Objective
The objective of the study was to compare the relative frequencies of pain in women with and without pelvic organ prolapse (POP).
Study Design
This was an ancillary analysis of a case-control study investigating functional bowel disorders in women with and without POP. Cases were defined as subjects with stage 3 or 4 POP and controls were subjects with normal pelvic support.
Results
Women with POP were more likely to experience lower abdominal or pelvic pain that was significantly bothersome and interfered with daily activities (odds ratio [OR], 9.7; 95% confidence interval [CI], 4.7–20.4). After controlling for confounders, women with prolapse were more likely to report pressure in the lower abdomen (OR, 2.3; 95% CI, 1.6–3.2), heaviness in the pelvic region (OR, 3.3; 95% CI, 2.3–4.3), and pain in the lower abdomen (OR, 2.6; 95% CI, 1.8–4.1).
Conclusion
Women with prolapse are more likely to report pain, pressure, or heaviness in the lower abdomen or pelvis compared with women with normal support.
Data from the 2005-2006 National Health and Nutrition Examination Survey estimates that pelvic floor disorders affect 24% of women in the United States, and that number is expected to rise rapidly with the aging population. A common symptom reported by patients with prolapse is the occurrence of pain, which is often attributed to pain in the lower back, abdomen, or pelvic areas. Despite the growing prevalence of pelvic organ prolapse, few data exist correlating abdominal and pelvic pain symptoms between women with prolapse and those with normal vaginal support.
Although lower abdominal and pelvic pain have been found to be highly prevalent among women, little is known about the association between advanced prolapse and specific patient-reported pain symptoms. Some women are asymptomatic, whereas others present with a myriad of clinical symptoms related to bladder, bowel, and/or sexual dysfunction. One prospective cohort study investigating the symptoms and severity of prolapse reported that 44% of the subjects complained of pelvic pain, and of those subjects experiencing pain, 69% reported that the pain had a negative impact on their quality of life. On the other hand, other investigators have demonstrated that women with a more advanced stage of prolapse report less pelvic and low back pain, thus failing to identify a strong correlation between prolapse and pain symptoms.
Because most studies investigating patient-reported pain symptoms and degree of prolapse failed to include a control group of women with normal vaginal support, it is difficult to determine whether actual differences exist from the normal population. A better understanding of the relationship between pain symptoms in women with and without prolapse may provide insight into counseling women on the likelihood that their pain symptoms are associated with their prolapse.
The objective of our study was to compare the relative frequencies of lower abdominal and pelvic pain between women with advanced pelvic organ prolapse to women with normal vaginal support. Our hypothesis was that the relative frequency of lower abdominal and pelvic pain would be increased in women with advanced pelvic organ prolapse as compared with women with normal vaginal support.
Materials and Methods
This case-control study was approved by our local institutional review board. It was a secondary analysis of a previously reported study investigating the functional bowel symptoms and anorectal disorders in patients with advanced pelvic organ prolapse. Subjects were defined as those who presented to a tertiary urogynecology clinic with advanced pelvic organ prolapse (stage 3 or 4). Controls were defined as subjects presenting to a general gynecology or women’s health clinic for annual examinations with normal pelvic support (stage 0 or 1) and without urinary incontinence. Demographic, historical, and physical examination information was collected.
All subjects completed a validated questionnaire on functional bowel disorders (Rome II Modular Questionnaire) as well as a generalized (Short-Form Health Survey-12) and a condition-specific (Pelvic Floor Distress Inventory-20) health-related quality-of-life scale. In the original study, assuming a baseline prevalence of constipation in the control group of 16%, a sample size of 123 subjects in each group provided 80% power to detect a difference between this baseline prevalence and an increased prevalence of 32% in the prolapse group, using a 2-group continuity-corrected χ 2 test with a 0.05 2-sided significance level.
For this analysis, the primary outcome was abdominal or pelvic pain based on the subject’s responses to specific pain-related questions abstracted from the Short-Form Health Survey-12 Questionnaire, Pelvic Floor Distress Inventory-20 (PFDI-20) Questionnaire, and the Rome II Modular questionnaires.
The following questions from the PFDI-20 were used to elicit whether the study subjects had symptoms of pelvic or lower abdominal pain: “Do you usually experience pressure in the lower abdomen”; “do you usually experience heaviness or dullness in the pelvic region”; and “do you usually experience pain or discomfort in the lower abdomen or genital region?” The question, “During the past 4 weeks, how much did pain interfere with your normal work (including both housework and work outside the home)” was abstracted from the Short-Form Health Survey-12 Questionnaire, whereas 2 questions (“In the last 3 months, did you often have discomfort or pain in your abdomen” and “In the last 6 months, did you have pain in your abdomen all the time [continuously] or most of the time [nearly continuously] [this should not be related to your menstrual cycle or period]”) were abstracted from the Rome II Modular Questionnaire.
The possible responses to the questions were “yes” or “no.” If the subjects answered “yes” to the questions from the PFDI-20, they were prompted to characterize the degree of bother as “not at all,” “somewhat,” “moderately,” or “quite a bit.” Subjects who answered “yes” but reported that the pain was “not at all bothersome” were also categorized as no pain. Subjects were arbitrarily characterized as having bothersome pain symptoms if they reported the degree of bother as “moderately” or “quite a bit” when answering the PFDI-20 questions.
Categorical data comparing lower abdominal and pelvic pain between cases and controls were analyzed using the χ 2 statistic and the Student t test for continuous data. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to estimate the relationship between lower abdominal and pelvic pain with advanced organ prolapse. Multiple logistic regression was used to adjust for potential confounding variables and was presented using adjusted ORs with 95% CIs. Statistical analysis was performed using JMP 8.0 (SAS Institute, Cary, NC), and statistical significance was set at P < .05.
Results
In the study, 128 cases and 127 controls were enrolled. Demographics and univariate comparisons between cases and controls were previously published. Relevant variables are summarized in Table 1 . Mean ages for cases and controls were similar (62.9 ± 10.5 years and 60.5 ± 11.6 years, respectively, P = .09). Cases were more likely to be white, have less medical comorbidity, to report a history of straining at work, and had previously undergone a hysterectomy or prolapse repair. Controls were more likely to achieve more years of formal education. There were no differences between marital status, household income, and use of antidepressants, narcotics, or laxatives between the 2 groups.
| Variable | Stage 3 or 4 POP (cases) (n = 128) | Normal vaginal support (controls) (n = 127) | P value |
|---|---|---|---|
| Age (y) mean ± SD | 62.9 ± 10.5 | 60.5 ± 11.6 | .09 |
| White | 113 (91.9) | 97 (76.4) | < .001 |
| Married | 88 (72.1) | 83 (66.4) | .36 |
| Education level | |||
| High school diploma | 30 (24.2) | 39 (31.5) | < .001 |
| College degree or higher | 16 (12.9) | 33 (26.6) | |
| Annual household income ≥$50,000 | 43 (51.8) | 56 (62.2) | .41 |
| Charlson Comorbidity Index | |||
| 0 | 101 (83) | 87 (71) | .01 |
| 1 | 16 (13.1) | 17 (13.8) | |
| ≥2 | 5 (4.1) | 19 (15.4) | |
| Antidepressant use | 22 (17.9) | 30 (25) | .18 |
| Narcotic use | 8 (6.6) | 8 (6.7) | .97 |
| Laxatives | 22 (17.9) | 24 (19.4) | .77 |
| Prior hysterectomy | 61 (48) | 32 (26) | < .001 |
| Prior rectocele repair | 17 (14) | 1 (1) | < .001 |
| Prior vaginal or prolapse surgery | 28 (23) | 3 (3) | < .001 |
| Prior anorectal surgery | 3 (3) | 0 | .08 |
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