Objective
The purpose of this study was to evaluate the association of metabolic syndrome (MS) with female pelvic floor dysfunction in middle-aged to older Korean women.
Study Design
A prospective cross-sectional study was performed that included a total of 984 Korean women (≥40 years old) who visited a comprehensive medical screening clinic. Pelvic floor dysfunction was assessed by the Pelvic Floor Distress Inventory-20 (PFDI-20); higher scores indicated a greater symptom burden.
Results
The adjusted mean score on the PFDI-20, and especially the Urinary Distress Inventory-6 subscale, was significantly higher in subjects with MS than those without MS. Furthermore, the PFDI-20 and all 3 subscales were significantly increased in correlation with the number of MS components that were present ( P < .05). In the multivariable analysis, MS was associated significantly with PFDI-20 ( P = .002) and the 3 subscores ( P < .05).
Conclusion
MS was significantly associated with the pelvic floor dysfunction among middle- to old-aged Korean women. Physicians should pay more attention to the pelvic floor symptoms for the patients with MS.
Pelvic floor disorders are prevalent among middle-aged to older women. In the United States, almost 24% of women report at least 1 pelvic floor disorder. Pelvic floor disorders are becoming a major health problem because their prevalence is rising as the relative proportion of elderly women increases, and pelvic floor disorders can significantly compromise quality of life for affected women.
Metabolic syndrome (MS) represents a constellation of cardiovascular risk factors that including central obesity, hyperglycemia, dyslipidemia, and hypertension ; the prevalence of MS increases sharply after middle age and occurs in up to 23.4% of women in the Unites States.
Recently, the association between vascular risk factors and pelvic floor dysfunctions has been suggested by some investigators. One group of investigators reported that lower urinary tract symptoms (LUTS) were more frequent in women with vascular risk factors (such as diabetes mellitus, hypertension, hyperlipidemia, and nicotine use). Other groups have suggested that women with type 2 diabetes mellitus or impaired fasting glucose levels had more symptoms of urinary incontinence that may be a result of microvascular damages to the pelvic floor. Furthermore, women with obesity and diabetes mellitus were significantly more likely to have pelvic floor disorders (such as stress urinary incontinence, overactive bladder, and anal incontinence). However, data from an investigation of the association between MS and pelvic floor dysfunction in women are still scant.
Therefore, we prospectively collected data from middle-aged to older women, who are a group that is highly susceptible to MS, to evaluate the association between MS and pelvic floor dysfunction.
Materials and Methods
Study population
We performed a prospective cross-sectional study of Korean women who visited a comprehensive medical screening clinic between May 2009 and January 2010. The screening clinic was located in an urban area, and all subjects had visited the clinic independently for routine health examinations. Women were eligible for inclusion if they were ≥40 years old. Participants were excluded if they had a history of malignancy or other severe psychologic or physical disorders that were not amenable to the study. We also excluded women who had received current or recent (≤1 year previously) hormone replacement treatment to avoid influence by the effects of hormone therapy on lipid profiles.
The protocol for the present study was approved by the local institutional review board (H0901-023-268), and all study participants signed declarations of informed consent.
Health investigation
Each participant gave a comprehensive medical history and underwent anthropometric measurements, laboratory testing, and questionnaire administration. Before any history data were obtained, subjects completed a questionnaire regarding their medical history, history of medical or surgical diseases, smoking habits (current, former, or never), and alcohol consumption (current, former, or never). Patient education level was assessed by the highest level of schooling that they had completed; financial status was measured by an individual’s household income. Postmenopausal status was defined as the cessation of menses for at least 1 year.
Each subject’s height and weight was measured to the nearest 0.1 cm or 0.1 kg, with the subject wearing a light robe and no shoes. Waist circumference was measured from the narrowest point between the lower border of the rib cage and the iliac crest. Blood pressure was measured in a sitting position at least twice after a 10-minute period of relaxation.
Blood samples were obtained in the morning after a 12-hour fast. From blood samples, we quantified levels of glucose, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDL-C), and total cholesterol.
MS
MS was defined according to the guidelines set forth by several organizations: the Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; the National Heart, Lung, and Blood Institute; the American Heart Association; the World Heart Federation; the International Atherosclerosis Society; and the International Association for the Study of Obesity. The presence of any 3 of the following 5 risk factors were sufficient for a diagnosis of MS: (1) elevated waist circumference ≥80 cm for Asian women ; (2) elevated triglycerides (≥150 mg/dL) or drug treatment for elevated triglycerides; (3) reduced high-density lipoprotein cholesterol (<50 mg/dL) or drug treatment for reduced high-density lipoprotein cholesterol; (4) elevated blood pressure (systolic ≥130 mm Hg and/or diastolic ≥85 mm Hg) or antihypertensive drug treatment in a patient with a history of hypertension; and (5) elevated fasting glucose level (≥100 mg/dL) or drug treatment for elevated glucose level. Furthermore, we arbitrarily defined as high-risk any individuals who had 1 or 2 components of MS for the preventive purpose. Therefore, 3 groups (normal vs high-risk vs MS) were included in the analyses according to the number of MS components.
Pelvic floor dysfunction
Pelvic floor dysfunction was measured by the Pelvic Floor Distress Inventory–20 (PFDI-20). The PFDI-20 is a valid and reliable condition-specific questionnaire that serves as both a symptom inventory and a measure of the degree of symptoms and distress that are caused by pelvic floor disorders. The PFDI consists of 20 questions that are separated into 3 subscales: the Pelvic Organ Prolapse Distress Inventory–6 (POPDI-6), the Colorectal-Anal Distress Inventory–8 (CRADI-8), and the Urinary Distress Inventory–6 (UDI-6). With these inventories, the respondents are asked whether they experience specific symptoms and, if so, the degree to which the symptom bothers them on a 4-point scale from “Not at all” to “Quite a bit.” Each subscale is scored from 0-100; higher scores indicate greater symptom burden. The PFDI-20 total score is the sum of these 3 subscale scores (0-300).
We compared PFDI-20 scores between women with and without MS. In addition, we specifically focused on 5 condition-specific questions that include PFDI-3, -9, -10, -16, and -17 for the major 3 pelvic floor disorders. That is, PFDI-3 (“Usually have a bulge or something falling out that you can see or feel in your vaginal area?”) was used to diagnose pelvic organ prolapse, because a positive response correlates with the presence of vaginal bulge on physical examination with high specificity. We also used PFDI-9 (“Usually lose stool beyond your control if your stool is well formed?”) and PFDI-10 (“Usually lose stool beyond your control if your stool is loose?”) for solid and liquid fecal incontinence, respectively. In addition, PFDI-16 (“Usually experience urine leakage associated with a feeling of urgency, that is, strong sensation of needing to go to the bathroom?”) and PFDI-17 (“Usually experience urine leakage related to coughing, sneezing, or laughing?”) were used for urgency and stress urinary incontinence, respectively. To define symptomatic pelvic floor disorders , we used the “bothersome symptom” for each question as a score ≥2 (“Somewhat”).
Statistical methods
The baseline characteristics of control subjects and subjects with MS were compared with the use of a 2-sample t test or Mann-Whitney U test for continuous variables and a χ 2 test or Fisher’s exact test for categoric variables. Correlation analyses between PFDI and known clinical risk factors were performed with a Pearson correlation or Spearman correlation for continuous variables or Spearman correlation analysis for categoric variables. The confounders for the multivariable analysis were determined based on statistical and clinical consideration: significant covariates in the univariate analysis ( P > .2) and clinical well-known risk factors of pelvic floor dysfunction.
Analysis of covariance was used to compare PFDI-20 scores of subjects with and without MS after adjustment for age, parity, menstrual status, and other factors (education, income, smoking, and LDL-C). In addition, PFDI-20 scores were compared according to the groups of MS (normal vs high-risk vs MS).
Multiple regression models were used to determine the relationship between PFDI scores and the presence of MS. Age, parity, menstrual status, education, income, smoking, LDL-C, and MS components were included with the Enter method. To avoid the problem of colinearity, we performed colinearity diagnostics; the tolerance of all variables was >0.1, and the variance inflation factor was <10. Because body mass index and waist circumference were highly correlated (Pearson’s correlation coefficient, 0.85; P < .001), we included waist circumference only in multivariate analysis to evaluate the clinical significance of waist circumference as an axial component of MS. Then, we further performed subgroup analysis (nonobese vs obese group) to control the confounding effect of body mass index to MS and pelvic floor dysfunction. Obesity was defined as a body mass index of ≥25 according to the World Health Organization criteria for Asia-Pacific region.
All statistical tests were 2-tailed, and statistical significance was defined as a probability value of < .05. We used the SPSS software package (version 17.0; SPSS, Inc, Chicago, IL) for all analyses.
Results
Study population
A total of 1060 Korean women were addressed consecutively. Among them, 1018 women completed the questionnaires, which was a response rate of 96.0%. After the exclusion of 34 women who received hormonal replacement treatment, 984 women with a mean age of 49.5 years (range, 40–77 years) were finally enrolled in this study. The frequency of MS was 14.0% (138/984 women). Average scores were 32.2 on the PFDI-20, 7.0 on the POPDI-6, 12.9 on the CRADI-8, and 12.2 on the UDI-6. Among selected condition-specific questions, the frequencies of bothersome symptoms were 5.8% (57 women) on the pelvic organ prolapse, 8.4% (83 women) on the solid fecal incontinence, 19.7% (194 women) on the liquid fecal incontinence, 14.8% (146 women) on the urgency urinary incontinence, and 38.4% (378 women) on the stress urinary incontinence.
Association between MS and PFDI-20
There were statistically significant differences in age, menstrual status, body mass index, education, household income, serum level of LDL-C, and 5 MS components between women with and without MS ( P < .05; Table 1 ). The PFDI-20 mean score, and especially the CRADI-8 and UDI-6 subscores, were significantly higher in subjects with MS ( P < .05).
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