Introduction

Most of the available literature on the impact of pelvic organ prolapse (POP) on quality of life comes from high-income countries, where parity and age are the usual risk factors [1, 2]. In low-/middle-income countries, however, high parity rates, heavy daily physical work, and poor nutrition are additional contributing factors for POP [3,4,5,6,7,8]. Countries in sub-Saharan Africa have much higher fertility rates (lifetime births per woman) than many other parts of the world, emphasizing the need for further research into POP in this region [9]. Although the burden of POP in sub-Saharan Africa is not precisely known, a recent meta-analysis concluded that the prevalence of POP in developing countries is about 15% overall [10]. A study at Panzi Hospital, a large tertiary referral center in Eastern Democratic Republic of the Congo (DRC), reported that 25% of prolapse patients who presented for surgery were premenopausal, highlighting the problem of early age of onset in this region [11].

The Pelvic Floor Distress Inventory Questionnaire (PFDI-20) and the Pelvic organ prolapse/urinary Incontinence Sexual Questionnaire (PISQ-12) are validated questionnaires that were created in English, and have been translated into and re-validated in French [12, 13]. The PFDI-20 evaluates the impact of pelvic floor disorders (PFDs) on the patient’s overall quality of life, whereas the PISQ-12 focuses on sexual function among patients with POP and/or urinary incontinence, including evaluations of physical, emotional, and partner-related components [14, 15]. In this study, we administered these questionnaires to a cohort of symptomatic pre-menopausal patients presenting for POP surgery at Panzi Hospital in Bukavu, DRC. Our aim was to characterize the pelvic floor symptoms and sexual function associated with advanced POP in this understudied younger population of patients.

Materials and methods

We conducted a prospective, descriptive study of all symptomatic premenopausal patients seeking surgical treatment for POP at Panzi Hospital between April 2019 and December 2021. We have previously described the approach at our institution for integrated care for patients with POP [11]. Briefly, patients are referred to our hospital from throughout the Eastern DRC region and neighboring countries. Patients receive a consultation with a gynecologist, who confirms the presence of POP and assesses its severity using the Pelvic Organ Quantification system. The gynecologist reviews the diagnosis with the patient and discusses treatment options. In addition, because almost 40% of women in our region have experienced prior sexual violence [16], every patient who presents to Panzi Hospital for gynecological care receives an evaluation by a social worker or a psychologist and may undergo treatment for their trauma. Ethical approval for this study was obtained from the Democratic Republic of the Congo Ministry of Public Health National Health Ethics Committee (Ref # 148PM2020).

Premenopausal patients seeking treatment for symptomatic prolapse, confirmed on examination, and electing to undergo surgical repair, were included in this study after informed consent was obtained. All patients underwent fertility-sparing repair with a hysteropexy surgery.

As part of standard clinical care at Panzi Hospital, pelvic floor symptoms and the impact of POP on sexual function were evaluated with the French-language versions of the PFDI-20 and PISQ-12 respectively [12, 13]. Because of low levels of literacy in our patient population, the questionnaires were administered by a trained interviewer fluent in both French and each patient’s native language. Demographic data were extracted from patient intake forms. Data are presented as means with standard deviations, or counts with percentages.

Results

A total of 107 premenopausal women with stage III/IV POP consented to this study between April 2019 and December 2021. Age at presentation to Panzi Hospital was 34.2 ± 6.7 years. Of this cohort, 102 patients (95.3%) had stage III prolapse, and the remaining 5 (4.7%) had stage IV prolapse (Table 1). Owing to travel distances, typically by foot, a hospital stay of 1 week, and local referral patterns, the vast majority of patients present with POP stage ≥ III. All 107 patients had multicompartment prolapse (Table 2). Most presented more than 2 years after the start of prolapse symptoms (n = 66, 61.7%); a minority waited 6 years or more (n = 14, 13.1%; Table 1). Regarding key underlying contributors to early-onset POP, multiparity was nearly universal, and 42% were grand multiparous women. Eighty-eight (82.2%) were farmers, implying heavy daily physical work; and 31 (29.0%) had a body mass index (BMI) < 20 kg/m2. All patients underwent fertility-sparing surgery with either a sacrospinous or uterosacral hysteropexy (Table 1).

Table 1 Demographics and clinical characteristics
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Table 2 Degree of apical prolapse with associated multicompartment prolapse
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Mean PFDI-20 score was 109.8 ± 27.6 (Table 3). The most common symptoms reported were lower abdominal pain (n = 88, 82.2%), heaviness or dullness (n = 102, 95.3%), bulging sensation (n = 99, 92.5%), and pain or discomfort in the lower abdomen or genital region (n = 87, 81.3%). Over half (n = 63, 58.9%) had to splint to defecate, and over two-thirds (n = 74, 69.2%) had flatus incontinence. Nearly half (n = 52, 48.6%) had stress urinary incontinence, and 15% reported being bothered “moderately” or “quite a bit.” Over half (n = 66, 61.7%) reported difficulty emptying completely with voiding, and 47 (43.9%) had to splint to void.

Table 3 Pelvic Floor Distress Index (PFDI-20) results
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All 107 patients also completed the PISQ-12. Only 37 patients (34.6%) reported being sexually active. Of the 84 patients who were married (78.5%), only 35 (58.3%) reported being sexually active. Most of the women who were not sexually active (n = 70, 65.4%) reported that their sexual inactivity was due to POP (n = 56, 80.0%). Overall, 52 (48.6%) reported usually or always having a negative emotional reaction during intercourse, and 66 (61.7%) reported avoiding sexual activity because of bulge symptoms (Table 4).

Table 4 Pelvic organ prolapse/urinary Incontinence Sexual Questionnaire-12 (PISQ-12) results
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Among the 37 women (34.6%) who reported being sexually active, most reported significant sexual impairment owing to the prolapse, with only 4 women (10.8%) reporting that they were not affected by their prolapse. Twenty (54.1%) reported that they were never/seldom sexually excited and 21 (56.8%) were never/seldom satisfied with their sex lives. The overall PISQ-12 scores among sexually active and sexually inactive groups were nearly identical.

Discussion

Our findings highlight the devastating effects associated with POP, including impaired sexual function, among young women in the DRC. This is one of the largest studies among premenopausal patients with POP.

There are a variety of contributing factors in the development of POP, including age, parity, heavy daily physical work, and poor nutrition [1,2,3,4,5,6,7,8]. Specifically, increasing parity has been shown to play a particularly important role in the pathophysiology of POP [17]. In our study, patients presented at a mean age of 34 years old, with most having symptoms for 2–5 years. Many of our patients had underlying risk factors for developing POP, as 42% were grand multiparous women, 80% were farmers, and 29% had a BMI < 20 kg/m2.

Previous studies have highlighted the stigma surrounding POP. Owing to a combination of a lack of money, limited access to conventional health care and the associated stigma, many patients in this region turn to traditional healers for help [3, 18]. In our study, most of the patients presented within 5 years of prolapse symptoms (n = 93, 86.9%). This figure compares favorably with previously published data from sub-Saharan Africa. In a small study by Gjerde et al. in Ethiopia, about half of the 24 women interviewed reported that they had had POP for 10 years or longer before seeking specialized gynecological care [19]. To decrease the stigma associated with this common issue and to encourage earlier presentation for treatment, Panzi Hospital implemented several outreach programs to the surrounding communities, including rural areas, to educate the population about POP and the availability of services. These outreach programs include mobile clinics that travel to rural areas in Eastern DRC, along with social workers who go to churches and meet with local leaders [11].

In Gjerde et al.’s qualitative study, the women also reported significant discomfort from their POP, affecting the ability to complete activities of daily living, including household chores, childcare, and gathering and carrying water and firewood [19]. Wusu-Ansah and Opare-Addo administered the PFDI-20 and the pelvic floor impact questionnaire to women in rural Ghana to determine the prevalence of POP and impact on women in that region. Twenty-one women in their cohort had POP, with 81% of these women reporting POP symptoms, but only 62% were bothered by their symptoms [20]. All the patients in our cohort were symptomatic when they presented for surgery, and 80% of them were farmers. Because their daily activities typically require heavy and prolonged physical exertion, these pelvic floor disabilities may impair their ability to provide for their families.

Pelvic organ prolapse has also been associated with impaired sexual health, including decreased libido, decreased frequency of sexual encounters, and difficulty achieving orgasms, as well as marital difficulties [21,22,23,24,25,26]. Gjerde et al. interviewed 24 women in Ethiopia with stage II to IV POP and described the women’s fear of consequences from disclosing their condition to their friends and families, including husbands [19]. Many women in this study chose to disclose the condition to their husbands only when it became more serious, with 4 of these women (16.7%) reporting that their husbands divorced them because of the prolapse. A study in Nepal found that 74% of their participants with POP had difficulty with sexual activity, with a mean age in their study of 54 years [27]. That study reported that 24% of the husbands re-married after their wives disclosed their condition. For our young premenopausal cohort, almost 80% were married and only 34.5% were sexually active. Over half of our cohort reported that they were never or seldom satisfied with their sex lives. Of the women who were not sexually active, 80% reported that this was because of their POP.

Of note, in the Eastern region of DRC, where Panzi Hospital is located, a 2010 study reported that almost 40% of women had experienced sexual violence [16]. Female genital mutilation (FGM) is relatively rare in our region, and some reports from the greater DRC suggest prevalence rates of  ~ 5% [28]. All the patients in our study, sexually active and not sexually active, filled out the PISQ-12 questionnaires, and 48.6% always or usually had negative emotional reactions during intercourse. Some of their negative reactions could be attributed to discomfort and/or urinary or fecal incontinence from POP. Nevertheless, we acknowledge that the PISQ-12 does not survey for sexual violence, and so our data cannot assess the role of this factor in our patients’ sexual inactivity or negative emotions during sex.

The strengths of this study include its relatively large sample size of premenopausal patients, for which there is a scarcity of published data. This study was also strengthened by using validated questionnaires that gathered data about both PFD symptoms and sexual function. A weakness of this study is that the cohort was a highly self-selected group, in that each patient had chosen to travel to the hospital for care. Additionally, even though all patients responded completely to the two validated surveys, one of the weaknesses of this study is that the questionnaires were administered orally owing to low literacy rates. Similar to previous studies among populations with low literacy, questionnaires were administered during interviews with trained clinical staff [29], who were aware that the patients were presenting for POP evaluation, but to limit confirmation bias, they were unaware of their physical examination findings.

Overall, our findings underscore the severity of the effect of pelvic floor symptoms on quality of life and sexual health among this young patient population in DRC. Our findings emphasize the importance of outreach, so that potentially earlier and more widely available treatments can be a priority for women with POP.