Reviewer ’s report  
 
Title:  Validation of the Pelvic Organ Prolapse Simple Screening Inventory (POPSSI) in a 
populatio n of Ethiopian women.  
 
Version: 0 Date: 20 Apr 2018 
 
Reviewer:  Laura Elizabeth  Dodge  
 
Reviewer’s report:  
 
Validati on of the Pelvic Organ Prolapse Simple Screening Inventory (POPSSI) in a population of 
Ethiopian women  
 
BMC Women's Health  
 
General comments  
 
This work describes the validation of the POPSSI for identifying pelvic organ prolapse among 
women in Addis Ababa, Ethiopia. This is an important goal, because if the validity of the 
POPSSI in this population can be confirmed, it will provide an easy tool for identification of 
prolapse in resource -poor settings where skilled exams are not possible. However, the 
manuscr ipt requires additional explanation in order to judge the usefulness of the findings and 
should also discuss the implications of identifying a medical issue in settings without access to 
medical care. The manuscript requires copy editing for typos. Detaile d comments and questions 
are provided below.  
 
 
Background  
 
Line 7: What is the incidence of POP among nulliparous women?  
 
Lines 45 -47: This sentence requires clarification, because as written it makes it sound as if the 
age at marriage may be steadily rising, which does not support the point that Ethiopian women 
may be uniquely predisposed to POP. Is it actually the proportio n of women married prior to age 
15 that is rising? It would be helpful to keep the statistic presented consistent as opposed to 
presenting age at marriage and making a comparison with the proportion married before age 15.  
 
Lines 54 -56: While Ethiopian women  may be uniquely predisposed to pelvic floor dysfunction, 
studying these factors is not the aim of the present study, and thus this sentence should be 
reworded to make it clear that the goal is to validate the POPSSI in this population.  
 
 
Methods  
 
Lines 15 -19: Were all eligible women approached to participate?  
Lines 21 -24: These sentences belong in the Results as opposed to the Methods.  
 
Line 28: It would be helpful to provide some additional information about the POPSSI either in 
the text or as an appendix.  It is mentioned in the Background that it was developed from the 
PFDI, but how does it compare in terms of length, questions, etc.? The questions are provided in 
the Results, but it not clear to the reader whether all of these questions are part of the PO PSSI or 
whether all of the POPSSI questions are represented.  
 
 
Results  
 
Line 8: This section should start with the total number of patients and the breakdown among 
those with and without prolapse. Was it possible to calculate a participation rate among thos e 
who were approached?  
 
Lines 12 -14: What was the distribution of POP -Q scores?  
 
Line 17: What is meant by "detective POP"? Is this referring to POP identified by the POP -Q? 
 
Lines 20 -22: Do the sensitivity and specificity vary based on the degree of prolaps e as identified 
by the POP -Q? It would seem reasonable that these test characteristics would improve with more 
severe degrees of prolapse. Indeed, this is mentioned in the following paragraph. It would be 
useful to see these results for each stage of prola pse. However, it is also important to present the 
number of patients in each group, as with only 109 prolapse patients in total, the number with 
stage IV cystocele, for instance, is likely very small. Perhaps the types should be combined for 
each grade of prolapse.   
 
Lines 20 -22: Here, is urinary incontinence indicating urinary urgency as used in the Iranian 
study?  
 
 
Discussion  
 
Lines 16 -18: What are the possible reasons for the large discrepancy in the sensitivity of SUI 
between the present study and the Ir anian study? The potential differences in the study 
population should be discussed here as opposed to in the Conclusion.  
 
Lines 18 -20: While these sensitivities are higher, they are still quite low.  
 
Lines 28 -34: Sensitivity is a characteristic of the test a nd is not affected by the study population 
per se. A higher overall incidence of POP in the study population would affect the predictive 
values but not the sensitivity or specificity. Therefore, while Ethiopian women may be 
predisposed to POP, this alone d oes not explain why the findings of the present study differ from 
those of the Iranian study. However, the severity of POP could explain these differences, as it is 
likely that the sensitivity and specificity are higher among those with more severe disease . This 
is why it is extremely important to know the distribution of POP severity among this population 
and the sensitivity and specificity for various degrees of POP. There were very few women in the 
Iranian study with grade III or IV POP, and I suspect th at this is not the case among women 
presenting to tertiary care in the present study.   
 
General: What are the implications of your findings? Given that only one question had high 
sensitivity, do you recommend shortening the tool to a single question, or ar e there other benefits 
of asking women the additional three questions?  
 
General: What are the implications of using this tool in resource -poor settings? Given that this 
will be used in areas without access to skilled medical care, what are the treatment opt ions 
available for women who are identified as having POP and who will provide those treatment 
options? Will those women be able to access adequate care for their prolapse?  
 
 
Conclusion  
 
The conclusion introduces several new concepts, including a discussion of the advantages and 
limitations of the present study. These would be better included in the Discussion and revised 
according to the comments above.  
 
Are the methods appropriate and we ll described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is re commended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
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financially from the publication of this manuscript, either now or in the future?  
 
3. Do yo u hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript ? 
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
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