








































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

SIUJ  •  Volume 4, Number 3  •  May 2023 SIUJ.ORG

Key Words Competing Interests Article Information

Concurrent surgery, rectal prolapse,  
vaginal prolapse, multidisciplinary care

None declared. Received on July 19, 2022 
Accepted on October 18, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2023;4(3):180–186

DOI: 10.48083/KUPV7345

180

ORIGINAL RESEARCH

Age- and Population-Adjusted Trends in Inpatient 
Surgical Management of Vaginal Prolapse, Rectal 
Prolapse, and Concurrent Vaginal and Rectal 
Prolapse Surgery

Justina Tam,1 Hannah G. Koenig,2 Celine R. Soriano,3 Alvaro Lucioni,1 Jennifer A. Kaplan,3 
Kathleen C. Kobashi,1,* Vlad V. Simianu, 3 Una J. Lee1

1 Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, United States 2 Research and Academics, Virginia Mason Medical Center, 
Seattle, United States  3 Department of Surgery, Virginia Mason Medical Center, Seattle, United States * Present address: Department of Urology, Houston Methodist, 
Houston, United States

Previous presentation: This study was previously presented at the Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction 
(SUFU) 2021 Virtual Winter Meeting as a non-moderated poster and the abstract was published in the SUFU 2021 Abstracts Issue of Neurourology  
and Urodynamics:
Tam J, Soriano C, Koeniga H, Lucioni A, Kaplan J, Kobashi K, et al. Age and population adjusted trends in inpatient surgical management of vaginal 
prolapse, rectal prolapse, and concurrent vaginal and rectal prolapse surgery in Washington State. Neurourol Urodyn.2021;40:S229–S229.

Abstract

Objective To report age- and population-adjusted trends in the prevalence of inpatient vaginal prolapse (VP), rectal 
prolapse (RP), and concurrent VP/RP surgical procedures in women in Washington State over a 12-year period.

Methods The Comprehensive Hospital Abstract Reporting System, an inpatient claims database, was queried for 
female patients aged 20 years or older with a diagnosis of VP and/or RP and associated surgical procedures from 2008 
to 2019. Rates for female patients were adjusted by age and population based on census results.

Results Between 2008 and 2019, inpatient admissions for concurrent VP/RP surgery remained stable, with adjusted 
rates ranging from 1.42 to 3.38 per 100 000, with a majority performed in patients < 80 years old. The population-
adjusted rate of inpatient RP repairs remained stable at 3.12 to 5.14 per 100 000. The population-adjusted rate of 
inpatient VP repairs decreased dramatically, from 81.79 to 6.96 per 100 000.

Conclusions The rate of inpatient RP and combined RP/VP surgical procedures was low and remained stable, 
while inpatient VP surgical repairs decreased substantially. Since the dataset is limited to inpatient surgery, this trend 
may reflect a shift to outpatient settings for VP surgeries. Nationally in the United States, there has been a trend 
toward multidisciplinary surgical management of concurrent VP/RP. However, this same trend does not appear to 
be reflected in Washington State, suggesting that nationwide trends may not be reflective of trends within each state. 
Further study is needed to understand how and why local trends in the management concurrent VP/RP may differ 
from national trends, and potentially improve concurrent VP/RP management using multidisciplinary approaches.

Introduction
Vaginal (VP) and rectal prolapse (RP) in women share a common pathophysiology and similar surgical approaches. 
The incidence of concomitant uterine/VP with RP is variable and has been reported to be ~38% in some analyses[1]. 

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Both VP and RP occur more commonly in women 
over the age of 65 years[2,3], and traditionally have 
been treated as separate entities. However, there has 
been a trend toward a multidisciplinary approach, with 
concomitant procedures being performed by colorectal 
surgeons and urologists or g y necologists[1,4,5]. 
Multidisciplinary approaches have been demonstrated 
to be safe and efficacious[1] and may improve surgical 
outcomes and patient symptoms[4,6–9]. Prior work has 
demonstrated that the national rate of multidisciplinary 
repair in women diagnosed with VP and RP increased 
from 0.7% in 2003 to 1.9% in 2017[5]. However, a more 
detailed analysis of these trends on a statewide level 
has not been reported. The objective of this study is 
to report age- and population-adjusted trends in the 
prevalence of inpatient VP, RP, and concurrent VP/RP 
surgical procedures in women in Washington State over 
a contemporary 12-year period.

Materials and Methods
The Comprehensive Hospital Abstract Reporting 
System (CHARS), a Washington State administrative 
inpatient claims database that captures all inpatient 
hospitalizations from all hospitals in the state, and 
includes data such as age, sex, zip code, diagnosis and 
procedure codes, billing codes, and procedure dates, 
regardless of insurance type, was queried for female 
patients 20 years of age or older with both a diagnosis 
of VP and/or R P and associated VP and/or R P 
surgical procedures from 2008 to 2019. The CHARS 
data dictionary is publicly available at https://www.
doh.wa.gov/ and includes diagnosis and procedural 
codes based on the Ninth revision of the International 
Classification of Diseases (ICD-9) and ICD-10 for 
admissions. The CHARS database does not utilize 
Current Procedural Terminology (CPT®) codes. Using 
the International Classification of Diseases Ninth and 
Tenth edition (ICD-9 and ICD-10) codes, women ≥ 20 
years of age with VP and/or RP diagnosis codes were 
identified (Appendix 1). ICD procedural codes for VP 
and RP operations were used to identify patients who 
had undergone treatment for prolapse (Appendix 1). 
Surgical procedures that were performed on the same 
date were considered concurrent, while those with 
different dates were considered staged. Demographic 
characteristics and rates of concurrent surgica l 

repair were analyzed. Rates were adjusted by age, and 
population of women, based on Washington State 
Census results for 2008 to 2019 using the direct method. 
The study was submitted for Institutional Review Board 
(IRB) review and was found to not constitute human 
subjects research and did not require IRB approval.

Results
Query of the CHARS database identified 17 840 female 
inpatient admissions with a diagnosis of VP and/or RP 
who had also undergone a VP and/or RP procedure. 
Of those, 15 279 (85.6%) underwent VP-only and 918 
(5.1%) underwent combined VP/RP repair. The majority 
of women identified in our query were < 80 years old, 
52.03% were identified as white, and 4.83% of the 
population were identified as minority groups (Table 1). 
Notably, there was no information provided on ethnicity 
in the database for 43.14% of the population.

Seventy-five percent of all VP-only, RP-only, or 
concurrent VP/RP inpatient surgeries were performed 
in the 7 most populated Washington State counties. 
The majority of all combined VP/RP procedures were 
performed in 10 facilities in a single county (King 
County, which includes the Seattle metropolitan area). 
The majority of patients identified in the query were 
residents of 5 counties (Table 2), and 75% of patients 
lived within 20 miles of their treating facilities. Among 
the top 15 centers performing VP and/or RP prolapse 
surgery, 2 centers were noted to have patient populations 
composed of nearly 95% of patients who resided less 
than 20 miles away (Figure 1).

Between 2008 and 2019, inpatient admissions for 
concurrent VP/RP surgery remained stable, with 
adjusted rates ranging from 1.42 to 3.38 per 100 000 
women (Figure 2), and 95% of combined procedures 
were performed in patients < 80 years old. The adjusted 
rate of inpatient RP-only repairs also remained stable, 
3.12 to 5.14 per 100 000 women, with 82% being 
performed in women < 80 years old. The adjusted rate 
of inpatient VP-only repairs decreased markedly, 
from 81.79 per 100 000 women in 2008 to 6.96 per 100 
000 women in 2019, with 94% of these surgeries being 
performed in women < 80 years old.

Discussion
Prior work has demonstrated that there has been 
a nationw ide trend of increasing utilization of 
multidisciplinary approaches toward treating VP/
RP concurrently, increasing from 0.7% of all surgeries 
performed for rectal prolapse or pelvic organ prolapse 
in 2003 to 1.9% in 2017[5]. However, the same trend 
for concurrent VP/RP surgery has not been clearly 
identified in Washington State. These data suggest that 
despite a nationwide trend toward multidisciplinary 

Abbreviations 
CHARS Comprehensive Hospital Abstract Reporting System
ICD International Classification of Diseases 
IRB Institutional Review Board
RP rectal prolapse 
VP vaginal prolapse

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approaches, this trend may not be occurring at similar 
rates in each state. Additionally, the previously reported 
rates[5] were not adjusted for population, age, or gender, 
which may affect the ability to compare the results. 
Although there was a significant nationwide increase in 
the number of concurrent VP/RP procedures, whether 
this increase is due to a growing and aging population 
with a higher incidence for pelvic organ prolapse has not 
been well studied.

The procedure rates described herein were obtained 
using the CHARS database, which collects record-
level information on inpatient and observation-patient 
community hospital stays. While limited to adminis-
trative data, this database has the advantage of captur-
ing all procedures performed provided that the patient 
was hospitalized, regardless of insurance status. We 
acknowledge the limitations of using this inpatient state-
wide database. However, the information captured adds 
to our knowledge of trends in the utilization of concur-
rent RP/VP surgery overall. Although some studies 
with small patient cohorts have suggested that rectal 
prolapse procedures such as laparoscopic rectopexy may 

be feasibly performed as outpatient procedures[10–13], 
the majority of RP surgeries are performed as inpatient 
procedures and concurrent VP/RP surgeries are there-
fore captured in this dataset, allowing for analysis of 
trends in this procedure. However, VP surgery can be 
performed either in an inpatient or outpatient setting, 
depending on many factors. The reporting of only 
inpatient VP surgeries is a limitation that prevents an 
accurate analysis of broader trends in VP and its proce-
dures. We acknowledge this limitation as it relates to 
the capture of all vaginal prolapse surgeries. The focus 
of this study is concurrent VP/RP surgery, which is 
captured in this dataset.

Between 2008 and 2019, the rate of inpatient VP 
surgery decreased substantially in Washington State 
from 81.79 per 100 000 women in 2008 to 6.96 per 
100 000 women in 2019. Previously published literature 
has demonstrated an increasing utilization of outpa-
tient urologic procedures[14], suggesting that this trend 
could represent an increase in utilization of outpatient 
VP surgeries or a true decrease in VP surgery over time. 
The shift of surgery from inpatient to outpatient possi-

TABLE 1. 

Demographics by prolapse type for female inpatient admissions 2008–2019 in Washington State 

 Prolapse type

 
Total prolapse

n = 17 840

Vaginal and rectal 
combination

n = 918

Vaginal only
n = 15 279

Rectal only
n = 1643

n % n % n % n %

Age group

< 50 years 4078 22.86 266 28.98 3485 22.81 327 19.90

50–64 years 6421 35.99 355 38.67 5557 36.37 509 30.98

65–79 years 6025 33.77 250 27.23 5270 34.49 505 30.74

80+ years 1316 7.38 47 5.12 967 6.33 302 18.38

Ethnicity*

American Indian/Alaskan Native 78 0.44 2 0.22 62 0.41 14 0.85

Asian 209 1.17 15 1.63 167 1.09 27 1.64

Black/African American 98 0.55 7 0.76 78 0.51 13 0.79

Hispanic origin 435 2.44 13 1.42 395 2.59 27 1.64

Native Hawaiian/Pacific Islander 40 0.22 0 0.00 36 0.24 4 0.24

White 9283 52.03 582 63.40 7561 49.49 1140 69.39

Excluded/Not provided 7697 43.14 299 32.57 6980 45.68 418 25.44

*All ethnicity categories/labels taken directly from the Comprehensive Hospital Abstract Reporting System database.

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TABLE 2. 

Female inpatient admissions for top 15 facility counties and residential counties by prolapse type

Facility county of care

Total prolapse 
(n = 17 840)

Combination vaginal and 
rectal prolapse

 (n = 918)

Vaginal only 
(n = 15 278)

Rectal only 
(n = 1643)

County (n*) Ads. % County (n*) Ads. % County (n*) Ads. % County (n*) Ads. %

King (17) 6136 34.39 King (10) 808 88.02 King (17) 4487 29.37 King (12) 841 51.19

Spokane (4) 1965 11.01 Spokane (4) 53 5.77 Spokane (4) 1656 10.84 Spokane (4) 256 15.58

Pierce (5) 1590 8.91 Pierce (4) 35 3.81 Pierce (5) 1381 9.04 Pierce (5) 174 10.59

Snohomish (4) 1290 7.23 Snohomish (2) 9 0.98 Snohomish (4) 1211 7.93 Snohomish (3) 70 4.26

Benton (3) 887 4.97 Benton (1) 6 0.65 Benton (3) 815 5.33 Benton (3) 66 4.02

Yakima (4) 761 4.27 Kitsap (1) 4 0.44 Yakima (4) 755 4.94 Thurston (2) 54 3.29

Clark (2) 759 4.25 Chelan (1) 1 0.11 Clark (2) 747 4.89 Kitsap (1) 41 2.50

Whatcom (1) 538 3.02 Clark (1) 1 0.11 Whatcom (1) 516 3.38 Chelan (1) 29 1.77

Kitsap (1) 482 2.70 Thurston (1) 1 0.11 Kitsap (1) 437 2.86 Skagit (2) 28 1.70

Cowlitz (1) 414 2.32   Cowlitz (1) 402 2.63 Whatcom (1) 22 1.34

Thurston (2) 399 2.24   Clallam (1) 370 2.42 Cowlitz (1) 12 0.73

Clallam (1) 380 2.13   Thurston (2) 344 2.25 Clark (2) 11 0.67

Skagit (3) 361 2.02   Walla Walla (2) 339 2.22 Clallam (1) 10 0.61

Walla Walla (2) 342 1.92   Skagit (3) 333 2.18 Whitman (2) 8 0.49

Grays Harbor (1) 302 1.69    Greys Harbor (1) 301 1.97 Jefferson (1) 7 0.43

Patient residential county

Total prolapse 
(n = 17 840)

Combination vaginal and 
rectal prolapse 

(n = 918)

Vaginal only 
(n = 15 278)

Rectal only 
(n = 1643)

County Ads. % County Ads. % County Ads. % County Ads. %

King 6136 34.39 King 356 38.78 King 2919 19.10 King 841 51.19

Spokane 1965 11.01 Snohomish 311 33.88 Snohomish 1762 11.53 Spokane 256 15.58

Pierce 1590 8.91 Spokane 30 3.27 Pierce 1322 8.65 Pierce 174 10.59

Snohomish 1290 7.23 Pierce 28 3.05 Spokane 1265 8.28 Snohomish 70 4.26

Benton 887 4.97 Kitsap 23 2.51 Yakima 794 5.20 Benton 66 4.02

Yakima 761 4.27 Thurston 19 2.07 Clark 656 4.29 Thurston 54 3.29

Clark 759 4.25 Island 15 1.63 Benton 653 4.27 Kitsap 41 2.50

Whatcom 538 3.02 Skagit 14 1.53 Whatcom 603 3.95 Chelan 29 1.77

Kitsap 482 2.70 Whatcom 13 1.42 Kitsap 589 3.85 Skagit 28 1.70

Cowlitz 414 2.32 Clallam 11 1.20 Clallam 432 2.83 Whatcom 22 1.34

Thurston 399 2.24 Yakima 11 1.20 Thurston 397 2.60 Cowlitz 12 0.73

Clallam 380 2.13 Benton 9 0.98 Cowlitz 363 2.38 Clark 11 0.67

Skagit 361 2.02 Mason 6 0.65 Grays Harbor 330 2.16 Clallam 10 0.61

Walla Walla 342 1.92 Kittitas 5 0.54 Skagit 279 1.83 Whitman 8 0.49

Grays Harbor 302 1.69
Kootenai 
(Idaho)

5 0.54 Franklin 228 1.49 Jefferson 7 0.43

Note: Percentages calculated out of total prolapse type sample. *Denotes number of facilities within that county. Ads.: Admissions.

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bly reflects the US health care system’s shift toward more 
cost-effective outpatient settings and insurance reim-
bursement patterns[15].

The prevalence of VP has been found to vary across 
racial groups[16,17], and racial disparities have been 
identified in women undergoing pelvic organ prolapse 
surgery[18]. For this reason, we were interested in evalu-
ating the trends in multidisciplinary approaches in treat-
ing prolapse across racial groups. Low rates of VP and/or 
RP surgery have been noted in minority groups[16,17]. 
However, this observation could not be clearly assessed 
using the CHARS database, as racial information was 
not provided for 43.14% of the patient population.

The majority of all inpatient VP-only, RP-only, and 
concurrent VP/RP surgeries were performed in the 
most populated counties in Washington State, and the 
majority of patients lived within a 20-mile radius of 
their treating facilities. Indeed, in 2 facilities, the patient 
population was nearly entirely composed of patients who 
resided less than 20 miles away (Figure 1). It should also 
be noted that the distances described here are straight-
line distances and may not be an accurate reflection of 
the time or actual distance required to travel to treat-
ment centers, particularly in Washington State, where 
patients may need to utilize ferry services in order to 
reach the more densely populated regions where high-

FIGURE 1. 

Proportion of patients receiving care locally (within 20 miles) at top 15 Washington State facilities from 2008 to 2019 
by average annual volume of vaginal prolapse, rectal prolapse, or concurrent vaginal and rectal prolapse surgeries. 
Centers sorted in descending order of average number of prolapse procedures per year for each center.

FIGURE 2. 

Female inpatient prolapse procedures by prolapse type for Washington State from 2008 to 2019. Total prolapse is 
combined total of vaginal, rectal, and concurrent vaginal and rectal prolapse surgeries.

De-identi�ed treatment centers, by number of prolapses per year

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

A
110

B
100

C
93

D
81

E
74

F
58

G
57

H
50

I
48

J
48

K
45

L
42

M
41

N
40

O
39

Local Non-Local

N
um

be
r o

f P
ro

la
ps

e 
Pr

oc
ed

ur
es

 P
er

fo
rm

ed

Year of inpatient admission

Total* Prolapse

Vaginal Prolapse Only

Rectal Prolapse Only

Rectal and Vaginal Prolapse

3500

3000

2500

2000

1500

1000

500

0

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

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SIUJ.ORG SIUJ  •  Volume 4, Number 3  •  May 2023

er-volume facilities are located. Patients electing surgi-
cal management are more likely to travel farther, as do 
patients travelling from areas with fewer women and 
older people[19,20]. Distance travelled to reach care 
may be a barrier to patient care, and longer distances 
travelled have been associated with later presentation 
to care, and greater likelihood of planning surgery at 
presentation[19]. There may be a multitude of reasons for 
this, including patients electing treatments that require 
fewer follow-ups due to the long distances required for 
follow-up, lack of available services in less-populated 
counties, or patients who have failed conservative thera-
pies at facilities closer to their homes. Overall, our study 
showed that VP and/or RP surgical care was concen-
trated in the most populated areas of Washington State.

Additional limitations of this database include the 
lack of recorded clinical variables, including outcomes, 
complications, recurrence, and patient-specific vari-
ables such as degree of prolapse or comorbid diseases. 
These results may not be generalizable, as the data are 
specific to Washington State. Strengths of the analysis 
include the ability to adjust surgery rates by gender, state 
population, and age. In addition, all patients undergo-
ing inpatient VP-only, RP-only, and concurrent VP/RP 
procedures in Washington State are included, and not 
limited by insurance status.

National trends have shown an increase in utiliza-
tion of concurrent VP/RP surgery. To assess this trend 
on a more local level, these procedures were examined 
in Washington State over a 12-year time period and 
were found to have remained stable. The reasons for 
this cannot be clearly identified using the CHARS data-
base. Future directions may include investigations into 
contributing factors that may play a role in increasing 

awareness of the prevalence of concurrent VP and RP 
as well as supporting integrated and collaborative treat-
ment for women with concurrent VP and RP.

Conclusion
The rates of inpatient RP and combined VP/RP 
surgical procedures between 2008 and 2019 were low 
and remained stable in Washington State. Inpatient 
VP surgical repairs decreased from 81 to 6 per 100 
000 women over the same time period, which may 
represent an increase in outpatient VP procedures. 
Although previously published data suggest that a 
multidisciplinary approach to VP and RP is increasing 
nationwide, the trend seen here does not seem to reflect 
the same increase, suggesting that nationwide trends 
may not be reflective of local trends within each state. 
Further study is needed to understand how and why 
local trends in the management concurrent VP/RP may 
differ from national trends, and potentially improve 
concurrent VP/RP management using multidisciplinary 
approaches.

Acknowledgements
We thank Virginia M. Green, PhD, for editorial 
assistance.

Financial Disclosure
No funding or other financial support was received.

Ethics Statement
The Institutional Review Board of Benaroya Research 
Institute at Virginia Mason determined that this study 
did not constitute human subjects research and thus this 
study did not require IRB approval.

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