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Linköping University Medical Dissertations, No.
1103
Genital prolapse surgery

A study of methods, clinical outcome and impact of pelvic floor muscle function
Kristina Crafoord
Linköping 2009
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Serie: Linköping University medical dissertations,
No. 1103
©
Kristina Crafoord, MD, 2009
ISSN 0345-0082
ISBN: 978-91-7393-689-7
Printed by LiU-Tryck, Linköping, Sweden, 2009
Cover design: Dennis Netzell
Photo: Kristina Crafoord
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To the women in the study who endured all investigations
in my search of enlarging the knowledge
of pelvic floor disorders.....
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不怕走慢，就怕不動。

Do not fear going forward slowly; fear only to stand still.

(Chinese proverb)
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Contents
Contents ....................................................................................................................................... 5
List of Original Articles............................................................................................................. 7
Abbreviations .............................................................................................................................. 8
Introduction ................................................................................................................................. 9
Anatomy of the pelvic floor .................................................................................................... 10
Development of pelvic organ prolapse .................................................................................. 15
Symptoms associated with pelvic organ prolapse ................................................................ 16
Clinical evaluation of pelvic organ prolapse......................................................................... 18
Surgical treatment of pelvic organ prolapse.......................................................................... 20
Background for the study......................................................................................................... 24
Aims of the study...................................................................................................................... 26
Material ...................................................................................................................................... 27
Study populations........................................................................................................27
Methods...................................................................................................................................... 30
Review of patient records............................................................................................30

Questionnaires.............................................................................................................30
Clinical assessment .....................................................................................................31
Methods of assessing the pelvic floor muscle function...............................................31
Prolapse surgery ..........................................................................................................35
Statistical methods.......................................................................................................36
Results and comments.............................................................................................................. 37
Shift in surgical treatment ...........................................................................................37

Subsequent POP surgery ............................................................................................ 38
Anatomical outcome of POP surgery..........................................................................40
Symptoms of pelvic floor dysfunction ........................................................................42
Factors associated with symptoms of PFD, POP and outcome of surgery .................44
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General discussion.................................................................................................................... 49
Comments on methodology ........................................................................................49

Pelvic floor muscle function .......................................................................................52
Results of POP surgery ...............................................................................................53
Future perspectives......................................................................................................55
Conclusions ............................................................................................................................... 56
Sammanfattning på svenska .................................................................................................... 57
Acknowledgements .................................................................................................................. 60
References.................................................................................................................................. 63
Appendix A ............................................................................................................................... 70
Appendix B................................................................................................................................ 78
Appendix C................................................................................................................................ 88
Paper I-V
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List of Original Articles
This dissertation is based on the following original publications, which will be referred to in
the text by their Roman numerals:
I Crafoord K, Sydsjö A, Nilsson K, Kjølhede P. Primary surgery of genital prolapse: a

shift in treatment tradition. Acta Obstet Gynecol Scand 2006; 85(9): 1104-8.
II Crafoord K, Sydsjö A, Kjølhede P. Genital prolapse surgery after a shift in treatment

tradition: an analysis of subsequent prolapse surgery. Acta Obstet Gynecol Scand
2008; 87(4): 445-56.
III Crafoord K, Sydsjö A, Johansson T, Brynhildsen J, Kjølhede P. Factors associated

with symptoms of pelvic floor dysfunction six years after primary operation of
genital prolapse. Acta Obstet Gynecol Scand 2008; 87(9): 910-5.
IV Crafoord K, Brynhildsen J, Lindehammar H, Kjølhede P. Pelvic floor neuropathy in

relation to symptoms, anatomy and outcome of vaginal prolapse surgery: a
neurophysiologic study. In manuscript 2009.
V Crafoord K, Brynhildsen J, Hallböök O, Kjølhede P. The predictive value of

anorectal manometry on subjective and objective findings and outcome of pelvic
organ prolapse surgery. A prospective study. In manuscript 2009.
The published papers are reprinted with permission from the publisher.
The studies in this thesis are approved by the Ethics research committees of the Faculty of
Health Sciences at Linköping University (paper I – V) and at the Regional Hospital in Örebro
(paper I – III). The amendment of the prospective study (paper IV and V) is approved by The
Regional Ethical Review Board in Linköping.
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Abbreviations
ANCOVA analysis of covariance
ANOVA analysis of variance
ARM anorectal manometry
ARPA anal resting pressure area
ASPA anal squeeze pressure area
BMI body mass index
CI confidence interval
EAS external anal sphincter muscle
EMG electromyography
FI fecal incontinence
IAS internal anal sphincter
ICS International Continence Society
MARP maximal anal resting pressure
MASP maximal anal squeeze pressure
MLR multiple logistic regression
MUP motor unit potential
OR odds ratio
PCM pubococcygeus muscle
PFD pelvic floor dysfunction
PFM pelvic floor muscle
PNTML pudendal nerve terminal motor latency
POP pelvic organ prolapse
POP-Q pelvic organ prolapse quantification
SD standard deviation
UI urinary incontinence
UTI urinary tract infection
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Introduction
In Sweden, genital prolapse surgery has traditionally been carried out with a complete vaginal
repair encompassing of all three vaginal compartments concomitantly. This was done
independent of the symptoms, size and extent of the prolapse. The Manchester operation was
the most common prolapse operation (Danielson 1957). In the late 1980s this surgery with
repair in all three compartments was debated and posterior colporrhaphy was especially
questioned (Rud 1989). The risk of de novo urinary stress incontinence and dyspareunia was
highlighted (Borstad et al. 1989; Brun-Poulsen 1990; Haase et al. 1988). POP surgery of only
the vaginal compartments with symptomatic prolapse or very large prolapse was advocated by
the gynecological profession and so called prophylactic surgery in compartments without
obvious prolapse was abandoned (Rud 1989). The extent to which these recommendations
were followed and the clinical consequences they had have not been evaluated.
Genital prolapse or vaginal prolapse is characterized by a portion of the vaginal canal
protruding to or from the opening of the vagina. The term is synonymous with pelvic organ
prolapse (POP). POP is defined by the International Continence Society (ICS) as the descent
of a pelvic organ into or beyond the vagina, perineum or anal canal (Bump et al. 1996). On
the basis of this definition, more than half of the adult female population may have POP
(Swift et al. 2005). The size of a prolapse is not well correlated to the occurrence of symptoms
but women with a prolapse that protrudes outside the vagina are more likely to have
symptoms (Tan et al. 2005). Epidemiologic studies from Scandinavia have reported the
prevalence of symptomatic POP to be 12 - 15% (Tegerstedt et al. 2004; Uustal Fornell et al.
2003). In clinical studies the prevalence of POP that protrudes outside the vaginal introitus is
2-6%, (Samuelsson et al. 1999; Versi et al. 2001).
The etiology of POP is complex and multi-factorial (Dietz 2008; Jelovsek et al. 2007;
Maher et al. 2007). Several studies have demonstrated that changes in collagen metabolism
are a factor in the development of POP (Edwall et al. 2008; Söderberg et al. 2004; Song et al.
2007). The pelvic floor muscles seem to play an important role in the support of the pelvic
organs and for the development of POP (Athanasiou et al. 2007; DeLancey et al. 2007; Dietz
2007). Information in the literature about the pathophysiological impact of pelvic floor
muscles on POP and symptoms of prolapse is scarce.
Surgical treatment of POP is a challenge to the gynecologist. The issues when, where
and how to perform the surgery, preferably as a single procedure, giving the best outcome for
the patient, are constantly in question. This attracted my curiosity and inspired me to start the
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studies reported on here. In this thesis I will highlight some aspects of POP surgery and its
consequences as well as the influence of pelvic floor muscle pathophysiology on pelvic organ
prolapse.
Anatomy of the pelvic floor

Both the anatomy and physiology of the pelvic floor is complex. To understand the
mechanism of POP and treatment it is important to have detailed knowledge about the
anatomy.
The pelvic viscera are part of the pelvic floor and play an important role in the support
through their connections with the cardinal and the uterosacral ligaments (Wei et al. 2004).
With normal anatomy in upright position, the distal vagina has a 45-degree angle from
the vertical. In the mid-vagina the angle between vagina and vertical increases to 60 to 70
degrees giving the vagina a “banana-shape” (Rovner 2000).
The vaginal support can be described in three levels (Fig. 1) (DeLancey 1999):
Level I: The cardinal and uterosacral
ligaments (parametrium) attach the
uterine cervix to the pelvic walls and the
sacrum, respectively and the uppermost
portion of the paracolpium suspends the
superior part of vagina to the pelvic
walls.
Level II: In the mid portion of vagina the
paracolpium attaches the vagina lateral
to the pelvic wall, thereby stretching the
vagina transversely between the bladder
and the rectum. The vagina is, in this
level, attached to the arcus tendineus
Figure 1. The levels of support (DeLancey, with permission) fascia pelvis (“the white line”) and the
superior fascia of the levator ani.
Figure 1. The three levels of vaginal support. Level III: The distal vaginal walls are
(DeLancey, with permission.) directly attached to the surrounding
structures. Anteriorly, the vagina fuses with the urethra; posteriorly, with the perineal body,
and laterally with the levator ani muscles. The lower part of the posterior wall is, in part,
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supported by the rectovaginal septum, which connects the perineal body to the pelvic wall. It
is present in the caudal 2 to 4 cm of vagina. Above this, there is only adventitia between the
vagina and the rectum.
The pelvis has two fascias: the parietal fascia
covers the muscles, and the visceral fascia
surrounds the pelvic organs. The vagina is
attached by fibrous connective tissue to the
parietal fascia, usually named the endopelvic
fascia. The white line is a band of connective
tissue reaching from the pubic symphysis to the
ischial spine on both sides of the pelvis. The
perineal body is the central fusion between the
halves of the perineal membrane in the lower
1/3 of vagina. The connection extends cranially
to approximately 2-3 centimeters above the
hymeneal ring. The densest part is the distal
perineal body. Cranially it is becomes
progressively thinner. The posterior wall has a
U-shaped contour in level III (DeLancey 1999).
The levator ani muscles are attached to the
perineal body and directly connected to the
upper surface of the perineal membrane
Figure 2. The perineal membrane and
attachments (A). Separation of the fibers in (DeLancey 1999).
this area (B) leaves the rectum unsupported The perineal membrane (also called “the
and results in a low rectocele.
(DeLancey, with permission). urogenital diaphragm”) in the anterior part of
the pelvis, below the levator ani muscles and at
the level of the hymen, is a three-dimensional
structure composed of a dorsal and a ventral portion (Stein et al. 2008). The dorsal portion has
bilateral fibrous sheets, which attach the lateral walls of the lower one third of the vagina and
the perineal body to the ischiopubic ramus (level III) (Fig. 2).
The ventral portion is part of a solid tissue mass involving the compressor urethra and
the urethrovaginal sphincter of the distal urethra. Here the perineal membrane is continuous
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with the insertion of the arcus tendineus fascia pelvis. The levator ani muscles are connected
with the cranial surface of the perineal membrane (Stein et al. 2008) (Fig. 3).
A B
Figure 3. A) Position of the perineal membrane. B) Levator ani muscles seen from below the
edge of the perineal membrane. (DeLancey, with permission.)
The levator ani muscles consist mainly of striated muscles and lie below the endopelvic
fascia. The levator ani muscles are traditionally subdivided into an anterior part, the
pubococcygeus muscle, and a posterior part, the ileococcygeus muscle. Together with the
coccygeus muscles the levator ani muscles form the bottom of the pelvis (Fig. 4).
Figure 4. The muscles of the female pelvic floor seen from below. (Reprinted with permission.)
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The levator ani muscles extend from the pubic bone anteriorly to the ischial spine
posteriorly and are attached to the white line. In the midline the levator ani muscles fuse but
leave a hiatus (the urogenital hiatus) through which, from ventrally to dorsally the urethra,
vagina and rectum pass. The hiatus is posteriorly supported by the perineal body and the
external anal sphincter, and anteriorly is bounded by the pubic bone. The iliococcygeus,
pubococcygeus and coccygeus muscles form a transverse muscular shelf (the levator plate)
from the pelvic sidewalls, above the ischioanal fossa. Medially, the muscles slope down
sharply to form a vertical portion. The external anal sphincter muscles and the puborectalis
muscle are situated outside and the internal sphincter inside this vertical portion.
The puborectalis muscle has previously been considered to be a part of the levator ani
muscle but is now considered to be below the transverse portion of the pubococcygeus,
iliococcygeus and coccygeus muscles and outside the vertical portion of the levator muscle
(Shafik 1979) (Fig. 5). The puborectalis muscle binds the vertical portion of the levator ani
muscle to the pubic symphysis, and encloses the intrahiatal structures (i.e. the urethra, vagina
and rectum).
Septum rectovaginale
Cervix
Rectum
Anorectal angle
Pubic symphysis
M. puborectalis
M. pubococcygeus
EAS
IAS
Anal canal
Figure 5. The anorectal angle. (Reprinted with permission.)

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The anal canal is surrounded by the internal and external anal sphincter muscles. The
external anal sphincter (EAS) forms a ring of muscle around the anal canal and is continuous
with the puborectalis muscle The EAS is a striated muscle under voluntary control but is
continuously active with a resting tonus. It is approximately 4 cm in length and surrounds the
internal anal sphincter. The internal anal sphincter (IAS) is a smooth muscle continuous with
the circular muscles of the rectum. It exhibits a continuous state of tonic contraction. A high-
pressure zone is found in the anal canal during the resting state, the peak pressures are found 2
cm from the anal verge. Both sphincters contribute and predominantly the IAS with 70-85%
of the resting tone.
Figure 6. Course of the pudendal nerve. (Reprinted with permission.)
The somatic innervations of the levator ani muscles is by direct branches from the sacral
plexus (S3-5) and the pudendal nerve ((S2-4) both autonomic and somatic) is responsible for
innervations of the external anal sphincter and the puborectalis muscles (Barber et al. 2002)
(Guaderrama et al. 2005) (Fig. 6). The autonomous sympathetic (L2-4) and parasympathetic
(S2-4) innervations is supplied by the inferior hypogastric plexus, which has an important
function in the smooth muscle relaxation and contraction of the pelvic floor, bladder, vagina
and rectum.
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Development of pelvic organ prolapse
The interaction between the pelvic floor muscles and the supportive connective tissue is
essential for the support of the pelvic organs. When the pelvic floor muscles work properly
the urogenital hiatus is closed. The pelvic ligaments and fascias are normally under minimal
tension due to the support of the levator ani muscles. If the pelvic muscles are damaged, the
urogenital hiatus opens and the stress on pelvic ligaments and fascias thereby created can
cause breaks or stretching in these structures thus promoting development of prolapse (Wei et
al. 2004). This has been described as “the boat in the dock”-mechanism by DeLancey
(DeLancey 2002) (Fig. 7).
Figure 7. The boat corresponds to the uterus/vagina, the ropes to the ligaments/fascias and
the water to the supportive pelvic floor muscle. The ropes act to hold the ship in the center of
its berth. - The support system will not function if the water level falls; the ropes holding the
boat will be stressed and eventually break.
The muscle may be injured directly or indirectly by damage to the nerves that innervate
the muscles. The development of POP is progressive when the muscles are no longer able to
maintain the support (Chen et al. 2006).
Lacerations and stretching of the pelvic ligaments and fascias caused by direct trauma
or continuing stress can lead to the formation of prolapse even without obvious muscle
damage. Inherited disorders of collagen or muscle tissue causing weakness may also promote
development of POP.
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Symptoms associated with pelvic organ prolapse
Pelvic floor symptoms may be due to dysfunction of an adjacent organ system because of loss
of vaginal support (for instance urinary stress incontinence) or muscular or neurogenic
damage to the pelvic floor (i.e. fecal incontinence). The source of a symptom (i.e. constipation
or obstructed defecation and chronic straining) can also contribute to the development of
POP. Pelvic floor dysfunction (PFD) is the joint designation of a group of clinical conditions
that includes urinary incontinence, fecal incontinence, pelvic organ prolapse, sensory and
emptying abnormalities of the lower urinary tract, defecatory dysfunction, sexual dysfunction
and several chronic pain syndromes. Symptoms that usually are associated with POP and their
prevalence are shown in Table 1.
Table 1. Common symptoms of pelvic organ prolapse and reported prevalence of the symptoms.
Type of symptom Symptom Prevalence
Local symptoms: Vaginal protrusion or bulge 10-100%
Pelvic pressure or heaviness 10-49%
Urinary symptoms: Manual reduction to start or complete voiding 9-44%
Feeling of incomplete emptying 30-50%
Urinary stress incontinence 13-83%
Urgency/ urge incontinence 21-73%
Bowel symptoms: Difficulty in defecation 20-23%
Digitation or splinting of vagina, perineum or anus to complete
6-35%
defecation
Incontinence of flatus, liquid stool or solid stool 10-31%
Sexual symptoms: Dyspareunia 8-69%
The POP symptoms are not consistently associated with the size or site of POP
(Ellerkmann et al. 2001) as demonstrated in Fig. 8. The prolapse often needs to extend beyond
the level of the hymen if mechanical symptoms are to occur (Swift et al. 2003; Gutman et al.
2008; Mouritsen et al. 2003). Reports of a bulge are very common in association with
occurrence of POP (Swift et al. 2003; Tegerstedt et al. 2005). The symptoms of needing to
manually reduce the bulge to urinate or defecate are also associated with prolapse (Tan et al.
2005).
16
100
.
%
Prevalence %
ec 50
ne
Bulging sensation alv
reP
0
-3 -2 -1 0 1 2 >=3
Maximum extent of prolapse
1 00
.
%
Prevalence %
cen
el 50
av
Pelvic pressure er
P
0
-3 -2 -1 0 1 2 > = 3 .0
M a x im um e x t en t of p ro lap s e
Figure 8. Relationship between symptoms and maximal extent of prolapse. Maximal extent of prolapse
measured in 1-cm increments with the hymen = 0. Prolapse in which maximal extent is proximal to the
hymen is in negative numbers and beyond the hymen positive numbers.
(Modified from Tan et al. 2005).
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Clinical evaluation of pelvic organ prolapse
Evaluation of local/mechanical symptoms as well as functional symptoms from the lower
urinary tract, the bowels, and the effects on sexual life and on quality of life should be made
for all women with POP. An evaluation form is presented in Table 2.
Table 2. Evaluation form for assessing POP, based on clinical experience.

History
 Complete medical (including heredity, hypermobility), surgical, obstetric and
gynecological history
 Pelvic symptoms (as vaginal protrusion/ pelvic pressure, worsening by lifting)
 Urinary symptoms (difficulty starting voiding/splinting, emptying, incontinence)
 Bowel patterns (straining, frequency, splinting to defecate, fecal incontinence)
 Sexual function problems
 Patient self-reported pelvic symptom questionnaire/s that assess bowel, urinary
and sexual function.
Physical examination
 Abdominal palpation
 Vaginal examination (start with visual inspection at maximal straining; in
lithotomy and upright position; staging level of protrusion in each vaginal
compartment related to the hymenal plane; if cystocele central/paravaginal/both)
 Cough provocation test with and without reposition of the prolapse
 Digital pelvic examination and assessment of pelvic floor muscle strength
 Bimanual gynecological/anorectal examination
 Vaginal ultrasound examination (residual urine, ovarian tumor, myoma)
 Neurological examination to assess sensory and motor function
(physical disability, mental status, perineal sensation)
POP-Q
The Pelvic Organ Prolapse Quantification (POP-Q) system as the standardization of grading
of prolapse was approved by the International Continence Society, the American
Urogynecologic Society, and the Society of Gynecologic Surgeons in 1996 (Bump et al.
1996). Measurements of the descent of the anterior, posterior wall and the anterior lip of the
cervix/vaginal cuff in cm above or below the plane of the hymeneal remnants (negative above
and positive values below) are measured with the patient straining (Fig. 9). The length of the
genital hiatus and the perineal body are measured when the patient strains. The length of
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vagina is measured in a resting state. Depending on the measurements the pelvic organ status
is divided into stages 0-4.
Points:
Aa. Located in the midline of
the anterior wall 3 cm proximal
to the external urethral
meatus.
Ba. The most distal part of the
upper vaginal wall.
C. The most distal edge of the
cervix or leading edge of the
vaginal cuff.
D. Point representing the
location of posterior fornix (not
measured if cervix is abscent)
Bp. The most distal part of the
posterior vaginal wall.
Ap. In the midline of the
posterior wall 3 cm proximal to
the hymen.
Figure 9. Six points (Aa, Ba, C, D, Bp and Ap), genital hiatus (gh), perineal body (pb), total vaginal
length (tvl) used for pelvic organ support quantification. (Reprinted from Bump et al 1996, with
permission.)
Vaginal Profile (Baden) Quantitative POP
Stage 0
Midplane
Grade 1 of vagina Upper half vagina
Stage 1
Hymeneal Lower half vagina

Grade 2
ring
(-) 1 cm
Vestibule Labia minora Stage 2
(+) 1 cm
Labia majora
Introitus
Grade 3 Stage 3
Complete
eversion
Grade 4 Stage 4
Figure.10. Comparison of ordinal classifications of pelvic organ prolapse.
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In Fig.10 the different levels of staging according to the Baden-Walker halfway system
and the POP-Q are shown (Baden et al. 1972; Bump et al. 1996). Vaginal prolapse in the
different vaginal compartments are shown in Fig. 11.
A B
C D
Figure 11. Cystocele (A), Rectocele (B), Descent of uterus (C) and Descent of the vaginal vault (D).
Surgical treatment of pelvic organ prolapse

The aims of surgical treatment are to restore vaginal support and function and relieve
symptoms in women with symptomatic POP. The indications for POP surgery are most often
relative, depending on subjective and objective findings and the patient’s preferences.
History
In the 19th century amputation of the cervix and perineorrhaphy were used in surgical prolapse
treatment for repairing damages of childbirth and restoring vaginal closure. The aim of these
vaginal operations was to enable a pessary to be used for the prolapse (Pearce 2004).
Archibald Donald (1860-1937) of Manchester, England started the surgical treatment of
genital prolapse by combining correction of all three vaginal compartments. In this way no
pessary was required postoperatively.
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Donald performed his first “colporrhaphy” in 1888. He emphasized “What one must
recognize, if one is to have any success in the operations, is that the raw surface, anterior or
posterior, or in exceptional cases, both, must be high, wide, and deep, and that the deep
tissues, triangular ligament, or levator ani muscles must be brought together by deep buried
stitches”. His colleague William Edward Fothergill (1865-1926) further developed the method
by extending the incision in the anterior vaginal wall to join the incision of the cervix, and
plicate the parametria anterior to the cervix (Pearce 2004). This has later been known as the
Manchester-Fothergill operation (Bemis 1974).
In 1957 Carl-Olof Danielson described the Manchester operation to be the most
common vaginal prolapse operation in the Scandinavian countries during the 1940-50s
(Danielson 1957). He emphasizes, in his thesis, the aim of a “complete” operation and
especially the amputation of the cervix to be of importance to avoid recurrence of the
prolapse.
In 1959 Jeffcoat reported a high prevalence of dyspareunia in women operated with
combined anterior and posterior colpoperineorrhaphy (Jeffcoate 1959). He recommended that
the posterior colpoperineorrhaphy be practiced only when a significant degree of rectocele or
perineal deficiency existed, to be determined by examination preoperatively, before the
patient’s muscles were relaxed by anesthesia.
Dyspareunia and urinary incontinence
were highlighted as postoperative problems in
reports from Scandinavia (Borstad et al. 1989;
Brun-Poulsen 1990; Haase et al. 1988). The
recommendations given to the Swedish
gynecologists by the Reference Group in
Urogynecology within the Swedish Society of
Obstetrics and Gynecology in 1989 were
intended to avoid posterior repairs in the
women with asymptomatic rectocele. Advice
was also given to avoid “overcorrection” of
the cystocele (Rud 1989). Levator ani
Figure 12. Colpoperineorrhaphy with plication of
the levator muscles (from Shaw´s textbook of plication is nowadays not recommended in
Operative Gynaecology 1960 2nd ed. With sexually active women (Weber et al.
permission)
2005)(Fig. 12).
21
Several modifications of the methods have been described in order to make it possible
to more selectively repair specific support defects. Paravaginal repair was first described by
White 1909 as a vaginal procedure. The repair corrected the paravaginal defects by
reattaching the anterior lateral vaginal sulci to the obturator internus muscles and fascia at the
level of arcus tendineus fascia pelvis (“white line”) transvaginally or abdominally.
In 1993 Richardson described rectocele repair by suturing specific breaks in the
rectovaginal fascia (Richardson 1993). These breaks are detected peroperatively after incision
of the vaginal mucosa and are sutured specifically.
During the recent decade meshes/implants have been introduced in prolapse surgery.
Various mesh materials, biologic and synthetic, have been suggested and different surgical
approaches have been suggested. So far scientific information about outcomes of operations
with meshes and the indications for use of these is limited.
There are numerous surgical methods described to treat pelvic organ prolapse. Often
these are modifications of the traditional methods or they are modifications adapted to
individual circumstances of the prolapse and the patient. The methods may also differ in use
of suture material, surgical technique and conditions related to anesthesia and perioperative
care. A summary of the most commonly reported procedures and their application in treating
each vaginal compartment is given in Table 3.
Table 3. Summary of procedures described for treatment of pelvic organ prolapse.
Vaginal
compartment Vaginal procedures Abdominal procedures
Anterior Anterior colporrhaphy Colposuspension
Paravaginal repair Paravaginal repair
Anterior prolapse repair with mesh Anterior repair with mesh
Apical Vaginal hysterectomy Sacrocolpopexy
McCall culdoplasty Paravaginal repair
Amputation of the cervix Levator myorrhaphy
Plication of cardinal ligaments
Vault attachment to iliococcygeus fascia
Vault attachment to sacrouterine ligaments
Vault repair with/without mesh
Sacrospinosus ligament suspension
Levator myorrhaphy
Posterior Posterior colporrhaphy Laparoscopic sacrocolpo-
Posterior colpoperineorrhaphy perineopexy (combination of apical
Levator ani plication and posterior defects)
Site-specific repair
Rectovaginal fascia reattachment
Rectovaginal fascial repair with/without mesh
Posterior repair with mesh
22
Anterior colporrhaphy is shown Fig. 13.
Figure 13. Traditional anterior colporrhaphy (from Urogynecologic Surgery, ed. W G Hurt, with
permission)
23
Background for the study
It was a clinical impression that a change in mode of surgical treatment of genital prolapse
occurred in late 1980s. Information about the long-term effects of POP surgery is incomplete
and no Swedish data have been presented. In order to investigate these matters we formulated
a series of research questions:
Research questions
 Did any change in the extent of POP  If a shift de facto was observed in
surgery, concerning the number of treatment tradition, what were the
compartments treated, occur between consequences regarding subsequent
the early 1980s and 1990s? POP surgery?
 What was the subjective outcome in  Which risk factors for adverse outcome
terms of symptoms of pelvic floor regarding symptoms of pelvic floor
dysfunction six years after primary dysfunction at long-term follow-up
prolapse surgery? could be identified?
The normal supporting function of the pelvic floor muscles depends on the anatomical
positions of the muscles, on the activity of the pelvic floor muscles at rest (active support) and
on the integrity of the fascia (passive support). Several studies have indicated that impaired
function and constitution of the pelvic floor muscles are associated with development of POP,
and urinary- and fecal incontinence (Snooks et al. 1984; Allen et al. 1990; Hanzal et al. 1993;
Parks et al. 1977; Weidner et al. 2000b; Zhu et al. 2005). The outcome of surgery for pelvic
floor dysfunction has also been associated with neuromuscular damage (Benson et al. 1993;
Kjølhede et al. 1997; Morley et al. 1996; Welgoss et al. 1999), but there are only few studies
in this field. The associations between symptoms of pelvic floor dysfunction and the
neuromuscular constitution of the pelvic floor muscles in POP have not previously been
investigated. The results of POP surgery vary and are not always satisfactory (Maher et al.
2007). Symptoms may be cured by POP surgery, persist or occur de novo after POP surgery.
Even the anatomical outcome varies in a similar way. So far, no study has investigated the
neuromuscular function of pelvic floor muscles as a prognostic factor for outcome of POP
surgery. Analyses of the function of pelvic floor muscles can be established either by direct
measurement of muscle fiber function by means of electromyography (Weidner et al. 2000a)
or by means of anorectal manometry, which measure the summary function of the internal and
external anal sphincter muscles and the puborectalis part of the levator ani muscles (Read et
al. 1992). Neurophysiological measurements of pelvic floor muscles with electromyography
24
(EMG) and nerve conduction studies are methods that can characterize the integrity of the
muscle, nerve and neuromuscular junction and can localize an injury and quantify the severity
of the problem (Olsen et al. 2001). Anorectal manometry (ARM) is a method that assesses the
anorectal function and provides insight into the pathophysiology of anorectal disorders (Read
et al. 1992).
The impact on the neuromuscular function of pelvic floor muscles on symptoms and
extent of POP as well as on the outcome of POP surgery is so far not well investigated. In
addition to and as a consequence of our previous studies of POP surgery, I found it of great
interest to investigate the neuromuscular function of pelvic floor muscles in women who were
scheduled for POP surgery.
The following hypotheses and research questions were elaborated:
Hypotheses Research questions

 Neuromuscular damage of pelvic floor  Are neurophysiologic findings of the
muscles identified by neurophysiologic pubococcygeus muscles and external
investigations can be related to anal sphincter muscle associated with
symptoms of pelvic floor dysfunction symptoms of pelvic floor dysfunction
and degrees of pelvic organ prolapse and size and extent of POP in women
and further may be predictive for the who are undergoing primary surgery for
outcome of the POP surgery. POP?
 Can the neurophysiologic findings
predict the outcome of surgery with
respect to symptoms and anatomy?
 Pelvic organ prolapse and bowel  How are the long-term results
emptying symptoms, and degree and concerning symptoms of pelvic floor
extent of POP as well as outcome of dysfunction and anatomy after primary
vaginal POP surgery, in particular POP surgery?
posterior colporrhaphy, can be  Are anorectal manometric findings
predicted by anorectal manometric associated with symptoms of pelvic
findings preoperatively. floor dysfunction and size and extent of
POP in women who are undergoing
primary surgery for POP?
 Can the anorectal manometric findings
and changes in these predict long-term
outcomes in terms of symptoms and
anatomy after primary POP surgery?
Based on these research questions a series of studies were conducted and the specific aims of
this thesis were prepared.
25
Aims of the study
The aims of the study were:
i. to evaluate whether a shift in the extent of genital prolapse surgery occurred

between 1983 and 1993 regarding prevalence of complete repair versus selective
repair.
ii. if a shift occurred, to analyze the consequences of such a shift regarding the need
for subsequent prolapse surgery and to analyze the frequency of complementary
and recurrent surgery with respect to size of the prolapse and extent of the primary
POP surgery.
iii. to determine the prevalence of symptoms of pelvic floor dysfunction in women

six years after vaginal prolapse surgery and to analyze predictive factors for these
symptoms.
iv. to analyze subjective and objective outcomes of POP surgery concerning change
in PDF-symptoms and anatomical status of the vaginal compartments at long term
follow up.
v. to evaluate whether neurophysiologic findings of the levator ani muscles and

external anal sphincter muscle and anorectal manometry pressure measurements,
respectively were associated with preoperative symptoms of pelvic floor
dysfunction and the extent and degree of pelvic organ prolapse.
vi. to investigate whether the neurophysiologic findings and anorectal manometry

pressure measurements respectively could predict the anatomical and subjective
outcomes of the prolapse surgery.
26
Material
Study populations
The retrospective material (Paper I-III)
The cohorts of women operated for genital prolapse at the departments of Obstetrics and
Gynecology at Linköping University Hospital, Örebro Regional Hospital and the County
Hospital of Värnamo in 1983 (Period I) and 1993 (Period II) were identified from the local
County patient and operation registers. In order to achieve samples of approximately similar
size in the hospitals the samples from the County Hospital in Värnamo were expanded to also
include all patients operated on in 1982 and 1992, respectively.
The patient records were retrieved and reviewed. The women without previous prolapse
surgery were identified and these women constitute the study group. The prolapse operation
was the first POP operation in these women, i.e. it was primary surgery.
The study material in Paper I-III is illustrated in the flow-chart (Fig. 14).
The prospective material (Paper IV and V)
Women admitted to the department of Obstetrics and Gynecology at the University Hospital
in Linköping for surgical treatment of genital prolapse, comprising at least a posterior
colporrhaphy, between November 1999 and Mars 2004 were eligible for the study. Exclusion
criteria in the study were occurrence of previous surgery for POP, urinary or fecal
incontinence, or total hysterectomy, significant physical, neurological or psychic disability; or
complete vaginal eversion (stage 4 – prolapse).
One single investigator (the Ph.D. student) was to perform all preoperative
examinations and participate in the laboratory investigations. Given this constraint – that all
women in the study were to be examined by a single physician - only those patients scheduled
for preoperative evaluation on the days when this physician was in residence were given
written and verbal information about the study. No selections were otherwise done
deliberately among the potentially eligible women.
The flow-chart of the study material in Paper IV and V is presented in Fig. 15.
27
The retrospective studies (Papers I – III)
Period I Period II
1982/83 1992/93
Missing records n = 293 n = 317
n=4
Previous POP surgery Previous POP surgery

n = 32 n = 36
Primary Surgery: Primary Surgery:

n= 261 n = 281
Paper I:
Complete Selective Complete Selective
repair repair repair repair
n=180 n=81 n=101 n=180
Six years postoperative follow-up

n=9
n=5
n= 4 n=3
Paper II n=3
n=5
No subsequent
No subsequent
POP surgery
POP surgery
n = 254 n = 259
Deceased n =19
Complementary POP surgery
Postal questionnaire
Not answered n=52

Complementary and recurrent
POP surgery
Answered
Paper III the questionnaire
Recurrent POP surgery
n = 188
Figure 14: Flow-chart of the retrospective material and the relations to the different studies
28
The prospective study (Paper IV and V)
Figure 15. Flow chart showing the study population in the prospective material. One woman deceased
before long-term follow-up and two other women did not want to participate in the clinical examination at
long-term follow up. Follow-up visits with clinical examination were conducted approximately two years
postoperatively in these three women. No questionnaires were obtained from the deceased woman or
from one of the two women who declined to participate in the clinical assessment at follow-up.
29
Methods
Review of patient records
In the retrospective study the patient records were systematically reviewed in 1999 by three
experienced gynecologists. Demographic, clinical, and surgical data were extracted and
collected in a standardized form. The categorization of the size of the prolapse noted in the
patient record was done according to the Baden-Walker half-way system (Baden et al. 1972).
Information about subsequent POP surgery was noted and categorized as a) recurrent POP
surgery, i.e. the subsequent surgery was done in a vaginal compartment that previously was
operated upon at the primary surgery; b) complementary POP surgery, i.e. the subsequent
surgery was carried out in a previously not operated vaginal compartment; or c) combination
of a) and b).
Questionnaires
Follow-up study of the retrospective material
(Paper III)
A postal questionnaire with 68 questions concerning symptoms of pelvic floor dysfunction
was developed. The questionnaire consisted of questions regarding demographic and clinical
data and detailed questions concerning symptoms of prolapse, bowel and urinary function and
sexual issues. The questions concerning the symptoms of pelvic floor dysfunction used in the
study were excerpted from validated questionnaires (Oliveira et al. 1996; Uustal Fornell et al.
2003).
The questions were constructed as simple sentences and the answers were given by
placing a cross or checkmark in boxes next to the written alternatives. The number of boxes
was limited to between two and ten. The alternative answers to the questions concerning
symptoms were mostly constructed to facilitate reporting of the frequency of occurrence of
the symptom. The descriptive and demographic continuous data were given by specification
of a number. The questionnaire was sent by mail to the patient with a letter providing
information and a stamped envelope. One reminder was sent to those who did not respond
within four weeks.
The questionnaire, in Swedish, is shown as Appendix A.
30
The prospective study questionnaires
(Paper IV and V)
A questionnaire consisting of 81 questions was prepared. The questionnaire was in
construction and content essentially similar to the questionnaire used in the retrospective
study as described above. More detailed questions about certain aspects of demographic and
clinical issues were added to this questionnaire. The Swedish version of the questionnaire is
presented as Appendix B. The questionnaire was completed by the women in the prospective
study before the POP surgery and at the follow-up visits two-three years postoperatively. At
the long-term follow-up visit four to eight years after surgery the questionnaire was extended
by the addition of questions concerning the degree of satisfaction with the result of the
surgery and quality-of-life aspects (excerpted from UDI 6 and IIQ7 (Uebersax et al. 1995)).
The questionnaire at long-term follow-up is shown as Appendix C.
Clinical assessment
(Paper IV and V)
Pelvic examination was done with the patient in dorsal lithotomy position. The pelvic organ
prolapse quantification system (POP-Q) (Bump et al. 1996) was used to objectively
characterize the vaginal profile. Urethral competence was assessed by means of a cough
provocation test with and without repositioning of the prolapse and by a modified one-hour
pad test (Abrams et al. 1990). All patients were preoperatively examined by one
urogynecologist (KC). The postoperative assessments of POP-Q were done by three
investigators.
Methods of assessing the pelvic floor muscle function

Neurophysiological investigations
Concentric needle EMG
Electromyography (EMG) involves measurement of electrical activity in striated muscle
tissue and the activity relates to the neuromuscular condition. Motor unit potentials (MUPs)
are recorded (Fig. 16). The analysis of recorded EMG (“motor unit” EMG) helps in the
differentiation of normal, denervated/reinnervated and myopathic muscle. Surface or
intramuscular electrodes can be used. In the context of this study the concentric needle
electrode has a central insulated platinum wire (Fig. 16). Electomyographic activity can be
measured mostly to a distance of 2.5 mm from the electrode (Sehapayak 1985). The signals
are amplified and recorded. Analysis of the recordings is computerized. The number and
31
characteristics of MUPs recorded depend upon the local arrangements of muscle fibers within
the motor unit and the extent of muscle contraction.
Figure 16. Concentric needle electrode in needle guide and EMG curve.
EMG from the external anal sphincter muscle
All neurophysiologic tests were performed with MedelecSynergy™ EMG-system

(Viasys™ Healthcare, UK). A ground electrode was placed on the right thigh and the patient
was placed in dorsal lithotomy position.
The pubococcygeus part of the levator ani muscles were located on both sides by
transvaginal palpation during slight contraction and reached transvaginally with the
concentric needle electrode guided though a needle holder placed on the examiners index
finger. Several positions within the muscles were examined. Local anesthetic was not used.
Several sites were sampled from the muscle by the concentric needle electrode. The EAS was
examined with the EMG needle inserted through the skin on each sides of the anal orifice at
“3 and 9 o´clock” with a finger inside the anus for guidance. All muscles were examined
during slight and maximal contraction. The audio output from the electromyographic system´s
loudspeaker allowed assessment of the quality of recordings. The EMG-electrodes used were
stainless steel disposable concentric needle electrodes (Medtronic, Denmark) with length 50
mm, diameter 0.46 mm, and recording area 0.07 mm². Filter setting was 10 Hz – 10 kHz.
Analysis of the EMG signal was done when sharply contoured motor unit potentials (MUPs)
were seen and the audio output of the recorder revealed a crisp sound. Only MUPs without
noise and with good baseline were analyzed.
The EMG activity of the muscles was analyzed by two methods that measure the size
and configuration of the MUPs: The first method was the Multi-MUP analysis. Ten to 20
32
unique MUPs from each muscle were recorded from different sites in the muscles during rest
and moderate contraction. The following MUP parameters were analyzed: amplitude,
duration, number of phases, number of turns, area and the percentage polyphasic MUPs (more
than four phases). The mean value for each MUP parameter in each muscle was used for
analysis.
The second method was turns/amplitude analysis. Turns per second, mean amplitude per
turn and consequently the ratio were analyzed. Signals from five to ten different sites were
recorded at different levels of muscle contraction.
The needle positioning in the muscles was performed by the urogynecologist (KC) and
the analysis of the recordings by the neurophysiologist (HL).
Pudendal nerve terminal motor latency (PNTML)
Pudendal nerve terminal motor latency (PNTML) involves measurement of the time, the
latency, from stimulation of the pudendal nerve at the level of ischial spine to the responding
contraction of the EAS. It is a functional evaluation for a motor nerve. A special electrode (St
Mark’s electrode) (Fig. 17) has been developed (Kiff et al. 1984). The electrode is placed on
the examiner’s gloved index finger and the pudendal nerve is stimulated at the ischial spine
using a transrectal approach. At the base of the finger the electrode records the muscular
contraction response of the anal sphincter muscle. Stimulation is applied of square wave
pulses of 0.2 ms duration and increasing intensity. By adjustment of the fingertip’s position
until maximal response is received, the sphincter muscle responses are recorded. The
stimulation is repeated until two reproducible responses are recorded from each side. The
latency from stimulation to onset of the response is measured.
Figure 17. St Mark´s electrode for recording of pudendal nerve latency. Test of the pudendal nerve
latency and the amplitude. 33
The amplitude of the recorded compound muscle action potential is measured from baseline
to first negative peak (Fig. 17). The examination is classified as abnormal if both sides have a
latency of more than 2.5 ms (Österberg et al. 2000; Ricciardi et al. 2006).
The pudendal nerve terminal motor latency (PNTML) was measured using a disposable
St Mark’s electrode (Dantec-Medtronics, Minneapolis, MN) (Kiff et al. 1984). Stimulation of
square wave pulses of 0.2 ms duration and increasing intensity was applied. Small adjustment
of the stimulator position was done until the maximal response was recorded from the
sphincter muscle. The stimulation was repeated until two reproducible responses were
recorded from each side. The latency from stimulation to onset of the response was measured.
The amplitude of the recorded compound muscle action potential was measured from baseline
to first negative peak. The pudendal nerve latency tests and analysis of the recorded signals
were performed by the neurophysiologist (HL).
Ano rectal manometry (ARM)

Anorectal manometry gives information about anal sphincter pressure at rest and pressure
generated at voluntary contraction. The sphincter pressures are measured at different levels of
the anal canal and give an indication of the strength of the sphincters (Fig. 18).
Figure 18. Measurements of anal sphincter pressures at rest and squeeze at different levels in the
anal canal. The resting and maximum squeeze pressures are plotted at the different levels from the
anal verge. The areas under the curves at the distance 0 - 5 cm from the anal verge are calculated by
computer.
The resting pressure is mainly due to the function of the internal anal sphincter and normally
50 mmHg. The maximum squeeze pressure, normally > 100 mmHg, is mostly due to the
external anal sphincter muscle function. The anal sphincter function is characterized by the
closure pressure generated by the sphincter muscles and by the length of the pressure zone in
34
the anal canal. Anal continence is dependent on sufficient closure pressure generated by the
sphincter muscles in conjunction with a sufficient length of the pressure zone, i.e. the
functional length of the anal canal. The area under the curve of the pressure-distance plot
curve is considered to be a more adequate measure of anal sphincter function than pressure
measurement alone (Fig. 18)(Hallböök et al. 1995).
In the present study the ARM measurements were conducted according to the method
described by Sundblad et al (Sundblad et al. 1993) using the stationary pull-through
technique. The equipment used was ABB Goerz. Metrawatt SE 120, with microtip transducer
(MTC ®; MMS ups 2020, Enschede, NL) and the computer program software MMS Version
8.3; Windows ™ (version 2004 (8.0.4) ©4D SA, 1985-2006; 4D Sweden AB, Isafjordsgatan
36, 164 40 Kista).
Before the manometry the patient had used an enema to clean the rectum. The patient
was positioned in the left lateral position, and the catheter was gently inserted 8 cm in the
rectum. Following equilibration, the pressures were measured at rest, while the patient
performed a single maximal squeeze effort, followed by a period of rest. The measurements
were repeated at 6 cm and at five subsequent stations by 1 cm intervals, as the catheter was
progressively moved in caudal direction. The maximal anal resting pressure (MARP) and
squeeze pressure (MASP) were determined and registered. From the graphic presentation of
the pressure-distance plot the area under the curve at the distance zero to five centimeters was
automatically calculated by the software Kalkylations 4th Dimension, 4-D Runtime
Interpreted™ according to the method described by Hallböök et al (Hallbook et al. 1995).
Consequently values of the anal resting pressure area (ARPA) and anal squeeze pressure
ASPA) area were derived. All ARM examinations and readings were done by one specially
trained assistant nurse.
Prolapse surgery
(Paper IV and V)
The surgery was performed under general or spinal anesthesia. The POP surgery should
include a posterior repair. Surgery in the anterior and apical vaginal compartments was
performed concomitantly if considered necessary by the surgeon depending on the pre- and
peroperative status and symptoms. The colporrhaphies, posterior and anterior, were carried
out with the two-layer suturing technique; one of the endopelvic fascia and recto vaginal
septum using interrupted sutures in the midline plication, and the second by suturing the
35
vaginal epithelium. Plication of the levator ani muscles and perineorrhaphy was performed if
the attachments to the perineal body were considered by the surgeon to be disrupted and/or if
the perineal body was deficient, respectively. Only resorbable sutures were used in the
colporrhaphies. Meshes and implants were not used.
Statistical methods
Statistical evaluations were accomplished by means of non-parametric tests. For comparisons
of unpaired data on ordinal scale odds ratio (OR) with 95 % confidence interval (CI), Yates
corrected -test or Fishers exact test were calculated when appropriate. For continuous data
Mann-Whitney U-tests were used. For comparison of paired ordinal data the McNemar test
was used and for continuous data the Wilcoxon Signed Rank test was applied.
Analysis of variance (ANOVA) or analysis of covariance (ANCOVA) tests were used
to determine associations between effect parameters and independent variables. Subsequent
post hoc testing was done with Fisher's PLSD test.
Multiple logistic regression (MLR) analyses were used to identify predictive factors.
Adjustments were carried out for known and potential confounders when appropriate. Results
of MLR are presented as OR and 95%CI.
A difference was considered significant when p < 0.05. As a consequence of multiple
testing, the Bonferroni adjustment can be applied ad lib.
The statistical analyses were carried out with the software StatView® for Windows,
Copyright©, 1992-1998, Version 5.0.1 (SAS Institute Inc., SAS Campus Drive, Cary, NC
27513, USA).
36
Results and comments
Shift in surgical treatment
(Paper I)
During the two time periods, 542 women were treated with primary POP surgery, 261 in the
period I (1983) and 281 in period II (1993). The demographic and clinical preoperative data
did not differ significantly between the two periods.
The proportion of POP surgery with complete repair was significantly lower in period II
compared with period I (36% vs. 69%). It was especially evident that the use of posterior
colporrhaphy had significantly changed. Eighty-six per cent of the women in period I had a
posterior colporrhaphy and 58% in period II.
The results indicate that a shift from complete repairs to selective repairs occurred
between the time periods and that it was the use of posterior colporrhaphy in particular that
was reduced. Thus it seems that Swedish gynecologists complied with the recommendations
generated from the reports published in the 1980s expressing concern about the troublesome
side effects of complete repairs and posterior repairs.
It seems that this has continued to evolve. Data from the National Board of Health and
Welfare in Sweden show a continuing reduction of the use of complete repairs, especially the
Manchester repair, from 1998 and onwards as presented in Fig. 19.
Type of POP surgery in Sweden
n
3500
3000 Anterior repair
2500
Posterior repair
2000
Manchester repair
1500
Complete repair + vaginal
1000 hysterectomy
500
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure 19. Number of patients with POP surgery in Sweden 1998-2007 (data from the National Board
of Health and Welfare in Sweden (http://www.socialstyrelsen.se/Statistik/statistikdatabas/index.htm)).
37
Subsequent POP surgery (retrospective study)
(Paper II)
In all, subsequent POP surgery was performed on 29 of the 542 women (5.4%) within the
follow-up period of six years. The prevalence of subsequent POP surgery after primary POP
surgery in the two periods differed significantly. Of the women operated on in period I, 2.7%
(7/261) had subsequent POP surgery and of those operated on in period II, 7.8% (22/281) had
subsequent POP surgery. This increase was mainly due to an increase in the use of
complementary procedures. None of the women from period I had a complementary
procedure whereas 5% (9/180) of the women in period II had a complementary procedures.
No significant difference was observed in occurrence of recurrent or combined procedures
between the two periods.
Subsequent POP operations were performed significantly more often in women who
had selective repairs as the primary surgery than in women who had complete repairs (7.7%
(20/261) vs. 3.2% (9/281)).
Women treated with a posterior colporrhaphy either alone or combined with an apical
repair were also more likely to have subsequent POP surgery than those who had neither of
these procedures.
Neither the size of the prolapse, nor the specific vaginal compartment that dominated
the prolapse were found to be associated with the occurrence of subsequent POP surgery.
The associations between the de facto surgery of the specific vaginal compartment and
occurrence of subsequent recurrent or complementary POP surgery are shown in Table 4. No
significant differences were seen in occurrence of recurrent or complementary POP surgery
between the various vaginal compartments.
Table 4. Frequency and type of subsequent POP surgery in relation to vaginal compartment.
Vaginal compartment
Type of subsequent POP surgery Anterior Apical Posterior
Recurrent 6/488 (1.2%) 11/404 (2.7%) 11/385 (2.9%)
Complementary 5/54 (9.3%) 5/138 (3.6%) 9/157 (5.7%)
The denominator in “Recurrent” expresses the number who had an operation in the compartment at the
time of primary surgery. In “Complementary”, the denominator corresponds to the number who was not
operated on in the specific compartment at the time of primary surgery. The numerator reflects the
number of women with subsequent surgery in the specified compartment.
38
The prevalence of subsequent POP surgery found in this study (5.4%) is low compared
with findings from other studies where the prevalence is found to be up to 33% (Benson et al.
1996; Moghimi et al. 2005; Tegerstedt et al. 2004). The rate of subsequent POP surgery
increases with follow-up time. The time interval between the first and the second operation
was on average 12.5 years in the study by Clark (Clark et al. 2003). In my study, the follow-
up time was six years. This may be a part of an explanation for the relative low prevalence.
As seen in Fig. 20 the cumulative relative incidence of subsequent surgery in the retrospective
material of this thesis continues to increase after the sixth postoperative year.
Complete repair period I

% Subsequent POP surgery Selective repair period I
Complete repair period II
16 Selective repair period II
14
12
10
8
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Years after primary surgery
Figure 20. The cumulative relative incidence (%) of subsequent POP surgery in patients with complete
and selective repair from period I and II beyond the 6-year follow-up in period I.
Complete repairs were encumbered with significantly higher complication rates than
selective repairs according to information from the patient records. In particular POP surgery
including posterior repair seemed to be more prone to higher complication rates than POP
surgery without posterior repair as seen in Table 5.
Table 5. Associations between the extent of POP surgery and complications
POP surgery including
Complete repair vs. selective repair posterior repair vs. no posterior repair
Without
Complete Selective Posterior posterior
repair repair OR repair repair OR
No. of women with (n = 281) (n = 261) and (95% CI) (n = 385) (n = 157) and (95% CI)
Any complication 37% 20% 2.17 (1.48 – 3.18) 36% 12% 4.15 (2.46 – 7.00)
Bleeding/hematom 10% 4% 2.67 (1.27 – 5.63) 9% 1% 8.49 (2.02 – 35.7)
Wound infection 6% 3% 1.69 (0.73 – 3.90) 6% 0.6% 10.5 (1.40 – 78.1)
UTI 21% 12% 1.82 (1.40 – 2.90) 20% 9% 2.35 (1.31 – 4.24).
Blood transfusion 4.6% 0.8% 6.28 (1.40 – 28.1) 3.6% 0.6% 5.94 (0.77 – 45.6)
UTI = Lower urinary tract infection
39
Anatomical outcome of POP surgery
(Paper V)
The POP surgery performed upon the 42 women in the prospective study is shown in Table 6.
Table 6. Type of POP surgery in 42 women.

Type of POP surgery Number and (%)
Complete repair: Manchester repair (12) 19 (45%)
Including vaginal hysterectomy (7)
Anterior and posterior colporrhaphy 8 (19%)
Posterior colporrhaphy 12 (29%)
Posterior colporrhaphy and apical repair 3 (7%)
The long-term anatomical outcome median 6.4 years after the primary surgery is
presented in Table 7. Overall, in 71% (30/42) of the cases, the surgery had improved the
preoperative stage of prolapse in at least one stage. Still, 67% (28/42) had stage 2 or 3
prolapse at long-term follow-up. Subdivided according to the vaginal compartment, the
outcome for the anterior compartment was worst with 50% (21/42) having stage 2 or 3
cystocele at follow-up. This was mainly attributed to the group who had had anterior
colporrhaphy. That group had cystocele stage 2 – 3 in 58% (15/26). In the group without
anterior colporrhaphy the corresponding figure was 37.5% (6/16). The apical compartment
was anatomically well supported in all patients at follow-up with no stage 2 or 3 prolapse. The
outcome of the surgery in the posterior compartment showed stage 2 and 3 prolapse in 26%
(11/42). These results are in accordance with previously reported papers (Fialkow et al. 2008;
Jeon et al. 2008; Kahn et al. 1997; Tegerstedt et al. 2004) showing that the surgery improves
the vaginal anatomy but emphasize the “fragility” of the anterior vaginal compartment after
POP surgery.
40
Table 7. Distribution of POP-Q stage preoperatively and at follow-up median 6.4 years later. Sub-
classification according to whether or not surgery was performed of the anterior and apical vaginal
compartments is included.
Preop Follow-up
(no. with) (no. with)
POP-Q staging (N = 42) Stage 0-1 Stage 2 Stage 3
Overall POP-Q stage
Stage 0-1 0 ------ ------ ------
Stage 2 15 6 7 2
Stage 3 27 8 16 3
Anterior compartment POP-Q stage

Stage 0-1 Anterior colporrhaphy 1 1 0 0
No anterior colporrhaphy 15 10 4 1
Stage 2 Anterior colporrhaphy 10 5 4 1
No anterior colporrhaphy 1 0 1 0
Stage 3 Anterior colporrhaphy 15 5 7 3
No anterior colporrhaphy ------ ------ ------ -----
Apical compartment POP-Q stage

Stage 0-1 Apical repair 8 8 0 0
No apical repair 20 20 0 0
Stage 2 Apical repair 9 9 0 0
No apical repair ------ ------ ----- -----
Stage 3 Apical repair 5 5 0 0
No apical repair ----- ----- ----- -----
Posterior compartment POP-Q stage

Stage 0-1 11 8 3 0
Stage 2 21 14 6 1
Stage 3 10 9 1 0
41
Symptoms of pelvic floor dysfunction
Paper III and IV
The prevalence of PFD symptoms preoperatively and the changes after primary POP surgery
are shown in Table 9.
Table 9. Preoperative symptoms in 42 patients and changes of these at postoperative follow-up

Outcome of symptom at follow-up
Preop No. of women
Resolved
completely Persistent p-
Symptom No.* or improved# or worse# De novo# values*
Prolapse symptoms
Vaginal protrusion 23/42 18/22 4/22 1/18 0.0002
Pelvic pressure or heaviness 29/42 19/28 9/28 2/12 0.0005
Bowel symptoms
Problems with emptying the bowel 17/37 13/16 3/16 2/19 0.0098
Splinting 11/37 9/11 2/11 2/24 0.0704
Feeling of incomplete bowel emptying 16/37 9/14 5/14 1/21 0.0269
Fecal incontinence
Gas 18/36 9/17 8/17 3/17 0.1489
Liquid 5/36 1/4 3/4 1/30 0.4795
Solid 1/36 0/1 1/1 1/33 1.000
Urinary symptoms
Difficulty starting voiding 6/35 6/6 0/6 0/27 0.0412
Feeling of incomplete bladder emptying 12/37 8/12 4/12 2/23 0.1138
Urinary incontinence 8/36 3/8 5/8 3/26 0.6831
All questions were not answered by all women. The number of affirmatives for each question is given in
the denominator.
# Persistent means that the symptom is still present but has either improved, but not significantly, is
unchanged or has become worse. De novo means that the symptom was not reported preoperatively
but developed during follow-up period and was reported as occurring at the follow-up. Improvement
means that the symptom still exists but has changed from occurring weekly or more often to occurring
less than once a week.
* McNemar test with continuity correction; df = 1.
There were significant improvements in the symptoms of prolapse, problems with
bowel emptying, feeling of incomplete bowel emptying and difficulty starting voiding but not
in splinting, feeling of incomplete bladder emptying and urinary - and fecal incontinence.
These results agree to a great extent with those of other published studies (Kahn et al. 1997;
Maher et al. 2004; Mellgren et al. 1995; Sloots et al. 2003).
42
The prevalence of the subjective symptoms of PDF six years after primary POP surgery
in the retrospective study and the prospective study are listed in Table 10. For most of the
symptoms there were striking similarities in the figures. Age, BMI and follow-up period but
not parity were comparable in the two studies.
Table 10. The prevalence of PFD symptoms reported in the questionnaire at follow-up 6 years
postoperatively in the retrospective and prospective studies.
Retrospective study Prospective study

PFD symptom (N = 188) (N = 42)
Prolapse symptoms
Vaginal protrusion 18% 12%
Pelvic pressure/heaviness 36% 26%
Bowel symptoms
Problems with emptying the bowel 19% 13.5%
Splinting 10.5% 11%
Feeling of incomplete bowel emptying 24% 16%
Fecal incontinence Gas 38% 36%
Liquid 13% 11%
Solid 4% 5.5%
Urinary symptoms
Difficulty starting voiding 7% 0%
Feeling of incomplete bladder emptying 28% 16%
Urinary incontinence episodes ≥ weekly 40% 22%
PFD = pelvic floor dysfunction
43
The distribution and combination of three main symptoms of PFD – vaginal bulge, urinary-
and fecal incontinence- is illustrated in Fig. 21. Only a very small proportion of the women
presented with the three main symptoms concomitantly.
Figure 21. Distribution of three main symptoms of PFD in women six years after primary POP surgery.
(Reprinted with permission from Acta Obstetricia et Gynecologica Scandinavica.)
Factors associated with symptoms of PFD, POP and outcome of surgery

(Paper III, IV and V)
The statistically significant associations between the anorectal manometry findings and the
prolapse and bowel symptoms are shown in Table 11. The mean value ± SD is given for each
group, i.e. the group of women who has the symptom and those who do not, and the p- value
of the subsequent comparison of the group means by the Fishers´ PLSD test is specified. No
significant associations were otherwise observed between the anorectal manometry
measurements and any of the other investigated symptoms of PFD or the size and extent of
the POP.
44
Table 11. Statistically significant associations between the symptoms vaginal protrusion and feeling of
incomplete bowel emptying, respectively and anorectal manometric findings
Group Group Analysis Fishers´
Anorectal with the without the of PLSD
manometry symptom symptom covariance* test
Symptom measurement Mean ± 1 SD Mean ± 1 SD p-value p-value
Vaginal protrusion MARP 42 ± 14 67 ± 31 0.0033 0.0013
MASP 84 ± 27 125 ± 55 0.0039 0.0037
ARPA 125 ± 46 193 ± 90 0.0074 0.0023
ASPA 250 ± 78 356 ± 156 0.0047 0.0073
Feeling of incomplete bowel MASP 122 ± 59 82 ± 26 0.0107 0.0102
emptying ASPA 332 ± 166 247 ± 76 0.0371 0.0489
*Adjusted for age and BMI.
No previous studies dealing with associations between anal pressures and symptoms or
extent of POP have been reported. This study showed that in particular the symptom “vaginal
protrusion” was significantly associated with a weaker anal sphincter muscle. In contrast to
this, the symptom “feeling of incomplete bowel emptying” was associated with a stronger
anal sphincter muscle. This may indicate that this symptom reflects an obstructed defecation
and not an impaired muscle function as suggested by Klingele et al. (Klingele et al. 2005).
At long-term follow-up none of the PFD symptoms were significantly associated with
the postoperative POP-Q stages, overall or compartmental. In contrast, urinary incontinence
and feeling of incomplete bladder emptying were significantly associated with parity, BMI,
and age (data not shown).
The anorectal manometry measurements deteriorated significantly after POP surgery as
shown in Table 12.
Table 12. Anorectal manometry measurements preoperatively and at repeated measurement, median
3.6 years after.
Preoperative Follow-up
Measurement Median and (range) Median and (range) p – value*
MAPS (mmHg) 42 21 - 122 43 14 - 75 0.0114
MAPS (mmHg) 95.5 40 - 260 87 29 - 166 0.0125
ARPA (mmHg * cm) 131 61.5 - 370 111.5 42 - 256 0.0135
ASPA (mmHg * cm) 276.5 123 – 717.5 233 94 – 408.5 0.0019
*Wilcoxon Signed Rank test.
45
The anal sphincter pressures are age dependent (Åkervall et al. 1990). The deterioration
in pressures observed in this study was more pronounced than expected for the influence of
the ageing factor alone. This might imply that the prolapse surgery may influence the muscle
function of the pelvic floor or that pelvic floor muscle function due to a pre existing damage is
more prone to deteriorate in women with prolapse than in normal women. The results of
anorectal manometry studies in rectocele repairs are contradictory (Maeda et al. 2003;
Mellgren et al. 1995; Yamana et al. 2006). The results in this study are in accordance with
those of Ho et al. and van Dam et al.(Ho et al. 1998; van Dam et al. 2000) Mellgren et al. in a
Swedish study of 25 women found an increase in anal resting pressure (Mellgren et al. 1995).
Contrary, Nieminen et al. found no changes in anal pressures (Nieminen et al. 2004). The
surgical approach of the rectocele repair differs in these studies, which may explain the
diversity of the results.
Statistically significant associations were found between the neurophysiologic findings
and the symptoms of PFD and stage of the POP. However, the post hoc testing with Fisher's
PLSD test revealed no statistically significant differences between group means in any of the
significant associations. These results indicate that there are associations between
neuromuscular damage of the pelvic floor muscles and symptoms of PFD and extent of POP.
The associations were heterogeneously distributed in the muscles and it was not possible to
determine discriminatory values of individual neurophysiologic characteristics to predict the
symptom or stage of the prolapse. This may support the theory about the multifactorial
pathophysiology of POP (Dietz 2008; Swift et al. 2001).
Predictive clinical factors for symptoms of PFD at long-term follow-up after primary
POP surgery are shown in Table 13.
46
Table 13. Predictive factors of symptoms of pelvic floor dysfunction after primary POP surgery. Only the statistically significant associations in the multiple
logistic regression analyses are presented. (Reprinted with permission from Acta Obstetricia et Gynecologica Scandinavica.)
Organ / dysfunction Predictive factor OR 95% CI p - value

Lower urinary tract dysfunction
Clinically significant urinary incontinence Urinary incontinence at the time of the prolapse operation 9.71 3.77 – 25.00 <0.0001
Anti urinary incontinence surgery before questionnaire 4.84 1.89 – 12.43 0.0010
Feeling of incomplete bladder emptying Prolapse operation with complete repair 0.23 0.09 – 0.60 0.0024
Anterior repair as part of the prolapse operation 0.28 0.10 – 0.78 0.0150
Apical repair as part of the prolapse operation 0.34 0.16 – 0.73 0.0055
Bowel dysfunction
Defecation with digitation Chronic pulmonary disease 6.45 1.69 – 24.58 0.0063
Feeling of incomplete bowel emptying Anterior repair as part of the prolapse operation 0.19 0.07 – 0.53 0.0014
Prolapse operation with posterior repair only 4.61 1.33 – 15.98 0.0159
Prolapse operation with posterior and anterior repair 9.35 1.53 – 57.37 0.0157
Clinically significant solid stool incontinence Anterior repair as part of the prolapse operation 0.25 0.07 – 0.88 0.0309
Prolapse symptoms
Vaginal protrusion Prolapse operation with complete repair 0.19 0.05 – 0.70 0.0123
Anterior repair as part of the prolapse operation 0.12 0.04 – 0.38 0.0003
Prolapse operation with posterior and anterior repair 7.09 1.03 – 48.76 0.0463
Sexual dysfunction
Discomfort or pain Feeling of vaginal protrusion prior to prolapse operation 4.11 1.26 – 13.35 0.0189
47
The extent of the POP surgery was a strong predictive factor for the symptoms
incomplete bladder and bowel emptying and solid stool incontinence. Complete repair and
anterior repairs were protective factors for the postoperative symptoms of vaginal bulge and
feeling of incomplete bladder emptying. Posterior repair alone was a risk factor for fecal
incontinence and feeling of incomplete bowel emptying.
Tegerstedt et al. found that a high prolapse stage was a risk factor for adverse outcome
(Tegerstedt et al. 2004). We found that the extent of the prolapse surgery was associated with
symptoms at follow-up and as in several other studies anterior repair was shown to improve
symptoms and discomfort (Bukkapatnam et al. 2005; Tegerstedt et al. 2004; Weber et al.
2001). Repair of the anterior compartment as part of the operation was a predictive protective
factor for the sensations of incomplete bladder and bowel emptying, solid stool incontinence
and vaginal protrusion, but had no impact on urinary incontinence. On the contrary, repair of
the posterior compartment as part of the operation was a highly significant risk factor for the
feeling of incomplete bowel emptying and vaginal bulging. Rovner et al. (Rovner et al. 2001)
found durable anatomical support in over 80 % of cases with posterior repair, but functional
outcome was less favorable. Kahn and Stanton (Kahn et al. 1997) also found that the
anatomical defect in the posterior wall was usually corrected by posterior repair but
contributed to bowel and sexual dysfunction and aggravated anal incontinence. We found that
posterior repair as a single procedure was strongly associated with solid stool incontinence but
we failed to demonstrate associations with the extent of surgery or sexual discomfort and
pain. Posterior repair with plication of the levator ani muscles has been associated with
postoperative occurrence of dyspareunia (Francis et al. 1961; Kahn et al. 1997). We could not
confirm this. Several factors have been shown to be confounding factors for sexual
dysfunction (Mishra et al. 2006; Ponholzer et al. 2005; Signorello et al. 2001). Standard
posterior repairs were performed in this study since site specific repair was not established in
the clinics. Studies of symptoms after site specific repair have indicated less pelvic floor
dysfunction although the results are not unanimous (Paraiso et al. 2006; Sardeli et al. 2007).
Neither the neurophysiologic investigations with EMG of the levator ani and external
anal sphincter muscles nor anorectal manometry measurements were found to predict
outcome of POP surgery concerning symptoms or anatomical outcome.
48
General discussion
Comments on methodology
The retrospective study design has advantages and disadvantages. The access to a cohort by
using patient records is less time consuming and less expensive. The accuracy of the data
relies on the written record and important data may be missing. Lack of a control group and
the risk of selection bias are the main objections to retrospective studies. The results should at
best be regarded as hypothesis generating (Hess 2004). A clear advantage of the retrospective
design is that the issue under investigation already has occurred at the time of the
investigation and therefore can hardly be influenced by the hypothesis.
The retrospective study and the follow-up study were planned in 1998-99. To achieve a
follow-up study with a minimum follow-up of 5 years and to evaluate a period before the
Scandinavian reports of side-effects of complete repairs that were published in 1988 - 1989
we selected 1983 and 1993 as the two time periods of investigation.
In the retrospective study, data on POP surgery were well documented in the patient
records from the three hospitals but information on symptoms and objective status were less
complete. All operations were registered in the hospital registers, thus the cohort of women
undergoing POP surgery during the specific years could be completely identified. All but four
patient records were retrieved and the data were collected in a standardized form by three
gynecologists. There are no reasons to believe that the selection of patients for surgery
differed between the two periods under investigation. No studies or instances of co-operation
were ongoing in the participating clinics affecting the prolapse treatment or surgery under the
actual periods of time and no reports concerning surgical treatment of POP were published
during the period that otherwise dramatically would change the mode of POP surgery as for
instance from vaginal surgery to an abdominal approach or by introducing grafts or implants.
A Swedish study of patients with POP surgery performed in the mid 1980s showed a similar
proportion of women with complete repairs as in this study (Tegerstedt et al. 2004).
Several factors may influence the outcome of the POP surgery. The surgical technique,
the skill of the surgeon and the constitution of the patient are important factors. In this study
no information was available concerning the surgeon’s skill and specific technique used. The
patients and the physician’s attitudes to recurrent prolapse surgery are important factors for
decisions about subsequent POP surgery. The possibility of conservative treatment and
reluctance of the patient and/or the doctor towards additional surgery may influence the
49
number of procedures of subsequent POP surgery. This would probably occur to the same
extent in both time periods and would thus not influence the outcome of the comparison.
The migration rate of women in the areas and ages corresponding to those of the study
groups were low during the time periods (www.ssd.scb.se/databaser). The possibility that
patients underwent subsequent prolapse operations outside the residential clinic was low since
no private clinics performing POP surgery were available at the time.
Survey by postal questionnaire has the advantage of being inexpensive and allows the
responder to answer when it is convenient. Interview by mail is not considered as intrusive as
other kinds of interviews. A response rate of 100% will rarely be achieved. There is no
generally accepted “acceptable” response rate but when the response rate reaches about 70%
it seems that most “non-response” biases disappear (Lydeard 1996). The response rate in the
present study (paper III) was 78%.
It is of importance that a questionnaire or a test actually measures what it is intended to
do, i.e. is valid. The procedure to validate a questionnaire or scale usually includes different
steps including other measuring scales. The term “content validity” means that a subjective
judgment has been made that the questionnaire includes all the relevant and important items.
The higher the content validity of measure, the broader is the inferences that we validly can
draw about the person under a variety of conditions (Streiner et al. 1995). The questions used
in the questionnaires (paper IV, V) were extracted from other validated or commonly used
scales (Hallböök et al. 1995; Oliveira et al. 1996; Uustal Fornell et al. 2003) and the content
validity was considered as high. No validation was performed specifically of the complete
questionnaires used in this study.
A prospective longitudinal study is time and cost consuming but allows data to be
consistently achieved. In the present prospective study patients were included during a period
of almost four and half years. The study extended over time more than planned for several
reasons: the principal investigators schedule, the practical planning and co-ordination of
laboratory facilities, and to a change in the priority of this category of patients due to limited
access to the operating room. During the period of inclusion in the study a total of 220 women
were operated on with POP surgery comprising a posterior repair. This means that
approximately 20% of patients eligible for the study de facto were included. Except for the
inclusion/exclusion criteria no selection procedures were used for the eligible women. They
were called to the POP operation according to the waiting list in order of time of admittance
and their own personal preferences. At the time of the call for preoperative assessment the
50
patient was informed by the research nurse by telephone of the study. Those who made a
preliminary agreement to participate were then appointed for assessment on a day when the
principal investigator was scheduled. No specific records were kept about the number of
women who were asked to participate or how many declined. The study sample might
therefore be considered to be representative. The number of eligible patients in studies
concerning POP surgery is seldom presented in the literature. The proportion of included
patients of the eligible in the present studies is similar or slightly higher than that in large
randomized prospective studies concerning hysterectomy (Gimbel et al. 2003; Learman et al.
2003; Persson et al. 2006).
The prospective study in this thesis was designed to analyze the influence of the pelvic
floor muscles on symptoms of PFD, stage and extent of POP and the outcome of surgery with
respect to symptoms and anatomy. Research data on neurophysiologic findings of pelvic floor
muscles in women with prolapse are sparse. Analysis of power for such a study is therefore
difficult to make. EMG measuring of an atrophic muscle can be difficult to evaluate because
the atrophic muscle gives only a weak, if any, electromyographic signal. The neuromuscular
testing may also have been biased by sub optimal positioning of the EMG needle and thus not
be representative for the muscle. All examinations were performed by the same investigators,
which can be considered an advantage ensuring consistency of the needle positioning and
interpretation of the quality of the signals. The MUP characteristics differed somewhat from
those of symptom-free nulliparous women previously reported by Weidner et al. (Weidner et
al. 2000a) This may be attributed to the POP in the women in the present study but it could be
an effect of different age or parity. The women in the study by Weidner were in average 35
years younger and nulliparous.
The needle EMG testing of the pelvic floor muscles was experienced as painful by some
patients and all muscles could not be investigated in all patients. This could have influenced
the results of the study if these patients had divergent EMG patterns compared with those who
completed the study.
There are several methods available for measuring anorectal pressures and no standard
method exists. In this study the standardized method described by Sundblad et al. and
Hallböök et al. was used. All patients were examined in the same laboratory with the same
equipment by one assistant nurse who had special training in the procedure and in making the
readings. The uniform use of this method strengthens the study and the interpretation of the
51
results. Results from the laboratory have been found to be reliable and reproducible and have
been presented previously (Hallböök et al. 1995; Sundblad et al. 1993).
Pelvic floor muscle function

The pelvic floor muscle function was characterized in two ways: by analyzing the
neuromuscular integrity in terms of electric activity and by analyzing the functional strength
in terms of pressure measurements.
In the neurophysiologic study each muscle was separately evaluated. The pelvic floor
acts as a unit, and maybe it therefore should be evaluated as a “functional unit” (Deindl et al.
1994). However, no information is available in the literature on how to translate the
quantification of MUP characteristics into a qualification of the muscle into normal and
abnormal. Such a translation would probably simplify the interpretation and make it easier to
determine the influence of the function of pelvic floor muscles on POP. Functional
asymmetry of pelvic floor innervation is known to exist in patients with pelvic floor
dysfunction but even in healthy subjects (Enck et al. 2004; Gooneratne et al. 2007). This may
probably explain the heterogeneity in the findings in this study. The concentric needle EMG
findings of the pubococcygeal part of the levator ani and the external anal sphincter muscles
showed some associations with symptoms of pelvic floor dysfunction and degree of prolapse
but no discriminatory values of the MUP parameters could be obtained. Neither could the
neurophysiologic findings predict outcome of POP surgery in terms of changes in symptoms
of pelvic floor dysfunction or anatomical outcome. Women with POP of the anterior
compartment and objectively proven urinary stress incontinence preoperatively had a
divergent neurophysiologic pattern in the PCM, compared with continent women with POP.
Likewise, women with symptoms of genital prolapse and defecation problems or fecal
incontinence had more divergent neurophysiologic patterns in the EAS than women without
these symptoms. Conventional EMG investigation does not seem to be clinically useful in
order to predict the outcome of POP surgery.
No publications have been presented concerning associations between anorectal
manometry and prediction and outcome after POP surgery. The findings concerning the
association between anal sphincter pressure and POP or fecal incontinence are contradictory
(da Silva et al. 2006; Mellgren et al. 1995; Yoshioka et al. 1991)
Vaginal bulge is the single symptom that is most strongly associated with vaginal
prolapse (Tegerstedt et al. 2005). In this study vaginal protrusion was significantly associated
with low anal sphincter pressure at rest as well as at maximal squeeze. This might imply that
52
the damage to the pelvic floor is more pronounced in those who develop this symptom. So far,
this actually has no clinical impact concerning choice of treatment of the POP or operation
method. The study did not demonstrate any association between anal sphincter pressures and
outcome of the operation concerning symptoms and anatomy. Although this might imply that
the anal sphincter function is not clinically important for the outcome of transvaginal
rectocele repair, many of the bowel dysfunction symptoms, even some of those that may be
related to the anal sphincter function, disappeared after posterior colporrhaphy. It is important
to emphasize that the study group was heterogeneous with respect to POP as well as with
respect to the extent of surgery. Such factors may influence the results.
Injury of the pelvic floor may affect the connective tissue, the muscles and the nerves.
Damage in each of these structures may lead to development of POP. The results of the
present studies could not reveal that neuromuscular damage alone was an etiologic factor for
POP but do support the assumption that the etiology is multifactorial. Neurophysiologic
measuring of EMG of the pubococcygeus muscle and external anal sphincter and pudendal
nerve latency and anorectal manometry were not found to predict outcome of POP surgery in
this study. However, the POP and the surgery were heterogenic, which might influence the
results. In order to determine the correct impact of the neuromuscular function on outcome of
surgery the prolapse and the surgery should be completely similar in all study subjects. Today
the diagnostic tools for making a precise and complete mapping of the structural defects
behind a prolapse are too insensitive to allow this standard to be reached. Thus the possibility
to establish a study group with completely uniform prolapse and completely uniform surgery
is almost utopian. There is a strong need for more studies on pelvic organ prolapse
pathophysiology in order to understand the mechanisms behind the development of prolapse
and how to treat it optimally.
Results of POP surgery

The outcome of POP surgery may be evaluated in different ways. The anatomical status has
previously been the most commonly used (Barber 2005). Measures of other aspects such as
PFD symptoms have become tools to determine the efficiency, safety, and side effects of
treatment (Barber 2005). Patient’s satisfaction must also be considered in the assessment of
outcome of POP surgery (Hullfish et al. 2002).
The outcome of POP surgery varies depending on the route of surgery, type of vaginal
surgery and length of follow-up. Anatomical outcome of anterior colporrhaphy is reported
with failure rates between 20-70% (Fialkow et al. 2008; Jeon et al. 2008; Weber et al. 2001).
53
The result of this study is similar in this aspect with a “failure” rate of 50% and high
incidence of subsequent surgery. The results of vaginal surgery of the posterior compartment
show recurrence rates around 14% after traditional posterior colporrhaphy with midline
fascial plication (Abramov et al. 2005; Maher et al. 2004). Posterior repair with discrete
fascial defect repair surgery have recurrence rate varying from 18 –33% (Cundiff et al. 1998,
Abramov et al. 2005; Sardeli et al. 2007). A similar rate of recurrence was found in the
present study (24%).
In the literature subsequent POP surgery is reported in 2.5 to 33%. The follow-up time
in these studies varied from 4.5 to 12.5 years (Benson et al. 1996; Clark et al. 2003; Fialkow
et al. 2008; Moghimi et al. 2005; Tegerstedt et al. 2004). The rate of subsequent POP
operations was 5% in this study after 6-years of follow-up.
Surgery in the anterior vaginal compartment resolves the majority of the voiding
dysfunction symptoms and bulge feeling if the anatomy is restored (Nguyen et al. 2001). In
posterior repairs the subjective outcome differs from good to functional failure rate in 15% or
more in both traditional posterior repair and discrete fascial repair (Gustilo-Ashby et al. 2007;
Maher et al. 2004; Sloots et al. 2003; Paraiso et al. 2006; Sardeli et al. 2007). There is a
controversy in the literature concerning whether a good functional outcome requires a good
anatomical result (Gustilo-Ashby et al. 2007; Sardeli et al. 2007). Sexual dysfunction can be
improved by POP surgery (Paraiso et al. 2006; Rogers et al. 2006; Thakar et al. 2008), but
dyspareunia may also be caused by the surgery, especially after posterior repair with levator
ani plication (Amias 1975; Jeffcoate 1959; Kahn et al. 1997; Borstad et al. 1989). In the
retrospective study, significantly more women who had posterior repair reported discomfort
or pain during or after sexual intercourse compared with those without posterior repair. No
association could, however, be demonstrated between the extent of the prolapse surgery and
pain or discomfort during sexual intercourse. This can probably be explained by the relatively
low number of women in the study or by the construction of the specific questions about
sexual dysfunction in the questionnaire. The result does therefore not exclude the possibility
that posterior repair with levator ani plication is associated with development of dyspareunia.
In the prospective study most of the symptoms of PFD were resolved or diminished
after the POP surgery but in about 20% the symptoms persisted or developed de novo. The
prevalence of symptoms of PFD in the retrospective study at long-term follow-up was rather
similar to those at the long-term follow-up in the prospective study although there was a time
span of almost 10 years between the investigations. Subjective good outcomes have been
54
related to anatomical correction (Gustilo-Ashby et al. 2007; Nguyen et al. 2001). Due to the
relatively low number of women in the present study it was, however, not possible to
determine significant associations between the anatomical and subjective outcome.
Future perspectives
In Sweden in 2007, over 6000 women were operated for genital prolapse
(http://www.socialstyrelsen.se/Statistik/statistikdatabas/index.htm).The genital prolapse
surgery has changed during the past 20 years from complete repairs of all vaginal
compartments to selective repair of only the affected sites. A number of different surgical
techniques have been developed but the outcome does not seem to have improved
substantially in comparison with the “old” traditional methods. Reinforcement with biological
and synthetic grafts and implants has been introduced in order to produce more durable
repairs, especially in the anterior compartment, and to deal with vaginal vault prolapse after
hysterectomy (Dwyer 2006; Winters et al. 2006). The use of biological implants has not been
satisfactory as judged from subjective or anatomical outcomes (Altman et al. 2006). The
grafts and implants have been accompanied by potential serious problems such as mesh
erosion, infection, pain and dyspareunia (Baessler et al. 2006; Milani et al. 2005).
Unfortunately, most of the new products and methods are introduced in clinical practice
before they have been scientifically and correctly evaluated. The use of new products should
only be started in connection with well-performed studies and under regulations (Altman et al.
2008).
There is a great need for improvement of POP treatment as has been demonstrated in
this study. Increased knowledge of the pathophysiology of pelvic organ prolapse is necessary
to understand the mechanisms of POP and to find better treatments. This could, in turn, help
in finding preventive measures for POP.
Efforts at prevention and treatment improvement will only be possible if research
clarifies the causative mechanisms and if scientifically valid studies discover why operations
fail. Specific biologic and behavioral factors that explain why certain women have recurrence
after surgery should be evaluated. Because the pelvic organ support system is comprised of
muscles, ligaments, and nerves arranged in a complex tension-based apparatus, the basic
nature of this work must include biomechanical analyses of the overall mechanism and
targeted research into the biology of muscle, ligament, nerve, and their complex interactions
in normal pelvic floor function and in symptomatic patient (DeLancey 2005).
55
Conclusions
The conclusions of the study were.
i. A shift in treatment tradition from complete repair to selective repair occurred between
1983 and 1993.
ii. The proportion of women who underwent subsequent POP surgery within six years after
the primary surgery increased significantly in the latter period. Those who had selective
repair as the primary prolapse procedure were found more prone to have subsequent
surgery than those who had complete repair. The increase was seen mainly as
complementary procedures and equally distributed between the three vaginal
compartments. Neither the size of the prolapse at the primary surgery nor a
hysterectomy was found to influence the occurrence of subsequent POP surgery.
iii. Symptoms of pelvic floor dysfunction were common at long-term follow up and found
to be associated with the extent of the surgery.
iv. At long term significant improvements were seen in the symptoms of prolapse,
difficulty starting voiding and problems with bowel emptying. The anatomical cure rate
of the anterior compartment was low with recurrence of cystocele in 50% of the
women. The posterior and in the particular the apical compartment were anatomically
well corrected.
v. The measurements of the neurophysiologic investigations and the anal sphincter

pressures showed associations with symptoms of PFD and the extent of the prolapse
preoperatively, but the individual characteristics showed no discriminatory values.
vi. Neither the neurophysiologic findings nor the anorectal manometry pressure
measurements could predict subjective and objective outcomes of the prolapse surgery
56
Sammanfattning på svenska
Framfall (prolaps) är ett tillstånd där slidväggen och/eller livmodern buktar ner till eller
utanför slidingången. Orsaken är svaghet eller skador i slidans stödvävnader som gör att
underlivsorganen som ligger i anslutning till slidan dvs. urinblåsan, livmodern/slidtoppen
och/eller tarmen sjunker ner i slidan. Skador på bäckenbottensmuskulaturen, nerver och
bindväv, som kan uppkomma under graviditet och framför allt vid förlossning, kan på sikt
leda till utveckling av framfall. Framfall är ibland ett helt symtomlöst tillstånd. Symptom på
framfall kan främst vara att något buktar fram i eller utan för slidöppningen eller en ”tryck
eller tyngdkänsla” i underlivet. Även symptom från urinblåsan och tarmen är vanligt
förekommande. Framfall är ett vanligt tillstånd och symptomgivande framfall förekommer i 8
– 10 % av den vuxna kvinnliga befolkningen.
Behandlingen av framfall är antingen konservativ med inläggning av prolapsringar i slidan
eller operation. Vid operationen sys skador och försvagningar i bindväven i slidväggen och
runt slidan, så att underlivsorganen åter igen får stöd och hålls uppe. Det är inte helt ovanligt
att framfallet kan komma tillbaka och att ytterligare en framfallsoperation kan behövas. Vissa
skador i bäckenbotten, till exempel skador på muskulaturen, kan inte lagas så lätt.
Muskulaturen ger stöd till slidan och underlivsorganen och kan vara olika mycket skadade.
Detta kan även ha betydelse för hur bra en operation ”håller”.
I Sverige gjordes år 2007 drygt 6000 operationer för framfall. På 1980-talet gjorde i Sverige
huvudsakligen så kallade ”fullständiga” framfallsplastiker. Dessa innebar en operation med
förstärkning av alla tre områden i slidan vid samma operationstillfälle, dvs framväggen,
bakväggen och slidtoppen, för att uppnå så bra hållfasthet i slidväggarna som möjligt.
Rapporter från Skandinavien på slutet av 1980-talet angav att fullständiga plastiker ökade
risken för utveckling av urininkontinens och besvär med smärtor vid samlag. På grund av
detta uppmanade man till försiktighet med den del av operationen som utfördes i bakre
slidväggen, om kvinnan inte hade symptom härifrån eller hade en påtaglig buktning i denna
del av slidan. En framfallsoperation där man inte opererar på alla de tre tidigare nämnda
ställen vid samma tillfälle, utan bara i en eller två av dessa, kallas selektiv plastik.
I denna avhandling har jag studerat huruvida det skedde en förändring i hur man opererade
framfall mellan 1980 och 1990-talet samt hur en eventuell förändring påverkade behovet av
kompletterande kirurgisk behandling av framfall. Dessutom studerades hur kvinnor mår
avseende symptom från underlivet 6 år efter operationen och hur operationsutfallet blev. Som
andra del i avhandlingen studerades om det finns ett samband mellan bäckenbotten-
57
muskulaturens funktion och förekomsten av symptom från bäckenbotten eller framfallets
omfattning och storlek samt om utfallet av framfallsoperationen kunde förutsägas av
muskelfunktionen.
I den första delen av avhandlingen fastställdes genom genomgång av patientjournaler vilka
operationstyper som använts för behandling av framfall på tre sjukhus i Mellansverige under
åren 1983 och 1993 (Linköping, Örebro, Värnamo). Dessutom togs det reda på om ytterligare
operationer för framfall hade gjorts de efterföljande sex åren. Sammanlagt opererades 542
kvinnor, 261 första perioden (1983) och 281 andra (1993). Andelen fullständiga plastiker
sjönk från 69 % i den första perioden till 36 % i den andra perioden. Särskild minskade
användningen av plastik i bakre slidväggen från 86 % till 58 %. Andelen kvinnor som
opererades med ytterligare framfallsoperation inom 6 år efter första operationen ökade från
2.7 % första perioden till 7.7 % andra. Detta drabbade i högre omfattning kvinnorna som hade
opererats med selektiv plastik jämfört med kvinnor som opererats med en fullständig plastik.
Genom en brevenkät med frågor om symptom från underlivet som skickade ut 1999 till de
kvinnor som opererats 1993 konstaterades att symptom på bäckenbottendysfunktion var
vanliga – 18 % angav symptom på buktning i slidmynningen, 19 % hade svårigheter att
tömma tarmen, 11 % behövde trycka mot slidvägg eller mellangård för att tömma tarmen,
40% angav ofrivilligt urinläckage minst en gång per vecka eller oftare, 28 % hade känslan av
ofullständig tömning av urinblåsan vid vattenkastning och 4 % angav sig ha läckage av
avföring. Symptomen var delvis knutna till vilken operation av framfallet som hade gjorts.
Fullständig plastik och operation av främre slidväggen var skyddande mot symptomen
buktning i underlivet och ofullständig tömning av urinblåsan. 40 % av kvinnorna hade aktivt
samliv, 15 % avstod samliv på grund av besvär med obehag och smärtor vid samlag. De
kvinnor som opererats med en framfallsoperation med plastik av bakre slidväggen hade i
större utsträckning besvär vid samlag än de som opererats för framfall på annat sätt.
I den andra delen av avhandlingen studerades 42 kvinnor som opererades för framfall mellan
1999 och 2004. Innan operationen undersöktes kvinnorna med neurofysiologisk undersökning
av bäckenbottenmuskulaturen och ändtarmsmuskeln medelst elektromyografi (EMG), där
man med hjälp av en nålelektrod mäter de elektriska signalerna i muskeln. Styrkan i
ändtarmsmuskeln undersöktes med anorektal tryckmätning i vila och vid knipning.
Alla kvinnorna opererades med plastik av bakre slidväggen. Operation med fullständig plastik
gjordes på 45 % av kvinnorna. Två till tre år efter framfallsoperationen upprepades
tryckmätningen av ändtarmsmuskeln och efter 4-8 år upprepades den gynekologiska
58
undersökningen. Färre kvinnor angav symptom i form av känsla av buktning i underlivet,
problem med tömning av tarmen och startsvårighet vid vattenkastning efter operationen men
besvär med urin- och avföringsinkontinens kvarstod hos en oförändrad andel. Andelen
kvinnor som hade behov av att trycka mot slidvägg eller mellangård för att få ut avföringen
minskade. Nytillkomna besvär med urinläckage förekom hos 12 % av kvinnorna och
inkontinens för gaser hos 18 %. Främre slidväggen var hos hälften av kvinnorna nedsjunken
till strax ovan eller utanför slidmynningen efter operationen. Resultaten av operationen av
slidtoppen eller livmodertappen och bakre slidväggen var bättre.100 % respektive 75 % hade
inte kvarvarande framfall av dessa delar av slidan.
EMG undersökningarna visade tecken till skador på muskler/nerver i bäckenbotten och
ändtarmsmuskel. Det förelåg samband mellan EMG-mätvärden och symptom samt framfallets
storlek och omfattning. Sambanden var dock inte så starka att man kunde finna en nivå där
man kunde särskilja dem, t.ex. mellan grad av framfall eller förekomst av symptom.
Tryckmätningarna av ändtarmsmuskeln visade också samband mellan tryck i ändtarmen och
symptom respektive framfalls storlek och omfattning. För dem med symptomet buktning ur
slidan var ändtarmstrycket lägre än hos dem som inte hade detta symptom. En försämring av
vilo- och kniptrycken i ändtarmen noterades efter operationen, mer än den förväntade effekten
av ökad ålder. Detta kan bero på den tidigare skadan av bäckenbotten, en påverkan på
muskulaturen av operationen eller en kombination av dessa.
Sammanfattningsvis konkluderas att operationsmetoderna på 1980-talet förändrades från i
huvudsak fullständiga plastiker till i större omfattning selektiva plastiker på 1990-talet.
Andelen som behövt ytterligare en framfallsoperation ökade, framför allt hos kvinnor som
opererats med selektiv plastik. Långtidsuppföljning visade att symptom från framfall,
urinvägar och tarm samt återfall av framfall i främre slidväggen var vanliga. Bäckenbotten
muskulaturen har betydelse för utvecklingen av framfall och symptom på bäckenbotten-
dysfunktion. De neurofysiologiska undersökningarna och tryckmätningarna av ändtarms-
muskeln kunde dock inte användas för att förutsäga utfallet på symptom och framfallet efter
framfallsoperation. Det faktum att utvecklingen av framfall beror på ett flertal orsaker och
inte bara muskel/nerv skador, kan också vara en del i förklaringen till våra fynd.
För att finna sätt att förhindra utveckling av framfall hos kvinnor samt att optimera
behandlingen behövs mer kunskap om bäckenbottens sjukdomslära. En mer förfinad
diagnostik av de enskilda skadorna och individuellt anpassade operationer torde vara önskvärt
för att få bättre och mer bestående resultat av framfallsoperationer.
59
Acknowledgements
A number of people have contributed, inspired and helped me to accomplish this thesis. I wish
to express my sincere gratitude to all of you. I especially want to thank:
First of all, Preben Kjølhede, Associate Professor at the Dept. of Obstetrics and Gynecology,
University Hospital, Linköping, my tutor and very good friend, for leading me toward the
scientific pathway with never-ending energy. For all support from his family also and
especially his wife Connie for always showing me great hospitality!
Jan Brynhildsen, Associate Professor, Dept. of Obstetrics and Gynecology, University
Hospital, Linköping, my second tutor, for friendship, support and superb “lateral” thinking
when desired.
Mats Hammar, Professor, Dean of the Faculty of Health Sciences, Linköping University, my
“third” tutor, for good support and great in reminding me to apply for grants.
Hans Lindehammar, MD, Ph.D, Dept. of Clinical Neurophysiology, co-auther, for
introducing me in the mystery of EMG´s and the life of the “MUPpets” and always being
available for my study patients; calm, cool and helpful.
Adam Sydsjö, MD, Ph.D, co-author, for an enormous help in removing dust from a lot of
patient records in Värnamo.
Göran Berg, Professor, Head of Obstetrics and Gynecology, Dept. of Clinical and
Experimental Medicine, Faculty of Health Science, Linköping University for being
enthusiastic and giving excellent support to my work.
My co-authors Olof Hallböök, Associate Professor, Dept of Surgery, University Hospital in
Linköping, Kerstin Nilsson, Associate professor, Dept. Obstetrics and Gynecology, Örebro
and Tomas Johansson, MD, for help in adding special knowledge to the papers.
Ulla Fransson, research nurse in the University Hospital in Linköping, for great help in
informing and recruiting patients to my study.
Ritva Johansson, research assistent nurse at the anorectal lab, the University Hospital,
Linköping for her dedicated and very professional handling of the patients and examinations.
Marie Rosberg, assistant nurse for additional help in the lab- mysteries when Ritva retired.
Birgitta Ohlsson, secretary, for being a real “Sherlock Holmes” in retrieving lost patient
records.
60
Lotta Berlin, physiotherapist, for help and sharing interest in the subject of pelvic floor
dysfunction and research.
The staff at the out-patient clinic, Dept. of Ob/Gyn, University Hospital in Linköping for kind
assistance and for always willing to help.
All staff at the gynecologic wards and operation rooms in both Linköping and Örebro for
dedicated work.
Gunnar Rydén, Associate Professor and “cowboy of the Pampas”, Eva Uustal Fornell, MD,
Ph.D, Gabriella Falk, MD, med.lic, Sivert Lindström, Professor, Lotta Lindh-Åstrand,
registered research nurse, Anders Spångberg, MD, PhD, Anna-Clara Spetz, MD, PhD, for
constructive criticism of my work.
Klaas Wijma, Professor, Dept of Clinical and Experimental Medicine, Faculty of Health
Sciences, Linköping University for support with the construction of part (6) of the
questionnaire.
Johan Bohr, Associate professor, Dept of Gastroenterology, Örebro and Susanna Walter,
MD, PhD, for giving me extra insights in the pelvic floors´ backyard.
Ingrid Östlund, MD, Ph.D, Head of the Dept of Obstetrics and Gynecology in Örebro, for
support and good help in providing me time for my scientific work.
Karin Franzén, MD, colleague and close friend for appreciated support and discussions in
the field of urogynecology and everything else. Beate Springer, MD, for kind help in the
urogynecological work.
All colleagues in Örebro and Linköping, for taking interest in and supporting me in my
research.
Margareta Landin, Birgitta Eriksson and the rest of the staff at the Medical Library, USÖ
for quick support and help with the reference program (thank God there is one!)
The Goddesses of Crete (Ann, Eliza, Gunnel, Margareta x2, Tulla, Anna, Kerstin, Ditte, all
MD´s) for being such good lady friends; temporary transferring me out of the world of
science into the “real world” now and then. You make such a good “sounding board”.
Katarina Helgeson and Päivi Nauclér (both MD´s) for the warmest friendship and
sisterhood - beyond time and borders.
All friends, including “Tjejgänget” of female doctors of Örebro for concern and interest.
Mats Fredrikson, Associate professor, for help in handling the statistical p´s.
John DeLancey, Professor and my “Guru” in urogynecology, for the permission to reprint his
illustrations.
61
Pia Agervi, MD, for didactic drawings of the female pelvic floor; ARGUS for giving the
permission to use them.
Glenn Hurt, Professor, for permission to reprint his surgical illustration.
Lawrence Lundgren, Professor emeritus, for translating my “SwEnglish” to English in this
book and to Dennis Netzell for great help in the cover “outfit”.
All relatives and especially my sister Karin Kromann and my brother Stefan Mattson with
families, for love and support.
My two sons, Christoffer (Master of Science in Engineering; currently my source in China)
and Jacob, MD and their girlfriends Diana and Ngan (MD) for encouragement, love and
understanding.
Most of all, to Sven, my ♥ husband and great support in life for joy, encouragement and love
in good and bad. And for being such a swell chief of the cuisine at times, serving me nice
meals and being a superb helper whenever there were (are) problems with the computer!
The study was supported by grants from The County Councils of Örebro and Östergötland,
Linköpings University, Konsul Thure Carlssons Minnesfond and Lions Forskningsfond mot
Folksjukdomar vid Hälsouniversitet i Linköping.
62
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http://www.socialstyrelsen.se/Statistik/statistikdatabas/index.htm
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=BE&huvudtabell=Flyttningar&omradetext=Befolkning&tabelltext=Flyttningar+efter+region
%2C+%E5lder+och+k%F6n%2E+%C5r+1968%2D1996&preskat=O&prodid=BE0101&start
tid=1968&stopptid=1996&Fromwhere=M&lang=1&langdb=1
69
Appendix A
Detta frågeformulär innehåller bland annat frågor om hur Du uppfattar Din

vattenkastning och tarmfunktion.
De flesta frågorna besvaras genom att kryssa i den ruta, som bäst stämmer för Dig.
Om Du är osäker, kryssa ändå i den ruta som känns riktigast.
Ditt namn:
Födelsedag:
år mån dag
Datum då Du fyller i frågeformuläret:
år månad dag
1. Hur mycket väger Du? kilo
2. Hur lång är Du? centimeter
3. Vilken typ av arbete har Du haft större delen av livet?
Stillasittande arbete.
Rörligt arbete utan tunga lyft
Tungt arbete med dagliga tunga lyft
4. Kryssa för om Du besväras av eller opererats för någon av följande åkommor. (Kryssa
för om flera alternativ passar på Dig).
astma
kronisk luftrörskatarr med hosta
sjukdom i nervsystemet (t ex MS, hjärnblödning/propp/diskbråck)
åderbråck på benen
ljumskbråck
magmunsbråck
diabetes mellitus
hjärtsjukdom
högt blodtryck
5. Kryssa för om Du använder någon av följande mediciner:
östrogen mot sköra slemhinnor i underlivet?
(t.ex. Ovesterintabletter, hormonkrämer, slidpiller eller dylikt)
östrogen mot övergångsbesvär (t ex östrogenplåster,
hormongel eller tabletter)
naturmedicin mot övergångsbesvär
vattendrivande medicin
medicin mot urinträngningar (t ex Cetiprin, Detrusitol
eller Ditropan)
medicin mot hjärtsjukdom eller högt blodtryck
70
6. Har någon av Dina föräldrar eller syskon besvärats av något av följande? (Om flera
alternativ passar, kryssa i dessa)
ljumskbråck
framfall av slidan eller livmodern
urininkontinens
gas- eller avföringsinkontinens
hemorrojder
framfall av ändtarmen
vet inte
7. Har Du fött barn?
Nej
Ja
Om Du inte fött barn, var god gå vidare till fråga 13. Om Du fött barn:
8. Normal förlossning den vanliga vägen, hur många?
stycken förlossningar
9. Om förlossning med sugklocka, hur många ?
10. Om förlossning med tång, hur många ?
11. Om förlossning genom kejsarsnitt, hur många?
12. Fick Du vid någon av förlossningarna någon bristning i underlivet?
Nej
Ja, några stygn syddes
Ja, snedklipp / stor bristning
Ja, stor bristning där ändtarmsmuskeln gick sönder
Kommer ej ihåg/vet ej
13. Kryssa för om Du genomgått någon/några av följande typer av underlivsoperation eller
behandling innan eller efter framfallsoperationen.(Kryssa för alla som är aktuella för Dig)
Operation mot framfall av slidan eller livmodern
Operation mot urinläckage
Operation mot cellförändringar på livmodertappen
Operation mot cancer i underlivet
Operation mot avföringsläckage från ändtarmen
Operation av hemorrojder
Operation mot ändtarms-framfall
Borttagande av livmodern
Borttagande av båda äggstockarna
Strålbehandling mot underlivet
71
14. Brukar Du träna knipövningar för bäckenbottenmusklerna?
Nej, sällan eller aldrig
Ja, någon gång i veckan
Ja, dagligen
15. Händer det att Du upplever tyngd eller tryckkänsla i underlivet?
Nej
Ja
16. Händer det att det känns som om något buktar fram och/eller skaver i underlivet?
Nej
Ja
17. Händer det att det läcker luft ur slidan så att det hörs?
Nej
Ja
Frågor angående tarmfunktionen.
Frågorna 18 - 21 handlar om hur ofta (eller sällan) Du har avföring, avföringens konsistens
och om Du behöver hjälpa till med mediciner. Frågorna gäller hur det varit under de två
senaste veckorna.
18. Hur många gånger brukar Du ha avföring?
dagtid? ................. nattetid?...............
19. Vilket är det högsta / lägsta antalet avföringar Du haft under ett dygn?
högsta?.................. lägsta?.................
20. Har det hänt att det gått flera dagar mellan avföringarna?
Nej
Ja Om ja, hur många dagar?....................
21. Hur brukar avföringens konsistens vara?
Lös Mjuk och formad Växlande mellan Hård

hård/lös
22. Hur ofta behöver Du något medel (stolpiller, droppar, tabletter eller lavemang) för att få
avföring?
Aldrig Mindre än en 1-6 gånger per Alltid för att

gång per vecka vecka få avföring,
eller varje dag
23. Tar Du några andra mediciner för tarmfunktionen?
Nej
Ja, Vilka då och hur ofta?.......................................
Frågorna 24 - 29 handlar om tarmtömningen och hur toalettbesöket fungerar. Frågorna
gäller hur det har varit de senaste två veckorna:
24. Hur ofta har Du svårt få ut avföringen?
Aldrig Mindre än en 1-6 gånger per Varje dag

gång per vecka vecka (Alltid)
72
25. Hur ofta måste Du hjälpa ut avföringen t.ex. genom att trycka med fingrarna i slidan
eller plocka ut avföringen?

26. Hur lång tid brukar Du behöva för att få ut avföringen?
5 minuter Cirka Cirka Mer än

eller mindre 10 minuter 20 minuter 20 minuter
27. Hur lång tid brukar Du behöva krysta för att få ut avföringen?

28. Hur ofta behöver Du återvända till toaletten inom en timme för att få tarmen tom?

29. Hur ofta har Du känsla av ofullständig tarmtömning?

Frågorna 30 - 33 handlar om smärta eller om problem som rör tarmfunktionen. Frågorna
30. Hur ofta har Du buksmärta?

31. Hur ofta har Du buksmärta som lindras när Du haft avföring?

32. Hur ofta har Du uppblåst buk?

33. Hur ofta har Du uppblåst buk som lindras när Du haft avföring?

Frågorna 34 - 42 handlar om läckage från tarmen av gas eller avföring. Frågorna gäller hur
det har varit de senaste två veckorna:
34. Hur ofta känner Du i förväg när Du skall ha avföring?
Alltid Oftast Ibland Aldrig

73
35. Hur ofta kan Du släppa gas utan att det läcker avföring?

36. Hur länge kan Du hålla avföringen om det inte finns tillgång till toalett?
30 minuter Cirka 15 Cirka 5 Inte alls

eller längre minuter minuter
37. Hur ofta har Du ofrivillig gasavgång?

38. Hur ofta händer det att Du får fläckar från tarmen i underkläderna

39. Hur ofta har Du läckage av avföring om den är lös?

40. Hur ofta har Du läckage av avföring om den inte är lös?

41. Hur ofta har Du någon form av skydd i underkläderna mot avföringsläckage på dagtid?

42. Hur ofta har Du någon form av skydd i underkläderna mot avföringsläckage nattetid?

Frågorna 43 - 45 handlar om hur Din tarmfunktion påverkar Dig i det dagliga livet.
43. Är tarmfunktionen besvärande för Ditt allmänna välbefinnande?
Inte alls Något En hel del Mycket
44. Medför tarmfunktionen begränsningar i Ditt sociala liv?

45. Finns det något Du måste avstå ifrån på grund av ängslan för gas- eller
avföringsläckage? (flera alternativ kan väljas)
Nej
Ja, promenader
Ja, gymnastik
74
Ja, att gå på kurser, möten, teater etc
Ja, sex
Ja, yrkesarbete
Ja, offentliga bad
Ja, annat
Frågor angående vattenkastningen
Frågorna 46-63 handlar om hur Din vattenkastning fungerar. Frågorna gäller hur det varit
under senaste året.
46. Har Du svårigheter att komma igång med vattenkastningen när Du sitter på toaletten?
Nej
Ja
47. Behöver Du krysta för att kasta vatten?
Nej
Ja
48. Hur länge får Du sitta på toaletten för att tömma urinblåsan?

49. Känns det som urinblåsan är tom när Du kastat vattnet?
Nej Ibland Ofta Alltid

50. Hur ofta behöver Du återvända till toaletten inom en timme för att få urinblåsan tom?

51. Händer det att Du läcker urin ?
Nej
Ja, enstaka gånger/ år
Ja, någon gång/ månad
Ja, någon gång/ vecka
Ja, dagligt besvär
Om Du svarat ja i fråga 51, och fortsätt med de följande frågorna. Om Du svarat nej var snäll
fortsätt med fråga 64.
52. Använder Du kostnadsfria inkontinenshjälpmedel (bindor/blöjor som skrivits ut på s k
hjälpmedelskort)?
Nej
Ja
Inför nästa avsnittet om urinläckage:
Trängning är när det känns som om Du känner Dig kissnödig och tvunget måste kissa direkt.
Ansträngning är att t ex nysa, skratta, hoppa, springa, lyfta tungt, snubbla, hosta, etc.
75
53. Hur många gånger kissar Du om dagen (mellan kl. 06 och kl 23)?
1-7 8-10 mer än 10

54. Hur många gånger kissar Du på natten (mellan kl 23 och kl 06)?
0-1 2-3 mer än 3

55. Blir Du kissnödig oftare om Du är nervös, stressad, diskar, tvättar eller kommer hem
och skall låsa upp dörren?

56. Kissar Du på Dig vid plötslig ansträngning?
Nej Ja ,ofta Ja, ibland Ja, utan

ansträngning
57. Kissar Du på Dig direkt vid ansträngning?
Nej Ja, ofta Ja, ibland Ja, efter

en stund
58. Har Du trängningar innan Du kissar på Dig?
Nej Ibland För det

mesta
59. Hur mycket urin kommer det när Du kissar på Dig?
Droppar En skvätt Blåsan töms

60. Kan Du "stänga av strålen" när Du kissar?
Ja, ofta Ja, ibland Nej

61. Har Du haft urinvägsinfektion under det senaste året?
Nej 1-2 3 gånger

gånger eller fler
62. Medför vattenkastningen eller urinläckaget begränsningar i Ditt sociala liv?

63. Finns det något Du måste avstå ifrån på grund av ängslan för urinläckage? (flera
alternativ kan väljas)
Nej
Ja, promenader
Ja, gymnastik
Ja, sex
76
Ja, yrkesarbete
Ja, offentliga bad / simhallsbesök
Ja, annat, skriv vad:...................................................
Frågorna 64-68 berör Ditt sexuella samliv. Frågorna gäller hur det har varit de senaste tre
månaderna.
64. Har Du aktivt samliv?
Ja
Nej - avstår helt pga eget obehag
Nej - har inte samliv (saknar partner, sjuk partner, etc)
Om Du svarat Nej - har inte samliv i fråga 64, var god gå till 69.
65. Har Du ont vid samlag?
Nej
Ja, alltid
Ja, ibland
66. Om Du svarade ja på fråga 65, kryssa för det som gäller för Dig:
(kryssa för flera rutor, om det passar för Dig)
Ont ytligt i slidan eller vulva
Ont djupt i slidan
Ont innan samlag
Ont under samlag
Ont efter samlag
67. Har Du svårigheter att genomföra samlag?
Nej
Ja, pga alltför trång slidmynning
Ja, pga att något tar emot innanför slidmynningen
Ja, pga annan orsak: Ange vilken..................................................
68. Har Du andra besvär vid samlag?
Nej
Ja, obehag med gasavgång från slidan
Ja, urinläckage i samband med samlag
Ja, annan besvär: Ange vilken/vilka.....................................
69. Dina kommentarer och synpunkter:
.....................................................................
.....................................................................
När Du har fyllt i frågeformuläret vill vi be Dig åter kontrollera att alla frågor är besvarade
och därefter skicka in frågeformuläret till oss i det bifogade portofria svarskuvertet.
77
Appendix B
Frågeformulär preoperativt.
Detta frågeformulär innehåller bland annat frågor om hur Du uppfattar Din vattenkastning,
tarmfunktion och samlivet.
Protokoll nr:
år månad dag
1. Vilken typ av fysiskt arbete, såväl hemma som utanför hemmet, har Du haft under
större delen av livet?
Sätt kryss i rutan 1 till 10 som passar bäst
1 2 3 4 5 6 7 8 9 10
inget fysiskt mycket tungt med

ansträngande många tunga lyft
2. Hur tungt har Ditt fysiska arbete varit under de senaste 5 åren?
Sätt kryss i rutan 1 till 10 som passar bäst
1 2 3 4 5 6 7 8 9 10
inget fysiskt mycket tungt med

ansträngande många tunga lyft
3. Röker Du?
ja
nej, aldrig rökt
nej, men har tidigare rökt
för om flera alternativ passar på Dig)
astma
sjukdom i nervsystemet (t ex MS, hjärnblödning/propp /diskbråck)
ljumskbråck
magmunsbråck
diabetes mellitus
hjärtsjukdom
högt blodtryck
östrogen mot sköra slemhinnor i underlivet? (t.ex. Ovesterintabletter,
hormonkrämer, slidpiller )
78
östrogen mot övergångsbesvär (östrogenplåster, hormongel eller tabletter)
medicin mot urinträngningar (t ex Cetiprin, Detrusitol eller Ditropan)
6. Har någon av Dina föräldrar eller syskon besvärats av något av följande? (Om flera
alternativ passar, kryssa i dessa)
ljumskbråck
framfall av slidan eller livmodern
urininkontinens
gas- eller avföringsinkontinens
hemorrojder
framfall av ändtarmen
vet inte
7. Har Du fött barn?
Nej
Ja
Om Du inte fött barn, var god gå vidare till fråga 17. Om Du fött barn:
8. Normal förlossning den vanliga vägen, hur många? stycken förlossningar
9. Hur mycket vägde barnet/n som förlöstes normalt?
1:…………..g 2:…………..g 3:……………g 4:……………g
10. Om förlossning med sugklocka, hur många ?
11. Hur mycket vägde barnet/n som förlöstes med sugklocka?
1:…………..g 2:…………..g
12. Om förlossning med tång, hur många ?
13. Hur mycket vägde barnet/n som förlöstes med tång?
1:…………..g 2:…………..g
14. Om förlossning genom kejsarsnitt, hur många?
15. Hur mycket vägde barnet/n som förlöstes med kejsarsnitt?
1:…………..g 2:…………..g
16. Fick Du vid någon av förlossningarna någon bristning i underlivet?
Nej
Ja, några stygn syddes
Ja, snedklipp / stor bristning
Ja, stor bristning där ändtarmsmuskeln gick sönder
Kommer ej ihåg/vet ej
17. Kryssa för om Du genomgått någon/några av följande typer av underlivsoperation eller
behandling innan framfallsoperationen.(Kryssa för alla som är aktuella för Dig)
Operation mot urinläckage
79
Operation mot cellförändringar på livmodertappen
Operation mot cancer i underlivet
Operation mot avföringsläckage från ändtarmen
Operation av hemorrojder
Operation mot ändtarmsframfall
Borttagande av livmodern
Borttagande av båda äggstockarna
Strålbehandling mot underlivet
Nej, aldrig
Ja, men sällan
Ja, dagligen
19. Om Ja i fråga 14, hur lärde Du Dig knipövning?
Genom gynekolog
Genom distriktsläkare
Genom uroterapeut
Genom distriktssköterska
Genom sjukgymnast
Genom barnmorska
Lärt Dig själv via broschyr
Lärt Dig själv via kassettband
Lärt Dig själv utan hjälp
Lärt Dig med annan hjälp
Frågorna 20 - 25 handlar om hur ofta (eller sällan) Du har avföring, avföringens konsistens
och om Du behöver hjälpa till med mediciner. Frågorna gäller hur det varit under de
två senaste veckorna.

dagtid? ................. nattetid?...............
21. Vilket är det högsta / lägsta antalet avföringar Du haft under ett dygn?
högsta?.................. lägsta?.................
Nej

hård/lös
80
24. Hur ofta behöver Du något medel (stolpiller, droppar, tabletter eller lavemang) för att
få avföring?

eller varje dag
Nej
Ja, Vilka då och hur ofta?.......................................
Frågorna 26 - 31 handlar om tarmtömningen och hur toalettbesöket fungerar. Frågorna







Frågorna 32 - 35 handlar om smärta eller om problem som rör tarmfunktionen. Frågorna


81



Frågorna 36 - 44 handlar om läckage från tarmen av gas eller avföring. Frågorna gäller hur
det har varit de senaste två veckorna:



39. Hur ofta har Du ofrivillig gasavgång?

40. Hur ofta händer det att Du får fläckar från tarmen i underkläderna

41. Hur ofta har Du läckage av avföring om den är lös?

42. Hur ofta har Du läckage av avföring om den inte är lös?

43. Hur ofta har Du någon form av skydd i underkläderna mot avföringsläckage på dagtid?

82
44. Hur ofta har Du någon form av skydd i underkläderna mot avföringsläckage nattetid?

Frågorna 45 - 47 handlar om hur Din tarmfunktion påverkar Dig i det dagliga livet.
45. Är tarmfunktionen besvärande för Ditt allmänna välbefinnande?


Nej
Ja, promenader
Ja, gymnastik
Ja, sex
Ja, yrkesarbete
Ja, offentliga bad
Ja, annat
Nej
Ja
Nej
Ja

83

53. Händer det att Du läcker urin ?
Nej
Ja, enstaka gånger/ år
Ja, någon gång/ månad
Ja, någon gång/ vecka
Ja, dagligt besvär
Om Du svarat ja i fråga 53, var god fortsätt med de följande frågorna. Om Du svarat nej gå
direkt till fråga 66.
54. Använder Du kostnadsfria inkontinenshjälpmedel (bindor/blöjor som skrivits ut på s k
hjälpmedelskort)?
Nej
Ja
Inför nästa avsnittet om urinläckage:
Trängning är när det känns som om Du känner Dig kissnödig och tvunget måste
kissa direkt.
Ansträngning är att t ex nysa, skratta, hoppa, springa, lyfta tungt, snubbla, hosta,
etc.
55. Hur många gånger kissar Du om dagen (mellan kl. 06 och kl. 23)?
1-7 8-10 mer än 10

0-1 2-3 mer än 3


Nej Ja ,ofta Ja, ibland Ja, utan ansträngning

59. Kissar Du på Dig direkt vid ansträngning?
Nej Ja, ofta Ja, ibland Ja, efter en stund

60. Har Du trängningar (blir plötslig kissnödig) innan Du kissar på Dig?
Nej Ibland För det mesta


84

63. Har Du haft urinvägsinfektion under det senaste året?
Nej 1-2 gånger 3 gånger eller fler


Nej
Ja, promenader
Ja, gymnastik
Ja, sex
Ja, yrkesarbete
Ja, annat, skriv vad:..................................................
Frågor angående samlivet
Frågorna 66-81 berör Ditt sexuella samliv. Frågorna gäller hur det har varit det senaste
året.
66. Lever Du i ett parförhållande?
Nej
Ja, gift eller sambo
Ja, särbo
67. Har Du under de senaste månader haft samlag
Ja
Nej
68. Om inte, varför? (markera den mest giltiga orsaken)
Ingen lust
Skulle vilja, men kan inte på grund av besvär från slidan/underlivet
Min partner kan inte/har svårt att genomföra samlag
Min partner är rädd att skada mig
Annan orsak: ange vilken/a:…………………………………………………
Aldrig
Sällan
Ibland
Ofta
Mycket ofta
Alltid
85
70. Om Du har eller har haft ont – kryssa för det som gäller (kryssa för de som gäller, ev.
flera)
Ont ytligt i slidan eller i blygdläpparna
Ont djupt i slidan
Ont djupt inne i buken
71. Om Du har ont, ange när: (kryssa för de som gäller, ev. flera)
Ont innan samlag
Ont under samlag
Ont efter samlag
72. Har Du besvär som gör att Du ibland måste avbryta eller inte kan genomföra samlag? I
så fall vilken/a anledning/ar?
Nej
Ja, slidan känns torr
Ja, på grund av allt för trång slidmynning
Ja, på grund av att något tar emot innan för slidmynningen:
Ja, på grund av annan orsak. Ange vilken:.........................
73. Har Du andra besvär vid samlag än det som nämns vid fråga 72?
Nej
Ja, obehag med ljud/luft från slidan
Ja, annat besvär. Ange vilken/vilka..............................................
74. Ibland används en ring för att hålla uppe ett framfall. Har Du fått prova en sådan?
Nej
Ja
75. Om Du inte provat ring, men blivit erbjuden detta, vad berodde det på att du avstod?
( kryssa för det – de som gäller)
Kändes onaturligt
Jag var rädd att det skulle kännas obehagligt
Jag trodde det skulle försämra mitt sexuella samliv
Annat, ange vilket:……………………………………………
Om Du inte har använd ring, var god gå till fråga 82.
76. Om Du använt ring kunde Du ha kvar ringen en längre tid
(1 månad eller längre tid)?
Nej
Ja
76. Om Du inte hade kvar ringen, vad berodde detta på?
Satt inte kvar, ramlade ut
Kändes obehagligt, skavde; blev uttagen
Annan orsak, ange vilken/a:
77. När Du använde ringen, hade Du samlag under denna tid?
(kryssa för den eller de som gäller)
86
Ja, medan ringen var kvar i slidan
Ja, provade, men det fungerade inte
Tog ut ringen vid samlag
Nej
78. Om det inte fungerade trots försök, varför? (kryssa för den eller de som gäller)
Obehaglig för mig själv
Obehaglig för min partner
Gav mig inte samma lustkänsla som utan ring
Annat, ange vilken/a:…………………………………
79. Om Du inte provat med samlag när Du hade ring, vad berodde det på? (kryssa för den
eller de som gäller)
Ingen lust till samlag
Kändes inte ”naturligt” med samliv med ring
Min partner ville inte
Annan orsak , ange vilken/a:……………………….
80. Vad förbättrades med ringen? (kryssa för den eller de som gäller)
Mindre tyngdkänsla
Mindre skavning i underlivet
Tarmtömningen förbättrades
Kunde hålla urinen längre tid i urinblåsan
Sexuella samlaget
Mindre urinläckage
Mindre mängd flytning
Annat, ange vilken/a:……………………………………….
81. Vad blev sämre med ringen? (kryssa för den eller de som gäller)
Mer tyngdkänsla
Mer skavning i underlivet
Tarmtömningen försämrades
Tätare vattenkastning
Sexuella samlaget
Mer urinläckage
Större mängd flytning
Annat, ange vilken/a:……………………………………
82. Dina kommentarer och synpunkter:
.....................................................................
När Du har fyllt i frågeformuläret vill vi be Dig åter kontrollera att alla frågor är besvarade och lämna
frågeformuläret till avdelnings sjuksköterskan.
87
Appendix C
Frågeformulär 4-8 år efter framfallsoperationen.

Detta frågeformulär innehåller bland annat frågor om hur Du uppfattar Din vattenkastning och
tarmfunktion.

år månad dag
1. Hur mycket väger Du? kilo

2. Hur lång är Du? centimeter
3. Har Du efter framfallsoperationen, som gjordes i samband med studien år …….. erhållit
behandling på nytt för framfall?
4. Ja, ny operation för framfall. Vilket år och var? ………………………………
5. Ja, fått behandling ring/inlägg i slidan
6. Ja, annan behandling. Vad?................................................................................
7. Har Du efter framfallsoperationen för 4-8 år sedan fått någon annan åkomma/operation
som Du anser påverkar Din vattenkastning eller tarmfunktion?
Ja Nej
8. Om Ja, skriv kort vad och hur:……………………………………………………………

…………………………………………………………..
9. Har Du förändrat Din fysiska kroppliga aktivitet sedan framfallsoperationen för 4-8 år
sedan?
Nej, den är helt oförändrad.
Ja, jag rör mig mindre nu
Ja, jag rör mig mera
10. Tänk tillbaka till tiden innan Du opererades för framfallet för 4-8 år sedan: Har Du kvar
symptomen från framfallet som Du hade då?
Nej.
Ja, men nu mindra uttalade
Ja, i samma utsträckning
Ja, men nu mera uttalade
Nej, men jag har fått andra besvär från underlivet: Skriv här
vilka? .................................................................................
11. Är Du nöjd med resultatet av framfallsoperationen som Du genomgick för4-8 år sedan
Ja, helt och hållet
Ja, delvis, men jag har vissa besvär
Nej. Skriv här varför :.................................................................
88
för om flera alternativ passar på Dig)
astma
sjukdom i nervsystemet (t ex MS, hjärnblödning/propp/diskbråck)
ljumskbråck
magmunsbråck
diabetes mellitus
hjärtsjukdom
högt blodtryck
östrogen mot sköra slemhinnor i underlivet? (t.ex. Vagifem
Ovesterin, hormonkrämer, slidpiller eller liknande)
östrogen mot övergångsbesvär (t ex östrogentabletter, plåster,
eller hormongel)
medicin mot urinträngningar (t ex Vesicare, Detrusitol,
Kentera, Emselex eller Ditropan)
Nej, sällan eller aldrig
Ja, dagligen
15. Händer det att Du upplever tyngd eller tryckkänsla i underlivet?
Nej
Ja
16. Händer det att det känns som om något buktar fram och/eller skaver i underlivet?
Nej
Ja, något buktar fram ur slidmynningen
Ja, något skaver i slidmynningen
17. Händer det att det läcker luft ur slidan så att det hörs?
Nej
Ja

89
18. Tycker Du tarmen och avföringen har förändrats efter framfallsoperationen för 4-8 år
sedan?
Nej
Ja, blivit bättre
Ja, blivit sämre
Frågorna 19-24 handlar om hur ofta (eller sällan) Du har avföring, avföringens konsistens
och om Du behöver hjälpa till med mediciner. Frågorna gäller hur det varit under fyra
senaste veckorna.
20. dagtid? ................. nattetid?...............
Nej

hård/lös
23. Hur ofta behöver Du något medel (stolpiller, droppar, tabletter eller lavemang) för att få
avföring?

eller varje dag
Nej Ja, Vilka då och hur ofta?...........................................
Frågorna 25-30 handlar om tarmtömningen och hur toalettbesöket fungerar. Frågorna gäller
hur det har varit de senaste fyra veckorna:




90


Frågorna 31-34 handlar om smärta eller om problem som rör tarmfunktionen. Frågorna
gäller hur det har varit de senaste fyra veckorna:




Frågorna 35-41 handlar om läckage från tarmen av gas eller avföring. Frågorna gäller hur
det har varit de senaste fyra veckorna:



38. Läcker Du gaser ofrivilligt?
Aldrig Mer sällan än Flera ggr i Varje vecka, Alltid, varje

1 gång i månaden men men inte varje dag dag
månaden inte varje vecka
91
39. Läcker Du lös avföring ofrivilligt?

gång i månaden men men inte varje dag dag
40. Läcker Du avföring med normal konsistens ofrivilligt?

41. Använder Du skydd i underkläderna på grund av ofrivillig läckage från tarmen?

Frågorna 42-44 handlar om hur Din tarmfunktion påverkar Dig i det dagliga livet.
42. Påverkas Din dagliga livsföring på grund av ofrivilligt läckage från tarmen?

gång i månaden men men inte varje dag dag

Nej
Ja, promenader
Ja, gymnastik
Ja, sex
Ja, yrkesarbete
Ja, offentliga bad
Ja, annat

45. Tycker Du vattenkastningen har förändrats sedan framfallsoperationen för 4-8 år sedan?
Nej
Ja, blivit bättre
Ja, blivit sämre
92
46. Har Du opererats för urinläckage efter framfallsoperationen för 4-8 år sedan?
Nej
Ja
Nej
Ja
Nej
Ja



52. Händer det att Du läcker urin?
Nej
Ja, enstaka gånger per år
a, någon gång per månad
Ja, någon gång per vecka
Ja, dagligen
53. Använder Du inkontinenshjälpmedel som skrivits ut på s k hjälpmedelskort?
Nej
Ja
Information inför nästa avsnitt om urinläckage:
Trängning är när det känns som om Du känner Dig kissnödig och tvunget måste kissa direkt.
Ansträngning är att t ex nysa, skratta, hoppa, springa, lyfta tungt, snubbla, hosta, etc.
54. Hur många gånger kissar Du om dagen (mellan kl. 06 och kl 23)?
1-7 8-10 mer än 10

0-1 2-3 mer än 3
93

Nej Ja, ofta Ja, ibland Ja, men sällan

58. Kissar Du på Dig direkt i samband med den fysiska ansträngningen?
Nej Ja, ofta Ja, ibland Ja, efter

en stund
59. Har Du trängningar innan Du kissar på Dig?
Nej Ibland För det

mesta


62. Har Du behandlats för urinvägsinfektion under det senaste året?
Nej 1-2 3 gånger

gånger eller fler

Nej
Ja, promenader
Ja, gymnastik
Ja, sex
Ja, yrkesarbete
Ja, annat, skriv vad:...................................................
Nedan följer frågor som berör symptom som kan förekomma specifik vid framfall och
urininkontinens samt hur det inverkar på Ditt dagliga liv. Besvara frågorna genom att ringa in
det alternativ som bäst beskriver i vilken utsträckning Du besväras av symptomen.
94
65.
Upplever Du, och i så fall hur mycket besväras Du av: Inte alls Lite Måttligt Mycket
att Du kissar ofta? 0 1 2 3
urinläckage vid urinträngning? 0 1 2 3
urinläckage vid fysisk ansträngning, hosta, osv? 0 1 2 3
små mängder av urinläckage (droppar)? 0 1 2 3
svårigheter att tömma urinblåsan? 0 1 2 3
värk eller obehag i nedre delen av buken eller
0 1 2 3
underlivet
66.
Har urinläckage eller framfall påverkad Din(a): Inte alls Lite Måttligt Mycket
förmåga att utföra hushållsarbete? 0 1 2 3
fysiska aktiviteter som promenader, simning osv? 0 1 2 3
nöjen som att gå på bio, koncert och dylikt? 0 1 2 3
förmåga at åka bil eller bus mer än 30 minuter
0 1 2 3
hemifrån
medverkan vid sociala evenemang utan för hemmet? 0 1 2 3
mentala hälsa (nervositet, depression, osv)? 0 1 2 3

känsla av frustration? 0 1 2 3
Frågorna 67-72 berör Ditt sexuella samliv. Frågorna gäller hur det har varit de senaste tre
månaderna.
67. Tycker Du Ditt sexuella samliv har förändrats sedan framfallsoperationen för 4-8 år
sedan?
Nej
Ja, blivit bättre
Ja, blivit sämre
68. Har Du aktivt samliv?
Ja
Nej - avstår helt pga. eget obehag/smärta
Nej - har inte samliv (saknar partner, sjuk partner, etc)
Nej
Ja, alltid
Ja, ibland
95
70. Om Du svarade ja på fråga 69, kryssa för det som gäller för Dig:
(kryssa för flera rutor, om det passar för Dig)
Ont ytligt i slidan eller blygdläppar
Ont djupt i slidan
Ont innan samlag
Ont under samlag
Ont efter samlag
71. Har Du svårigheter att genomföra samlag?
Nej
Ja, pga alltför trång slidmynning
Ja, pga att något tar emot innanför slidmynningen
Ja, pga annan orsak: Ange vilken..................................................
72. Har Du andra besvär vid samlag?
Nej
Ja, obehag med gasavgång från slidan
Ja, andra besvär: Ange vilken/vilka.................................................
...........................................................
73. Dina kommentarer och
synpunkter:……………………………………………………….
………………………………………………………..
När Du har fyllt i frågeformuläret vill vi be Dig åter kontrollera att alla frågor är besvarade och därefter
skicka in frågeformuläret i bifogat frankerat svarskuvert
96

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Linköping University Medical Dissertations, No.

Genital prolapse surgery

List of Original Articles............................................................................................................. 7

Anatomy of the pelvic floor .................................................................................................... 10

Development of pelvic organ prolapse .................................................................................. 15

Symptoms associated with pelvic organ prolapse ................................................................ 16

Clinical evaluation of pelvic organ prolapse......................................................................... 18

Surgical treatment of pelvic organ prolapse.......................................................................... 20

Background for the study......................................................................................................... 24

Aims of the study...................................................................................................................... 26

Review of patient records............................................................................................30

Results and comments.............................................................................................................. 37

Shift in surgical treatment ...........................................................................................37

Comments on methodology ........................................................................................49

Sammanfattning på svenska .................................................................................................... 57

I Crafoord K, Sydsjö A, Nilsson K, Kjølhede P. Primary surgery of genital prolapse: a

II Crafoord K, Sydsjö A, Kjølhede P. Genital prolapse surgery after a shift in treatment

III Crafoord K, Sydsjö A, Johansson T, Brynhildsen J, Kjølhede P. Factors associated

IV Crafoord K, Brynhildsen J, Lindehammar H, Kjølhede P. Pelvic floor neuropathy in

V Crafoord K, Brynhildsen J, Hallböök O, Kjølhede P. The predictive value of

Anatomy of the pelvic floor

Figure 5. The anorectal angle. (Reprinted with permission.)

Figure 6. Course of the pudendal nerve. (Reprinted with permission.)

Maximum extent of prolapse

Table 2. Evaluation form for assessing POP, based on clinical experience.

Vaginal Profile (Baden) Quantitative POP

Hymeneal Lower half vagina

Figure.10. Comparison of ordinal classifications of pelvic organ prolapse.

Surgical treatment of pelvic organ prolapse

Hypotheses Research questions

The aims of the study were:

i. to evaluate whether a shift in the extent of genital prolapse surgery occurred

iii. to determine the prevalence of symptoms of pelvic floor dysfunction in women

v. to evaluate whether neurophysiologic findings of the levator ani muscles and

vi. to investigate whether the neurophysiologic findings and anorectal manometry

Previous POP surgery Previous POP surgery

Primary Surgery: Primary Surgery:

Six years postoperative follow-up

Not answered n=52

Methods of assessing the pelvic floor muscle function

All neurophysiologic tests were performed with MedelecSynergy™ EMG-system

Ano rectal manometry (ARM)

Type of POP surgery in Sweden

3000 Anterior repair

Complete repair period I

Table 6. Type of POP surgery in 42 women.

Anterior compartment POP-Q stage

Apical compartment POP-Q stage

Posterior compartment POP-Q stage

Table 9. Preoperative symptoms in 42 patients and changes of these at postoperative follow-up

Retrospective study Prospective study

Factors associated with symptoms of PFD, POP and outcome of surgery

Organ / dysfunction Predictive factor OR 95% CI p - value

Pelvic floor muscle function

Results of POP surgery

The conclusions of the study were.

v. The measurements of the neurophysiologic investigations and the anal sphincter

Detta frågeformulär innehåller bland annat frågor om hur Du uppfattar Din

Lös Mjuk och formad Växlande mellan Hård

Aldrig Mindre än en 1-6 gånger per Alltid för att

Aldrig Mindre än en 1-6 gånger per Varje dag

Aldrig Mindre än en 1-6 gånger per Varje dag

5 minuter Cirka Cirka Mer än