PELVIC ORGAN PROLAPSE AMONG WOMEN IN SIDAMA REGION, ETHIOPIA: PREVALENCE, RISK FACTORS, AND EFFECT OF PELVIC FLOOR MUSCLE TRAINING

Abstract

Background: Pelvic organ prolapse (POP) is a condition characterized by the descent of pelvic vaginal compartment and the surrounding organs. It’s impact on a woman's quality of life can be substantial, resulting in psychological distress, social isolation, and physical complications. POP is a prevalent condition affecting millions of women worldwide. Despite its widespread occurrence, the true prevalence remains uncertain due to inconsistencies in diagnostic methods and reporting practices. Pelvic floor muscle training is a recommended first-line treatment for managing POP, but its effectiveness in low-income setting is understudied. Objectives This study aimed to enhance the understanding of pelvic organ prolapse symptom assessment, its prevalence and risk factors, and the management of mild to moderate pelvic organ prolapse among women in the Sidama Region, Ethiopia. Methods A total of 100 women with symptomatic prolapse completed the POP-SS questionnaire during the first round of interviews, with 61 completing a second round for test-retest reliability assessment. Content validity was evaluated using the content validity index and the construct validity was assessed through exploratory factor analysis. Known group validity was determined using the Kruskal-Wallis test. Internal consistency reliability was assessed using Cronbach's alpha, and test retest reliability was evaluated using the intraclass correlation coefficient to assess the stability of the questionnaire over time (Paper I). A community-based cross-sectional survey was conducted in the Dale-Wonsho Health and Demographic Surveillance Site from March to October 2023. A multi-stage stratified cluster sampling method was employed to select a representative sample of 816 women. Anatomical prolapse was diagnosed using the standardized pelvic organ prolapse quantification (POP-Q) method. Symptomatic prolapse was assessed through patient-reported symptoms, allowing for the identification of women experiencing significant discomfort or functional impairment. A complex survey-based modified Poisson regression was used to identify risk factors associated with prolapse (Paper II).Furthermore, a parallel-groups, two-arm cRCT was conducted in the Dale-Wonsho Health and Demographic Surveillance Site. A total of 187 women with symptomatic POP stages I-III from eight kebeles/clusters were randomized by cluster to receive either midwife-led pelvic floor muscle training plus lifestyle counselling (intervention group) or lifestyle counselling alone (control group). The primary outcomes included changes in prolapse symptom score (POP-SS) and prolapse quality of life (P-QoL). Mixed-effects generalized linear models were utilized to determine the effect of pelvic floor muscle training on prolapse symptoms and prolapse quality of life (Paper III). Results The pelvic organ prolapses symptom score questionnaire was successfully translated into Sidaamu Afoo, demonstrating good content validity (0.88) and high internal consistency (α= 0.79). Test retest reliability was also strong (ICC = 0.83). Exploratory factor analysis revealed two factors (physical and functional) explaining 70.6% of the variance, with significant loadings for each item. Known group validity showed a significant difference in median prolapse symptom scores across different prolapse stages (Kruskal-Wallis χ2 = 17.5, p < 0.001) (Paper I). In Paper II, among the 815 women surveyed, 779 (95.6%) underwent pelvic examinations. Anatomical prolapse (stages II-IV) was observed in 241 (30.90%, 95%CI: 24–38.7%) participants, The overall prevalence of symptomatic prolapse in the total sample was 189 (24.27%, (95% CI: 19.98–29.16%). Significant risk factors for anatomical prolapse included higher parity (APR: 1.17; 95%CI: 1.1-1.24), prolonged heavy lifting (APR: 1.26; (95%CI: 1.14-1.4), and prolonged labor (APR: 1.32; 95%CI: 1.1-1.56). Factors associated with symptomatic prolapse included early childbirth (APR for age at first birth < 18 years: 1.29 (95%CI: 1.1-1.52) and prolonged heavy lifting (APR: 1.16 (95%CI: 1.10-1.28). In the intervention study (Paper III), 187 women were randomized to the intervention (n=86) and control (n=101) groups. At six months, the intervention group showed significantly greater improvements in prolapse symptoms compared to the control group, with a mean change difference of -4.11 (99% CI: -5.38, -2.83). Significant improvements were also observed in the intervention group across various domains of the prolapse quality of life scale: -8.86 (99% CI: 13.84 -3.89) in physical domain; -11.18 (99% CI: -15.03, -7.32) in psychological domain, and 9.01 (99% CI: -10.49 -5.54) in personal relationship domain. A higher proportion (83.72%) of women in the intervention group perceived their condition as "better" after the intervention, compared to 41.57% in the control group. Conclusions The Sidaamu Afoo version of the POP-SS tool is valid and reliable for assessing pelvic organ prolapse symptoms. The prevalence of anatomical and symptomatic prolapse is notably high in the Sidama Region, with identified risk factors necessitating community-based education and interventions. Moreover, midwife-led PFMT combined with lifestyle counselling significantly improves symptoms and quality of life in women with mild to moderate POP, highlighting its potential for integration into maternal and reproductive health programs in low-resource settings. In addition, routine screening and campaigns are needed to identify the cases early.