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Prevalence of pelvic floor dysfunction in women attending obstetrics and gynaecology OPD at PES Institute of Medical Sciences asnd Research, Kuppam

The pelvic floor in females is required for various functions which include parturition, urination and urinary continence, defecation and faecal continence, pleasure and sexuality. Pelvic floor functions are controlled by the central nervous system and could be impaired due to anatomical injury or neurological dysfunction. Pelvic floor dysfunction is also referred to as pelvic floor disorders or pelvic floor weakness. Pelvic floor dysfunction is manifested as urinary incontinence (UI), faecal incontinence (FI), and pelvic organ prolapse (POP). The prevalence of PFD is estimated to be in the range of 12 to 42% and increases with age. PFDs are usually associated with a high number of pregnancies and heavy lifting. The tendency to develop PFDs increases with age due to the weakening of pelvic floor muscles mostly after the age of 55 years. With the advancement of age, the probability of pelvic floor dysfunction, particularly urinary or faecal incontinence increases. Among various risk factors of pelvic floor dysfunction, pregnancy and childbirth are considered to have a major ABSTRACT


INTRODUCTION
The pelvic floor in females is required for various functions which include parturition, urination and urinary continence, defecation and faecal continence, pleasure and sexuality. Pelvic floor functions are controlled by the central nervous system and could be impaired due to anatomical injury or neurological dysfunction. Pelvic floor dysfunction is also referred to as pelvic floor disorders or pelvic floor weakness. 1 Pelvic floor dysfunction is manifested as urinary incontinence (UI), faecal incontinence (FI), and pelvic organ prolapse (POP). The prevalence of PFD is estimated to be in the range of 12 to 42% and increases with age. PFDs are usually associated with a high number of pregnancies and heavy lifting. The tendency to develop PFDs increases with age due to the weakening of pelvic floor muscles mostly after the age of 55 years. 2 With the advancement of age, the probability of pelvic floor dysfunction, particularly urinary or faecal incontinence increases. Among various risk factors of pelvic floor dysfunction, pregnancy and childbirth are considered to have a major impact. Injury to pelvic floor muscles and the connective tissue or partial denervation of the pelvic floor, which occurs due to mechanical stretching during delivery may cause PFD after delivery.
The weakening of muscles and ligaments of pelvic floor cause concavity of pelvic diaphragm and pelvic contents located on the surface of the pelvic diaphragm which causes weakening of the hammock effect. Ligament attachments also weaken, exposing the bladder and vagina to intra-abdominal pressure. This pressure may result in prolapse of uterus and vagina which disturbs natural dynamics of organs located parallel with them, namely the bladder and rectum. This, along with increased abdominal pressure, will press the bladder neck in the opposite direction to normal physiological closure causing urine leakage. Prolapse may not be limited to bladder alone. 3 Pelvic organ prolapse a type of manifestation of PFD affects 30% of women in the age group of 20-59 years. Assessing pelvic organ prolapse requires a laborious quantitative pelvic examination or imaging studies. Prolapse is one of the common indications for gynaecological surgery in developed countries. In spite of this fact, its prevalence is not studied much. The extent and consequences of pelvic floor dysfunction have also not been studied extensively. 4 PFD causes social, economic, physical and psychological problems in women lowering their quality of life and productivity. With an increase in life expectancy, PFD prevalence is bound to increase, causing an economic burden on both developing and developed nations. It has been found that though PFD negatively affects the quality of life of an individual, very few women with PFD seek medical care due to many prevailing misconceptions. 81% of women with urinary incontinence, one of the main forms of manifestation of PFD, perceive the condition to be normal arising due to childbirth or age and has no treatment. Ignorance that PFD is a treatable medical condition combined with personal embarrassment attached with these conditions prevent many women from seeking medical care. 5 Many factors which include female gender, age, pregnancy, childbirth, type of delivery, number of births, obesity, menopause have a role to play in aetiology of PFDs. Dysfunction of pelvic floor muscles which have important functions is found to be the major cause of PFD. Impairment of one or more of the above functions will result in PFD. 6 Pelvic floor weakening depends on multiple factors, but there are a large number of predisposing factors which are preventable. Understanding clinical presentation and management of PFD will help to strengthen treatment and management practices.
The previous epidemiological studies showed global prevalence of POP between 2% and 20% among women ≤45 years of age. However, estimates in developing countries vary extensively, ranging from 3.4% in South India to as high as 56% in Egypt. The weighted prevalence rate of one or more pelvic floor disorder in the United States was 25.0%, including 17.1% of women with moderate-to-severe urinary incontinence, 9.4% (95% CI 8.6, 10.2) with faecal incontinence, and 2.9% with prolapse. 7 Various conditions of PFDs coexist. 16% of women with PFDs have more than one condition. It was found that 9% of women have both urinary incontinence and faecal incontinence and 7% had both urinary incontinence and pelvic organ prolapse. 8 Literature has various studies on different types of pelvic floor dysfunction and their association with various risk factors. But there are very few Indian studies on the prevalence of pelvic floor dysfunction among different populations. With this background the present study is conducted with the objective to assess the prevalence of PFD and related factors in females attending outpatient at PESIMSR, Kuppam.

METHODS
The present study was a Cross-sectional study conducted among females visiting the department of Obstetrics and Gynaecology at PESIMSR, Kuppam. A sample size of 300 calculated using the formula was selected thorough convenient sampling method. The subjects were recruited from January 2018-june 2019. Females in the age group of 18-70 years were included. Females with acute illness, who had a history of recent abdominal/ gastrointestinal/ gynaecological surgery, musculoskeletal issues, spinal cord injury, cerebral palsy and who could not comprehend the questionnaire were excluded from the study. Study was approved by institutional human ethics committee. Informed written consent was obtained from all the study participants. Confidentiality of the study participants was maintained.

Data collection
All the relevant parameters were documented in a structured study proforma which was pre-tested and validated by pilot study.
The questionnaire consists of socio-demographic details, obstetric history and screening questions related to different types of urinary incontinence and anal incontinence and pelvic organ prolapse. Obstetric history included number of children and mode of delivery.
Educational qualification in women was classified as those who had no schooling, those who had primary schooling (Class 1-10), and those with secondary schooling (Class 11 and 12), undergraduates and postgraduates.

Statistical methods
Age, number of children, education, occupation, BMI, sexual symptoms were considered as primary explanatory variables. PFD was primary outcome variable. Type of PFD was considered as the secondary outcome variable.
Descriptive analysis was carried out by mean and standard deviation for quantitative variables, frequency and proportion for categorical variables. Non-normally distributed quantitative variables were summarized by median and interquartile range (IQR). Data was also represented using appropriate diagrams like pie diagram.
All quantitative variables were checked for normal distribution within each category of explanatory variable by using visual inspection of histograms and normality Q-Q plots. Shapiro-Wilk test was also conducted to assess normal distribution AND a p value of >0.05 was considered as a normal distribution.
Categorical outcomes were compared between study groups using Chi square test /Fisher's Exact test (If the overall sample size was <20 or if the expected number in any one of the cells is <5, Fisher's exact test was used.) Indeandent sample T test / Mann Whitney U test was applied for numeric parameters comparison with categorical variables. P value <0.05 was considered statistically significant. IBM SPSS (version 22 Armonk, NY: IBM Corp.) was used for statistical analysis. 10

RESULTS
A total of 300 subjects were included in the final analysis of which 58 were having PFD. Figure 1 shows the data of females with and without pelvic floor dysfunction. Majority of them 52(17.33%) had Pelvic organ prolapse, followed by POP with UI, urinary incontinence and faecal incontinence was 1%, 0.67% and 0.33% respectively.   (Table 3).

DISCUSSION
The present study explored the prevalence of PFD and related factors in women. Out of 300 sample size, 58 of the women were diagnosed with PFD. PFDs are not only a major health problem but affect the quality of life of women reducing their productivity. Symptoms of urinary incontinence or faecal incontinence, pelvic organ prolapse, sexual dysfunction and chronic pain syndromes are different types of PFD which may occur separately or coexist in a single individual of which urinary incontinence and pelvic organ prolapse are the most common.
Pelvic organ prolapse is herniation of pelvic organs which include bladder, uterus, small bowel or rectal ampulla through levator hiatus. Urinary incontinence is the involuntary leakage of urine. 11 PFDs cause serious economic, social, physical and psychological problems in women. Even with high prevalence and their debilitating effect on the quality of life, there are not many studies which assess the prevalence of PFDs, particularly in developing countries like India. Most of the PFD are treatable, but many women continue to live with the condition due to many reasons.
One of the main reasons for women not seeking medical treatment is the embarrassment and stigma attached with PFD and lack of knowledge. Clinical profiling will help to assess the magnitude of the problem. It will help to increase awareness of various PFD conditions, their risk factors and available treatment options.
A total of 300 subjects were included in the final analysis out of which 58 were having PFD. Among the study population, 19.33% of participants had one or more types of PFD and remaining 80.67% of participants were without PFD. This prevalence of PFD found in this study is in comparison to a study done in India by Rao 15 It has also been reported in previous studies that increased pressure on the bladder during pregnancy causes an increase in the ureterovesical angle, and a decrease in the support of the bladder neck and urethra, which may be responsible for urethral hypermobility as well as UI. 16 Denervation, disruption and damage to levator complex caused during vaginal delivery increase the risk of development of POP. Ureterovesical angle is found to be increased in women after childbirth compared to non-pregnant women. 17 The finding of a higher percentage of vaginal deliveries in PFD participants in the present study and higher percentage of POP among other PFDs in this study can be compared to the findings in two studies one by Handa et al, in which it was reported that operative vaginal birth significantly increased the odds for all pelvic floor disorders, especially prolapse and in another study by Quiroz et al it was concluded that the odds of pelvic organ prolapse were almost 10 times higher after a single vaginal birth. 18,19 Very less percentage of participants are educated to graduation level, and very less percentage of participants are working professionals in the present study. Because of this, the majority of participants may not have PFD knowledge. Absence of sufficient knowledge results in the belief that they are simply "a normal part of ageing," or being unaware that treatment options exist.
Additional barriers to presentation include personal embarrassment, being unaware that PFDs are medical conditions, and being unaware that treatment options exist. 20 This is reported in a study by Chen et al. 5 A study by Mandimika et al, mentions that increasing knowledge of these conditions has demonstrated to increase compliance with treatments. 21 The pelvic floor is subjected to chronic stress in obese women which is due to elevated intra-abdominal pressure, and this may cause stress incontinence and other pelvic floor disorders. Additionally, it may affect the neuromuscular function of the genital tract and thereby contribute to the pelvic floor and urethral dysfunction. Age and parity are the two factors that work with obesity to cause an increased incidence of urodynamic stress incontinence. 22 The most important lifestyle factor is considered to be a high body mass index. The most probable mechanism of POP development among obese women is increase in intra-abdominal pressure which causes weakening of pelvic floor muscles and fascia. 23 The present study finding indicates higher BMI ranging from 25 to 34.99 in majority of participants with PFD which is in comparison with a study by Hendrix et al, in which it was shown that percentage of prolapses increased with increased BMI values. 24 The major limitation of the study includes a hospital based and small number of samples recruited. Hence the results cannot be generalized on the whole. To clarify the issue a large sample size and different hospitals from other geographical areas should be considered that will reflect the overall situation.

CONCLUSION
The present study concluded a high prevalence of Pelvic floor dysfunction similar to the reported global trends. Age, mode of delivery, obesity and number of children, BMI were found to be risk factors associated with pelvic floor dysfunction. Knowledge and education about the above risk factors can help in preventing PFDs to some extent. The participants with PFD mostly had a low level of education which can be linked with lack of knowledge regarding PFD conditions and the ignorance to the fact that early medical intervention will help in conservative management of PFD.