Pelvic Organ Prolapse -Health-Promoting Attitudes According to Sociodemographic Factors

1. Introduction

Pelvic organ prolapse (POP) disorders are a significant problem with a society-wide dimension, affecting the quality of life of many women around the world. Due to their prevalence and physical as well as psychological consequences, they have a significant impact on public health, as well as on economic and social aspects. Despite the huge number of women struggling with this aspect, public awareness still remains quite low. The increase in life expectancy and the quest for an improved quality of life are both contributing to an increase in the prevalence of POP, as well as an increase in the number of women seeking treatment and solutions to their symptoms. Currently available demographic data are not precise enough to accurately estimate the true prevalence of POP in the population. However, ongoing efforts by international associations such as IUGA ( International Urogynecological Association ) and ICS ( International Catheter Solutions ) to standardize the diagnosis and treatment of POP may greatly improve our ability to estimate the true incidence and prevalence of this condition in the coming years.

The purpose of this study is to assess the influence of sociodemographic factors on health-promoting behaviors in relation to pelvic organ prolapse in women of reproductive age.

The prevalence of POP is relatively difficult to determine. In the literature, figures range from 3 - 50%. According to the latest data, POP currently affects between 1 - 65% of women who have given birth in the past. As many as 20% of them require surgical intervention performed before the age of 80. Most surgeries are performed on women aged 60 to 69. Less than 58% of surgeries are performed in women under 60, and the recurrence rate after surgical interventions is as high as 13%. The problem in particular becomes apparent during menopause, when a woman’s hormonal status is disrupted, as well as during some gravity sports [1,2,3,4].

The primary theory explaining the etiology of this problem is the so-called integral theory. Its general premise is based on the flaccidity of the ligaments, muscles and connective tissue of the vagina [5,6].

According to its assumptions, there are three main levels of organ decline:

- anterior vaginal wall / cystocele - this is the most common form of prolapse of the reproductive organs. It refers to the lowering of the urinary bladder. This defect is associated with the highest rate of recurrence, despite the surgical treatment applied.

- posterior wall - mainly refers to rectocele (hernia of the rectum).

- top defect - involves uterine prolapse, cervix, as well as the vaginal stump after a previous hysterectomy. In addition, it can involve the small intestine, colon and bladder [3]

The complexity of this problem is also due to the vast number of possible causes and risk factors. We distinguish among these causes:

- functional - disorders that prevent normal functioning;

- Anatomical - abnormal anatomical structure;

- Neurogenic - a disorder in the normal functioning of the nervous system, which directs the work of internal organs;

- iatrogenic [7]

A number of factors affecting the incidence of POP have been described in the literature. However, a key role is attributed to weakness of the muscles and connective tissue surrounding the pelvic organs. The correct interaction between these two factors ensures optimal support of the internal organs. When the pelvic floor muscles are dysfunctional, the strength of the vaginal walls is weakened in response to changing pressure, thus causing abnormal tension on the ligamentous attachments to the lateral pelvic walls [6,8].

There are many factors that can be responsible for the weakening of the muscular apparatus. Among them, intense physical exertion and overexertion are often mentioned. Other possible mechanism include the abdominal muscle complex dyssynergy with PFM (Pelvic Floor Muscles) [4,6]. Women who have given birth by natural childbirth are at a higher risk of such complications. Compared to non-births, the risk increases 2 to 8 times. The risk of POP is 4 times higher after the first natural childbirth, 8 times after the second and 9 times after the third. Childbirth requires an intense effort from the muscles, which are constantly working during labor, contracting and then stretching again. The fetus’s head as it descends in the birth canal causes tremendous pressure and friction on the surrounding tissues. The risk of damage is 9 - times higher with a natural childbirth, compared to a cesarean section. The most common damage, associated with natural childbirth is observed in the pubococcygeal part of the anal lever muscle. Visualization of the course of labor shows that during the second period of labor, the anal lever muscle can be stretched by as much as 200% compared to its original length. In 55% of women with prolapse of the reproductive organ, damage is found to this very muscle. This is associated with an excessive increase in pressure and strong pushing of the parturient [8,9]

Other pre- and perinatal factors that increase the risk of POP are:

- baby’s birth weight > 4,000 g;

- mother’s age at birth > 35;

- maternal BMI > 25 kg/ m2;

- operative deliveries: using forceps, or vacuum aspiration;

- prolonged labor;

- episiotomy, especially central and mid-lateral incision < 60 ˚ [9]

Studies show the positive impact of introducing physiotherapy in a structured manner early in pregnancy. Such practices can influence a dramatic decrease in the incidence of incontinence by as much as 62% during pregnancy and by 29% in the 3 - 6 month postpartum period. However, despite studies, there is still insufficient data on the effectiveness of such exercises in the postpartum period.

With women’s life expectancy steadily increasing, the incidence of POP is expected to increase in direct proportion in the coming years. It is believed that in 2050, the number of women with POP in the US will increase by about 46% [5,8,10]

As we know, genetic predisposition plays an important role in susceptibility to various diseases, affecting the risk of developing them. It has been proven that genetic predisposition can increase the risk of POP by up to 2, 5 - times compared to the general population. Reduced collagen content in tissues is associated not only with menopause, but also with obesity, or vascular diseases. Particular attention is paid to the occurrence of varicose veins, embolism, rheumatic diseases, not only in a particular patient, but also in her first- and second-degree relatives. Genetic predisposition is also responsible for the type and “quality” of collagen produced. [5,11]

2. Material and Methods:

The survey was conducted using a questionnaire made available electronically and a paper questionnaire distributed to female patients of the Heliodor Święcicki Gynecology and Obstetrics Clinical Hospital of the Karol Marcinkowski Medical University in Poznan. Participation in the study was voluntary, the respondents were informed of the anonymity of the survey. 160 women participated in the study. An additional qualifying condition was the age of the women, from 15 - 49 years old. The patients were recruited between 10.2024 and 12.2024.

The questionnaire used in this study consisted of 30 questions. The questionnaire used included: Questions about age, residence, education, weight, height, presence of concomitant diseases, use of hormone therapy, and obstetric history. In the next section questions focused on the presence or absence of complaints of pelvic organ prolapse, urinary incontinence; and on knowledge of methods of prevention and treatment of genital static disorders.

To analyze the collected data, Statistica (Cloud Software Group, Inc. (2023), Data Science Workbench, version 14) and Microsoft Excel (Microsoft Office (2019), version 2205). The distribution of variables was assessed using the Shapiro-Wilk test. Mann-Whitney U test and Kruskal Wallis ANOVA test were used for comparisons between groups. Comparisons between assessment scores and self-assessment of knowledge were made using Wilcoxon’s paired rank order test. Using the Chi² NW (highest reliability) test, an examination of the relationship between variables was conducted. The confidence level used in all calculations was p<0.05.

3. Results:

The characteristics of the study group are shown in the Table 1 and Table 2.

Significantly less frequent use of a visit to a gynecologist was observed in women struggling with reproductive organs prolapse (p<0.001) (Table 3).

The analysis shows that urogynecological physiotherapist use is more frequent among patients with higher education and women living in larger cities (> 50,000 residents). In addition, a correlation between POP and greater interest in urogynecological physiotherapy was observed (Table 4).

Table 5 illustrates the statistical analysis, concerning the performance of exercises to strengthen the muscles of the lower pelvic floor, depending on the following variables: age, education, place of residence, having undergone natural childbirth, POP and urine incontinence.

As many as 60% of female respondents declare having knowledge of the characteristics of the work of a urogynecological physiotherapist. The remainder of the group - 40% - has no knowledge of this subject (Table 6).

Significant differences were observed in the answers posed depending on the age of the patients, education and place of residence. Younger respondents, i.e., <35 years of age, significantly more often declared greater knowledge of the characteristics of the work of a urogynecological physiotherapist (71.23%), compared to women > 35 years of age, among whom the percentage was 50.57%. Drastic discrepancies are also observed between respondents with a university education (in this group, as many as 84.09% of respondents declared knowledge of the subject matter) and women with education other than university (the percentage was 30.65%). A similar relationship applies to place of residence. Those living in localities with a population of > 50,000 confirmed their familiarity with the subject under study at 78.75%, while women living in smaller localities only at 41.25%.

In Table 7, greater knowledge in the topic of preventive methods for reproductive organs prolapse is observed among women with higher education and among women living in towns with a population of >50,000. For both relationships, the confidence level was less than 0.001.

The vast majority of patients, 77.50% (n=124), deny knowledge of the therapeutic method, which is pessarotherapy. Only 22.50% (n=36) have knowledge of it - Table 8.

4. Conclusions

• The level of knowledge about POP prevention and conservative treatment methods is low.
• Differences in the level of knowledge held depend primarily on factors such as age, place of residence, type of education held.

5. Discussion

The problem that is pelvic organ prolapse - POP is affecting an increasing number of women around the world. Epidemiological forecasts in recent medical studies clearly predict an increase in the number of women experiencing this problem in the future. This is largely due to the increasing average age of the population, the lifestyle we lead, as well as other environmental factors[5]. In view of this, it seems crucial to spread knowledge regarding both the prevention and treatment of female pelvic organ prolapse.

The results of published studies clearly indicate a low level of knowledge in the general female population, regarding pelvic floor muscle dysfunction, risk factors, as well as treatment options [5,7]

The results of the present study suggest only a partial understanding of the topic of pelvic organ prolapse, while lacking full awareness of prevention. Similar correlations can be observed in other scientific publications. As many as 81% of women participating in a survey conducted by the Brazilian Society of Gynecologists and Obstetricians declared that they had never received information about the possibility of this type of disorder. As in our study, the group with a higher level of knowledge was characterized by: higher education and living in areas with a large population [12]

Demographic variables prove to have a huge impact on the state of awareness and knowledge of the women surveyed. The difference in the level of knowledge between respondents with higher education and women with lower education was almost 32%. A similar observation was noted in a pilot study conducted by the International Urogynecology Journal in 2022. Younger women and those with higher education had a higher percentage of correct answers in the questionnaire on general knowledge about female genitalia and prolapse [13] . The same trend is observed in knowledge regarding risk factors. Those living in larger cities show greater knowledge regarding medical factors such as menopause, congenital spinal defects, and obesity. The most easily recognized factor was natural childbirth. Knowledge of risk factors greatly influences patients’ lifestyles and the use of health-promoting behaviors. A noticeable problem is the presence of myths and misconceptions among patients. Ethnicity among African-Americans, limited access to information, low levels of education, and low socioeconomic status are cited as major risk factors correlating with low knowledge in other articles. In contrast to my analysis, a study conducted by the Brazilian Society of Gynecologists and Obstetricians observed greater knowledge of POP pathophysiology among women suffering from the disorder [12] . The data we obtained show a higher frequency of this group of women identifying inappropriate behaviors as preventive methods.

The subject of genital static disorders is still a taboo subject. Conducting conversations on this topic requires respecting women’s privacy, maintaining discretion, and building trust between the person imparting knowledge and the patient. Despite public respect towards doctors, patients are relatively often not satisfied with their services. It has been shown in the literature that women often experience belittling of the problem, ignorance and a dismissive approach to the complaints they report [14] . A small percentage of women consult gynecological problems with health professionals. On average, 50% of the female population suffering from genital static disorders consult a health care professional. As identified reasons for such behavior are considered: shame, lack of knowledge, belittling the problem [12]. Many of them suffer also from sexual disorders [15,16]. A dismissive attitude towards the patient results in him giving up trying to seek help. This, in turn, leads to an exacerbation of symptoms and, ultimately, a reduction in the woman’s quality of life.

The subject of preventive measures in this area is developing rapidly. There are many methods, showing great effectiveness. Recent scientific studies even talk about the effectiveness of measures, which do not require much effort, i.e.: changing lifestyle, diet, quitting smoking, avoiding lifting heavy loads or doing physically demanding work [17] . The most popular preventive methods, and at the same time methods with demonstrated effectiveness in alleviating changes resulting from genital static disorders, are pelvic floor muscle exercises [4,6,18]. Despite the fact that more than half of the surveyed group agrees with the statement that preventive methods can have a positive effect on symptoms associated with pelvic organ prolapse, the percentage of patients using these methods is dramatically low. Improving women’s awareness of implementable preventive measures, as well as familiarizing them with pelvic floor muscle exercises, could reduce the number of cases of POP or reduce the severity of current lesions. The data collected during the survey unequivocally shows that more than half of the surveyed group has little or no knowledge of POP prevention methods. 60% of female respondents declare knowledge of the characteristics of the work of a urogynecological physiotherapist. At the same time, a similar percentage of respondents - 63% - have never performed exercises to strengthen the pelvic floor muscles [4,6]. A higher frequency of performed exercises is observed only in women who are younger, have higher education and live in larger cities. The same relationship is observed in respondents who gave birth by natural forces. However, no significant differences are noted in the frequency of exercise in relation to the age of the patient, urine incontinence or pelvic organ prolapse. Similar findings are observed in medical articles, which say that women with higher education are more likely to exercise, and women with a history of consultation with medical personnel. Correlations of low significance, however, were observed between knowledge of the pelvic floor muscles and the age of the patient, as well as experience of natural childbirth [12,13] . The correlations presented in the given articles coincide with the conclusions gathered in the study. The question that arises at this point is: what changes need to be made to achieve improvements in this area? We need to extend assistance to women in each variability group. It would seem beneficial to introduce free educational classes on pelvic floor muscle exercises. Such classes could be held at hospitals, or clinics easily accessible to patients from both smaller and larger towns. Alarming data is noted on the issue of pessarotherapy, which is currently growing in popularity. Mainly due to its non-invasiveness, ease of use and the positive benefits of its use [19] . As many as 77% of women surveyed are not familiar with this method, which could reduce the discomfort they experience on a daily basis. Again, greater familiarity with preventive methods is observed among women who are better educated , live in larger cities, but also those who struggle with urine incontinence. Female respondents also show moderate knowledge of appropriate forms of physical activity in the context of preventive measures. Although pelvic floor muscle exercises, yoga and Pilates are recognized as beneficial, some women still choose intense forms of activity that can negatively affect the pelvic floor. It is recommended to promote moderate forms of exercise, such as leisurely cycling and swimming, which promote health by leveling excessive strain on pelvic structures.

The problem of pelvic organ prolapse significantly affects the daily activity of women. These changes limit their social life, social life, participation in sports and even family life. Less frequent visits to the gynecologist are observed in this group of women, which may be due to a sense of shame, embarrassment, among other reasons. POP has a significant impact on women’s sex life. The resulting anatomical changes may be associated with discomfort during intercourse, and even with pain, which can result in a woman’s isolation, a drastic drop in self-esteem, a decrease in sexual desire, as well as a weakening of the relationship with her partner due to concerns about pleasing her partner and a sense of shame. The sexual needs of female patients should not be forgotten. In the general female population, about 30-40% of them report sexual dysfunction due to POP. However, in women suffering from pelvic floor disorders, the percentage rises to as high as 50 - 83% [20] . Patients struggling with pelvic organ prolapse also experience changes related to decreased lubrication of the vaginal tissues and loosening of the vaginal walls. It is also worth mentioning the less frequent achievement of orgasm in these patients. It is believed that the negative impact of POP on sexual life does not depend mainly on the resulting anatomical changes, but on psychological factors. In this group of women, there is a higher risk of depression, compared to the general population. Depression affects between 20 - 71% of women in this case [21] . Giving up intimacy is mainly associated with disturbed perception of one’s own body.

The results directly indicate the need for increased educational efforts. Lack of basic knowledge, on the pathophysiology of the lesions arising in the reproductive organs, as well as the possible health consequences and complications is a huge problem. This problem, may be responsible for the delay in the diagnosis of POP, or the introduction of inappropriate treatment.