Int Urogynecol J (2008) 19:10631069

DOI 10.1007/s00192-008-0591-1

ORIGINAL ARTICLE

Family history as a risk factor for pelvic organ prolapse

Mary T. McLennan & Jenine K. Harris &
Barbara Kariuki & Sara Meyer

Received: 13 December 2007 / Accepted: 14 February 2008 / Published online: 19 March 2008
# International Urogynecology Journal 2008

Abstract The aim of this study was to determine whether a

family history of prolapse and/or hernia is a risk factor for
prolapse. A cohort of 458 women seeking gynecological
care was classified as exposed (family history) or unexposed (without family history). We used 2 to assess
confounding and logistic regression to determine risk.
Nearly half (47.3%) of the 458 participants reported a
positive family history. Of these, 52.5% had prolapse. This
was significantly higher than the 28.9% rate of prolapse in
women without a family history (p<0.001). The crude risk
ratio for family history of prolapse and/or hernia and
prolapse was 1.8 (95% CI 1.42.3). After adjusting for
vaginal deliveries, incontinence, and hysterectomy, the risk
of prolapse was 1.4 (95% CI 1.21.8) times higher in
women with a family history of prolapse and/or hernia.
Heredity is a risk factor for prolapse. History taking should
include both male and female family members.
Keywords Family history . Hernia . Prolapse

Presented at Central Association of Obstetricians and Gynecologists

Awarded George W. Morley Paper Award Chicago, IL, USA, 17
October 2007
M. T. McLennan (*) : S. Meyer
Division of Urogynecology,
Department of Obstetrics and Gynecology and Womens Health,
Saint Louis University,
6420 Clayton Rd., Ste. 290,
St. Louis, MO 63117, USA
e-mail: [email protected]
J. K. Harris : B. Kariuki
School of Public Health, Saint Louis University,
St. Louis, MO, USA

Introduction
The overall prevalence of prolapse in the US is 21.7% in
1883 year olds [1], with rates as high as 27% in women
3049 years old and 30% in women 5089 years old [2].
The estimated lifetime risk for having a single operation for
prolapse or urinary incontinence by age 80 is 11.1% [3].
The National Institute of Child Health and Human
Development acknowledges that not enough is known
about the causes of prolapse [4]. It is therefore vitally
important to understand the natural history and risk factors
in order to develop better prevention strategies.
Prolapse is considered a hernia of the pelvic and/or
intraperitoneal contents into the vaginal canal. Wellestablished risk factors include age, parity, and previous
hysterectomy, especially if performed for prolapse and
collagen disorders [3, 5, 79]. Disputed risk factors include
body mass, mode of delivery, education, birth weight of
infant, race, chronic pulmonary diseases, lifting, and
maternal gynecologic history [1, 3, 614]. These factors
alone may not adequately explain why certain patients
develop prolapse. In the Womens Health Initiative, almost
one fifth of nulliparous women had some degree of
prolapse [15]. Studies have established family history as a
risk factor for other pelvic disorders such as urinary
incontinence [16]. Could prolapse also have a genetic
basis? To date, there is only one study assessing gene
expression. Visco and Yuan [17] found there was differential gene expression for the structural proteins in the
pubococcygeus muscle between five women with prolapse
and five controls. These differences are the result of either
genetic mutation or genetic inheritance. There is a small
amount of literature noting that patients whose female
family members have prolapse are at increased risk

1064

developing of prolapse [17, 18]. In a study of inguinal

hernias in women, Liem et al. [19] noted a positive family
history as an independent risk factor (OR=4.3, 95% CI
1.99.7). Hernias in male or female family members
increased the risk. In a prospective study of 8,104 US
women with inguinal hernias, Ruhl and Everhart [20] noted
a history of a previous umbilical hernia increased the risk of
inguinal hernia (HR=3.2; 95% CI 1.28.7).
If heredity plays a role in the development of pelvic
organ prolapse (POP), it could allow physicians to identify
women at high risk and develop early prevention and
intervention strategies to decrease the risk and ultimately
the prevalence of the disease. Studies to date assessing
prolapse risk factors have not included information on male
family members or other hernia sites. Our study seeks to
establish whether family history of weakened connective
tissue as evidenced by hernias in male relatives and by
hernias and/or prolapse in female relatives is a significant
risk factor for the development of pelvic organ prolapse.

Materials and methods

We conducted a cohort study of nonpregnant women
presenting for gynecological care in a university private
practice. This study was approved by the Saint Louis
University Institutional Review Board in the exempt
category. Therefore, women did not have to sign informed
consent. The survey was anonymous. Women were selected
to participate if they were: (1) presenting to the generalist or
urogynecology service at the Saint Louis University
Department of Obstetrics and Gynecology, (2) not pregnant, (3) competent to complete a survey, and (4) a new
patient (urogynecology service only). Although women
presenting to the urogynecology service were only included
if they were new patients, they were not excluded if they
had previous prolapse. New patients only were used to
prevent duplicate completions as patients may have a
number of subsequent visits. Excluded were those who
were pregnant or seeking oncology consultation, as
pregnancy and cancer treatment could affect the risk of
prolapse in unique ways and therefore would not provide
generalizable information regarding risk factors.
Surveys were distributed between August 2004 and
December 2005. While an attempt was made to give the
survey to all new patients, some may have been missed as it
was distributed by the check-in coordinator. This person
however is unaware of the reason for presentation so could
not have preferentially given it to any certain patient type.
The patients did not know about the survey before arrival
and therefore had no opportunity to enquire of the specifics
of their family history prior to being seen. Patients have
varying degrees of natural interest, but there was no

Int Urogynecol J (2008) 19:10631069

prompted interest on the researchers part. Using the survey

responses, women were classified as exposed or unexposed.
The exposed group included women indicating a family
history of hernia in male or female family members or pelvic
organ prolapse in female family members by responding
positively to one or more of the following questions:
1. Has any female in the family had trouble with their
bladder, vagina, uterus, or rectum falling out (prolapse)?
2. Has any female in the family had trouble with hernia(s)?
3. Has any male in the family had trouble with hernia(s)?
The unexposed group included women who indicated no
family history of genital prolapse or hernia. Women missing
exposure status information were excluded from analysis.
The outcome of interest was POP. Women were
identified as having POP based on the clinician recording
of POP status during a gynecological exam performed at
the time of the survey. That is, prolapse status was recorded
prospectively not by later review of the chart. Prolapse was
classified using the BadenWalker criteria half-way system
[21], with women having any grade of prolapse (1 through
4) being classified as having prolapse. This system was
employed for consistency as not all of the generalist
physicians were using the pelvic organ prolapse quantification system. The system was explained to the physicians,
and all patients were examined on identical gynecological
tables in the dorsal lithotomy position while asking the
patient to Valsalva. Previously identified potential risk
factors such as age, gravity, parity, mode of delivery,
incontinence, race, education, body mass index (BMI),
smoking, occupation, lifting, chronic cough, hormone
therapy, diabetes, prior hysterectomy, and constipation were
included as covariates. Information on these covariates was
obtained from the questionnaire itself, not by chart review.
Women were not specifically asked if they had previous
surgery for prolapse, only if they had a hysterectomy and the
reason (bleeding, fibroids, falling out, cancer, abnormal pap,
other). Lifting has been identified as a risk factor in previous
studies; however, it has typically been confined to lifting as a
characteristic of a womans occupation [10]. We included
lifting associated with exercise and lifting associated with
occupation into a single dichotomous variable (lifting or
nonlifting). Exercise status was also included as a covariate.
Statistical analyses were performed using Statistical
Package for the Social Sciences (version 13.0) and
Statistical Analysis System (SAS; version 9.1) statistical
software. For bivariate analyses, we used 2 statistics and ttests for independent samples to compare population
characteristics between women reporting a family history
of prolapse and/or hernia and those reporting no family
history. For those characteristics with more than 5% of
responses identified as missing or do not know, a
category for unknown was included in the analysis in order

Int Urogynecol J (2008) 19:10631069

to see if those women with missing information differed

significantly in reported history of prolapse and/or hernia.
Following bivariate analyses, we assessed for effect
modification and confounding to determine whether (1) the
relationship between a family history of prolapse and/or
hernia and POP was different at different levels of other
variables (effect modification), or (2) the relationship
between family history of prolapse and/or hernia and POP
was distorted by the influence of one or more other
variables (confounding). To assess for effect modification
we used the BreslowDay 2 test, which identifies
significant differences in the stratum specific estimates of
risk. To examine confounding, we calculated the adjusted
risk ratio (aRR) and used the 10% rule to identify potential
confounders and the MantelHaenszel 2 test to determine
significance.
Using SAS procedure GENMOD, we conducted logistic
regression with a binomial distribution and log link
function in order to determine the appropriate estimates of
the aRR for pelvic organ prolapse given family history of
prolapse and/or hernia and any confounders identified. For
this analysis, categorical variables were recoded to dichotomous dummy variables.

Results
Six hundred twenty-four women completed the survey
during 2004 and 2005. All patients receiving a questionnaire completed at least some of it (no one refused). All
patients were from the same office but individual providers
were not identified. Of the 624, 477 (76%) included
conclusive information regarding family history of prolapse
in female family members and/or hernia in female or male
family members. This was the initial group for analysis. We
did not attempt to contact those 147 women with missing
information, as there was no identifying information on the
survey. Two hundred and six of the 477 (43%) reported no
family history of prolapse or hernia, while 271 (57%)
reported at least one family member with this history. There
were significant differences in demographic, behavioral,
and medical history characteristics between those with a
positive family history and those without. Those reporting a
family history of prolapse and/or hernia were more likely to
be Caucasian, had a higher gravity and parity, had had a
hysterectomy, reported incontinence and constipation, and
were less likely to exercise. They were also more likely to
report a family history of incontinence and hysterectomy
(Table 1). The breakdown of conditions reported by the 271
women with a family history is reported in Table 2.
After removing 19 women with missing information
from the population, 458 women remained for the
subsequent analysis. The 19 women with missing values

1065

or do not know responses were significantly different

from the 458 with complete information. They were more
likely to be older, diabetic, and incontinent, diagnosed with
prolapse, and fail to report their BMI, family history of
hysterectomy, or incontinence.
Analysis of those with complete information, showed
that 194/458 (42.4%) were diagnosed with prolapse. Of
these, 180 (93.3%) had grade 2 prolapse. The various
grades are as follows: 13 (6.7%) grade 1; 39 (20.2%) grade
2; 68 (35.3%) grade 3; 73 (37.8%) grade 4, with one
individual missing grade-level data. Two hundred and
sixty-one of the 458 women (57.0%) reported having a
family history of prolapse and/or hernia. On initial analysis
without considering other variables, the risk for developing
prolapse was 1.5 times higher for women with a male
relative with a hernia compared to those without family
history of male hernia. Similarly, the risk of prolapse was
1.8 times higher for women with a female relative with
prolapse and/or hernia compared to women without the
female family history of prolapse and/or hernia.
Further analysis of these 261 with a positive family
history showed that 137 (52.5%) had the outcome of
interest (pelvic organ prolapse), which was significantly
higher than the 57 (28.9%) women diagnosed with prolapse
of the 197 women who did not have a family history of
prolapse and/or hernia (p<0.001). The crude risk ratio
(cRR) for the relationship between family history of
prolapse and/or hernia and pelvic organ prolapse was 1.8
(95% CI 1.42.3).
Comparing those with mild prolapse to those with severe
prolapse, we found that, of those with severe prolapse
(grade 34), 110 (78.0%) had a family history of prolapse
or hernia and 31 (22.0%) had no family history. Of those
with mild prolapse, 27 (50.9%) had a family history, and 26
(49.1%) had no family history. Therefore, the risk of severe
prolapse (grade 34) was 1.48 (95% CI 1.141.90) times
higher in those with a family history compared to those
without a family history which was statistically significant.
In contrast, a positive family history was not a statistically
significant risk factor for mild prolapse (grade 12) with a
relative risk 1.14 (95% CI 0.701.87).
Based on a significant BreslowDay test, we found
evidence of effect modification by the number of vaginal
deliveries (2 =7.9; p=0.02). Women with a positive family
history and one vaginal delivery had a prolapse rate of 26%
compared to 21% in those without a history. With multiple
vaginal deliveries, the rate was 76% for those with a family
history compared to 48% for those with no family history.
However our sample size was not sufficient to further
explore this apparent interaction between family history and
number of vaginal deliveries. Instead, we included vaginal
deliveries as a confounder, which is a biologically plausible
alternative.

1066

Int Urogynecol J (2008) 19:10631069

Table 1 Participant characteristics by family history of prolapse and/or hernia in the 477 women providing conclusive information on family
history

Demographic and behavioral characteristics

Age (mean, SD)
BMI
24.9 (underweight/normal)
>24.9 (overweight/obese)
Unknown
Current exercise
Education (years)
12
>12
Unknown
Lifting (occupation or exercise)
Race
AfricanAmerican
Caucasian
Unknownother
Ever smoker
Gynecological history
Cesarean deliveries
No c-sections
Single c-section
Multiple c-sections
Hysterectomy
Hormone therapy
Incontinent
Gravidity
No pregnancies
Single pregnancy
Multiple pregnancies
Parity
Nulliparous
Single birth
Multiple births
Vaginal deliveries
None
Single vaginal delivery
Multiple vaginal deliveries
Other medical history
Chronic cough
Constipation
Diabetes
Family medical history
Family history hysterectomy
Yes
No
Unknown
Family History Incontinence
Yes
No
Unknown

No family history (n=206)

Family history (n=271)

46.6

17.7

52.8

16.2

0.09

86
112
8
150

41.7
54.4
3.9
73.2

104
159
8
170

38.4
58.7
3.0
63.0

0.60

97
106
3
113

47.1
51.5
1.5
55.7

123
141
7
147

45.4
52.0
2.6
54.9

0.67

54
142
10
72

26.2
68.9
4.9
35.1

35
228
8
99

12.9
84.1
3.0
36.5

<0.001

183
13
9
58
75
107

89.3
6.3
4.4
28.4
36.6
51.9

239
16
15
114
93
196

88.5
5.9
5.6
42.2
34.4
72.3

0.84

47
27
132

22.8
13.1
64.1

36
26
209

13.3
9.6
77.1

0.006

53
26
127

25.7
12.6
61.7

46
28
197

17.0
10.3
72.7

0.03

64
39
103

31.1
18.9
50.0

63
35
173

23.2
12.9
63.8

0.01

15
48
12

7.3
23.4
5.8

21
93
26

7.8
34.7
9.6

0.85
0.01
0.13

78
125
5

36.9
60.7
2.4

149
112
10

55.0
41.3
3.7

<0.001

44
144
18

21.4
69.9
8.7

121
78
72

44.6
28.8
26.6

<0.001

0.02

0.86

0.75

0.002
0.63
<0.001

Int Urogynecol J (2008) 19:10631069

1067

Table 2 Breakdown of the types of family history reported by 271

women with a positive history
Type of hernia
Male hernia only
Prolapse only
Female hernia only
Prolapse and male hernia
Male and female hernia
Prolapse and female hernia
Prolapse and male and female hernia

Number (%)
100
49
43
34
17
16
12

(36.9)
(18.1)
(15.9)
(12.5)
(6.3)
(5.9)
(4.4)

We identified confounders by comparing the aRR for

each potential confounder to the cRR and identifying
differences of 10% or more between the aRR and cRR.
Using this 10% rule, we found significant evidence of
confounding by number of vaginal deliveries, hysterectomy
status, and incontinence. After adjusting for vaginal
deliveries, the risk for prolapse was 1.5 (95% CI 1.21.9);
after adjusting for hysterectomy status, the risk was 1.6
(95% CI 1.32.0), and after adjusting for incontinence the
risk was 1.6 (95% CI 1.22.0) times higher for women with
a family history of prolapse and/or hernia compared with
women without a family history of prolapse and/or hernia.
Results of the binomial logistic regression with prolapse
status as the dependent variable and family history of
prolapse and/or hernia, vaginal deliveries, incontinence
status, and hysterectomy status as the independent predictors indicated a significant overall result (2 =443; p<
0.001; Table 3). The model showed that, after adjusting
for these variables, the risk of prolapse was 1.4 (95% CI
1.21.8) times higher in women with a positive family
history.

Discussion
Given our findings, heredity is a potential risk factor for
developing pelvic organ prolapse. This study adjusted for
commonly reported risk factors and found the risk of
prolapse was 1.4 times higher in those with a family history
of prolapse or hernia which was statistically significant. In a
review of pelvic organ prolapse, Weber and Richter [22]
felt that the pathophysiology was multifactorial and
described the multiple-hit process whereby genetically
susceptible women may be exposed to multiple life events
that ultimately result in the development of clinically
significant prolapse. Genetically susceptible would imply
a potential role for not only the mothers genetic makeup
but also the fathers. It is in this latter area that we sought
additional information by asking specific questions as to
whether the father or brothers had a history of hernia, which
is considered by most to have a similar pathophysiology to

female prolapse. It is the addition of the male family history

that makes this study different from others reported to date.
A few studies have assessed the role of the female family
history. This is the largest to date. Our results are
comparable. Jack et al. [18] reported that women whose
female family members had prolapse were five times more
likely to develop prolapse compared to the general
population. On specific analysis of the patients family
tree, they noted that it appeared that there was both
maternal and paternal transmission. Buchsbaum et al. [16]
evaluated familial risk by comparing the prevalence of
prolapse in nulliparous postmenopausal women with the
rates in their sisters. They reported a high concordance in
the level of pelvic support between the two groups, with
some discordance in the level of pelvic support in sister
pairs where one sister was parous and the other was not. In
a study of Italian women, Chiaffarino et al. [10] reported
that the risk of urogenital prolapse was higher in women
whose mothers or sisters reported prolapse with an odds
ration of 3.2 (95% CI 1.17.6).
An interesting question to arise from this study is the
effect of the number of vaginal deliveries on the risk of
developing prolapse in those who also have a positive
family history. We noted that when there was one vaginal
delivery the rate of prolapse was similar in those with or
without a family history, but with multiple vaginal
deliveries the rate of prolapse was 1.6 times higher with a
positive family history. We did not have a large enough
sample to adequately test this trend statistically; however, it
is biologically plausible that the physical damage caused by
vaginal delivery triggers or enhances the effect of family
history. This alternate model requires further study. We are
continuing to recruit patients to enable us to stratify the risk
by the number of vaginal deliveries in an attempt to answer
this question. Understanding the interaction between the
two may be very important in advising young women with
affected family members as to the number of vaginal
deliveries advisable before risk of prolapse increases
significantly. With the increasing trenddemand for elective
Table 3 Association between family history of prolapse and/or
hernia, vaginal delivery, and pelvic organ prolapse determined by
logistic regression
Regression
coefficient
Constant
Family history
No vaginal deliveries
Single vaginal delivery
Multiple vaginal deliveries
Incontinence
Hysterectomy

2.9
0.4

0.8
1.8
0.2
0.4

adjusted
Risk Ratio

95% CI

1.4
1.0
2.3
5.8
1.3
1.5

1.21.8

1.14.9
3.110.7
1.01.6
1.21.8

1068

Cesarean section, this may play a role in the decisionmaking process for select patients.
Our study has two main limitations that impact the
generalizability of these study results. The patients were
recruited from a university private practice. We compared
our sample population to the Missouri population for the
demographic and behavioral characteristics included in this
study. Our subjects were slightly older and more likely to
be overweight or obese compared to the general population.
However, none of the other demographic or behavioral
characteristics were notably different between the two
populations. We did not collect income information in our
sample but because our location is a private practice, we
anticipate that their income would be higher than the
general population. There was also a significant difference
between women with missing values and those with
complete information for our study; however, we did not
use any of their information in the analysis and this was a
very small number of patients [19].
The second limitation was that we relied on subjects to
accurately recall their family history and did not verify their
answers. There were a number of women who did not know
their family medical history. Once again, women were
excluded from analysis if there was any missing information. Patients did not know of the study prior to arriving
and therefore were not prompted to know their family
history. Therefore, we believe that potential recall bias in
our survey responses occurred to the same degree in both
our exposed and unexposed patients. This would result in
nondifferential misclassification and would bias our calculated relative risk to the null, thus making the true association
stronger than our reported value of 1.4. However, we
acknowledge those that could argue that women with prolapse
may be more likely to ask a family member (differential
information bias) or conversely they may be more embarrassed to tell a family member about her organs falling out
than she is to tell about heart disease or hypertension. These
are not issues that any researcher can control.
In conclusion, while other studies have associated
prolapse mainly with age and parity, a family history of
prolapse and/or hernia is an additional risk factor that needs
to be considered. This study underscores the importance of
women knowing their family history (both maternal and
paternal) and reporting it to their physician. In addition,
researchers should include a history of prolapse or hernia in
both male and female family members among the potential
risk factors in future studies assessing the pathophysiology
of prolapse. Recommendations for counseling based on this
information are difficult until further studies are available.
However, it would be appropriate to tell a patient that her
family history may put her at increased risk and educate her
just as we do with patients who do chronic heavy lifting
despite limited literature. [614]

Int Urogynecol J (2008) 19:10631069

Acknowledgement Tina Barbaro who as a medical student and
Susan Barr MD as a resident aided in the distribution and collection of
questionnaires and/or data entry.
Conflicts of interest No conflict of interest for any author.

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