Background: 
Pelvic organ prolapse (POP), a common pelvic floor dysfunction, usually present with symptoms, such as vaginal bulge, splinting, or vaginal pressure. Other less common symptoms associated with POP are urinary and/or sexual dysfunction. “Vaginal laxity”, a symptom frequently encountered in parous women with POP, but has not been sufficiently evaluated in the Literature, nor been correlated with POP.Auditory passage of vaginal air (flatulence) is also a symptom reported in women with pelvic floor disorders (PFDs) and POP. Recently, vaginal passage of wind was characterized as a symptom of affecting 69% of women with PFDs with no clear correlation with the symptoms of POP.

Objective:
To study the association between vaginal laxity and other symptoms of POP, and to correlate it to objective findings on exam.

Methods:
A retrospective cohort study that includes women seen in KFMC Urogynecology clinic during the study period of January 2013 to April 2015.Demographic information and clinical characteristics was collected for all women pre and post-operative POP quantification (POP-Q) data was obtained.

Results:
Among 384 women have POP using POP-Q; 187 (48.4%) had Prolapse as a chief complaint; 135 women (35.2 %) had Vaginal laxity. Age 47.8 ±11.7 (23, 99) years old, parity 3 (0, 19). Vaginal delivery, vaginal wind, pressure complaint, diabetes increase risk of vaginal laxity; OR (7.65, 21.84, 2.24, 3.90 respectively). Vaginal laxity is associated with POP especially stage II anterior and posterior prolapse CI 95%;0.59 (0.44, 0.78) and 0.59 (0.45, 0.78) respectively (P value <0.001).Vaginal flatus complaint was reported by 74(30.3) patients that had GH (measurement from middle of external urethral meatus to posterior midline hymen) median widening of ≥4 cm, its likelihood was 1.23 times more than the subjects that had GH median widening of <4 cm within which 34(26.2) had vaginal flatus. The difference was not significant.

Table 1.  Distribution of symptoms among 376 patients



SYMPTOM	

N (%)
SUI	242(64.1)
Frequency	231(61.3)
Urgency Urinary Incontinence	206(54.6)
Nocturia	81(21.5)
Straining to urinate	35(9.3)
Slow stream	43(11.4)
Sensation of Incomplete emptying	82(21.7)
Post void dribble	75(19.9)
Recurrent urinary infections	68(18.0)
Bulge per vagina	171(45.3)
Vaginal Pressure	134(35.5)
splitting of vagina	53(14.1)
Voiding dysfunction	23(6.1)
Vaginal wind	113(30.0)
Vaginal Laxity	135(35.8)
Other	1(0.003)


Table 2. Correlation of vaginal laxity with demographics and coexisting symptoms. (UTI= urinary tract infections; SVD= spontaneous vaginal delivery)

 	Unadjusted OR (95% CI)	P-value	Adjusted OR (95%CI)	P-value
Age	0.947 (0.927-0.967)	<0.001	0.924 (0.885-0.964)	<0.001
SUI	1.616 (1.032-2.53)	0.036	1.527 (0.648-3.6)	0.334
Frequency	1.199 (0.78-1.845)	0.408	0.852 (0.341-2.127)	0.731
Urgency incontinence	1.165 (0.763-1.779)	0.48	1.61 (0.724-3.58)	0.242
Nocturia	1.186 (0.715-1.97)	0.509	0.477 (0.193-1.18)	0.109
Straining to Urinate	0.959 (0.461-1.993)	0.91	1.738 (0.337-8.972)	0.509
Slow Stream	0.452 (0.21-0.973)	0.042	0.271 (0.057-1.282)	0.100
Incomplete Emptying	0.526 (0.302-0.917)	0.023	0.633 (0.242-1.651)	0.349
Post-void dribble	0.983 (0.578-1.669)	0.948	1.42 (0.581-3.472)	0.442
Frequent UTI	1.002 (0.579-1.735)	0.993	0.596 (0.24-1.479)	0.264
Bulge	1.901 (1.244-2.905)	0.003	3.25 (1.459-7.235)	0.004
Pressure	1.801 (1.166-2.782)	0.008	2.004 (0.906-4.43)	0.086
manual reduction	1.786 (0.994-3.208)	0.052	0.752 (0.251-2.25)	0.610
voiding dysfunction	0.64 (0.246-1.663)	0.359	0.254 (0.044-1.483)	0.128
vaginal wind	12.495 (7.424-21.029)	<0.001	15.477 (6.931-34.56)	<0.001
Chronic cough	0.614 (0.307-1.23)	0.169	0.426 (0.136-1.339)	0.144
constipation	1.042 (0.674-1.613)	0.852	0.999 (0.494-2.018)	0.997
				
Fecal Incontinence	1.558 (0.466-5.202)	0.471	1.04 (0.125-8.626)	0.971
lifting	0.776 (0.42-1.431)	0.417	0.484 (0.159-1.473)	0.201
Parity	0.924 (0.872-0.979)	0.007	0.947 (0.842-1.066)	0.369
SVD	1.238 (0.724-2.115)	0.436	1.03 (0.51-2.079)	0.934
Cesarean Section	0.8 (0.501-1.279)	0.352	0.389 (0.168-0.899)	0.027
Forceps	0.918 (0.361-2.332)	0.857	1.92 (0.351-10.503)	0.452
Sexually Active	2.231 (1.375-3.621)	0.001	1.938 (0.77-4.879)	0.160
Dyspareunia	1.232 (0.721-2.107)	0.446	0.382 (0.145-1.005)	0.051
Menopause	2.578 (1.556-4.271)	0.000	0.641 (0.251-1.638)	0.353
Diabetes	1.115 (0.694-1.791)	0.653	2.003 (0.889-4.514)	0.094

Conclusions:
Vaginal laxity has a strong clinical correlation with POP and associated with its symptoms.Vaginal laxity and genital flatus have a clinical correlation with POP which is more likely to be associated with significant POP especially posterior.

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