Symptoms and preoperative goals in patients with pelvic organ prolapse

INTRODUCTION

Pelvic organ prolapse (POP) is a common morbidity. Its frequency is estimated differently [1-3] but may reach half of the female population [4]. Generally, conservative and surgical methods both are used to treat this condition. The first type of treatment involves the use of pessaries and training of the pelvic floor muscles. The frequency of the latter is estimated at 12% of the entire female population, covering a wide range of surgical corrections via the transvaginal or transabdominal route using traditional laparotomy, laparoscopy, or robot [2, 4]. The aim of the surgery is to correct existing defects. At the same time, the aim of correction is to eliminate the symptoms associated with a given defect.
In 1996, the International Continence Society (ICS) and the American Urogynaecological Society (AUGS) introduced the Pelvic Organ Prolapse-Qualification (POP-Q) system for diagnostics and treatment evaluation, based on the geometric assessment of the disturbed anatomy of the pelvic organs. This system is based on measurements at 6 points related to the hymen plane. Measurements at 6 points determine the advancement of prolapse. Grade 0 defines the perfect condition, while grades 1-5 indicate increasing advancement.
The creators of the POP-Q system based on geometric assessment recommended drawing attention to the need for the simultaneous use of nomothetic questionnaires, based on those developed by research groups and arbitrarily assuming what symptoms should occur in patients with POP-Q. Meanwhile, these questionnaires do not fully take into account the subjective symptoms occurring in given patients [5]. Therefore, few idiographic studies assess preoperative goals provided by the patients themselves [1, 2, 6, 7].
According to Rutkowska et al., the symptoms of static disorders can be divided into 2 groups. The first includes “something falling out”, a feeling of heaviness, pressure, and irritation in the vagina. The second, more advanced group includes the need for prolapsed vagina repositioning before micturition and the need to extract faeces with a finger. Patients’ goals are, to some extent, a function of their ailments. Therefore, it is important to know these ailments. In POP we rarely deal with cases without symptoms. These are the so-called asymptomatic cases of vaginal lowering. Typically, such cases involve reduction in the first and second degrees [8]. The preoperative goals defined by the patients did not fully correspond to the symptoms reported by them at admission [7].
The aim of the study was to assess the symptoms reported by women when admitted to surgical treatment due to POP and their preoperative goals.

MATERIAL AND METHODS

The study included 62 patients qualified for surgery who were hospitalised between 2013 and 2014 in the Department of Gynaecology, Oncological Gynaecology, and Obstetrics of the University Clinical Hospital F. Chopin in Rzeszow, due to pelvic organ prolapse. At admission patients declared symptoms chosen from a list prepared by the authors based on the report by Digesu et al. [9] and with Polish validation by Rzepka et al. [10]. Additionally, they assessed the intensification of each of them in a 5-degree Likert scale from not at all to extremely. Then the patients were examined and qualified to surgery. Every patient signed an informed consent form. Preoperatively they described their 5 most important individual goals.
The statistical analysis carried out included the characteristics of the collected material and the study results using the descriptive statistics method in the form of an average and standard deviation.

RESULTS

The demographic and social characteristics are presented in Table 1. The average age was 58 years. The largest percentage were women who gave birth 2 (39%) or 3 times (29%). Six per cent of the surveyed group completed only primary school, 74% completed high school, and 20% university. Married women prevailed in the study group; they constituted 71%. The rural residents comprised 52% of the respondents. Most of the surveyed women (77%) reported an average financial situation (Table 1). The preoperative diagnoses and type of surgery performed are listed in Table 2. In the analysed material, the largest number were patients with POP (42%), fewer were with stress urinary incontinence (39%), and the least with parallel POP and stress urinary incontinence (19%). Vaginoplasty and tapes correcting stress urinary incontinence dominated in the analysed material. Retroperitoneal urethral suspension operations of the Burch type were less common (5%). Symptoms reported upon admission by patients in the study group were classified into 4 categories. The first of them concerned limitations resulting from POP. The others concerned the function of urination, emotions, and the sexual sphere (Table 3).
Table 3 additionally presents the patients’ self-assessment of the importance of individual preoperative symptoms on a Likert scale. The most bothersome symptom limiting the patient with static disorders was limitation in lifting (3.45 ±1.28). The least burdensome restriction was the choice of clothing (2.71 ±1.26). The most bothersome symptom related to urination was anxiety when coughing and sneezing (3.52 ±1.20), and the least bothersome symptom was unpleasant odour (2.85 ±1.48). The most bothersome emotional symptom was the lack of joy in life (3.15 ±1.20), and the least bothersome symptom was the feeling of being sick (2.77 ±1.26). The only sexual symptom was sexual worry (2.63 ±1.37).
Patients reported more preoperative goals than symptoms upon admission. They were classified, like symptoms, into 4 analogous groups (Table 4). Among the treated women, most of them mentioned normal functioning in the category of preoperative goals (25.8%), and the least of them reported not wearing additional replacement pads (4.8%). The most common goal regarding urination was not to wear pads (35.5%). Occasionally 3.2% of women expected not to wear additional underwear. Comfort in life, mental and physical, were the common goals of women (54.8%). A small group of patients, 1.6% in the emotional category, expected a short hospital stay. Sexual goals in the form of a good relationship with a partner were reported by 8.1% of women.

DISCUSSION

Identification of symptoms reported by patients with POP and their preoperative goals allows for individualisation of surgical treatment methods. Additionally, it is assumed that in most cases a given defect causes specific symptoms, these are the so-called site-specific symptoms [11]. It is assumed that correction of such defects will free the patient from the associated symptoms. Widely used nomothetic questionnaires asking about preoperative symptoms and goals do not allow for individualisation but enable comparison of studies from different centres. They are therefore a good, unified tool for comparing such studies. On the other hand, nomothetic surveys created by researchers assume that patients have goals consistent with the list they created [1]. The literature is dominated by studies assessing preoperative goals in patients with pelvic organ prolapse [1, 2, 6, 7, 12]. Our assessment of symptoms reported at admission and their comparison with preoperative goals, which is the subject of this work, is unique. The registration of preoperative goals given by patients can be found in research by Sung et al. These authors used the idiographic method to compare the effects of surgical treatment and the use of pessaries using goal attainment scaling. They found that the goals given by the patients were highly individual and variable. The most common goal was the resolution of voiding disorders [2]. In our study, the preoperative goals were also numerous and highly individualised. In our report, the most common goal in the restriction group was broadly assessed normal functioning, and in the urination group, generally assessed normal urination. Also, in the group of other goals, the broadly understood expectation of good physical and mental life comfort dominated. This group also had goals of a successful surgical procedure. An interesting study was conducted by de Boer et al. They compared the results of an interview conducted by doctors and self-assessment questionnaires of patients’ preoperative goals. These authors found discrepancies in goal assessments by doctors and patients. They recommend the use of validated questionnaires, i.e. the use of the nomothetic method, because according to them it gives a more objective look at functional results [6]. Aponte et al. stated that symptoms of pelvic organ prolapse are variable and the severity of prolapse does not necessarily correlate with perceived symptoms or other associated conditions, including urinary and defecation dysfunction and sexual dysfunction. According to these authors, the doctors’ approach to the treatment of pelvic organ prolapse is different. The doctors’ goals are to restore anatomy and avoid complications. Patients’ goals differ from these goals; hence, discussing preoperative goals and establishing realistic goals before treatment may allow for individualised surgical therapy and improved patient satisfaction [1].
It is important to emphasise the role of nurses and midwives in patients education in the aspect of prevention of POP. This role is different in special circumstances like perioperative period, puerperium, and advanced age. In all these conditions, the nurse and midwife’s recommendations should include education in toileting behaviour and avoiding lifting. However, during the postpartum period and in advanced age, patients should be encouraged to exercise the pelvic floor muscles [13].
Our study comparing patients’ symptoms and their preoperative goals may be useful for nurses who are members of the diagnostic and therapeutic team, as well as for the basis of subsequent work on goal attainment scaling. We found differences between the symptoms reported by patients and the preoperative goals, both qualitative and quantitative. The number of symptoms reported at admission is lower than the preoperative goals. In our opinion, this results from the process of dealing with patients, including the information provided with the informed patient’s consent. During their stay, patients become aware of their new and broader preoperative expectations.

CONCLUSIONS

In cases of the pelvic organ prolapse, it is important not only to identify their geometric position, usually carried out by doctors, but also the symptoms reported by patients and recorded by nurses at admission to hospital, and preoperative goals identifying their expectations. The pioneering work juxtaposes these 2 groups.
The most bothersome symptoms in a patient with POP were limitation in lifting, anxiety when coughing and sneezing, lack of joy in life, and sexual worry. The least bothersome symptom was limitation in planning activities and the need to stay near the toilet and feeling sick.
Preoperative goals regarding the removal of restrictions, including urination, included broadly understood expectations of normal functioning and urination. Other goals included mental and physical comfort. Specific goals included the ability to exercise, not wearing pads, and successful surgery.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References