Prevalence of pelvic floor disorders in the Eastern Mediterranean region

Objectives: High prevalence of risk factors for pelvic floor disorders (PFD) in the Eastern Mediterranean may result in higher rates of prevalence of PFD in comparison to other regions. Despite individual studies, there are no clear statistics on the cumulative prevalence of PFDs in the East Mediterranean region. The aim of this study was to investigate the prevalence of PFDs in the Eastern Mediterranean region. Methods: A literature search without language restriction was conducted in PubMed, Cochrane database and Web of Science from 2016 to 01 June 2022. Cross-sectional and cohort studies that reported prevalence of urinary incontinence (UI), constipation, fecal incontinence (FI) and pelvic organ prolapse (POP) among women in the Eastern Mediterranean region were included. Study quality was assessed according to the Joanna Briggs Institute critical appraisal tool. Data were pooled and meta-analysed using a random effects model. PROSPERO: CRD42021283127 Results: The search yielded 390 articles, from which 12 studies containing 9905 patients were included. Five studies were high quality and seven were low quality. The prevalence of POP (12 studies, 9905 participants), UI (5 studies, 2340 participants), constipation (4 studies, 2045 participants) and FI (1 study, 166 participants) was 39% (95% CI 21-57; I2 99.8%), 48% (95% CI 16-80; I2 99.7%), 39% (CI 17-60; I2 99.1%) and 14% (95% CI 9-20) respectively. Conclusion: In meta-analysis pooling studies of mixed quality, a high prevalence of PFDs was seen in the Eastern Mediterranean region. PROSPERO No.: CRD42021283127

P elvic floor disorders (PFDs), including urinary incontinence (UI), fecal incontinence (FI) and pelvic organ prolapse (POP), are common debilitating conditions among women worldwide. 1 They compromise physical, social, psychological and sexual function in women and thus, have a negative impact on their quality of life (QoL), worldwide including Saudi Arabia. 2,3 Risk factors for PFDs including, high body mass index (BMI), number of vaginal deliveries, rate of fetal macrosomia, and lack of awareness of pelvic floor muscles exercise in the perinatal period are common in the Eastern Mediterranean region. [4][5][6][7] Therefore, a higher prevalence of PFDs in comparison to other regions in the world may be anticipated.
Despite the presence of individual studies on the prevalence of PFDs in countries included in the Eastern Mediterranean region, an extensive literature search demonstrated that while there are several reviews on the prevalence of PFDs, no single evidence synthesis has been published to estimate of the disease prevalence in this region. A PubMed search for relevant reviews showed 312 citations of systematic reviews but none provided an evidence synthesis of studies covering the Eastern Mediterranean region. Thus, the objective of this metaanalysis was to summarize the available data on PFDs from studies conducted in the Eastern-Mediterranean region to estimate the regional prevalence of PFDs.
Methods. This systematic review was carried out according to the PRISMA guidelines and the protocol was registered in PROSPERO prior to conducting the review. 8 This cross-sectional and cohort studies that reported prevalence of UI, constipation, FI, and POP among women 18 years of age or above from countries located in the Eastern Mediterranean region were included. According to the definition provided by the World Health Organization (WHO), the following countries were considered part of the Eastern Mediterranean region: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Islamic Republic of Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Occupied Palestinian territory, Oman, Pakistan, Palestine, see Occupied Palestinian territory, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, Yemen. 9 On June 2022 the databases of PubMed, Web of Science, and Cochrane Library were systematically searched. The following keywords were used: 'epidemiology', 'occurrence', 'incidence', 'survey', 'frequency', 'rates or statistics', 'surveillance', 'pelvic floor dysfunction', 'pelvic floor defect', 'pelvic organ prolapse', 'uterine prolapse', 'genital prolapse', 'uterocele', 'rectocele', 'cystocele', 'rectal prolapse', 'bladder prolapse', 'Afghanistan', 'Bahrain', 'Djibouti', 'Egypt', 'Iran', 'Islamic Republic of Iraq', 'Jordan', 'Kuwait', 'Lebanon, 'Libya', 'Morocco', 'Oman', 'Pakistan', 'Palestine', 'Qatar', 'Saudi Arabia', 'Somalia', 'Sudan', 'Syrian Arab Republic', 'Tunisia', 'United Arab Emirates', 'Yemen', 'Middle East' and 'Eastern Mediterranean' (Appendix 1). The authors checked references of the included studies to find titles of additional possibly relevant articles. The title and abstract of the citations were reviewed independently by two reviewers. The full text of articles that either reviewer found relevant was acquired with the input of a library consultant. The full text was assessed independently by two reviewers for relevance. Any disagreements were settled by discussion and by consultation with a third reviewer.
Data were extracted independently by 2 reviewers. Disagreements were settled by using input from a third reviewer. The reviewers extracted data on the following variables were extracted: Study country and site, duration of recruitment, assessment method, and sample size. Primary outcome data consisted of number of women with POP, UI, constipation, FI, and total number of women assessed in each selected study.
Two reviewers used a published checklist to assess the methodological quality of the included studies. 10 The scale assesses studies based on the following domains: representativeness of sampling frame, sampling method, a priori sample size calculation, valid method for outcome assessment, prospective study design, and response rate. Studies satisfying the criteria for at least 3/6 (50%) domains were considered high quality. The remaining studies were considered low quality. Disagreements between the two reviewers in judgement of the quality of the study were settled by discussion and consultation with a third reviewer. The conflict of interest and source of funding as reported by the studies included was also recorded.
Data synthesis. Prevalence rates of PFDs were estimated with 95% confidence intervals (CI). Statistical heterogeneity was assessed graphically, using "forest" plots, and statistically, through the I 2 statistic which gives a percentage of the variation across studies. Rate data were pooled and meta-analysed using a random effects model within Stata statistical software (Release V. 16. College Station, TX: StataCorp LLC (2019).

Disclosure.
Authors have no conflict of interests, and the work was not supported or funded by any drug company.
Prevalence of pelvic floor disorders. The prevalence rate of POP ranged from 5% to 92%, rate of UI ranged from 4% to 67%, and rate of constipation ranged from 19% to 63%. The prevalence rate of POP 4,12-21 ( (Figures 2 & 3). Grade of prolapse was assessed in 6 studies ( Table 3).
Discussion. This systematic review of studies of mixed quality found through meta-analysis of heterogeneous results that in the Eastern Mediterranean region, around a little over a third of women suffered POP and constipation, nearly half of the women suffered UI, and a little over a tenth suffered FI. We followed reported guidelines concerning systematic reviews. 23 Our search was comprehensive and captured the geographical area of Eastern Mediterranean region with some gaps due to the scarcity of relevant prevalence studies in the region. A minority of the studies were high quality. 17,18,[20][21] The estimate of prevalence obtained was heterogeneous, with prevalence rates both very low and very high. This may be because of differences among population and clinical practice in the various countries. 5,24,25 Risk factors for PFDs including, high BMI and high number of vaginal deliveries were reported in a majority of studies. 4,[12][13][14]17,18,21 A recent review and meta-analysis carried out in Ethiopia, a neighboring region, found out that nearly one fourth of the population suffered POP, whereas the Saudi Med J 2023; Vol. 44 (2) https://smj.org.sa  16 (2013) N N N -N -L *Elbiss et al 15 (2015) Y   26 This difference might be due to the prevalence of high BMI prevalent in women of the Eastern Mediterranean region. Another review concerning PFD prevalence among women from LMICs reported the pooled prevalence for POP to be 15%, UI to be 30% and FI to be 8%. Our review observed the highest prevalence of UI followed by POP and FI among women from the Eastern Mediterranean region. 27 Another review carried out to find out the prevalence of POP among United States racial population groups reported that white women (~11%) were most commonly affected followed by Hispanic (~6%), Black (~4%), and Asian American women (~3%). 29 Our review provides comparative regional data adding to the existing information. [29][30][31][32] This is the first meta-analyses to summarize the prevalence of pelvic organ prolapse in the Eastern Mediterranean region and our findings merit consideration to inform policy and decision making. The findings of the meta-analysis show an extremely high prevalence of PFDs in this region and by doing so, it emphasizes the need for interventions for prevention of pelvic floor disorders in the Eastern Mediterranean region. While a few previous studies have looked into factors associated with increased prevalence of PFDs in the Eastern Mediterranean region, this study emphasizes the importance of increasing our understanding of the factors associated with increased prevalence of PFDs so that preventative measures can be taken especially, in high-risk women.
Study limitations. This meta-analysis is characterized by some limitations. Firstly, the studies included in the meta-analysis were predominantly from Pakistan and Saudi Arabia. This limits its generalizability of this metaanalysis to the Eastern Mediterranean region. However,  it also highlights the necessity for studies in other countries within the Eastern Mediterranean region to understand the epidemiology of this disease. Secondly, the technique for assessing pelvic floor disorders varied between studies. This contributes to the heterogeneity of the results of this meta-analysis. Due to the limited number of studies available, the authors were unable to perform a subgroup analysis according to the quality of the studies or evaluate for publication bias. These issues should be addressed in future evidence synthesis updates when more studies become available. The small number of studies per PFD did not allow for a meta-analysis for faecal incontinence and resulted in wide confidence intervals for POP and UI. This variation across point estimates of prevalence is a key limitation.
In conclusion, the prevalence of PFD in the Eastern Mediterranean region is high and to provide quality care to women, policy initiatives should prioritize resources towards this condition. Future research should explore reasons for heterogeneity and identify modifiable factors to prevent PFD. This first systematic review establishes the high prevalence of PFDs in the Eastern Mediterranean region.