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A Review of the Epidemiology and

Pathophysiology of Pelvic Floor Dysfunction:
Do Racial Differences Matter?
Shunaha Kim, BSc, Marie-Andree Harvey, MD, Shawna Johnston, MD
Department of Obstetrics and Gynaecology, Queen's University, Kingston ON

Abstract Resume

Objective: To describe the current state of knowledge regarding Objectif: Decrire I'etat actuel des connaissances en ce qui concerne
etiology of pelvic floor dysfunction with special consideration to the I'etiologie de la dysfonction du plancher pelvien, en portant une
effect of racial background on the epidemiology and attention particuliere aux effets de I'ethnicite sur I'epidemiologie et
pathophysiology of this disease. la pathophysiologie de cette maladie.

Methods: We performed a nonsystematic review of the literature to

detail the current knowledge of the etiology of pelvic floor Methodes: Nous avons mene une analyse non systematique de la
dysfunction. Additionally, we performed a systematic search of litterature en vue de rendre compte des connaissances actuelles
MEDLlNE, Cinahl, and the Cochrane database for English- sur I'etiologie de la dysfonction du plancher pelvien. De plus, nous
language articles registered from January 1, 1989, to June 31, avons mene des recherches systematiques dans les bases de
2003, that evaluated racial differences in the epidemiology and donnees MEDLlNE, Cinahl et Cochrane en vue d'en tirer les
pathophysiology of pelvic floor dysfunction. We also reviewed the articles de langue anglaise, publies entre Ie 1er janvier 1989 et Ie
references of identified articles. 31 juin 2003, qui evaluaient les differences raciales en matiere
d'epidemiologie et de pathophysiologie de la dysfonction du
plancher pelvien. Nous nous sommes egalement penches sur les
Results: We identified 11 articles that examined the effect of racial references contenues dans les articles retenus.
background on stress urinary incontinence (SUI), urodynamic
stress incontinence, and (or) pelvic organ prolapse. We identified 2
studies that measured the prevalence of subjective stress urinary Resultats : Nous avons identifie 11 articles examinant I'effet de
incontinence. Six cross-sectional studies compared the prevalence a a
I'ethnicite sur I'incontinence I'effort (IE), I'incontinence I'effort
of urodynamically confirmed SUI and (or) pelvic organ prolapse confirmee par test urodynamique etlou Ie prolapsus d'un organe
among different groups. White women had a higher risk of pelvien. Nous avons identifie deux etudes qui evaluaient la
developing urodynamic stress incontinence. Three studies noted a
prevalence de I'incontinence I'effort subjective. Six etudes
anatomical and physiological differences among the different transversales ont compare la prevalence de !'IE confirmee par test
groups. urodynamique etlou du prolapsus d'un organe pelvien parmi
differents groupes. Les femmes de race blanche couraient un
risque accru de presenter une incontinence a I'effort confirmee par
Conclusions: Both quantitative and qualitative defects in collagen
test urodynamique. Trois etudes ont constate des differences
(endopelvic fascia) and compromised levator ani muscle function
anatomiques et physiologiques parmi les differents groupes.
have been identified as important etiologic factors in the
development of pelvic floor dysfunction. Parity, vaginal delivery,
menopause, and aging have been most clearly associated with
collagen defects and levator ani muscle dysfunction. The literature Conclusions: Des anomalies quantitatives et qualitatives du
suggests that white women are at increased risk for SUI. At collagene (fascia endopelvien) et I'alteration de la fonction du
present, there is insufficient evidence to draw any conclusions muscle releveur de I'anus ont ete identifiees comme etant des
regarding the role of racial differences in pelvic organ prolapse. It facteurs etiologiques importants dans I'apparition d'une
is possible that differences in prevalence rates for both SUI and dysfonction du plancher pelvien. La parite, I'accouchement vaginal,
pelvic organ prolapse may be attributed to inherent anatomical and la menopause et Ie vieillissement ont ete les facteurs les plus
physiological differences among racial groups. clairement associes aux anomalies du collagene et la a
dysfonction du muscle releveUr de I'anus. La litterature semble
indiquer que les femmes de race blanche courent des risques
accrus d'IE. A I'heure actuelle, nous ne disposons pas de donnees
suffisantes pour tirer quelque conclusion que ce soit I'egard du
role des differences raciales en ce qui concerne Ie prolapsus d'un
~ ~;PeIVicfloQr dY6f!Jnction. ~jc o~ pfOlapse, urinary organe pelvien. II est possible que les differences en matiere de
In~. ost;e$s.uririary IDcontinence, racial ••thnicity prevalence de I'IE et du prolapsus d'un organe pelvien puissent
etre attribuables aux differences anatomiques et physiologiques
~ngh;rtttreirts; Nonedecisred. . inherentes aux differents groupes raciaux.
~on~niber2,·2004 J Obstet Gynaecol Can 2005;27(3):251-259

MARCH JOGe MARS 2005 • 251


INTRODUCTION is seen on urodynamic testing. It must be stressed that the

diagnosis of urine loss by symptoms alone can be inaccu-

elvic floor dysfunction (PFD) is a general term used to
rate. In a recent meta-analysis, SUI had a positive predictive
describe conditions that compromise the female conti-
value for USI of only 79%.3
nence mechanism (urinary and fecal) and (or) pelvic
organ support. Both the epidemiology and pathogenesis of Urinary incontinence is one of the most common and
PFn are still poorly understood, although recent work has important chronic health problems occurring in modern
provided several new insights and suggested opportunities society. It is associated with a signiflcant negative effect on
for further research. While trauma to pelvic floor structures quality of life, including daily social, sexual, and mental
during childbirth remains central in discussions regarding functioning. 4,5 The direct and indirect health care costs of
the etiology of PFD, other possible factors, including genet- UI can be substantial. In 2002 Langa et al 6 estimated the
ics and aging, may also be involved. The exact mechanisms average additional annual cost of informal care associated
with UI in American women older than age 70 years using
by which racial background influences the prevalence of
pads to be US $2000. In 1995 Wagner et aU reported an
PFD are not known. We recognize it is possible that the
annual expenditure exceeding US $27 billion for the man-
concept of race is outdated.
agement of urinary incontinence in the US. UI has been
However, the use of racial designators is not intended to be recently estimated to account for approximately 2% of
offensive or exclusionary to any individual or group of indi- health care costs in the US.8
viduals. Unlike alternative terms such as "ethnicity," which
Although UI is generally recognized as being a fairly com-
includes shared cultural traditions, I racial designators con-
mon condition, actual reported prevalence rates of UI in
note shared physical characteristics determined by a com-
women have varied considerably.9 Estimates of prevalence
mon genetic origin.2 Therefore, we use "race" or "racial
range from 17% to 45% in adult women. IO Such wide varia-
background" in an attempt to explain a possible genetic link
tion may be related to differences in the populations of
as an etiologic factor in PFD. The following review outlines
women studied, so the ability to generalize and compare the
the current state of knowledge regarding the epidemiology
results across different populations is limited. Further, the
and the pathophysiology ofPFD, with a particular focus on
deflnition of UI has differed, often dramatically, among
the relation between stress urinary incontinence (SUI), pel-
studies. Validated questionnaires have only recently been
vic organ prolapse (prolapse), and racial background. For
developed and used to assess the epidemiology of urinary
this review, the databases searched included MEDLINE,
Cinahl, and the Cochrane Library. We also performed a
manual review of available references and of proceedings of
recent meetings of the International Continence Society Pelvic Organ Prolapse
(1997 and 1999-2003), the International Urogynecologic The term "prolapse" includes a group of disorders that
Association (2002-2003), and the American Urogyne- compromise normal pelvic organ support. In women, con-
cologie Society (1997-2003); we included only English- nective tissue (fascia and ligaments), muscles, and bony
language articles. structures together provide normal support to the pelvic
organs, including the uterus, the bladder and urethra, and
DEFINITIONS AND EPIDEMIOLOGY the rectum and anus. Prolapse presents with mechanical
symptoms (pelvic heaviness, introital lump, vaginal pain,
Urinary Incontinence and possibly low back pain), and (or) bladder, bowel, or sex-
Urinary incontinence (UI) is deflned as the involuntary loss ual dysfunction. Findings on examination include laxity or
of urine. In women, it is most commonly associated with descent of the anterior vaginal compartment (commonly
activities causing increased intra-abdominal pressure, such referred to as cystocele), posterior compartment
as coughing or lifting (stress urinary incontinence [SUI]), or (rectocele/ enterocele), or apical compartment (uterine or
with urinary urgency (urge urinary incontinence [UUI]). vault prolapse). However, these symptoms have not been
These terms, SUI and UUI, refer to subjective symptoms shown to be associated speciflcally with severity of prolapse
reported by patients. Urodynamic studies are performed for or with speciflc compartmental defects. 1I Until such associ-
objective diagnosis. Urodynamic (formerly, "genuine") ations have been deflned, prolapse will continue to be
stress incontinence (USI) is defmed as the objective loss of diagnosed only when descent of the vaginal walls is demon-
urine associated with increased intra-abdominal pressure in strated on pelvic examination, ideally with a standardized
the absence of a detrusor contraction. Detrusor overactivity and validated method such as the Pelvic Organ Prolapse
(formerly, "detrusor instability") is diagnosed when unin- Quantiflcation system (pOP-Q).tZ While prolapse is rarely
hibited detrusor muscle activity (with or without urine loss) associated with mortality or severe morbidity, the condition

252 • MARCH JOGe MARS 2005

A Review of the Epidemiology and Pathophysiology of Pelvic Floor Dysfunction: Do Racial Differences Matter?

does exert a significant negative effect on a woman's sexual also be important, though it has not been clearly established
functioning13 and quality oflife. 14 as an independent risk factor for the development of
Surprisingly, although more than 400 000 surgical proce- PFD.31 In most women, it is likely that the consequences of
dures for prolapse are performed annually in the VS,15 the childbirth trauma are not immediately apparent but are
present later in life, when they are compounded by age-
prevalence of prolapse has not been well studied.
Samuels son et al. 16 documented prolapse on pelvic exami- related deterioration and possibly hormonal deprivation
nation in 30.8% of 487 premenopausal Swedish women following menopause.
(aged 20 to 59 years). Similarly, Versi et al. 17 found a Anatomic and functional changes have been observed in
cystocele in 51 % of 285 women presenting for evaluation of women following vaginal delivery. Peschers et al. 32 noted
menopausal complaints, a rectocoele in 27%, and uterine greater mobility of the bladder neck on ultrasound in
descent in 20%. It is estimated that 11 % of women will postpartum women who delivered vaginally, compared
undergo surgery for prolapse or VI by age 80 years; 30% of with women who had elective Caesarean sections or with
this group will require repeat surgery.18 nulligravid women. Additional observations include wors-
ened levator function in parous women, compared with
FUNCTIONAL ANATOMY OF THE PELVIC FLOOR nulliparous women,33 and excessive pelvic floor descent in
women who have had 3 or more deliveries, compared with
Pelvic floor integrity in women is maintained by the coordi-
those who have had fewer than 3 deliveries. 34 With respect
nated actions of muscles Oevator ani, urethral, and anal
to specific obstetric history risk factors, Kearney et al. 35
sphincters), nerves (sacral plexus and pudendal nerve), and
showed that women with a defect of the pubovisceral mus-
connective tissue (endopelvic "fascia," perineal body, and
cle on magnetic resonance imaging (MRI) had a second
utero-sacral and cardinal ligaments) anchored to the bony
stage of labour that was 1 hour longer, that they were 3.5
pelvis. Levator ani muscle integrity is of paramount impor-
times more likely to have had an operative delivery, that
tance-it is the primary support mechanism. Its function is
twofold. First, the levator ani muscles close the urogenital they were twice as likely to have had an episiotomy, and that
they were 3 times more likely to have sustained an anal
hiatus, preventing protrusion of organs through that aper-
sphincter rupture, compared with women without defects
ture: Second, the fused posterior component of the muscles
of the pubovisceral muscle. All these observations point to
(the levator plate) provides hammock-like support for the
muscle or connective tissue damage as possible sequelae of
pelvic organs, preventing stretch and tension on the sup-
vaginal delivery in women with PFD.
portive connective tissue. 19 Should the levator ani muscles
fail in providing support, the endopelvic connective tissue Vaginal delivery may alter pelvic floor function by causing
would be placed under tension and, with time, may attenu- neuropathy in the pudendal or sacral nerves. Nerve injury
ate or tear. Thus the interaction between the levator mus- (from pressure necrosis) can occur following pressures as
cles and the connective tissue network provides functional low as 80 mm Hg applied for as little as 2 hours.36 During
support to the pelvic viscera. The pathophysiology of PFD labour, pressures as high as 240 mm Hg can be applied to
is directly related to the functional anatomy of the pelvic the pelvic floor,37 sometimes for several hours duration.
floor. In this context, any force or process that interrupts Wall et al. 38 have shown that excessive stretching on periph-
the integrity of the neuromuscular or connective tissue eral nerve tissue is also deleterious and often permanent.
supports may result in PFD. The pudendal nerve may therefore also be injured by exces-
sive stretching during descent of the fetal head, particularly
ETIOLOGIC FACTORS in its most caudad portion, from Alcock's canal (at which
site the nerve is fixed to the surrounding structures) to the
Parity muscle attachments. Observations supporting this hypo-
It is possible that pregnancy may be an independent risk thesis include prolonged pudendal nerve terminal motor
factor for the development of PFD, but this is difficult to latencies, present in 16% of primiparous women following
establish because most studies have examined only parity as vaginal delivery,39,40 and evidence of partial denervation
a risk factor, instead of considering gravidity as well. Vagi- documented on electromyography (EMG),31 following
nal birth is presumed to be one of the most important deter- vaginal delivery (with later re-innervation).
minants of PFD. Parity has been clearly identified as a risk
factor for urinary incontinence20-24 and pelvic organ pro- Age and Menopause
lapse. 25-28 Specifically, forceps delivery has been associated Increasing age is another factor often cited as a risk factor
with a significant increase in the risk of SVI29 (odds ratio for PFD, though scant epidemiologic evidence exists to
[OR] 10.4; P = 0.04; 95% confidence interval [CI], support this conclusion unequivocally. Most of the studies
1.2-93.4).30 The duration of the second stage oflabour may reported are cross-sectional in design rather than

MARCH}OGC MARS 2005 • 253


prospective cohort series, and most include only older more often found in tendons. Type III collagen forms ran-
women. Nonetheless, from the available data, it appears domly organized, branched fibres and is found in more flex-
that all types of urinary incontinence in women increase in ible tissues such as the skin, aorta, and uterus. A mixture of
prevalence with advancing age,15,18,22 though some data are Type I and III collagen is the main structural component of
conflicting. 10,42 Specifically, Olsen 18 found that among sur- pelvic connective tissue. 64 Further strength is conferred
gi<:ally managed cases of pelvic organ prolapse and UI, the upon this collagen through cross-linking between the indi-
age-specific incidence of pelvic organ prolapse and UI vidual tropocollagens. 61
increased with advancing age. Additionally, GureI27 found If collagen is responsible for the strength of the pelvic con-
on univariate analyses that age was significantly correlated nective tissue, then one can hypothesize that abnormal con-
with prolapse,compared with control subjects without pro- nective tissue is a key factor leading to PFD, even in the
lapse. Perucchini et a/.43 noted that striated muscle layers of absence of extrinsic insults on the pelvic floor. This would
the urethra were thinner at the vesical neck in older women. explain the development of PFD innulligravid women.
Because age and menopause are integrally linked, it is diffi- Further, milder degrees of abnormality in the fascia and lig-
cult to define a clear role for age in the development ofPFD aments may still allow adequate function when exposed to
without considering that the underlying etiology may, in normal stressors but inadequate function when exposed to
fact, be estrogen deprivation alone. 23 Menopause is excessive outside stressors such as vaginal delivery. This
assumed to be a risk factor for SUI, especially if one consid- would potentially explain the development of PFD in some
ers the close anatomic and embryologic associations of the women, whereas other women with similar circumstances
reproductive and urinary tracts. Both the urethra and the at delivery would not develop PFD.
bladder contain estrogen receptors in high number,44 and Several preliminary observations that support this hypo-
therefore, both tissues are similarly responsive to the pres- thesis have been made. A higher incidence of prolapse has
ence or loss of estrogen. Estrogen receptors have also been been reported in women with Ehlers-DanIos syndrome, a
found in endopelvic fascia, levator ani, and uterosacralliga- collagen disorder. 65 Joint hypermobility is thought to be a
ments. 45,46 However, research thus far has not delineated a surrogate marker of defective collagen, because it is associ-
clear causal role for menopause in the development of ated with disorders like Ehlers-DanIos syndrome. 64 Norton
PFD. Investigators have not found any consistent increase et al. 66 found that joint hypermobility did not appear to be
in the risk of UI around the time of menopause. 10,47,48 associated with SUI but that subjects with joint
Versi49 reported a fall in proximal urethral pressure after hypermobility had a significantly higher prevalence of pro-
menopause, but found that the prevalence of prolapse did lapse when compared with women with normal joint mobil-
not correlate with menopausal statusP Randomized con- ity. Bai et al. 67 found that among Korean women aged
trolled trials have failed to show a beneficial effect (over pla- between 40 and 59 years, the average finger extension angle
cebo) with estrogen replacement on SUI in menopausal was significantly higher for women with prolapse than for
women. 50 Clearly, further study is needed in this area. women without prolapse. At the tissue level, Bakas et al. 68
found that the amount of Type III collagen was significantly
Raised Intra-Abdominal Pressure reduced in women with USI. Chen et al. 61 showed that
Raised intra-abdominal pressure, especially if chronic, may women with SUI and prolapse had higher rates of collagen
also contribute to the development ofPFD.51 Several stud- turnover than did control subjects. Norton et al. 69 found
ies have confirmed that obesity or increased body mass that women with prolapse had an increased proportion of
index (BM!) is a risk factor for PFD,52-54 as well as chronic Type III collagen in biopsies taken from vaginal skin. In
cough and chronic constipation. 55,56 In fact, a decrease in contrast, Norton et al. 69 found no difference in the ratio of
BMI appears to improve SUI. 57 There is no clear consensus Type I to Type III collagen at the vaginal apex between
on the role of smoking as a risk factor for SUI,I8--21,58--60 women with SUI only and control subjects. Overall, these
although there is at least an indirect link because smoking early results suggest that a qualitative or quantitative disor-
predisposes individuals to chronic cough. der of collagen may exist in some patients with PFD,
though it is difficult to draw conclusions because all the
Collagen studies reported thus far have had small sample sizes.
Connective tissue is composed primarily of collagen and
elastin proteins in the form of fibres embedded in a ground Family History
substance of polysaccharides. 61 The collagen provides ten- There has been speculation as to whether family history is a
sile strength, while the elastin provides flexibility.62 More risk factor for PFD. Van Dongen70 observed that prolapse
than 12 types of collagen have been identified. 63 Type I col- occurred equally in identical twins who were given the same
lagen is very strong, usually organized into large fibres, and conditions of physical stress. Mushkat et a/. 71 noted a

254 • MARCH lOGe MARS 2005

A Review of the Epidemiology and Pathophysiology of Pelvic Floor Dysfunction: Do Racial Differences Matter?

threefold increase in prevalence of USI among first-degree complaints are not helpful in differentiating the etiology of
relatives of female subjects with USI. More recently, Elia et incontinence. 54,76 Surveys are also limited by self-selection
al.72 reported that the odds ratio for having at least one bias77 and possibly language fluency and socioeconomic sta-
relative with urinary incontinence was greater for an incon- tus. Notably, all studies determine an individual's ethnicity
tinent woman (OR 2.6; 95% CI, 1.50-4.48) than for a conti- or racial background either by self-report or by assessment
nent woman presenting to a urogynaecology clinic. This of physical characteristics. While both of these methods are
was also true when studying incontinent and continent open to subjective interpretation of physical characteristics
women from a general gynaecology clinic (OR 9.6; 95% CI, by either the woman herself or the observer, it can be
4.17-22.25). Data from the Norwegian EPICONTl3 popu- assumed that there is a reasonable degree of correlation
lation study showed that daughters of incontinent women between the subjectively assigned and "true" racial
had an OR of 1.4 (95% CI, 1.3-1.6) for being incontinent background.
when compared with daughters of continent women.
Younger sisters of incontinent women had an OR of 1.9 RACIAL DIFFERENCES AND URODYNAMIC
(95% CI, 1.5-2.5) for being incontinent when compared STRESS INCONTINENCE
with younger sisters of continent women. Having 2 inconti- In a large population-based study of postmenopausal
nent foremothers further increased the odds of developing women using a self-report questionnaire, Brown et al. 78
incontinence (OR 2.9; 95% CI, 1.1-7.6). Chiaffarino et al. 74 described the prevalence of urinary incontinence (all types)
also reported that the risk of prolapse was higher in women and its associated risk factors. The prevalence of weekly
with mothers or sisters reporting the condition. Even more SUI was higher in white women than in black women (OR
convincing evidence arises from Buchsbaum et al. ,75 who 2.8; 95% CI, 1.6-5.1), but only 8% of survey participants
found that 25 of 27 parous and nulliparous sister pairs had were black. Thom et al. 54 conducted a mail survey of mem-
identical staging of prolapse in the anterior and apical com- bers of a large health maintenance organization, 76.8% of
partments. Certainly, it is possible that some families may whom were self-described as white, 7.5% as black, 5.7% as
have an inherited disorder of collagen integrity. Asian, and 5.4% as Hispanic. These authors found that the
distribution by type of incontinence (urge, mixed, or stress)
did not differ significantly by self-identified background.
We found only 6 studies that compared objectively diag-
It is also possible that the relation between family history
nosed USI and genital prolapse in different racial groups
and PFD may run beyond familial relationships and be
(fable 1).79-84 Five of these relied on data collected only
explained by broader genetic factors among racial groups.
from women who had been referred to urogynaecology
Accordingly, the possible etiologic role of racial differences
clinics.79- 83 From these limited data, it may be concluded
is a major epidemiologic question in the area of PFD. As
that there is a greater incidence of USI in white women,
previously noted, racial signifiers connote shared physical
compared with black women. Reports are inconclusive with
characteristics determined by a common genetic origin2 and
respect to differences between white women and women of
are used in the context of this review to define a broad
other backgrounds.
group of people with similar physical characteristics. We
acknowledge that the currently available literature is largely
based on the simple assumption that racial groups are PELVIC ORGAN PROLAPSE
homogeneous. Clearly, this assumption is flawed . In our
society, there is significant ethnic and racial diversity even Scherf et al. 85 studied the prevalence of pelvic organ pro-
among groups of people who are self-defined as white, lapse in women from a homogenous black population
black, or Asian. Therefore, the following represents what is (mean age 32.6 years) in The Gambia, West Africa.
known, with acknowledged limitations, about the role of Speculum examination was performed on 1067 women.
racial differences in the development of pelvic floor dys- Prolapse was objectively documented in 46% of these
function. Conclusions drawn from this literature are thus women. This compares to a prevalence of 30.8% in a popu-
not perfect, but they do suggest a possible etiologic role for lation of women with a mean age of 39 years in the
racial differences in the complex problem of pelvic floor Samuels son study16 and a prevalence of 51 % in a peri-
dysfunction. menopausal population in the Versi study.17
There are limited data comparing PFD among racial Reports from Heyns in South Africa cited genital prolapse
groups. Most data are restricted to survey formats and are as being more common in white women than in black
based on subjective symptoms alone, possibly limiting their women 86 ; subsequent studies have disagreed. Four studies
validity, because several studies have shown that subjective in the last 10 years found no significant difference in the

MARCH lOGe MARS 2005 • 255


Table 1. Comparative studies assessing the prevalence of urinary stress incontInence (USI) and pelvic organ
prolapse (POP) and racial background
Study Population Proportion OR of having USI Proportion with Other findings Quality of
studied with USI POP evidence 93.94
Bump79 54 Black 27% Black NR 24% Black Black women with USI: Level 11-2
heavier, higher parity, greater
146 White 61% White 23% White diuretic use, more often dia-
(P 0.0008) betic, better passive urethral
closure pressure, and greater
urethral axis mobility than
white women.
Graham and 183 Black 22% Black NR No significant Being white most significant Level 11-2
Mallett 80 differences predictor of USI (OR 2.21 ;
132 White 46% White 95% CI, 1.31-3.73).
Mattox and 121 Hispanic 30% Hispanic NR 18% Hispanic Hispanic women had higher Level 11-2
Bhatia gravidity and higher parity,
50 White 6% White 18% White compared with white women
of comparable age.
Duon~ and 195 Hispanic 67% Hispanic NR NR Black women had signifi- Level 11-2
Korn cantly higher urethral closure
95 White 59% White pressures than did Hispanic,
white, or Asian women .
66 Asian 56% Asian

42% Black
Boreham et a/. 119 White NR White> Hispanic NR Parity and USI independently Level 11-2
(OR 0.31 ; 95% =
related (P 0.03)
125 Black CI, 0.14-0.71) >
Black (OR 0.18;
193 Hispanic
95% CI,
Chang and 73 Wh ite NR NR Stage 2 or Black women had higher Level III
Sultana 84 higher body weight and were more
34 Black prolapse: likely to smoke than Asian
67% Asian women and white women.
60 Asian
28% White White women had lower
26% Black parity and used more hor-
mone replacement therapy.
OR: odds ratio; NR: not reported.


incidence of prolapse between white women and black DIFFERENCES AMONG RACIAL GROUPS
women79- 81 ,84 (Table 1). However, differences in parity may
be an explanation, as Bump and colleagues found that black While inherent anatomical and physiological differences
among racial groups have not been proven, several interest-
women with more severe pelvic organ prolapse also had sig-
ing preliminary observations have been made. Howard et aL
nificantly more vaginal deliveries than did white women compared the structure and function of the urethral
(4.2 vs. 2.7; P =0.004) with no other significant differences sphincter in both black and white nulliparous continent
women. 87 The study was cross-sectional in design and
found between groups.79 Chang and Sultana found that
included 18 black women and 17 white women. Black
Asian women had higher rates of pelvic organ prolapse than women demonstrated a 29% higher urethral closure pres-
did women in other racial groupS.84 In total, the available lit- sure than did white women during a maximum pelvic mus-
erature suggests that being white, or possibly Asian, may
cle contraction (P 0.008). A nonsignificant trend toward
higher maximum urethral closure pressure at rest and larger
predispose women to the development of prolapse. It is, .urethral volume was also observed in black women.
however, impossible to draw any firm conclusions. Though both these findings would suggest better urethral

256 • MARCH JOGe MARS 2005

A Review of the Epidemiology and Pathophysiology of Pelvic Floor Dysfunction: Do Racial Differences Matter?

function in black women, there was also greater bladder general population. Ethnic rninotlnes are consistently
neck mobility during maximum performance of a Valsalva underrepresented as participants in medical research. Racial
manoeuvre when measured with the cotton swab test (36% differences in the willingness to participate in medical
greater, P = 0.02), compared with white women. Because research may be due to lower levels of trust or to the value
the women in this study were all continent, the importance given to medical research by a given ethnic community.92
of these observations in the clinical context of PFD is Racial differences in the prevalence of and risk factors for
unclear. PFD may provide important etiologic clues. Perhaps in the
future we will have enough information to recommend
Another recent study examined differences in pelvic floor
appropriate preventative strategies for those groups at risk.
area between black women and white women. Baragi et aL88
measured the bony pelvises of 40 black and 40 white female
cadavers, concluding that the overall pelvic floor cross-
sectional area in black women was 5.1 % smaller than in Funded by the Department of Obstetrics and Gynaecology,
white women (P = 0.037). Weidner et aL89 also studied dif- Queen's University, Kingston ON
ferences between black women and white women, using
electromyography and MRI. All the women were
nulliparous and had neither symptoms nor signs of PFD.
1. Pocket Oxford English Dictionary. 9th ed. New York: Oxford University
Differences between white women and black women were
Press; 2002. Soanes; p. 305.
noted in the motor unit action potentials in the external anal
2 Pocket Oxford English Dictionary. 9th ed. New York: Oxford University
sphincter. Black women demonstrated much greater ability
Press; 2002. Soanes. p. 739.
to recruit motor units in the external anal sphincter than did
3. Harvey MA, Versi E. Predictive value of clinical evaluation of stress urinary
their white counterparts. 90 In another study, Weidner et al. 91 incontinence: a summary of the published literature. Int Urogynecol] Pelvic
noted that black women had thicker levator ani muscles on Floor Dysfunct 2001;12:31-7.
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