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Selecting diagnostic strategies in primary pelvic organ prolapse

Groenendijk, A.G.

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Citation for published version (APA):Groenendijk, A. G. (2009). Selecting diagnostic strategies in primary pelvic organ prolapse.

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CHAPTER 2Contribution of primary PelvicOrgan Prolapse to micturition anddefecation symptoms Annette G. GroenendijkErwin BirnieJan-Paul W. Roovers Gouke J. Bonsel

Submitted

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Proefschrift Groenendijk_proefschrift 19-10-09 10:35 Pagina 35

ABSTRACT

ObjectiveTo investigate the contribution of primary Pelvic Organ Prolapse (POP) tomicturition and defecation symptoms.

Method64 patients who visited the outpatient clinic for primary POP and 50 controlswho did not seek medical care for POP. Degree of POP was evaluated with thePOP-Quantification (POP-Q) system. Micturition and defecation symptomswere evaluated with the validated urinary distress inventory (UDI) anddefecation distress inventory (DDI). The MOS SF-36 health survey and theCenter for Epidemiological Studies Depression scale (CES-D) were used tomeasure self-perceived health status and depressive symptoms, respectively.

ResultsPOP had a moderate impact on feeling and seeing a vaginal bulge, andcontributed only a small part to obstructive voiding and overactive bladdersymptoms. To an even lesser extent these symptoms were explained by patientcharacteristics or psychological factors. We found no relationship between POPand urinary incontinence, nor between patient characteristics or psychologicalfactors and urinary incontinence. Clinical depression explained for a greaterpart constipation symptoms (explained variance 13 percent) than pelvic floordefects (explained variance 5 percent). Other defecation symptoms wereunrelated to POP, patient characteristics or psychological factors.

ConclusionThe degree of POP and prolapse symptoms are associated but such a strongassociation does not exist between POP and micturition or defecationsymptoms. We recommend to be restrictive with surgical prolapse repair inpatients with POP who have micturition or bowel symptoms as maincomplaint.

KeywordsDefecation symptoms •Depression •Micturition symptoms •Pelvic floordysfunction •Pelvic organ prolapse

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INTRODUCTION

Pelvic organ prolapse (POP) is a common disorder often associated withsymptoms such as a vaginal bulging, pelvic heaviness, bothersome micturitionand defecation symptoms as well as sexual dysfunction, often with a negativeimpact on quality of life1, 2. It is unclear whether the anatomical position of thebladder, bowel and uterus compromise the bladder and bowel function directly,or whether abnormal anatomy and dysfunction of the pelvic floor share acommon etiology. Moreover, it is unclear to what extent micturition anddefecation symptoms can be explained by the presence and degree ofanatomical abnormalities involved in POP. With the exception of vaginalbulging, none of these symptoms are specific to vaginal prolapse since they alsoexist in women without POP3. Whether or not the symptoms are related to POPis an essential step in patient management. POP patients in whom defecationsymptoms dominate might be primarily referred to the gastro-enterologist, but ifthese patients present with a vaginal prolapse, these patients are usually referredto the gynecologist. For gynecologists, it is common practice to offer thesepatients POP surgery with the intention to correct the anatomy as well as restorepelvic floor function. This treatment policy is based on the assumption that therelationship between POP and symptoms is not merely association but one ofcausality. However, critical physicians frequently realize that with respect topelvic floor function their surgical results can be disappointing4, 5.

In this study we investigate the relationship between POP and pelvic floorsymptoms in a group of patients who present with symptomatic POP and in acontrol group of patients with asymptomatic POP or without POP. We investigatedto what extent bladder and bowel symptoms are related to specific anatomicaldefects of the pelvic floor or to other factors like patient characteristics (e.g. age,parity, body weight, educational level) and psychological characteristics.

MATERIAL AND METHODS

We conducted a cross-sectional study between January 2000 and January 2002consisting of two cohorts. One cohort consisted of 64 women with symptomaticPOP stage 2 or more treated at the gynecology outpatient clinic of the OnzeLieve Vrouwe Hospital. These patients participated in a larger study on theevaluation of the diagnostic work-up of patients with symptomatic primaryPOP6, 7, 8. The second cohort consisted of a control group of 35 women whowere referred to the gynecology outpatient clinic for other complaints than POPand 15 women without gynecological complaints and who were not referred.

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Contribution of POP to micturition and defecation symptoms


Exclusion criteria for both groups were: being less than 6 months postpartum,having congenital defects of the urogenital and/or gastro-intestinal tract, a fibroiduterus with a size of more than 12 weeks of pregnancy, large ovarian cysts,prolapse surgery and/or hysterectomy in medical history, a poor generalcondition precluding surgical therapy or insufficient Dutch language proficiency.The study was approved by the Medical Ethical Board of the Onze Lieve VrouweHospital. Structural medical review and physical examination were carried outduring the first visit at the gynecology outpatient clinic of the Onze Lieve VrouweHospital. Degree of POP was assessed using the POP-Quantification (POP-Q)system with the patient sitting 45 degrees upright in a gynecological examinationchair while she was instructed to strain forcefully9. In agreement with the studyof Kahn et al., we used the sum of the anatomic landmarks genital hiatus (gh) andperineal body (pb) as measure for perineal descent10. All pelvic examinationswere performed by the first author [AGG]. In addition to a standard historyreview, each patient was invited to complete the following surveys. 1) The MOSSF-36 generic health-related quality of life questionnaire was used to measureself-perceived health status11. We used the overall physical and mental healthsummary scores (score range: 0-100, a higher score indicates better health) asindicators of physical and mental health . 2) The Center for EpidemiologicalStudies Depression scale (CES-D) was used to measure depressive symptoms12

(scores range: 0 (no symptoms) - 60 (maximal symptoms); a cutoff score of 16indicates clinical depression). 3) For the measurement of urogenital and bowelsymptoms and symptom-related bother, we used two disease-specific symptomquestionnaires; Firstly, the 19-item urinary distress inventory (UDI) consists of fivedomains: genital prolapse (e.g. feeling and/or seeing a vaginal bulge), urinaryincontinence (e.g. urine leakage related to physical activity, coughing orsneezing and urine leakage related to the feeling of urgency), overactive bladder(e.g. frequency, urgency and nocturia), obstructive micturition (e.g. feeling ofincomplete bladder emptying and difficulties to empty the bladder) anddiscomfort/pain (e.g. lower abdominal pressure, pain or discomfort lowerabdomen, push on the vaginal wall to have bowel movement). Secondly, the 15-item defecation distress inventory (DDI) consists of four domains: constipation,fecal incontinence, painful defecation and incontinence for gas. Constipationconsists of the following symptoms: less than three bowel movements a week, in25% of the time straining at defecation, feeling of incomplete evacuation,sensation of anal blockage, difficulties with emptying the rectum (manualremoval of feces out of the rectum or push on the vaginal wall). Each domainscore ranges from 0-100, a higher score indicates more bother of reportedsymptoms13, 14. Both questionnaires have been validated in Dutch.

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Analysis Differences in degree of pelvic organ prolapse, patient characteristics, andreported pelvic floor symptoms between the study and the control group wereevaluated using the Student’s independent samples t-test (for Gaussiandistributed variables), the nonparametric Mann-Whitney U test (for skewedvariables) and the chi square test (for nominal/ordinal variables).

The impact of the individual risk factors (age, body mass index (BMI),parity, perineal trauma, summary physical health (as proxy for comorbidity) andeducational level), alongside specific pelvic floor defects (anterior, middle andposterior compartment defects) and psychological health status (clinicaldepression and summary mental health) on the UDI and DDI domain scores(log transformed scale) was assessed using multiple linear regression analysis(enter method). The resulting beta-coefficients represent the impact on the logUDI or log DDI domain score when the risk factor is changed with one unit ofmeasurement. Adjusted R2 was used as measure of model fit. The change inadjusted R2 was used to quantify the contribution of patient characteristics,psychological health, and specific pelvic floor defects to the full model,entering patient characteristics first, then psychological health, and finallyspecific pelvic floor defects (stepwise multiple linear regression analysis).

SPPS for Windows v15.0 was used for data management and statisticalanalysis. A two sided p value <0.05 was considered a statistically significantdifference.

RESULTS

Table 1 depicts the characteristics of the study and control groups. Women inthe study group were on average older and had higher parity as compared tothe control group. Patients in the study group on average had higher POP stagecompared to the control group (POP III/IV: 74% vs. 4%, respectively) and theirphysical health was significantly worse.

Moreover, the study group reported significantly more bother fromurogenital and bowel symptoms; significant differences between the groupswere found for all UDI domains and the flatus and fecal incontinence domainsof the DDI. Feeling of vaginal protrusion (50/64 (78%)) and overactive bladdersymptoms (45/64 (70%)) were the most frequent and bothersome symptoms inthe study group followed by complaints of discomfort and pain. In the controlgroup, the most prevalent and bothersome complaint was urinary incontinence(22/50, 44%). Frequently reported defecation symptoms in both groups werefalse urge for defecation (27/64 (42%) and 17/50 (34%), respectively),

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obstructed defecation (29/64 (45%) and 12/50 (24%)) and feeling of incompletedefection (29/64 (45%) and 8/50 (16%), respectively).

Table 2 shows the strength of the relationships between defecation (DDI)and micturition (UDI) scores on the one hand and patient’s characteristics,POP-Q scores and psychological characteristics on the other.

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Characteristics Study group (n=64) Control group (n=50) P valueAge (years), mean (SD) [range] 56.1 (10.4) [35-77] 48.9 (8.1) [37-72] <0.01Body Mass Index (BMI), mean (SD) [range]a 25.38 (4.3) [18.4-39.1] 24.0 (4.3) [18.4-41.3] 0.99Educational level 0.68

Primary school /lower vocational education 22 (34%) 6 (12%)Secondary school/high school 21 (33%) 23 (46%)Academic/university 22 (34%) 21 (42%)

Parity 0.040 0 (--) 4 ( 8%)1 15 (23%) 21 (42%)2 22 (35%) 16 (32%)3 5 (23%) 8 (16%)≥4 12 (19%) 1 (2%)overall, mean 2.3 1.6

Type of delivery 0.36Vaginal delivery, no forceps or vacuum 56 (88%) 40 (80%)Forceps and/or vacuum 8 (12%) 9 (18%)Caesarian section only 0 (--) 1 (2%)

Perineal trauma, no. of patients 0.52No perineal trauma 16 (25%) 16 (32%)Episiotomy or rupture 48 (75%) 34 (68%)

POP-Q points, mean (SD)b

Aa -0.8 (1.1) -2.0 (1.2)Ba 2.2 (2.2) -1.9 (1.3)C -0.2 (4.1) -5.7 (1.4)Gh 4.1 (1.1) 2.2 (0.7)Pb 2.7 (0.7) 2.9 (0.6)Ap 0.2 (1.4) -1.6 (1.5)Bp 0.3 (1.6) -1.5 (1.5)TVL 8.1 (1.1) 8.6 (1.1)

Table 1 Patient’s characteristics


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Prolapse feeling. Pelvic floor defects, dominated by anterior vaginal wallprolapse (Ba) and perineal descent of the pelvic floor (gh+pb), accounted for 31%(p<0.01) of the variance in symptom scores. The impact of clinical depression andsummary mental health on prolapse feeling was small (increase in varianceexplained: 2%, p=0.14). Patient characteristics overall explained 14%. A higher BMI

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Characteristics Study group (n=64) Control group (n=50) P valuePOP-Q stage <0.01

Stage I 0 (--%) 24 (48%)Stage II 17 (27%) 24 (48%)Stage III 42 (66%) 2 ( 4%)Stage IV 5 (8%) 0 (-- %)

UDI domains, median (IQR)Prolapse symptoms 33.3 (45.8) 0.0 ( 0.0) <0.01Obstructed voiding 16.7 (33.3) 0.0 ( 0.0) <0.01Overactive bladder 27.8 (30.6) 0.0 (22.2) <0.01Discomfort and pain 22.2 (31.9) 5.6 (16.7) <0.01Urinary incontinence 13.3 (26.7) 6.6 (13.3) <0.01UDI total 127.8 (69.1) 22.2 (35.0) <0.01

DDI domains, median (IQR)Constipation 4.7 (17.3) 0.0 ( 9.5) 0.08Fecal incontinence 0.0 (13.3) 0.0 ( 0.0) 0.02Painful defecation 0.0 (0.0) 0.0 ( 0.0) 0.64Flatus incontinence 16.7 (41.7) 0.0 (33.3) 0.02DDI total 34.5 (67.4) 21.0 (45.4) 0.03

General health (MOS SF-36), mean (SD)Summary mental health 46.3 (14.6) 50.3 (15.0) 0.42Summary physical health 48.5 (11.3) 54.3 (11.7) <0.01

Depression (CES-D)Clinical depression c 23 (36%) 13 (26%) 0.52

BMI= body mass index IQR = interquartile range; SD = standard deviationa BMI of women in the normal population is 18-24 (body mass index = kg/m2)b Point D was not correctly measured in all case and was excluded from the studyc Defined as a CES-D score ≥16

Table 1 Patient’s characteristics (continued)


adjusted for other covariables was associated with lower scores of prolapse feeling. Obstructive voiding. Voiding problems were associated to specific pelvic

floor defects but the overall contribution was modest (9% of explainedvariance, p=0.004). Voiding problems were predominantly related to patientcharacteristics, explaining 21% of variance (p<0.01). The relationship betweenpresence of perineal trauma and voiding obstruction was inverse. Patients withbetter overall physical health had significantly less bother from voiding

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UDI-prolapse feeling (log scale) UDI-obstructive voiding (log scale)

ß-coefficient [95%-CI] P value Change ß-coefficient [95%-CI] P value Change

in R2 in R2

adjusted adjusted

(p value (p value

of change) of change)

Constant 3.28 [-7.17 to 7.29] 0.11 4.69 [0.74 to 8.64] 0.02

Patient characteristics 0.14 0.21

Age (years) 0.00 [-0.03 to 0.04] 0.80 (p<0.01) -0.01 [-0.05 to 0.02] 0.44 (p<0.01)

BMI -1.00 [-0.17 to -0.3] <0.01 0.02 [-0.05 to 0.09] 0.55

Parity 0.14 [-0.08 to 0.36] 0.22 0.16 [-0.07 to 0.38] 0.17

Perineal trauma -0.19 [-0.80 to 0.42] 0.54 -0.95 [-1.56 to -0.35] <0.01

Physical health -0.02 [-1.13 to 0.25] 0.28 -0.06 [-0.09 to -0.02] <0.01

Educational level 1a -0.20 [-0.73 to 0.72] 0.96 0.44 [-0.30 to 1.17] 0.24

Educational level 2b -0.44 [-1.13 to 0.25] 0.21 -0.22 [-0.91 to 0.46] 0.52

Psychological factors 0.02 0.00

Clinical depression 0.65 [-0.02 to 1.32] 0.06 (p=0.14) -0.35 [-1.01 to 0.32] 0.30 (p=0.35)

Mental health -0.01 [-0.04 to 0.02] 0.7 -0.02 [-0.05 to 0.01] 0.24

POP-Q points 0.31 0.09

Ba 0.22 [0.04 to 0.39] 0.01 (p<0.01) -0.03 [-0.20 to 0.14] 0.71 (p<0.01)

C 0.04 [-0.07 to 0.15] 0.51 0.10 [-0.00 to 0.21] 0.06

Bp 0.17 [-0.02 to 0.36] 0.07 0.09 [-0.09 to 0.28] 0.33

gh+pb 0.31 [0.05 to 0.58] 0.02 0.18 [-0.09 to 0.44] 0.18

Full model 0.47 0..30

(p<0.01) (p<0.01)a Secondary education; reference is primary school /lower vocational educationb Higher professional education; reference is primary school /lower vocational education

Table 2 Multiple linear regression analysis showing the relationship between patient’s

characteristics, psychological characteristics and anatomical defects at the one hand and pelvic

floor symptoms (log scale) at the other hand.


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obstruction, but the impact was small.Overactive bladder. Overactive bladder symptoms were mainly related to

pelvic floor defects (14% of variance explained, p<0.01), especially to posteriorvaginal wall prolapse (point Bp) and to a lesser extent point C. The contributionof patient characteristics was overall small (7% of variance explained). Onlyeducational level had a significant impact on overactive bladder symptoms i.e.women with lower vocational education had more bother of overactive bladdersymptoms.

Discomfort and pain. Discomfort and pain were mainly related to pelvicfloor defects (12% of variance explained), especially posterior vaginal wall

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UDI-overactive bladder (log scale) UDI-discomfort and pain (log scale) DDI-constipation (log scale)

ß-coefficient [95%-CI] P value Change ß-coefficient [95%-CI] P value Change ß-coefficient [95%-CI] P value Change

in R2 in R2 in R2

adjusted adjusted adjusted

(p value (p value (p value

of change) of change) of change)

3.09 [-0.91 to 7.09] 0.13 4.93 [0.88 to 7.91] 0.01 3.32 [-0.08 to 6.71] 0.06

0.07 0.10 0.06

0.00 [-0.04 to 0.04] 0.99 (p=0.04) -0.01 [ 0.05 to 0.02] 0.36 (p=0.01) 0.00 [-0.03 to 0.03] 0.99 (p=0.07)

-0.01 [-0.08 to 0.06] 0.85 -0.04 [-0.11 to 0.03] 0.25 -0.08[-0.14 to -0.02] 0.01

-0.03 [-0.26 to 0.19] 0.77 0.09 [-0.11 to 0.29] 0.36 0.09 [-0.10 to 0.28] 0.35

-0.33 [-0.94 to 0.28] 0.28 0.19 [-0.35 to 0.72] 0.49 -0.12 [-0.64 to 0.40] 0.69

0.01 [-0.03 to 0.04] 0.67 -0.04 [-0.07 to -0.01] 0.02 -0.03[-0.06 to -0.01] 0.02

-9.81 [-1.72 to -0.24] 0.01 -0.09 [-0.74 to 0.57] 0.79 0.58 [-0.31 to 0.87] 0.69

-0.54 [-1.23 to 0.16] 0.13 -0.18 [-0.79 to 0.43] 0.56 0.28 [-0.31 to 0.87] 0.07

0.00 0.07 0.13

0.27 [-0.40 to 0.94] 0.43 (p=0.49) 0.73 [ 0.14 to 1.32] 0.02 (p<0.01) 0.96 [0.39 to 1.53] <0.01 (p<0.01)

0.001 [-0.03 to 0.03] 0..97 -0.01 [-0.04 to 0.01] 0.37 -0.01 [-0.04 to 0.01] 0.35

0.14 0.05

-0.02 [-0.15 to 0.19] 0.80 (p<0.01) -0.02 [-0.17 to 0.13] 0.79 -0.02 [-0.16 to 0.13] 0.82 (p=0.03)

0.11 [-0.00 to 0.21] 0.06 0.05 [-0.05 to 0.14] 0.35 0.12 -0.08 [-0.17 to 0.02] 0.10

0.24 [ 0.06 to 0.43] 0.01 0.17 [ 0.00 to 0.33] 0.05 (p<0.01) 0.12 [-0.04 to 0.28] 0.16

-0.01 [-0.27 to 0.26] 0.97 0.24 [ 0.00 to 0.47] 0.05 0.26 [ 0.03 to 0.49] 0.03

0.21 0.29 0.24

(p<0.01) (p<0.01) (p<0.01)


prolapse (Bp) and perineal descent of the pelvic floor (gh+pb). However,discomfort and painscores were also partially explained by patient andpsychological characteristics; patients with lower overall physical health andclinically depressed patient reported significantly higher levels of discomfortand pain.

Constipation. Constipation was predominantly related to psychologicalfactors (13% of variance explained). Particularly clinically depressed patientsreported higher levels of constipation. Constipation was to a lesser extent alsorelated to pelvic floor defects (5% of variance explained, p=0.03); particularlyperineal descent (gh+pb) had a significant impact on constipation (p=0.03). Ofthe patient characteristics only BMI and physical health were significantlyrelated to constipation.

Other UDI and DDI domains. None of the covariables studied had asignificant impact on urinary incontinence (UDI) and fecal incontinence,painful defecation and incontinence for gas (DDI).

DISCUSSION

In this study we found a poor association between anatomical and functionalabnormalities of the pelvic floor. Anatomical defects and, to a lesser extent, patientcharacteristics were associated with obstructive voiding and overactive bladder butnot with urinary incontinence. Any association between psychological factors andmicturition symptoms appeared absent. Regarding defecation symptoms, thesesymptoms appeared to be unrelated to anatomical abnormalities, patient characte-ristics or psychological factors, except for constipation which was associated withpsychological factors and, to a lesser extent, with perineal descent. Since theproportions of explained variance of all pelvic floor symptoms were low, it can beconcluded that it is still unclear on which other factors the presence of micturitionand defecation symptoms depend.

Some limitations of this study need to be discussed. Firstly, compared toother studies, only few of our patients presented with severe posteriorcompartment prolapse15. As our study group represents an average distributionof vaginal prolapse patients, we do not believe this to be an importantdrawback. An overrepresentation of patients with severe posterior wall defectsis likely to strengthen the relationship between posterior defects and defecationsymptoms. Secondly, we did not document whether patients or controls hadcomorbidity. Instead, we used the SF-36 summary physical health as proxymeasure which probably is a more valuable measure of a patient’s general

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health status to investigate whether this factor is associated with pelvic floorfunction. Thirdly, patients and controls had different characteristics and wecould only adjust in the multiple regression analysis for the documentedprognostic factors. We do not think that prognostic incomparability plays animportant role as all theoretical prognostic factors were documented in bothgroups.

Although POP and urinary incontinence frequently coincide, we found nosignificant relationship between POP and overall urinary incontinencesymptoms. An explanation would be that POP and urinary incontinence have acommon etiology (weakness of the pelvic floor and supportive tissue) ratherthan a direct causal relationship with the affected compartment. We also foundthat posterior compartment prolapse was associated with overactive bladdersymptoms whereas, in contrast to what one may expect, anterior wallcompartment prolapse was not. Only few studies on the relationship betweenPOP and these symptoms are known. Some researchers found a relationshipbetween anterior wall prolapse and overactive bladder symptoms due to outletobstruction of the bladder16, while others could not corroborate thatassociation17. Our findings are in agreement with the findings of other reportsthat show that the site of POP and the type of pelvic floor symptoms are notconsistently related18, 19.

Experienced discomfort and pain in the pelvic area appeared to be relatedto clinical depression but from this study we cannot conclude whether this is acausal relationship or not. Furthermore we found that discomfort and painsymptoms were stronger related to posterior vaginal wall prolaps and perinealdescent than to anterior vaginal wall prolapse. Maybe the feeling of pressure onthe pelvic floor is caused by invisible structural abnormalities of the posteriorcompartment like enterocele20, 21.

Surprisingly, we found no significant effect of age and parity on urogenitaland defecation symptoms. There are two reasons why a clear association of ageand parity with symptoms was absent in our study. Either our sample size maybe too low to observe such association or the variation in these factors in ourstudy population is small, disallowing the detection of significant associations.Furthermore, we found that a higher BMI was inverted related to prolapsefeeling. While literature supports overweight as a risk factor for pelvic organprolapse22, other studies show a protective effect of higher BMI level on pelvicfloor injury23, 24.

Defecation symptoms are frequently reported by women with POP25 butwhether they are the cause or the result of POP is unclear. Also researchers

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report conflicting results about the relationship between the severity of prolapseand bowel symptoms26, 27. The association between pelvic floor defects anddefecation symptoms in our study appeared to be small to absent. Oneexplanation is that other factors than POP are predominantly responsible fordefecation symptoms. The multifactorial pathophysiology of defecationdisorders is likely to reduce the contribution of POP i.e. posterior vaginal wallprolapse amongst other factors, e.g. occult anorectal anomalities, pelvic floordyssynergia, endocrine and metabolic factors and use of medication. Anotherexplanation could be that small and mild posterior wall prolapses as frequentlyfound in our study group should be regarded a physiologic condition oftenpresent in women without defecation complaints28. Apparently, these defectsare too small to cause outlet obstruction. Finally, it is questionable whetherPOP-Q scores are the best representation of abnormalities of the recto-vaginalwall7, 29 since imaging techniques like defecography and MRI can revealanatomical abnormalities of the posterior compartment that are not representedby abnormal POP-Q scores30.

Special attention should be paid to constipation. This symptom can eitherbe explained by impaired colon transit (slow transit constipation) or byobstruction of the bowel outlet like in POP (outlet obstruction constipation)31,32. The DDI we used to assess the presence of constipation is not validated todetermine the etiology of this symptom. While outlet obstruction seems areasonable explanation for the association between perineal descent andconstipation, the association between clinical depression and constipationpoints to slow transit constipation as the result of different life style, reducedmobility, different eating habits, decreased fluid intake, use of medication andpsychological distress, all factors common in depressed patients33, 34.Additional diagnostic tests e.g. quantification of bowel evacuation could helpto distinguish between both types of constipation if doctors feel that such adistinction is helpful to optimize treatment selection.

Although POP and prolapse symptoms are associated, a strongrelationship does not exist in our study group between POP and micturition ordefecation symptoms. This finding has important clinical implications.

First, in patients with POP who are not bothered by prolapse symptoms,surgical repair to correct the anatomical disorder seems ill-founded, and werecommend conservative management of pelvic floor symptoms. This can beachieved by having incontinence nurses providing information about theoptimal diet and fluid intake, by referring patients for specialized pelvic floorphysiotherapy, and by prescription of symptomatic drug treatment35. Second,patients scheduled for POP surgery should be informed that coexisting

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micturition and defecation symptoms are not necessarily the result of POP andthese may persist after surgery. Moreover, based on our results, we advise to payattention to the presence of clinical depression in patients who experiencebothersome constipation. Whether patients who report bothersome constipationbenefit from screening for the presence of clinical depression, should beevaluated in future studies.

The low proportion of explained variation in micturition and defecationsymptoms stress the urge to further explore which factors determine the highprevalence of micturition and defecation symptoms in patients who presentwith POP. Improved insight into these factors may help to optimize thediagnostic work-up and treatment setting in patients with pelvic floordysfunction.

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