ABSTRACT
Objective To devise a validated measure of vaginal rugae and assess the relationships between vaginal rugae and important clinical parameters.
Methods Two techniques of assessing vaginal rugae were developed and their inter-/ intra-observer variability assessed. Examination variability was assessed using intraclass correlation and by way of an analysis of the absolute difference between the two rugal quantitations. After validating the assessment technique, the rugal quantitations of 88 women were compared to clinical parameters such as age, estrogen status, stage of prolapse, parity, history of anterior vaginal wall surgery, and body mass index. Linear regression analysis was used to assess the relationships between vaginal rugae score and these clinical parameters.
Results The mean age and body mass index of the subjects were 56 years (standard deviation (SD) 13.8 years) and 30.4 kg/m^sup 2^ (SD 7.5 kg/m^sup 2^), respectively. The median parity was 2 (range 0- 1.1). A history of anterior vaginal wall surgery was present in 29% of subjects and 46% were estrogen-deficient. Scores for the two techniques to quantitate vaginal rugae were normally distributed. Both techniques demonstrated satisfactory interexaminer reliability. Increasing age and deficient estrogen status were found to be independent predictors of less vaginal rugae.
Conclusions Vaginal rugae can be reliably quantitated. Loss of vaginal rugae is associated with estrogen deficiency and advancing age.
Key words: VAGINA, RUGAE, ESTROGEN, PELVIC ORGAN PROLAPSE
INTRODUCTION
Vaginal rugae are transverse epithelial ridges most commonly seen on the outer third of the female vagina. Reportedly, the infant vagina at birth closely resembles the mature state, with deep cryptic rugae presumably secondary to maternal estrogen exposure; yet, as estrogen concentrations subside, the vagina becomes thin, dry, non-elastic and non-rugated1. A similar mechanism apparently accounts for the non-rugated appearance of the vagina in postmenopausal women. Rugae are also thought to flatten or stretch with some forms of anterior vaginal wall support defects2. Thus, vaginal rugae are believed to render insight into the hormonal and structural integrity of the vagina and may be useful in caring for women with symptomatic vaginal atrophy and/or prolapse.
Despite the potential utility of evaluating rugae, we cannot identify any reported standardized scale to quantify vaginal rugae. Furthermore, these presumed associations between vaginal rugal appearance and hormonal status or pelvic organ prolapse have never been objectively confirmed. We set out to establish a reproducible and accurate descriptive scale of vaginal rugae and to correlate it with important clinical parameters such as hormone status and stage and location of pelvic organ prolapse.
METHODS
The Institutional Review Board at the Cleveland Clinic approved this research and all subjects were provided written informed consent before participation. Two examinations utilizing a standardized technique were prospectively performed by five possible health-care providers on 88 women presenting to the gynecology clinic at the Cleveland Clinic Foundation. The examiners included three faculty members (M.D.B., M.D.W. and M.F.P.), one urogynecology fellow (J.L.W.), and one nurse with extensive experience examining women. All examinations were done with the patient in the supine lithotomy position using a standard gynecological examination table. The first 53 women were used to determine the interexaminer and intraexaminer reliabilities of two devised techniques to quantitate vaginal rugae. To assess interobserver reliability, a duplicate examination was performed by a second examiner blinded to the initial examiner’s results. The intraexaminer reliability portion of the study was derived from those women whose routine medical care required a second visit to the Cleveland Clinic Foundation gynecology clinic. Intraexaminer reliability was assessed by a repeat examination done at a minimum of 3 weeks after the initial examination by one of the original two examiners.
Assessment of anterior vaginal wall rugae was performed along with the standard pelvic examination using two different techniques. The first technique involved examination of a point 3 cm distal from the urethra along the anterior vaginal wall. With a ring forceps placed at this point, the number of transverse ridges contained within the ring opening (1.5 cm in vertical length) at rest and with straining was determined (Figure 1). In the second technique, overall visual impression (qualitative measure) of anterior vaginal wall rugae at rest and straining was assessed on a 10 cm visual analog scale (VAS) with endpoints, ‘no rugae’ and ‘maximum rugae’ (Figures 2 and 3).
Historical and clinical parameters were collected on 88 subjects including age, body mass index, estrogen status, history of anterior vaginal wall surgery, International Continence Society pelvic organ prolapse quantification (POPQ) stage and parity. While serum estrogen was not measured, estrogen exposure was considered present if the patient was premenopausal or currently using oral or vaginal estrogen preparations.
Figure 1 Drawing of rugae assessment technique utilizing a ring clamp placed 3 cm from the urethral meatus along the anterior vaginal wall. The number of transverse ridges is recorded within the border of the ring
Figure 2 Visual analog scale for the global assessment of vaginal rugae
Interexaminer and intraexaminer examination reliabilities were evaluated utilizing intraclass correlation. Intraclass correlation coefficients (ICC) between 0.81 and 1.00 were considered near perfect agreement between the two examinations. ICC values between 0.61 and 0.80 were considered satisfactory agreement, and values between 0.41 and 0.60 are regarded as poor agreement. Additionally, the absolute difference between the two examinations, both intra- and interexaminer, of rugal quantitations were determined for the transverse ridge number and VAS techniques. Standard least squares linear regression analysis was used to determine independent predictors for vaginal rugae quantity. Because the VAS technique demonstrated better inter- and intraexaminer reliabilities, the rest results from both examiners were used in the regression analysis. Visual analog score was used as the dependent variable, and age, body mass index, history of vaginal surgery, estrogen status, and POPQ stage of prolapse were considered independent variables. Both higher-order terms and interaction terms were explored. All statistical tests were evaluated at the 0.05 level of significance. Statistical analysis was performed using SPSS 11.5 (Chicago, IL, USA).
Figure 3 Drawing of vaginal rugae demonstrating the range of visually assessed vaginal rugae from none to maximum
RESULTS
The mean age of subjects was 56 (SD 13.8) years, the mean body mass index was 30.4 kg/m^sup 2^ (SD 7.5 kg/m^sup 2^) and the median parity was 2 (range 0-11). Twenty-nine percent of subjects had a history of anterior vaginal wall surgery and 46% were estrogen- deficient. Thirty-five percent of subjects had Stage III or IV pelvic organ prolapse by the POPQ system. Another 34% of subjects had Stage II pelvic organ prolapse, with 18 and 13% of subjects having Stage O or I pelvic organ prolapse, respectively. Both the rugae ridge quantity and visual analog score data were normally distributed. Scores for both the transverse ridge number and VAS were not significantly different between rest and straining; subsequently, only rest values are reported. Fifty-three women were used to determine the interexaminer reliability of the two rugal quantification methods. Seventeen women returned for repeat examination to determine the intraexaminer reliability. The interobserver correlation for the transverse ridge quantitation was 0.61 (p
With reference to the interobserver reliability, the mean absolute difference in the two transverse ridge quantitation results was 1.3 (95% confidence interval (CI) 0.93-1.67). The mean absolute difference between the two examinations results using the visual analog scale was 1.8 cm (95% CI 1.42-2.18). Likewise with reference to the intraobserver reliability of the examination, the mean absolute difference between the repeat transverse ridge quantitations was 2.3 (95% CI 1.83-2.77), while the repeat VAS score absolute difference was 2.7 cm (95% CI 2.22-3.18).
Linear regression of the historical and clinical parameters (age, body mass index, parity, history of vaginal surgery, estrogen status, and POPQ stage) to predict the results of the VAS technique to measure anterior vaginal rugae found age and deficient estrogen status as independent predictors of lower vaginal rugae score (age, examiners 1 and 2,p = 0.006; estrogen status, examiner 1, p = 0.03; examiner 2, p = 0.04). Stage of prolapse, body mass index, parity and history of anterior vaginal wall surgery demonstrated no relation to rugae score.
DISCUSSION
Vaginal rugae are believed to yield important clues as to the str\uctural integrity and hormonal status of the lower genital tract. We have demonstrated that use of a 10 cm visual analog scale renders reliable intra- and interexaminer results. The numbering of transverse ridges 3 cm from the urethra along the anterior vaginal wall, while demonstrating satisfactory interexaminer reliability, is limited by poor intraexaminer reliability. This deficiency is likely due to the small numbers of women who were re-examined. The technique, however, is further limited by assessing vaginal rugae only at the distal anterior vagina. Alternatively, the visual analog scale technique renders a more global assessment of anterior vaginal wall rugae. Despite the reported value of assessing vaginal rugae, we have not identified any reported technique on how to quantify vaginal rugae.
Reliable assessment of vaginal rugae is the first step in determining the validity of the claimed associations between rugae appearance and those clinical parameters ascribed to it. Based on our observations, a global impression via a VAS is best suited to objectify assessment of vaginal rugae.
While it has been apparently assumed that estrogen affects vaginal rugae, we have documented a quantifiable association. Our study did not measure serum estrogen concentrations nor made a distinction between oral or topical estrogen, and this limitation is acknowledged. Postmenopausal vaginal atrophy is common and the diagnosis ordinarily made with visual inspection of the epithelium3. Visual inspection of the vaginal epithelium includes a subconscious assessment of the quality and quantity of the vaginal rugae. Nilsson and colleagues’ showed that administration of oral estrogen resulted in a shift in the vaginal maturation index and pH. A high vaginal pH (>6) was found to be a good, accessible marker for vaginal atrophy. Vaginal pH was not obtained as part of this study but it would be notable if vaginal pH were correlated with a quantified assessment of vaginal rugae, since both seem to be associated with estrogen exposure. Yet, other studies have failed to find an association between estrogen levels and the vaginal maturation index4. Furthermore, the same and other studies fail to document an association between postmenopausal symptomatology and estrogen levels4 or vaginal atrophy5. Use of a VAS to quantify the visual inspection of the vaginal epithelium may be a useful tool to further explore some of these issues regarding vaginal atrophy and postmenopausal symptomatology.
Anterior vaginal prolapse, or cystocele, is thought to result from site-specific support defects within and around the trapezoidal pubocervical connective tissue suspending the anterior vaginal wall and bladder6. Some have suggested that anterior vaginal wall support defects can be predicted by the appearance of the anterior vaginal wall rugae. For example, loss of mid-line vaginal rugae would be associated with a defect in the mid-line connective tissue supports. Creation of a scaled assessment of vaginal rugae alone is of little practical value, yet the long-held belief among seasoned vaginal surgeons that vaginal rugae could be used to identify vaginal wall defects (lateral, central or apical) had not been examined in a quantified manner. There appears to be no association between vaginal support and vaginal rugae. We have already documented poor inter- and intraexamiiier reliabilities with the clinical evaluation of anterior vaginal wall support defects7. Taken together, we are dubious of the value that assessing vaginal rugae has in determining the presence and location of anterior vaginal support defects.
The effect of age, independent of hormone status, is interesting. Conceptually, given the association between age and surface skin wrinkles, one might expect more rugae with advancing age, but this is an oversimplification. Indeed, age effects on the skin include epidermal flattening, loss of normal rete ridge pattern, papillary dermal elastin, increased disorganized reticular dermal elastic fibers, lessened dermal collagen, altered dermal collagen fiber morphology, and decreased dermal microvasculature8. Perhaps, the known thinning of skin that occurs with aging8 also occurs in the vagina and, in effect, leads to less visible rugae. Better understanding of the mechanism behind formation of vaginal rugae would shed light on the identified age effect on rugae appearance.
In conclusion, we have devised a technique to objectify the clinical evaluation of vaginal rugae. Using the VAS technique, more vaginal rugae have been shown to be a marker of estrogen exposure, yet age alone appears to cause a diminution of vaginal rugae independent of estrogen loss. The utility of vaginal rugae in assessing patients with pelvic organ prolapse is unclear but appears limited.
Conflict of interest Nil.
Source of funding Nil.
References
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2. Shull BL. Clinical evaluation of women with pelvic support defects. Clin Obstet Gynecol 1993;36:939-51
3. Nilsson K, Risberg B, Heimer G. The vaginal epithelium in the postmenopause: cytology, histology and pH as methods of assessment. Maturitas 1995;21:51-6
4. Stone SC, Mickal A, Rye PH. Postmenopausal symptomatology, maturation index, and plasma estrogen levels. Obstet Gynecol 1975;45:625-7
5. Davila GW, Singh A, Karapanagiotou I, et al. Are women with urogenital atrophy symptomatic? Am J Obstet Gynecol 2003;188:382-8
6. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:68-73
7. Whiteside JL, Barber MD, Paraiso MF, Hugney CN, Walters MD. Clinical evaluation of anterior vaginal wall support defects: interexaminer and intraexaminer reliability. Am J Obstet Gynecol 2004;191:100-4
8. Cook JL, Dzubow LM. Aging of the skin: implications for cutaneous surgery. Arch Dermatol 1997;133:1273-7
J. L. Whiteside, M. D. Barber, M. F. Paraiso and M. D. Walters
The Cleveland Clinic Foundation, Department of Gynecology and Obstetrics, Cleveland, Ohio, USA
Correspondence: Dr J. L. Whiteside, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon NH 03756, USA
ORIGINAL ARTICLE
2005 International Menopause Society
DOI: 10.1080/13697130500042490
Received I 1-06-04
Revised 17-07-04
Accepted 17-07-04
Copyright CRC Press Mar 2005
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