The effect of physical activity on pelvic organ prolapse

DOI: 10.1111/j.1471-0528.2009.02112.x www.blackwellpublishing.com/bjog Urogynaecology The effect of physical activity on pelvic organ prolapse NS Ali-Ross, ARB Smith, G Hosker The Warrell Unit, St Mary s Hospital, Manchester, UK Correspondence: Dr NS Ali-Ross, The Warrell Unit, St Mary s Hospital, Manchester M13 0JH, UK. Email n4naddy@hotmail.co.uk Accepted 30 December 2008. Objective The objective of this study was to determine whether pelvic organ prolapse increases after physical activity. Design Prospective observational study. Setting St Mary s Hospital, Manchester, UK. Sample Women undergoing surgery for pelvic organ prolapse. Methods Fifty-four women were recruited to the study. Symptoms and POPQ findings were assessed after a period of prescribed activity and overnight bedrest. Main outcome measures Primary outcome was an increase in Pelvic Organ Prolapse Quantification (POPQ) measurements with activity. Secondary outcomes were association of symptoms or quality-of-life scores (Pelvic Floor Distress Inventory [PFDI] and Pelvic Floor Impact Questionnaire [PFIQ]) with an increase in POPQ measurements. Results There was a significant increase in POPQ stage and five vaginal parameters (Aa, Ba, C, Ap and Bp) with physical activity (P < 0.001). Reported symptoms, higher PFDI and PFIQ scores and higher individual symptom bother scores were not more common in the women with greater pelvic organ descent (measured by the POPQ system) following physical activity. Conclusions Greater pelvic organ prolapse was found on POPQ examination following physical activity, but this was not associated with worsening of symptoms and greater impairment of quality of life. Keywords Pelvic heaviness, pelvic organ prolapse, physical activity, vaginal lump. Please cite this paper as: Ali-Ross N, Smith A, Hosker G. The effect of physical activity on pelvic organ prolapse. BJOG 2009;116:824 828. Introduction Women commonly report worsening symptoms of prolapse with prolonged standing and lifting. Sung et al. 1 demonstrated considerable variation in symptoms in women with pelvic organ prolapse with more severe symptoms reported in the evenings and with certain activities such as walking and lifting. Epidemiological data suggest that strenuous activity may increase the need for prolapse surgery. 2,3 Jorgennsen et al. 2 found that Danish auxillary nurses were nearly twice as likely to undergo surgery for prolapse and herniated lumbar disc operations than the general population. Chiaffarino et al. 3 reported that housewives were three times more likely to undergo surgery for prolapse than managerial/professional women. Higher intra-abdominal pressures have been recorded in the erect position compared to supine and some activities, such as brisk walking, lifting and carrying weights. 4 6 Therefore, physical exertion associated with raised intra-abdominal pressure may have an impact on the pelvic organ supports resulting in worsening prolapse. This study was designed to assess whether any short-term changes occur in the symptoms and signs of pelvic organ prolapse using the validated Pelvic Organ Prolapse Quantification (POPQ) system. 7 Methods Consecutive women admitted to St Mary s Hospital, Manchester, UK, for prolapse surgery were prospectively recruited to this study. The sample size was calculated based on an estimated 20% (one POPQ stage) increase in prolapse associated with activity. Fifty women were required to detect a difference of 0.5 SD, with 90% power and a significance level of 5%. Women who had no medical contraindications to physical activity and were able and willing to give informed consent were eligible. Written information on the study was given to the women 2 weeks prior to admission at a preoperative visit. (Ethical approval was obtained for this study, and the 824 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

Physical activity and pelvic organ prolapse protocol followed guidelines from the Declaration of Helsinki.) Women due to underwent prolapse surgery were routinely admitted to the ward the night before the procedure. On admission, the women were counselled about the study. Demographic data were collected from all eligible women. Those who agreed to participate in the study were asked to remain mostly mobile for between 4 and 6 hours after which they were asked to perform 1 hour of prescribed activities. The prescribed activities involved walking about for 45 minutes (including going up and down one flight of stairs), standing up from sitting five times, bending down as if to pick something off the floor ten times and jogging/stamping briskly on the spot for one minute. Immediately following this, the women were asked to pass urine before undergoing the activity phase POPQ examination in the semi-recumbent dorsal lithotomy. The vaginal points Aa, Ba, C, D, Ap and Bp were measured during maximal Valsalva, and genital hiatus (GH), perineal body (PB) and total vaginal length (TVL) were measured at rest. Although GH and PB are measured during maximal Valsalva in the POPQ system, this was not clear in the original standardisation document and the error was only identified part way through the project. 7 As these parameters were not involved in staging, we opted to continue measuring GH and PB at rest in this study to maintain consistency. The presence of the symptoms of vaginal lump and pelvic heaviness were documented during this examination. The women were re-examined the following morning, having remained in bed overnight (except for toileting) until the rest phase POPQ was performed. Symptoms were documented as present or absent and worse, the same or improved compared with the activity phase. Both examinations were carried out by the same examiner in a standard fashion immediately following micturition. Those who agreed to join the study were also asked to complete the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ). 8 Urogynaecological symptom bother scores were calculated from the PFDI by averaging the scores of questions pertaining to symptoms of vaginal lump, pelvic heaviness, low backache, voiding difficulty, urinary urgency, urge incontinence, stress urinary incontinence, constipation, fecal urgency, fecal incontinence and perineal splinting. Therefore, 11 symptom bother scores were derived from the PFDI. Statistical analyses were performed using the software package SPSS 13.0 (Manchester, UK). Changes in the POPQ and symptoms with physical activity were analysed with Pearson s chi-square test as the data were categorical rather than continuous. The significance level was set at P 0.05. Results Eighty women were admitted to St Mary s Hospital for prolapse surgery between April and December 2003. Nine women were ineligible due to medical contraindications to activity. Fourteen women declined to participate and 3 women were unable to do so due to a misplaced examination room key and evacuation due to a fire. Fifty-four women agreed to take part in this study. The inclusions and exclusions were demographically matched in all areas except for previous hysterectomy. The characteristics of the inclusions and exclusions are shown in Table 1. The distribution of POPQ stages following rest phase and activity phases is shown in Table 2. Overall, there was a significant increase in POPQ stage with activity (Pearson s chisquare test = 66.27, P < 0.001). Thirty-eight (70%) women maintained the same POPQ stage following rest and activity. Two (4%) women had a lower POPQ activity stage than POPQ rest stage and 14 (26%) had a higher POPQ activity stage. No woman increased or decreased by more than one POPQ stage. Among the 14 women who increased in stage following activity, 3 went from stage 1 to 2, 8 went from stage 2 to 3 and 3 went from stage 3 to 4. Both the women who had lower POPQ activity stages compared with POPQ rest stages went from 3 to 2. We also excluded the nine women with POPQ rest stage 4, which by definition could not increase, and repeated the paired analysis. This did not alter our results. We showed significant increases in all the vaginal measurements except D (Pearson s chi-square test 209.92, P < 0.001). These results are shown in Table 3. The lack of significant change in the apical measurement D is likely to reflect the fact that this point is not measured in women without a uterus. In our study, the majority (33/54) had had a previous hysterectomy and hence did not have an apical measurement for D.The difference in the POPQ parameters was calculated for each woman. The greatest differences between the activity and the rest values occurred in the anterior point Ba (median difference 0.5 cm, interquartile range [IQR] 0.0 1.1) and the apical points Table 1. Characteristics of included and excluded women Characteristics Inclusions (n 5 54) Exclusions (n 5 26) Age (years), 59 (55 66) 58 (51 63) NS Parity, 3 (2 3) 3 (2 4) NS Body mass index (kg/m 2 ), 27 (25 30) 28* (25 31) NS Prolapse operations, 1 (0 1) 0 (0 0) NS Continence operations, 0 (0 1) 0 (0 0) NS Hysterectomy, n (%) 33 (61) 7 (27) 0.004 Postmenopausal, n (%) 46 (85) 22 (85) NS HRT, n (%) 16 (30) 9 (35) NS Mann Whitney test and Pearson s chi-square test used as appropriate. HRT, Hormone replacement therapy; NS, non significant. *Two missing values. P ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 825

Ali-Ross et al. Table 2. The distribution of the overall POPQ stages in the rest and activity phases POPQ stage Rest phase (number of women) Activity phase (number of women) 1 4 1 2 24 21 3 17 20 4 9 12 Pearson s chi-square test 5 66.27, P, 0.001. C and D (median differences 0.5 cm, IQR 0.0 1.1 and 1.0 cm, IQR 0.0 1.5, respectively). GH, PB and TVL remained the same at both examinations in 76, 70 and 61%, respectively. Increased values were found in 13, 19 and 11%, and reduced values were found in 11, 11 and 28%. Although the difference in the rest and activity GH, PB and TVL measurements were significant (Pearson s chi-square test 246.29, P < 0.001), change occurred similarly in both directions for GH and PB. More women demonstrated a reduction in TVL with activity, which may reflect the loss of tissue elasticity in some women with prolapse. This may result in more marked prolapse following activity being less easily replaced before measuring TVL. The presence of vaginal lump or pelvic heaviness at the time of the examination following activity was not recorded in two women. Of the remaining 52 women, 41 (79%) reported a vaginal lump and 33 (63%) reported pelvic heaviness. The symptoms following the rest phase were graded as less than,the same as and more than that of the activity phase examination by the women themselves. Rest phase symptom reporting was missing in four women for vaginal lump and five women for pelvic heaviness. Among the remaining women, the change in symptoms translated to vaginal lump being worse following activity Table 3. Analysis of change in individual POPQ parameters following prescribed rest and activity POPQ point Median (IQR) value at rest (cm) Median (IQR) value activity (cm) Aa 0 (22.0 to 1.0) 0 ( 1.1 to 2.1) 0.001 Ba 0.5 ( 1.0 to 3.3) 1.3 (0 4.0) 0.001 C 0.5 ( 1.0 to 3.3) 1.3 (0 4.0) 0.001 Ap 2.0 ( 2.5 to 1.0) 1.0 ( 3.0 to 1.0) 0.001 Bp 1.3 ( 2.5 to 2.0) 0.3 ( 2.0 to 2.3) 0.001 D 6.5 ( 7.3 to 6.0) 6.0 ( 6.3 to 4.8) 0.09 GH 4.5 (3.5 5.0) 4.5 (3.9 5.0) 0.001 PB 3.3 (3.0 4.0) 3.5 (3.0 4.0) 0.001 TVL 7.5 (7.0 8.0) 7.5 (7.0 8.0) 0.001 Pearson s chi-square test. P compared with rest in 27 (54%) women, the same in 21 (42%) and improved in 2 (4%). Concerning pelvic heaviness, 20 (41%) women had worsening of this following activity, 28 (57%) were unchanged and 1 (2%) woman reported improvement. Similar findings occurred when the nine women with a POPQ rest stage 4 were excluded. Reported worsening of symptoms, higher PFDI and PFIQ scores and higher individual symptom bother scores were not associated with POPQ findings following physical activity. The same was found when the nine women with POPQ rest stage 4 were excluded. Discussion The development of prolapse and awareness of prolapse symptoms are posture dependent. The most common symptom of prolapse, a sensation of vaginal bulge in or beyond the vagina, often diminishes or disappears when lying horizontal. It is not known how much time or how much activity is required to maximise the anatomical appearance of a prolapse. This study demonstrates that physical activity can lead to an increase in the degree of prolapse evident on examination. This has implications for the clinicians involved in the assessment of women who present with prolapse symptoms. There may be other influences on the anatomical appearance of prolapse, such as the time of the menstrual cycle or loading of the bladder or bowel. In this study, 14 women increased in POPQ stage with activity, but in all cases, this was by only one stage. This may have been influenced by the POPQ system being a short ordinal scale with only five discrete stages. Although one stage was the minimum increase possible, it represents approximately a 20% increase in the POPQ scale. In reality, no standard mathematical relationship exists between the POPQ stages (e.g. stage 2 is not double of stage 1). Thus, an increase from stage 1 to 2 may have involved less increase in prolapse than upstaging from stage 2 to 3 or stage 3 to 4. The majority of women (8/14) increased from stage 2 to 3. In other words, these women had a prolapse within 1 cm of the hymenal ring at rest, which increased to greater than 1 cm beyond the hymenal ring but to less than TVL-2 cm following activity. Although all three vaginal compartments increased with activity, this was maximal for the anterior and apical compartment. This may reflect greater sensitivity of these compartments to physical exertion or posture. In the upright position, the long axis of the vagina runs superoposteriorly in front of the perineal body and then horizontally over levator ani towards the coccyx. Therefore, in addition to fascial supports, the posterior vagina sits in front of the muscular perineal body and levator ani, which may afford it more direct support than the anterior or apical compartments. This may explain, in part, why anterior vaginal prolapse is more common than posterior prolapse and has high reported recurrence rate following surgery. 9 If 826 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

Physical activity and pelvic organ prolapse muscular bulk and tone are helpful in supporting the posterior compartment, then some women may benefit from pelvic floor muscle training. Although overall there were significant increases in the vaginal POPQ parameters and stage, this was not universal. Some women had less or the same prolapse following activity compared with the rest phase. There are several reasons why such a finding may occur. First, it may be that greater pelvic organ descent is not specific to those with prolapse. Women generally may have some normal variation in pelvic floor support with physical activity, but as we did not have an asymptomatic group of controls, this was not quantified. Also, the influence of other variables such as rectal loading was not controlled and may have influenced the sensation of vaginal fullness or bulging. Second, the level of activity involved in this study may also have influenced our results. Despite being asked to perform prescribed activities, this was only for 1 hour in all women. Prior to this, all women were asked to remain mostly mobile for up to 6 hours. This was carried out to minimise the disruption of their medical management and to allow women to judge what level of activity they found comfortable. It is quite possible that the women were not as active as they would have been at home or work. By the same token, rest the night before planned surgery may differ from resting at home. Anxiety may cause difficulty sleeping and frequent toilet visits. Therefore, overall, it is possible that our results underestimate the effect of activity on prolapse. Third, due to practical restrictions, it was not possible to randomise the sequence of rest and activity phases as many women were starved overnight and had surgery in the morning. Neither was it possible to blind the examiner to whether the women were in the activity or rest phase as this was implicit by the time of day. It is unclear whether a more rigorous period of activity would have revealed a greater change in the anatomical findings. A community-based study with women performing standardised activities that represent normal life (e.g. hoovering, carrying shopping bags etc.) for longer than 1 hour and involving blinded examiner(s) may provide more valid information. More women reported worsening vaginal lump (54%) and pelvic heaviness (41%) following activity than demonstrated increases in POPQ stage (26%). Once again, the rather coarse staging system may have contributed to this. However, worsening symptoms were not associated with increased POPQ signs. Neither did worse overall quality of life (measured by the PFDI and PFIQ) nor higher symptom bother scores show association with the women who demonstrated greater prolapse. Symptom reporting may be variable and influenced by psychological issues such as repeated attention drawn to pelvic floor symptoms and other variables such as rectal loading and individual expectation. However, it is possible that the symptoms and quality-of-life tools measure different aspects of prolapse than the POPQ system. Conclusions This study demonstrated that one in four women increase in POPQ stage following activity. Significant increases in pelvic organ descent in all three vaginal compartments were found. Worsening symptoms of vaginal lump or pelvic heaviness did not show association with increased prolapse following exertion. Until this is more fully understood, women complaining of prolapse might be better assessed later in the day or following specified activities, particularly if their symptoms do not correlate with examination findings. Furthermore, studies of prolapse treatment should include standardisation of activity before the anatomical result is assessed. Disclosure of interest None. Contribution to authorship N.S.A.-R. contributed to the conceptualisation of the study, recruitment and evaluation of the women and preparation of the manuscript. A.R.B.S. contributed to the conceptualisation of the study and supervised the writing of the manuscript. G.H. was provided statistical advice and support. Details of ethics approval Ethical approval was granted by Central Manchester Local Research Ethics Committee. Funding None. Acknowledgement We would like to thank the clerical and nursing staff who enabled us to identify all the women due to be admitted for prolapse surgery during the study period. j References 1 Sung VW, Clark MA, Sokol ER, Rardin CR, Myers DL. Variability of current symptoms in women with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:787 98. 2 Jorgennsen S, Hein HO, Gyntelberg F. Heavy lifting at work and risk of genital prolapse and herniated lumbar disc in assistant nurses. 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