Frequency of Urinary Symptoms in Post Menopausal Women with Uerovaginal Prolapse

Frequency of Urinary Symptoms in Post Menopausal Women with Uerovaginal Prolapse

1. Samina 2. Irshad Nabi 3. Ghulam Nabi Khokhar 4. Israr Ahmed Akhund 5. Muhammad Ishaq

1. Asstt. Prof. of Obst & Gynae, 2. Asstt. Prof. of Community Medicine, 3. Prof. of Pharmacology 4. Prof. of Physiology, 5. Prof. of Surgery, Jinnah Medical College Peshawar.

ABSTRACT

Objective: To determine the frequency of urinary symptoms in postmenopausal women with Uterovaginal Prolapse

Study Design: Descriptive study

Place and Duration of Study: This study was conducted in Department of Obstetrics & Gynecology Unit II , Dow University of Health Sciences & Civil Hospital Karachi Pakistan from July 2006 to June 2007/

Materials and Methods: 60 (sixty) Consecutive pts were included in the study through structural Proforma from the outpatient, ward or emergency. Informed consent was obtained. A detailed history and related examinations and investigations were done. These include Urine DR, Urine C/S and Urodynamics like cystometry in selected patients.

Results: Majority of Women found have symptoms were at the age of 60 yr (36.66%) While urinary symptoms less seen at the age of 80 yr (6.66%) while Parity 6-10 was higher in Postmenopausal women to have urinary symptoms (63.33%). The urinary symptoms found in Postmenopausal women were frequent urine passing (33.33%), Nocturia (83.33%), Retention of urine (20.0%), Dysuria (26.66%), Voiding difficulty (53.35%), Urge incontinence (20.0%) and Stress incontinence (53.33%).

Conclusion: Pelvic organ Prolapse and urinary symptoms like incontinence are prevalent in older women and are associated with age. Large studies are required to assess the relationship of urinary symptoms with Uterovaginal Prolapse. Because these urinary symptoms effect over quality of life of women so it is recommended to reduce genital prolapsed and associated urinary symptoms by implementing some measures such as health education of women and weight control.

Key Words:Postmenopausal, Uterovaginal Prolapse, urinory symptoms


 

INTRODUCTION

Urogenital Prolapse also called Pelvic Organ Prolapse (POP), is the downward descent of the pelvic organs (bladder, uterus and rectum ) that results in their protrusion through the vagina1.

Urogenital prolapse occurs when there is a weakness in the supporting structures of the pelvic floor allowing the pelvic visceras to descent and ultimately fall through the anatomical defect , while usually not life threatening prolapsed is often symptomatic and is associated with a deterioration in quality of life and may be the cause of bladder and bowel dysfunction2.

In a healthy women in whom the levator ani has normal tone and the vagina has adequate depth, the upper vagina lies nearly horizontal when she in upright. The result in a ‘flap valve’ in which the upper vagina presses against the levator plate when there is an increase in intra abdominal pressure, when the levator ani loses tone, it moves from a horizontal to a semi-vertical position, creating a widened genital hiatus (i.e the distance between the external urethral meatus and the posterior midline hymen) that forces the pelvic structures to rely on connective tissue for support, when the connective tissue support also fails, as a result of possible collagen decrease and tearing , prolapse may occur1.

The female genital organ are maintained in their normal anatomical position by a number of fascia candensation (endo pelvic fascia) reffered to as ligaments, especially the transverse cervical (cardinal) and uterosacral ligaments, weakness in any of these supportive structures leads  to uterine descent, particularly around the period of menopause when oestrogen withdrawl causes a second insult to thr integrity of the pelvic supports already weakened by repeated vaginal deliveries. Hence child birth and ageing constitutethe most important associated factors of female genital prolapse3.

The true incidence is uncertain due to the fact that a number of women with Uterovaginal prolapse may not present for management due to the privacy attached to the affectation of the sexual / reproductive organs coupled with the stigmatization accorded associated clinical entities such as urinary and fecal incontinence. However, existing data suggest that about 50% of parous women suffer some form of genital tract prolapse  and only 10-20% of them seek medical care4.

Though not a life threatening condition it mis a sourse of severe morbidity and psychological upheaval to the patient who in often socially withdrawn and stigmatized. It is one of the common indications for major pelvic reconstructive gynecological surgeries, only recently, the World Health Organization (WHO) alerted all nations including developing countries of the need for greater recognition of the health of ageing women , since the number of ageing women appear to be increasing in proportion to the increasing life expectancy of each population4

 In the Women’s Health Initiative Study, investigators found a 41.1% prevalence of pelvic organ prolapse at a standard physical assessment in postmenopausal women older than 60 yrs who had not had a hysterectomy. Poor conduct of labour, as in bearing down before full cervical dilatation , prolonged traction from high forceps delivery, and downward pressure on the fundus during attempts to deliver the placenta (crede’s manoeuvre) are all obstetric factors which predispose to U V prolapse. It is also common in conditions of chronically raised intra abdominal pressure which include COAD (Chronic Obstructive Airway disease), obesity, abdominal tumour, straining during defaecation and heavy physical exertion. Very  rarely it could be due to the congenital weakness of the pelvic floor muscles (as in Spina bifida) joint hypermobility (as in connective tissue abnormalities) and altered collagen metabolism3.

The process of ageing can result is  loss collagen, weakness of fascia and connective tissue.

 These effects are noted particularly of during the postmenopause as a consequence of oestrogen deficiency. Women usually present with non specific & specific symptoms. The non specific symptoms are lump , local discomfort , backache, bleeding / infection if ulcerated, dyspareunia or apareunia, rarely in extremely severe cystourethrocele, uv prolapsed  or vault prolapse , renal failure may occur as a result of ureteric kinking, While the specific symptoms are in case of cystourethrocele, urinary frequency and urgency, voiding difficulty, UTI and stress incontinence5.

The urinary incontinence can be categorized into 4 main types: Stress, Urge, Overflow and Functional incontinence, although most patients present with a mixed picture . Urinary Incontinence can restrict the social, family, professional and sexual activities of women and lower their quality of life by generating social isolation and emotional stress, often combined with a feeling of inferiority and depression. Along with these physical and social consequences, there is also a financial burden which is substantial and growing6.

Urinary urge incontinence and overactive bladder in age related and its prevalence rate is found to be similar amoung western and asian women. Stress and urge urinary incontinence are common in postmenopausal women and have different risk factors suggesting yhat approaches to risk factors modification and prevention might differ and should be specific to types of incontinence. There is a special need for conducting studies amoung our population as risk factors for incontinence such as grand multiparity and obesity are common in our community. Urinary frequency and incontinence also have religious significance for our population. According to Islamic tradition, women must wash after every void or episode of urine leakage. This can be very troublesome at the time of Hajj or pilgrimage when frequent prayers are performed 7.

The global prevalence of urinary incontinence is about 49% for stress urinary incontinence, 22% for urge urinary incontinence and 29% mixed incontinence. Urinary urge incontinence and overactive bladder is age related while stress and urge urinary incontinence is common in postmenopausal women8.

Approximately 1 in 3 women over the age of 65 yr have some degree of incontinence. By the age of 80 yrs 15% to 40% of community dwelling elderly have experienced incontinence7.

It is estimated that 50% to 70% of incontinence persons do not seek help for their problems and in a survey of Primary Care Physicians most enquired about incontinence in 25% or fewer of their patients. For these reasons, it is essential that questions about incontinence be included in the routine assessment of every older patient9.

Despite the high prevalence of urinary symptoms in the elderly and it’s  profound impact on quality of life, These urinary symptoms continues to be under reported and under diagnosed due to reluctance of pts  as well as providers to have the false belief that it is an unavoidable consequence of aging.

The aim of our study is to determine the frequency of urinary symptoms in postmenopausal women with Uterovaginal prolapse.

MATERIALS AND METHODS

The study was carried out in the department of obstetrics and Gynecology unit II, Dow University of Health Sciences and Civil Hospital Karachi Pakistan. This was a Descriptive Study from July 2006 to January 2007. Sixty patients were included in the study through structured proforma by purposive sampling technique from the outpatient, ward or emergency. Informed consent was obtained. The inclusion criteria were patients with all degree of uterovaginal prolapse, postmenopausal women, married & unmarried women. Inclusion criteria were women with diagnosed renal pathology, recurrent UTI, pregnant women and medical disorder such as Diabetes Mellitus.

A detailed history and related examination and investigations were done. These include urine DR, Urine C/S, and urodynamics like cystometry in selected patients. (Frequency was defined as the passage of urine seven or more times a day, or being awoken from sleep more than once a night to void which in also known as Nocturia. Urgency means a sudden desire to void, while dysuria defined as urethral pain during micturation. Retention of urine means failure to empty the bladder totally. Voiding problems include hesitancy, a poor stream straining to void incomplete bladder and also frequency, urgency and dysuria. Stress incontinence means loss of urine on physical effort which urgeincontinence is an involuntary loss of urine associated with a strong desire to void).

RESULTS

In  this study the frequency of urinary symptoms found in postmenopausal women were like frequent urine passing (33.33%), Nocturia (83.33%), Retention of urine (20.0%), Dysuria (26.66%), Voiding difficulty (53.33%), Urge incontinence(20.0%), while stress incontinence (53.33%).

Table No.1: Clinical presentations / symptoms of Pt: in frequnecy of urinary symptoms in postmenopausal women with uv prolapse

Table No 1 A                          N=60

Symptoms

YES

%

NO

%

Frequent urine Passing

20

33.33%

40

66.66%

 

Table No 1 B                          N=60

Symptoms

YES

%

NO

%

Nocturia

50

83.33%

10

16.66%

 

Table No 1 C                          N=60

Symptoms

YES

%

NO

%

Retension of urine

12

20%

48

80%

 

Table No 1 D                          N=60

Symptoms

YES

%

NO

%

Dysuria

16

26.66%

48

73.33%

 

Table No 1 E                          N=60

Symptoms

YES

%

NO

%

voiding difficulty

32

53.35%

28

46.66%

 

Table No 1 F                          N=120

Incontinence of urine

Yes

%

No

%

Urge incontinence

12

20%

48

80%

Stress incontinence

32

53.33%

28

46.66%

Table No.2: Age Distribution      n=60

Age (yr)

Frequency

Percentage

40

2.0

3.33%

45

4

6.66%

50

12

20.00%

55

6

10.00%

60

22

36.66%

65

2

3.33%

70

6

10.00%

75

2

3.33%

80

4

6.66%

Majority of women found have symptoms were at the age of 60 yr (i.e 36.66%) while urinary symptoms less seen at the age of 40 yr (i.e 3.33%)  and the age of 80 yr (6.66%), while Parity 6-10 was higher in postmenopausal women to have urinary symptoms (i.e 63.33%).

Table No.3: Parity                             n=60

Parity

Frequency

Percentage

0-1

0

0%

2-5

22

36.66%

6-10.

38

63.33%

DISCUSSION

Menopause is the permanent cessation of menstruation resulting from the loss of ovarian and follicular activity. It usually occurs when women reach their early 50’s but it can vary between 40 & 58 yr of age. The incidence of certain conditions (eg: Diabetes, breast cancer, cervical carcinoma) increases after menopause, Female pelvic organ prolapse is a common condition in Parous women8.

According to one study conducted at Liaquat National Hospital Karachi 27.8% women who had urinary incontinence were postmenopausal9.

In our study majority of women found have symptoms less seen at the age of 40 yr (i.e. 3.33%) and at the age of 80 yr (i.e. 6.66%).

According to one study UI was more in women with high parity 9, while in this study parity 6-10 was higher in postmenopausal women to have urinary symptoms (i.e. 63.33%).

One study conducted at AKU Hospital Karachi Pakistan which states that the frequent urine passing symptoms occur in 44 (23.7%) of respondent and 74 (39.8%) experienced nocturia 6.

In our study the frequent urine passing symptoms found in postmenopausal women with Uterovaginal Prolapse is (33.33% ) while nocturia found (83.33%)

Urinary urgency with or without incontinence effects one in four adults over the age of 65 yr while stress.

A Postal Study from US in more than 3,500 women reported UI in 45% of women including one quarter of those between the age of 30 & 39 yrs and half of those between the ages of 50 & 90 yrs 10, while in our study urge incontinence reported 20.0% while stress incontinence reported 53.33%

According to one study dysuria occurred 18 (42.9%) of the with UV Prolapse 4. While in our study Dysuria found 26.66%, Voiding difficulty 53.35% found and Retention of urine found 20.0%.

CONCLUSION

Pelvic organ prolapsed and urinary symptoms like incontinence are prevalent in older women and are associated with age, Menopause and no hormone therapy. Large studies are required to assess the relationship of urinary symptoms with Uterovaginal Prolapse. Because these urinary symptoms effect over quality of life of women so it is recommended to reduce genital prolapsed and associated urinary symptoms by implementing some measure such as health education of women and weight control.

 

REFERENCES

1.       Kuncharapu I, Majeroni BA, Johnson DW. Pelvic organ prolapse. Am Fam Phys 2010;81(91):
1111-17.

2.       Srikrishna S, Robinsen D. Urogenital prolapse. In: Lussely DM, Baker PN, editors. Obstetrics and gynaecology. London: Hodder Arnold; 2010.p.
725-34.

3.       Ojiji EC, Dike EI, Anolue FC, Nzewuihe ACE, Ejikem CC. Uterovaginal prolapsed at a university Teaching Hospital in South- East Nigeria. Orient J of Med 2013;25 [3-4]: 107-12.

4.       Onowhakpor EA, Omo-Agoja LO, Akani CI, Fey Waboso P. Prevalence and Determinants of uterovaginal prolapsed in Southern Nigeria. Niger Med J 2009;50(2) : 29-32.

5.       Uterovaginal prolapsed. In: Monga A, editor. Gynaecology by Ten Teachers. London: Hodder  Arnold; 2006.p.200-06.

6.       Tahir S, Abdullah A. Frequency of Urinary incontinence and the associated obstetrics & gynaecology risk factors. J of Surg Pak (Int) 2012; 17 (2):48-52.

7.       Stephan E, Hajjar RR. Urinary incontinence in older adults. J Med Liban 2012.

8.       Rizvi RM, Nazim MH. Frequency of urinary symptoms in women attending gynaecology clinics at the AKUH, Pakistan. J PMA 2005;55(11):
489-492.

9.       AF, AAJ, SB, AH, Kh S. Postmenopausal Urogenital Diseases in Bangladesh A Study of Kumuddin Women Medical College & Hospital. KYAMCJ 2013; 3 (2): 290-93.

10.    Costatini E, Lazzeri M. Urogenital Prolapse Surgery – An update on Post operative urinary incontinence. Touch Briefing 2008: 74-76.

 

Address for Corresponding Author:

Prof. Dr. Muhammad Ishaq

Chairman & Founder
Jinnah Medical College Warsak Road, Peshawar.

Contact No: 0333-9152060