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UROGYNECOLOGY

Lower abdominal and pelvic pain with advancedpelvic organ prolapse: a case-control studyJhansi Reddy, MD; Matthew D. Barber, MD, MHS; Mark D. Walters, MD; Marie Fidela R. Paraiso, MD; J. Eric Jelovsek, MD

OBJECTIVE: The objective of the study was to compare the relative fre-quencies of pain in women with and without pelvic organ prolapse (POP).

STUDY DESIGN: This was an ancillary analysis of a case-control studynvestigating functional bowel disorders in women with and withoutOP. Cases were defined as subjects with stage 3 or 4 POP and con-rols were subjects with normal pelvic support.

RESULTS: Women with POP were more likely to experience lower ab-dominal or pelvic pain that was significantly bothersome and interfered

with daily activities (odds ratio [OR], 9.7; 95% confidence interval [CI],

Obstet Gynecol 2011;204:537.e1-5.

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4.7–20.4). After controlling for confounders, women with prolapsewere 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 withwomen with normal support.

Key words: advanced prolapse, lower abdominal pain, pelvic organ

prolapse, pelvic pain

Cite this article as: Reddy J, Barber MD, Walters MD, et al. Lower abdominal and pelvic pain with advanced pelvic organ prolapse: a case-control study. Am J

Data from the 2005-2006 NationalHealth and Nutrition Examina-

tion Survey estimates that pelvic floordisorders affect 24% of women in theUnited States,1 and that number is ex-

ected to rise rapidly with the agingopulation.2,3 A common symptom re-orted by patients with prolapse is theccurrence of pain, which is often attrib-ted to pain in the lower back, abdomen,r pelvic areas. Despite the growingrevalence of pelvic organ prolapse, fewata exist correlating abdominal and pel-ic pain symptoms between women withrolapse and those with normal vaginalupport.

From the Center for Urogynecology andReconstructive Pelvic Surgery, Obstetrics,Gynecology, and Women’s Health Institute,Cleveland Clinic, Cleveland, OH.

Presented at the 31st Annual Scientific Meetingof the American Urogynecologic Society, LongBeach, CA, Sept. 30-Oct. 2, 2010.

Received Oct. 20, 2010; revised Dec. 16,2010; accepted Jan. 13, 2011.

Reprints: J. Eric Jelovsek, MD, ClevelandClinic, Department of Obstetrics andGynecology, Desk A-81, 9500 Euclid Ave.,Cleveland, OH 44195. jelovsj@ccf.org.

0002-9378/$36.00© 2011 Mosby, Inc. All rights reserved.

Although lower abdominal and pelvicain have been found to be highly prev-lent among women, little is knownbout the association between advancedrolapse and specific patient-reportedain symptoms.4,5 Some women aresymptomatic, whereas others presentith a myriad of clinical symptoms re-

ated to bladder, bowel, and/or sexualysfunction. One prospective cohorttudy investigating the symptoms andeverity of prolapse reported that 44% ofhe subjects complained of pelvic pain,nd of those subjects experiencing pain,9% reported that the pain had a nega-ive impact on their quality of life.6 On

the other hand, other investigators havedemonstrated that women with a moreadvanced stage of prolapse report lesspelvic and low back pain, thus failing toidentify a strong correlation betweenprolapse and pain symptoms.7

Because most studies investigatingpatient-reported pain symptoms anddegree of prolapse failed to include acontrol group of women with normalvaginal support, it is difficult to deter-mine whether actual differences existfrom the normal population. A betterunderstanding of the relationship be-tween pain symptoms in women withand without prolapse may provide in-

omen on the like-

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lihood that their pain symptoms are as-sociated with their prolapse.

The objective of our study was to com-pare the relative frequencies of lowerabdominal and pelvic pain betweenwomen with advanced pelvic organ pro-lapse to women with normal vaginalsupport. Our hypothesis was that the rel-ative frequency of lower abdominal andpelvic pain would be increased in womenwith advanced pelvic organ prolapse ascompared with women with normal vag-inal support.

MATERIALS AND METHODS

This case-control study was approved byour local institutional review board. Itwas a secondary analysis of a previouslyreported study investigating the func-tional bowel symptoms and anorectaldisorders in patients with advanced pel-vic organ prolapse.8 Subjects were de-fined as those who presented to a tertiaryurogynecology clinic with advanced pel-vic organ prolapse (stage 3 or 4). Con-trols were defined as subjects presentingto a general gynecology or women’shealth clinic for annual examinationswith normal pelvic support (stage 0 or 1)and without urinary incontinence. De-mographic, historical, and physical ex-

amination information was collected.

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All subjects completed a validated ques-tionnaire on functional bowel disorders(Rome II Modular Questionnaire)9 as wells a generalized (Short-Form Health Sur-ey-12)10 and a condition-specific (Pelvic

Floor Distress Inventory-20)11 health-re-lated quality-of-life scale. In the originalstudy, assuming a baseline prevalence ofconstipation in the control group of 16%, asample size of 123 subjects in each groupprovided 80% power to detect a differencebetweenthisbaselineprevalenceandanin-creased prevalence of 32% in the prolapsegroup, using a 2-group continuity-cor-rected �2 test with a 0.05 2-sided signifi-cance level.8

For this analysis, the primary outcomewas abdominal or pelvic pain based onthe subject’s responses to specific pain-related questions abstracted from theShort-Form Health Survey-12 Question-

TABLE 1Demographics of women with stagwith women with normal vaginal s

Variable

SP(

Age (y) mean � SD...................................................................................................................

White 1...................................................................................................................

Married...................................................................................................................

Education level..........................................................................................................

High school diploma..........................................................................................................

College degree or higher...................................................................................................................

Annual household income �$50,000...................................................................................................................

Charlson Comorbidity Index..........................................................................................................

0 1..........................................................................................................

1..........................................................................................................

�2...................................................................................................................

Antidepressant use...................................................................................................................

Narcotic use...................................................................................................................

Laxatives...................................................................................................................

Prior hysterectomy...................................................................................................................

Prior rectocele repair...................................................................................................................

Prior vaginal or prolapse surgery...................................................................................................................

Prior anorectal surgery...................................................................................................................

Data are presented as n (%) unless otherwise noted.POP, pelvic organ prolapse.

Reddy. Lower abdominal and pelvic pain in advanced pro

naire, Pelvic Floor Distress Inventory- a

537.e2 American Journal of Obstetrics & Gynecolo

20 (PFDI-20) Questionnaire, and theRome II Modular questionnaires.

The following questions from thePFDI-20 were used to elicit whether thestudy subjects had symptoms of pelvic orlower abdominal pain: “Do you usuallyexperience pressure in the lower abdo-men”; “do you usually experience heavi-ness or dullness in the pelvic region”; and“do you usually experience pain or dis-comfort in the lower abdomen or genitalregion?” The question, “During the past4 weeks, how much did pain interferewith your normal work (including bothhousework and work outside thehome)” was abstracted from the Short-Form Health Survey-12 Questionnaire,whereas 2 questions (“In the last 3months, did you often have discomfortor pain in your abdomen” and “In thelast 6 months, did you have pain in your

or 4 POP comparedport

e 3 or 4(cases)128)

Normal vaginalsupport (controls)(n � 127) P value

.9 � 10.5 60.5 � 11.6 .09..................................................................................................................

(91.9) 97 (76.4) � .001..................................................................................................................

(72.1) 83 (66.4) .36..................................................................................................................

..................................................................................................................

(24.2) 39 (31.5) � .001..................................................................................................................

(12.9) 33 (26.6)..................................................................................................................

(51.8) 56 (62.2) .41..................................................................................................................

..................................................................................................................

(83) 87 (71) .01..................................................................................................................

(13.1) 17 (13.8)..................................................................................................................

(4.1) 19 (15.4)..................................................................................................................

(17.9) 30 (25) .18..................................................................................................................

(6.6) 8 (6.7) .97..................................................................................................................

(17.9) 24 (19.4) .77..................................................................................................................

(48) 32 (26) � .001..................................................................................................................

(14) 1 (1) � .001..................................................................................................................

(23) 3 (3) � .001..................................................................................................................

(3) 0 .08..................................................................................................................

e. Am J Obstet Gynecol 2011.

bdomen all the time [continuously] b

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or most of the time [nearly continu-ously] [this should not be related toyour menstrual cycle or period]”) wereabstracted from the Rome II ModularQuestionnaire.

The possible responses to the ques-tions were “yes” or “no.” If the subjectsanswered “yes” to the questions from thePFDI-20, they were prompted to charac-terize the degree of bother as “not at all,”“somewhat,” “moderately,” or “quite abit.” Subjects who answered “yes” butreported that the pain was “not at allbothersome” were also categorized as nopain. Subjects were arbitrarily character-ized as having bothersome pain symp-toms if they reported the degree ofbother as “moderately” or “quite a bit”when answering the PFDI-20 questions.

Categorical data comparing lower ab-dominal and pelvic pain between casesand controls were analyzed using the �2

statistic and the Student t test for contin-uous data. Odds ratios (ORs) with 95%confidence intervals (CIs) were calcu-lated to estimate the relationship be-tween lower abdominal and pelvic painwith advanced organ prolapse. Multiplelogistic regression was used to adjust forpotential confounding variables and waspresented using adjusted ORs with 95%CIs. Statistical analysis was performedusing JMP 8.0 (SAS Institute, Cary, NC),and statistical significance was set atP � .05.

RESULTSIn the study, 128 cases and 127 controlswere enrolled. Demographics and uni-variate comparisons between cases andcontrols were previously published.8

Relevant variables are summarized inTable 1. Mean ages for cases and controlswere similar (62.9 � 10.5 years and

0.5 � 11.6 years, respectively, P � .09).ases were more likely to be white, have

ess medical comorbidity, to report a his-ory of straining at work, and had previ-usly undergone a hysterectomy or pro-

apse repair. Controls were more likely tochieve more years of formal education.here were no differences between mar-

tal status, household income, and use ofntidepressants, narcotics, or laxatives

e 3up

tagOPn �

62.........

13.........

88.........

.........

30.........

16.........

43.........

.........

01.........

16.........

5.........

22.........

8.........

22.........

61.........

17.........

28.........

3.........

etween the 2 groups.

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Responses to questions pertaining tothe presence of pain in the pelvis andlower abdomen are summarized in Table2. Women with advanced prolapse weremore likely to experience pressure (59%vs 21%, P � .001), heaviness or dullness(60% vs 12%, P � .001), or pain or dis-omfort (46% vs 9%, P � .001) in theirower abdominal or pelvic region, whichas significantly bothersome comparedith women with normal vaginal sup-ort. Furthermore, the pain signifi-antly interfered with their ability toerform work inside and outside theousehold (61% vs 37%, P � .001).After controlling for race, education,

medical comorbidities, prior hysterec-tomy, and prolapse repair, women withprolapse were more likely to report pres-sure in the lower abdomen (adjusted OR,2.3; 95% CI, 1.6 –3.2), heaviness or dull-ness in the pelvic region (adjusted OR,3.3; 95% CI, 2.3– 4.3), and pain or dis-

TABLE 2Risk of reporting pelvic or lower ab3 or 4 POP compared with women

Pain question

Pelvic Floor Distress Inventory-20..........................................................................................................

1a. Do you usually experience pressure in..........................................................................................................

1b. Bothersome pressureb

..........................................................................................................

2a. Do you usually experience heaviness opelvic region?

..........................................................................................................

2b. Bothersome heaviness or dullnessb

..........................................................................................................

3a. Do you usually experience pain or discabdomen or genital region?

..........................................................................................................

3b. Bothersome pain or discomfortb...................................................................................................................

Short-Form Health Survey-12..........................................................................................................

1. During the past 4 weeks, how much didyour normal work (including both workand housework)?

...................................................................................................................

Rome II Modular Questionnaire..........................................................................................................

1. In the last 3 months, did you often havein your abdomen?

..........................................................................................................

2. In the last 6 months, did you have painthe time (continuously) or most of the tcontinuously)?

...................................................................................................................

Data are presented as n (%) unless otherwise noted.CI, confidence interval; OR, odds ratio; POP, pelvic organ prola Logistic regression model included race, education, Charlson

or “quite a bit” when answering the PFDI-20 questions.

Reddy. Lower abdominal and pelvic pain in advanced pro

comfort in the lower abdomen or genital

region (adjusted OR, 2.6; 95% CI, 1.8–4.1). In addition, the pain significantly in-terfered with their ability to perform workboth inside and outside the household (ad-justed OR, 2.4; 95% CI, 1.6–4.3).

COMMENTThis study demonstrated that womenwith advanced pelvic organ prolapsewere more likely to report symptoms ofpain, pressure, or heaviness in the lowerabdominal or pelvic region comparedwith women with normal vaginal sup-port. Moreover, these symptoms weremore likely to be clinically bothersomeand restrict their ability to perform workboth inside and outside the household,after controlling for potential confound-ers. To our knowledge, this is one of thefew studies specifically investigating pa-tient reported pain symptoms in womenwith advanced prolapse compared with

minal pain in patients with stageh normal vaginal support

Stage 3 or 4POP (n � 128)

.........................................................................................................................

lower abdomen? 71 (59).........................................................................................................................

68 (57).........................................................................................................................

ullness in the 72 (60)

.........................................................................................................................

69 (58).........................................................................................................................

fort in the lower 56 (46)

.........................................................................................................................

56 (46).........................................................................................................................

.........................................................................................................................

in interfere withside the home

76 (61)

.........................................................................................................................

.........................................................................................................................

comfort or pain 39 (33)

.........................................................................................................................

our abdomen all(nearly

13 (11)

.........................................................................................................................

.

orbidity Index, and prior hysterectomy and prolapse repair; b Both

e. Am J Obstet Gynecol 2011.

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Previous studies have found either aweak or no correlation between symp-toms of pain and the presence of ad-vanced prolapse.7 For example, Heit etal7 found no association between pel-vic organ prolapse and symptoms ofpelvic or low back pain. Their study in-cluded a sample size of 152 womenwith symptomatic prolapse and used avisual faces scale to quantify the degreeof pain rather than direct questions.However, this study lacked a controlgroup of subjects with normal vaginalsupport.7

Our findings were consistent withlarger cohort studies examining pelvicsymptoms in women with pelvic floordisorders.6,12-14 In an epidemiologic sur-ey study conducted in France, Fritel etl12 reported a significant association be-

tween symptoms of pelvic organ pro-lapse and lower abdominal pain orheaviness (adjusted OR, 4.79; 95% CI,

trols� 127) P value

Adjusted OR(95% CI)a

..................................................................................................................

(21) � .001 2.3 (1.6–3.2)..................................................................................................................

(17) � .001..................................................................................................................

(12) � .001 3.3 (2.3–4.3)

..................................................................................................................

(6) � .001..................................................................................................................

(9) � .001 2.6 (1.8–4.1)

..................................................................................................................

(8) � .001..................................................................................................................

..................................................................................................................

(37) � .001 2.4 (1.6–4.3)

..................................................................................................................

..................................................................................................................

(12) .006 3.1 (1.4–6.7)

..................................................................................................................

(3) .04 4.4 (1.1–17.8)

..................................................................................................................

e symptoms defined as the degree of bother as “moderately”

dowit

Con(n

......... .........

the 26......... .........

21......... .........

r d 15

......... .........

8......... .........

om 11

......... .........

10......... .........

......... .........

paout

47

......... .........

......... .........

dis 14

......... .........

in yime

4

......... .........

apse

Com ersom

2.98 –7.71). However, this study was

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limited because the presence or degreeof prolapse could not be verified be-cause the study subjects were neverexamined.12

In another prospective study ofwomen with symptomatic pelvic organprolapse, Ellerkmann et al6 noted that

4% of subjects reported symptoms ofelvic pain and those experiencing pain,9% reported it had a negative impact onheir quality of life. Because this studyacked a control group of asymptomaticomen, it is difficult to draw conclusionsetween the presence of pelvic pain andymptomatic prolapse.6 Swift et al13

noted that 48% of the women in theirobservation study correlating symptomswith degree of prolapse reported lowback and groin pain with 33% reportingit as bothersome. The authors did not re-port on the prevalence of pain symptomsby stage of prolapse and excluded painsymptoms from their final analysis;therefore, the specific association be-tween pain symptoms and prolapse wasnot clearly reported.

The strengths of our study were thecase-control study design that included acontrol group of women with normalvaginal support, the use of 3 valid andreliable questionnaires, and the demon-stration of differences seen in all pain-related questions within these question-naires. Because the majority of previousstudies investigating patient-reportedpain symptoms and advanced prolapsewere retrospective or uncontrolled co-hort studies, this study should provideadditional support for the associationbetween pain and pelvic organ prolapse.Control subjects in this study werewomen seeking annual well-women carefrom the same tertiary referral medicalcenter, and these women underwent agynecological examination to verify nor-mal vaginal support minimizing the riskof referral or proximity bias.

These findings only begin to touch onthe complex interplay between advancedpelvic organ prolapse and patient-re-ported pain symptoms. We know thatpelvic floor disorders have both physicaland psychosocial implications, whichmay affect a woman’s perception of painand bother.15,16 In a study of women

ith chronic pelvic pain, Tu et al16 noted

537.e4 American Journal of Obstetrics & Gynecolo

that women with chronic pelvic pain ex-hibited signs of enhanced pelvic floorpain sensitivity compared with healthycontrols.

It is unclear whether women with painand advanced prolapse are more likely toseek medical attention than womenwithout pain and advanced prolapse.Heit et al17 demonstrated that the prob-ability of choosing expectant manage-ment rather than surgery increased as thepreoperative pelvic pain score increased(OR, 1.6; 95% CI, 1.07–2.40). The au-thors speculated that this may reflect thepatient’s perception that surgery wouldincrease the amount of postoperativepain or that surgery would not reducethe amount of preoperative pain present.Future studies investigating health-seek-ing behaviors of women with pelvic floordisorders should incorporate some as-pects of measuring pain to determinewhether women with advanced pro-lapse are more or less likely to seekmedical attention if they also have painsymptoms.

Previous studies have demonstratedthat reviewing patient goals and discuss-ing expectations are paramount to opti-mizing patient and surgeon satisfactionfollowing the treatment of pelvic floordisorders.19,20 Recent studies have dem-onstrated that patients should expectimprovement of pain following surgeryfor pelvic organ prolapse. Barber et al18

reported clinically significant improve-ments in pain scores 6 and 12 monthsfollowing surgical correction of stage 3or 4 pelvic organ prolapse.

Based on our findings, health care pro-viders can counsel patients that pain isassociated with their prolapse but to ul-timately determine whether advancedprolapse is a cause of lower abdominal orpelvic pain or whether it will improveafter surgery needs to be confirmed infuture studies. Such data would allowhealth care providers to better counselpatients on expectations following vari-ous treatment options for pelvic floordisorders.

Because this was an ancillary analysisof a study designed to assess the correla-tion of functional bowel symptoms andanorectal disorders in women with ad-

vanced prolapse, this study does not fully

gy JUNE 2011

investigate all possible confounders thatcould impact lower abdominal andpelvic pain symptoms. Chronic painis a commonly reported symptom bywomen with numerous potential causes.Study subjects were not specifically que-ried regarding all potential causes oflower abdominal and pelvic pain. Fur-thermore, the case-control study designprecluded us from being able to con-clude whether pain is a consequence ofprolapse or a risk factor for developingpelvic floor disorders. Women were en-rolled in the study when they presentedto tertiary care urogynecology and gen-eral gynecology clinics, and hence, thefindings may not be generalized towomen with advanced prolapse in thecommunity.

Despite these limitations, this studyinvestigated lower abdominal and pelvicpain symptoms in women with andwithout advanced prolapse using 3 validand reliable measurement tools. Fromthese data, we can conclude that womenwith advanced prolapse seeking medicalattention were more likely to reportlower abdominal and pelvic pain symp-toms than women without prolapsewho were presenting for routine care.Furthermore, women with prolapseand pain symptoms were more likely toreport these pain symptoms as signifi-cantly bothersome. Future studies willneed to be conducted to better under-stand the relationship between pa-tient-reported pain symptoms andprolapse and the potential for resolu-tion of pain symptoms following pro-lapse repair. f

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10. Ware J Jr, Kosinski M, Keller SD. A 12-ItemShort-Form Health Survey: construction ofscales and preliminary tests of reliability and va-lidity. Med Care 1996;34:220-33.11. Barber MD, Walters MD, Bump RC. Shortforms of two condition-specific quality-of-lifequestionnaires for women with pelvic floor dis-orders (PFDI-20 and PFIQ-7). Am J Obstet Gy-necol 2005;193:103-13.12. Fritel X, Varnoux N, Zins M, Breart G, RingaV. Symptomatic pelvic organ prolapse atmidlife, quality of life, and risk factors. ObstetGynecol 2009;113:609-16.13. Swift SE, Tate SB, Nicholas J. Correlation ofsymptoms with degree of pelvic organ supportin a general population of women: what is pelvicorgan prolapse? Am J Obstet Gynecol 2003;189:372-9.14. Gutman RE, Ford DE, Quiroz LH, ShippeySH, Handa VL. Is there a pelvic organ prolapsethreshold that predicts pelvic floor symptoms?Am J Obstet Gynecol 2008;199:683.e1-7.15. Jelovsek JE, Barber MD. Women seeking

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have decreased body image and quality of life.Am J Obstet Gynecol 2006;194:1455-61.16. Tu FF, Fitzgerald CM, Kuiken T, Farrell T,Harden RN. Comparative measurement of pel-vic floor pain sensitivity in chronic pelvic pain.Obstet Gynecol 2007;110:1244-8.17. Heit M, Rosenquist C, Culligan P, GrahamC, Murphy M, Shott S. Predicting treatmentchoice for patients with pelvic organ prolapse.Obstet Gynecol 2003;101:1279-84.18. Barber MD, Amundsen CL, Paraiso MF,Weidner AC, Romero A, Walters MD. Quality oflife after surgery for genital prolapse in elderlywomen: obliterative and reconstructive surgery.Int Urogynecol J Pelvic Floor Dysfunct 2007;18:799-806.19. Mallett VT, Brubaker L, Stoddard AM, et al.The expectations of patients who undergo sur-gery for stress incontinence. Am J Obstet Gy-necol 2008;198:308.e1-6.20. Elkadry EA, Kenton KS, Fitzgerald MP,Shott S, Brubaker L. Patient-selected goals:a new perspective on surgical outcome.

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