51	14,25
4–5	89	24,86
≥ 6	215	60,05
Occupation
Unemployed	353	98,6
Shopkeeper	2	0,56
Nurse	2	0,56
Teacher	1	0,28
Marital status
Married	307	85,75
Widowed	48	13,41
Divorced	2	0,56
Single	1	0,28

The most frequent motif for consultation were the sensation of mass in the vagina(146 acs,4078%) and tumefaction of the vulva (138 cases, 38.55%) (Table 2). Five patients (1.4%) had urinary incontinence and two patients (0.56%) had urinary retention. The most frequent genital prolapses type was middle, made of the hysterocele essentially (150 cases, 41.90%). The stage III of genital prolapses was the most frequent in 76.51% (274 cases).

Table 2

Motifs of consultation of patients with POP at Mother and Child Health Centre in Maradi, 2024
Motif of consultation	Numbers(N = 358)	Percentage (%)
Swelling of the vulva	138	38,55
Sensation of a vaginal mass	146	40,78
Perineal heaviness	36	10,06
Stress urinary incontinence	6	1,68
Pelvic pain	19	5,31
Swelling of the vulva and leucorrhoea	1	0,28
Perineal heaviness and swelling of the vulva	2	0,56
Perineal heaviness	1	0,28
Pelvic pain and dyspareunia	1	0,28
Bleeding	6	1,68
Sensation of a vaginal mass and urine retention	1	0,28
Pelvic pain and leucorrhoea	1	0,28

With regard to paraclinical examinations, pelvic ultrasound was performed in 65.36% (234 cases) of patients. Eleven patients (3.07%) had anaemia with a haemoglobin level of less than 11g/dl. Five patients (1.4%) were HIV positive and 5.86% (21 cases) had chronic hepatitis B.

In terms of treatment, all patients underwent surgery. (100%), and the vaginal access was most used in 57.55% (206 cases) of cases, The abdominal surgical access was used in 40.21% of cases (144 cases) and the mixed way (abdominal associated to vaginal access) in 2.24% of cases (8 cases). Conservative treatment was performed in the majority of patients (197 cases, 55.02%). Hysterectomy was performed in 44,98% (161 cases), whereas the most frequent intraoperative complications was the vesical lesions in 0.56% (2 cases), and, ureteral and vascular lesion in 0,28% (1 case). The most post operative complications were urinary retention (6 cases, 1.68%), surgical site infection (3 cases, 0.84%), postoperative haemorrhage (2 cases, 0.56%) and urinary incontinence (1 case, 0.28%). The post-therapeutical evolution was marked by the disappearance of genital prolapses in 100% of cases, no recurrence of prolapse has been observed. The Table 3 provides a summary of the clinical and therapeutical characteristics of POP in the patients.

Table 3

Clinical and therapeutical characteristics of POP in the patients at Mother and Child Health Centre in Maradi, 2024
Variables Number of cases(N = 358) Percentage (%)
Type of genital prolapse
Anterior (cysto-colpocele)	70	19,55
Middle (hysterocele)	150	41,90
Posterior (rectocele)	4	1,12
Association of anterior and middle genital prolapse	96	26,82
Association of anterior and posterior genital prolapse	20	5,59
Association of middle and posterior genital prolapse	5	1,4
Association of 3 genital prolapse type	13	3,63
Stage of genital prolapse
Stage I	0	0,0
Stage II	70	19,55
Stage III	274	76,54
Stage IV	12	3,35
Surgery
Hysterectomy	161	44,98
Hysteropexia	118	32,96
Cystocele cure	65	18,16
Rectocele cure	4	1,12
Association	99	27,65
Intra-operative complication
None	355	99,16
Vesicale lesion	2	0,56
Ureteral and vascular lesion	1	0,28
Post-operative complication
None	346	96,65
Transient urinary retention	6	1,68
Transient urinary incontinence	1	0,28
Haemorrhage	2	0,56
Surgical site infection	3	0,84
Post therapeutical evolution
Recurrence genital of prolapse	0	0
Disapearance of genital prolapse	358	100

By multivariate analysis we found a significant correlation between age and stage of prolapse, with age greater than or equal to 50 years associated with an advanced stage of prolapse (P-value = 0.0005). Multiparity is also an important risk factor for prolapse in our patients, however there is no statistically significant correlation between parity and advanced stage of prolapse (P-value = 0.06).

This study reports the epidemiological, clinical and therapeutic data on 358 cases of genital prolapse collected over a period of 8 years in a secondary maternity unit in Niger. The incidence of POP was 2.8% in this study. According to the literature, the reported prevalence of POP is highly varied according to different studies and is found to be anywhere between 3% and 50% [3–5, 13]. The prevalence observed in our series is similar to that observed by Hamri et al in Morocco with 2.4%[14]. Our frequency is lower than those observed by Coulibaly et al[4] in Mali (9.89%), Seven et al[15] in Turkey (5.6%) and Rodrigues et al[16] in Brazil (7.5%). On the other hand, a lower prevalence was reported by Kishawas et al [17] in Bangladesh (1.1%), Zhu et al [18] in China (1.2%), Tshimbundu Kayembe et al [3] in the DRC (1.2%) and Fanny et al [19] in the Ivory Coast (0.5%). These wide variations of the incidence of POP are due to differences in study design, inclusion criteria, and accompanying indicator symptoms used among studies [13].

In our series, the age group most affected was that comprising women aged 50–90 (44.69%), with an average age of 46.14 years. Similar results have been reported in most studies with a mean age of 44 years in the USA [20] and 50 years in Mali [4]. Adjoussou et al[21] in France [15] found older patients with a mean age of 65.1 years. Advanced age is recognised as a risk factor for POP. This is because, Among women having symptomatic POP, the age distribution increases dramatically. Women between the age of 20–29 account for 6% of the women suffering from POP, while women aged 50–59 years account for 31% with POP and close to 50% of women with POP are aged 80 years or older [13, 22]. With increased longevity and an increase in the demographic of women over 65 years, it is expected that in the near future POP will become a major health concern. Wu et al, have estimated that in the USA in 2050, the prevalence of women suffering from symptomatic POP will increase to 46%, which translates to over 5 million individuals [13, 23].

In our series, the patients were multiparous (60.05%), unemployed (98.6%), not schooling (92.74%), and live in rural areas (75.14%), with a low socio-economic level. All these conditions have been identified as risk factors for POP [1, 13, 24, 25].

In our study, The most frequent complaint at consultation were the sensation of mass in the vagina (40,78%), Our results are comparable to those of Bendimrad H [26] in Morocco in 2017 who reported 78.75% of cases of vaginal mass sensation or externalization of the genitals mass. However, Coulibaly et al in Mali, [4] found 65% of vaginal mass. In the series by Tshimbundu Kayembe et al [3] in the DRC, a combination of gastrointestinal, urinary and genital complaints was found in 97.3% of patients and the preoperative symptomatology was marked by a sensation of pelvic mass associated with polakyria with or without stress urinary incontinence in 30.4%, constipatin in 27%, dysuria in 25%, and anal incontinence in 7.4%.

In our study, the middle pelvic organ prolapse consisting of hysterocele is the most common type of pelvic organ prolapse: isolated in 41,90% of cases, associated with anterior pelvic organ prolapse in 26.82% of cases, with posterior pelvic organ prolapse in 1.4% of cases and two preceding ones in 3.63% of cases. During mass campaign in two hospitals in the city of Kananga in the Democratic Republic of Congo, Tshimbundu et al [5] observed a similar result with 37,3% of isolated hysterocele, and associated with anterior pelvic organ prolapse in 24.60% of cases, with posterior pelvic organ prolapse in 1.50% of cases and two preceding ones in 20.10% of cases. Our results are not consistent with those of Tshimbundu Kayembe et al [3], Blain et al [27], Handa et al, [ 28] and Amblard et al [29].

Our sequence of pelvic organ prolapses types consisting of hysterocele-cystocele-rectocele is different from the majority of African studies which reported sequences consisting of cystocele-hysterocele-rectocele [3, 14, 30] and cystocele-rectocele-hysterocele [27, 28, 29].

By examining the stage of prolapse, we observed that the stage III of genital prolapses was the most frequent in 76.51% of cases. Our results corroborate those of Coulibaly et al [4], Tshimbundu et al [5], of Miaadi et al [32], and Thomin et al [33] who also reported a predominance of stage III with proportions ranging from 56–70%. Handa et al [28] reports that advanced stages (III and IV) of pelvic organ prolapse are associated with a poor prognosis due to their numerous symptoms which prompt patients to consult, whereas stage I is asymptomatic and not requires treatment. This asymptomatic nature explains the absence of stage I prolapse in our series. The predominance of stage III prolapse in our series may be explained by the fact that in our context, patients only consult a specialist when functional discomfort is significant, due to lack of financial resources, ignorance of the disease and taboo surrounding sexuality.

Regarding treatment, surgery was performed in all our patients (100%). Similar practices have been reported by Tshimbundu et al [5] in the DRC, Boulanger et al in France [34] and Coulibaly et al [4] in Mali. Surgery appears to be the treatment of choice in developing regions. Indeed, surgery in the treatment of pelvic organ prolapse is ideal for correcting anatomical lesions without causing new disorders [3, 5, 34, 35].

Pessary treatment was not used in any of our patients. In the literature, pessary treatment is widely used, with a proportion of over 11% in most studies. [34, 35]. Pessaries are frequently used by clinicians with high numbers of clinicians using a pessary as first-line treatment for prolapse [36]. En RDC, Tshimbundu et al [5] also reported that no pessaries were used in their series. There are three reasons for the absence of pessary use in our patients: Firstly, strategy of favoring surgical repair in all healthy patients in our environment, as Boulanger et al, and Tshimbundu et al, reported [5, 34]. Secondly, the increase in the number of externalized pelvic organ prolapses makes their control with pessaries very difficult and the long-term complications caused by the use of pessaries limit their use [5, 37]. Thirdly, the use of pessaries is limited in Niger by their cost and accessibility.

In our study, the vaginal surgical approach was more used in 57.55% of patients. A similar approach was reported by the majority of African and European authors [3, 4, 5, 34].

The vaginal surgical approach has the advantages of reducing the operating time compared to that of abdominal surgery and allowing a more rapid return to activities [5, 34, 38].

Laparoscopic treatment was not used in our series. This therapeutic method is not yet available in our department. Also, laparoscopic surgical approach does not allow the treatment of stress urinary incontinence and vulvar gaping [4, 5].

Hysterectomy associated with cystocele and rectocele treatment is the most common type of treatment performed in our patients. Our results are in line with those of most authors [3, 4, 5, 34, 38].

Our surgical approach can be explained by the predominance of pelvic organ prolapse of the middle type isolated and associated with the anterior and posterior type and by the average age of our patients is 44.14 years with 63.96% of patients aged over 40 years. Also, uterine conservation in POP is only carried out if there are no uterine anomalies discovered in the oncological cervicovaginal smear, systematic endometrial biopsy, and pelvic ultrasound [34]. In our setting, these systematic pre-operative examinations were not carried out, due on the one hand to the absence of histology laboratory, and on the other hand to the low social and economic level of our patients [3–5].

Treatment by transvaginal polypropylene prostheses was not performed in our patients due to the unavailability of these materials in our country. In developed countries, the installation of transvaginal polypropylene prostheses associated with the treatment of pelvic organ prolapse was the most practiced with more than 80% of patients [39]. In our study, intraoperative complication rate was 0,84%. Our rate is lower than that of Tshimbundu et al, with an intraoperative complication rate of 2.00%, [3] and De Tayrac et al, with 5.80% of intraoperative complication rate [40]. Postoperative complications were noted in 3.36% of our patients, mainly transient urine retention, transient urinary incontinence, haemorrhage and surgical site infection. According to the literature, postoperative complications are rare during POP surgery, with a prevalence ranging from 0–20% [3–5, 41]. We recorded a low rate of intraoperative and postoperative complications relative to our sample and our study duration, which may be explained by the improvement in working conditions in the operating room, the mastery of surgical techniques and the quality of postoperative care.

Concerning the post-therapeutical evolution of the POP, no recurrence of the prolapse were observed in our study. Our result is different than those of many authors who reported an reccurence rate from 2% to higher than 30% [3, 40, 42]. This difference could be explained by the monocentric nature of our study and our practitioners' mastery of surgical techniques.

Limitations

This study is the first on POP in our department. In addition to providing the frequency of this pathology in a regional maternity unit in Niger, our study helps to identify the profile of patients at risk. However, the retrospective nature of the study and the failure to evaluate genetic risk factors and not being involved in the occurrence of pelvic organ prolapse and its strength is to be the first to study the epidemiological, clinical, and therapeutic profile of pelvic organ prolapse in our region were the weakness of this study.

The findings of this study indicate that POP is a common practice within our department. The socio-demographic profile is that of an old age, uneducated, unemployed and multiparous woman. The symptomatology usually consists of the vaginal mass associated with urinary troubles. Middle POP stage III is the most common. Surgical treatment is the most practiced and hysterectomy by vaginal surgical approach is the most practiced. Treatment by transvaginal polypropylene prostheses is available in our region.

POP

Pelvic Organe Prolapse

MCHC

Mother and Child Health Centre

-Acknowledgement

Not Applicable

Author contribution

AAI, HSD, ZLS, MAM : concept, design, data collection and analysis, discussion, writing and revision of the manuscript. MO, SOG, JHS,MBA, HN and MN : statistics, results, data analysis, and writing. All authors read and approved the fnal manuscript.

-Funding

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

-Availability of data and materials

The data will be made available by the corresponding author upon reasonable request.

-Ethics approval and consent to participate:

Ethics approval was obtained by the ethics committee of Dan Dicko Dancoulodo University of Maradi. The institutional review board of our Hospital (Mother and child health Centre of Maradi) waived the requirement for written informed consent from the patients because of the retrospective nature of the study. The study was conducted according to the principles of the World Medical Association Declaration of Helsinki. The reporting of the study conforms to the STROBE guidelines.[43]

-Consent for publication

Not applicable

-Competing interests

The authors declare that there is no conflict of interest.

-Author detail

AAI : Medecin Doctor, Obstetric gynaecologist, Department of Obstetrics & Gynecology,Dan Dicko Dankoulodo University of Maradi, Mother and Child Health Centre; Maradi, Niger

HSD : Medecin Doctor, Obstetric gynaecologist, Department of Obstetrics & Gynecology,Abdou Moumouni University in Niamey, Issaka Gazoby Maternity, Niamey, Niger

ZLS : Medecin Doctor, Obstetric gynaecologist, Department of Obstetrics & Gynecology, Andre Salifou University of Zinder, Mother and Child Health Centre; Zinder, Niger

MAM : Medecin Doctor, Obstetric gynaecologist, Department of Obstetrics & Gynecology,Dan Dicko Dankoulodo University of Maradi, Mother and Child Health Centre; Maradi, Niger

MO : Medecin Doctor, Obstetric gynaecologist, Department of Obstetrics & Gynecology, Abdou Moumouni University in Niamey, General Referal Hospital, Niamey, Niger

SOG : Medecin Doctor, Obstetric gynaecologist, Department of Obstetrics & Gynecology, Andre Salifou University of Zinder, Mother and Child Health Centre; Zinder, Niger

JHS : Medecin Doctor, Obstetric gynaecologist, Department of Obstetrics & Gynecology,Dan Dicko Dankoulodo University of Maradi, Mother and Child Health Centre;Maradi, Niger

MBA : Medecin Doctor, General surgeon, Department of Surgery, Referal Hospital in Maradi, Maradi, Niger

HN : Medecin Doctor, Histologist, Department of pathology, Abdou Moumouni University in Niamey, Niamey, Niger

MN : Full Professor of Obstetrics and Gynaecology; Department of Obstetrics & Gynecology,Abdou Moumouni University in Niamey, Issaka Gazoby Maternity, Niamey, Niger

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Prevalence and management of pelvic organ prolapse. A retrospective cohort study

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