Prolapse severity, symptoms and impact on quality of life among women planning sacrocolpopexy

Medium-term outcomes 2 years after laparoscopic sacrocolpopexy: a retrospective cohort study in Japan

This study was performed to investigate medium-term outcomes and reoperation rates after laparoscopic sacrocolpopexy (LSC). We examined 119 patients undergoing LSC for symptomatic pelvic organ prolapse (POP). The primary outcomes were subjective failure and anatomical failure at 2 years; a score ≥ 2 on question 3 of the PFDI-20 was considered to indicate subjective failure. POP-Q stage 2 or higher in any compartment was considered to indicate anatomical failure. Secondary outcomes were reoperations for POP recurrence, mesh-related complications, and stress urinary incontinence (SUI). The rates of subjective failure and anatomical failure were 4.2% (n = 5) and 9.2% (n = 11), respectively. Reoperations were needed in 13.4% (n = 16) of patients, including SUI with tape procedure in 7.5% (n = 9), POP recurrence in 4.2% (n = 5), and mesh-related complications in 1.6% (n = 2). The subjective failure rate at 2 years after LSC was acceptably low.Impact StatementWhat is already known on this subject? Laparoscopic sacrocolpopexy (LSC) has clinical efficacy equivalent to open sacrocolpopexy, and there is evidence that LSC involves less blood loss and shorter length of hospital stay. However, there is still insufficient evidence to assess medium-term outcomes after LSC in Japan.What the results of this study revealed? The findings of this study showed excellent medium-term rates of subjective failure (4.2%) and anatomical failure (8.4%) after LSC. We demonstrated that patients with persistent postoperative vaginal bulge (subjective failure) also had no improvement in postoperative urinary and colorectal symptoms. Our cohort had low rates of reoperation (13.4%) after LSC. The most common reoperations were for stress urinary incontinence (SUI) (7.5%), followed by pelvic organ prolapse (POP) recurrence (4.2%) and mesh-related complications (1.6%).What are the implications of these findings in clinical practice and/or further research? This study showed that LSC is a safe and effective treatment for POP. Comparative evaluation of anatomical outcomes and the patient's condition is required to understand the extent to which LSC positively impacts a woman's pelvic floor-related quality of life.

International Urogynecological Consultation: clinical definition of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This segment of Chapter 1 of the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) reviews the literature on the clinical definition of POP with the intent of creating standard terminology.

METHODS

An international group containing nine urogynecologists and one university-based medical librarian performed a search of the literature using pre-specified search terms in PubMed, Embase, and Scopus. Publications were eliminated if not relevant to the clinical definition of POP, and those articles remaining were evaluated for quality using the Specialist Unit for Review Evidence (SURE). The resulting list of articles was used to inform a comprehensive review and creation of the clinical definition of POP.

RESULTS

The original search yielded 31,931 references, of which 167 were used by the writing group. Ultimately, 78 are referenced in the manuscript.

CONCLUSIONS

The clinical definition of POP for this review of the literature is: "anatomical prolapse with descent of at least one of the vaginal walls to or beyond the vaginal hymen with maximal Valsalva effort WITH the presence either of bothersome characteristic symptoms, most commonly the sensation of vaginal bulge, or of functional or medical compromise due to prolapse without symptom bother."

Long-Term Assessment of a Prospective Cohort of Patients Undergoing Laparoscopic Sacrocolpopexy

OBJECTIVE

To report long-term outcomes after laparoscopic sacrocolpopexy.

METHODS

We conducted a prospective descriptive cohort study on 331 consecutive patients who underwent laparoscopic sacrocolpopexy for symptomatic prolapse (Pelvic Organ Prolapse Quantification [POP-Q] system stage 2 or greater) at one center, with minimum 1.5 years of follow-up by April 30, 2014. Primary outcome measures were Patient Global Impression of Change score and failure at the apex (C≥-1 cm; POP-Q stage 2 or greater). Secondary outcomes were anatomical failure in other compartments, duration of follow-up, occurrence and time point of complications, reinterventions, and functional outcomes by response to a standardized 24-question interview on prolapse and bladder, bowel, and sexual function. Assessment was by an experienced clinician not involved in patient management.

RESULTS

The follow-up rate was 84.6% (280/331); 185 of 331 (55.9%) patients were both physically examined and interviewed, and 95 of 331 (25.7%) were interviewed only. The median age at interview was 72 years (interquartile range 13 years), with a follow-up period of 85.5 months (interquartile range 46 months). Approximately 83% (231/280) reported improvement; 5.7% (16/280) were unchanged, 5.7% (16/280) felt slightly worse, and 6.8% (17/280) reported clear deterioration. Anatomical failure at point-C was 8.6% (16/185); anterior (22.2%, 41/185) and posterior (28.6%, 53/185) prolapse were more common than apical prolapse. Of those with level-I anatomical cure, 10.1% (17/185) felt worse; half of them (9/17) because of prolapse in another compartment. The others had urinary problems (41.2%, 7/17), obstructive defecation (11.8%, 2/17), or dyspareunia (11.8%, 2/17). Conversely, the majority of patients with recurrence at the vault (62.5%, 10/16) self-reported to be improved. The reoperation rate was 17.8% (48/270), including 19 (7.0%) for graft-related complications and nine (3.3%) for prolapse.

CONCLUSION

More than four out of five patients (82.5%) felt improved 86 months after laparoscopic sacrocolpopexy. Of those not improved, two thirds had recurrent prolapse; however, typically mid-vaginal. The other third reported urinary or bowel problems or dyspareunia. Reintervention for prolapse was 3.3%. The most common reasons for reoperation were graft-related complications (7.0%) and urinary incontinence (6.7%).

Validation of the Polish version of the Pelvic Floor Distress Inventory

INTRODUCTION AND HYPOTHESIS

The aim of this study was to develop a Polish language version of the short form of the Pelvic Floor Distress Inventory (PFDI-20) and to validate it in a sample of Polish-speaking women with pelvic floor disorders (PFDs).

METHODS

The PFDI-20 was initially translated in a stepwise fashion as guided by the International Urogynecological Association (IUGA) Translation Protocol. After initial forward translation from English to Polish, a community review process consisting of cognitive interviews and confirmation via back translation was performed. The final Polish version of the PFDI-20 was administered to Polish-speaking patients presenting with PFDs at university-based urogynecology clinics in Poland and the United States, along with a Polish version of the King's Health Questionnaire (KHQ). Internal consistency and criterion validity were assessed. Test-retest reliability was assessed in 100 patients after 2 weeks.

RESULTS

A total of 254 women with PFDs enrolled in this multicenter study. Complete data from 44 Polish-speaking women in the United States and 200 women in Poland were analyzed. Participants had a mean age of 60.3 ± 11.2 years and mean body mass index (BMI) 27.6 ± 4.7. Internal consistency as measured by Cronbach's alpha was good (0.89). Criterion validity was adequate between responses on the KHQ and PFDI-20 with Pearson correlations in particular domains (0.27-0.50, P < 0.05). Excellent test-retest reliability was demonstrated by intraclass correlation using a two-way mixed-effects model with absolute agreement (0.87).

CONCLUSIONS

The Polish version of the PFDI is a reliable tool for evaluating pelvic floor symptoms in Polish-speaking women with PFDs.

Development and Validation of a Quantitative Measure of Adaptive Behaviors in Women With Pelvic Floor Disorders

PURPOSE

To establish validity for the Pelvic Floor Disorders Network (PFDN) self-administered Adaptive Behavior Index (ABI) and to assess whether ABI assesses known discordance between severity of pelvic floor symptoms and self-reported bother.

METHODS

In addition to the ABI questionnaire, participants in 1 of 6 Pelvic Floor Disorders Network trials completed condition-specific measures of pretreatment symptom severity (including Pelvic Floor Distress Inventory; PFDI) and health-related quality of life (Pelvic Floor Impact Questionnaire; PFIQ). The final survey was developed from an iterative process using subject and expert endorsement, factor analyses, and response distributions. Domains were created using a development cohort (n = 304 women), reliability and validity were established using a validation cohort (n = 596 women), and test-retest reliability was assessed (n = 111 women).

RESULTS

Factor analyses supported an 11-item avoidance domain and a 6-item hygiene domain. Cronbach' alphas were 0.88 and 0.68, respectively. Test-retest reliability was 0.84 for both domains. Construct validity was demonstrated in correlations between the ABI domains and baseline PFDI and PFIQ (r values, 0.43-0.79 with all P values <0.0001). Moreover, the ABI accounted for 8% to 26% of unexplained variance between the symptoms severity measure and the impact on health related quality of life. After treatment, avoidance domain scores improved for urinary and fecal incontinence groups and hygiene scores improved for the fecal incontinence group.

CONCLUSIONS

The ABI is a reliable and valid measure in women with pelvic floor disorders. Adaptive behaviors account in part for discordance between pelvic floor symptom severity and bother.

Management of pelvic organ prolapse in the elderly - is there a role for robotic-assisted sacrocolpopexy?

Abdominal sacrocolpopexy is considered the gold standard treatment for symptomatic pelvic organ prolapse (POP). Since its introduction, robotic-assisted sacrocolpopexy has emerged as a popular minimally invasive alternative to open repair. Epidemiologic data suggest that the number of women seeking surgical treatment for POP will increase to ~50% by 2050, and many of these women will be elderly. Advanced age should not preclude elective POP surgery. Substantial data suggest that medical comorbidities and other preoperative markers may be more important than age in predicting adverse surgical outcomes. POP surgery in the elderly has been extensively studied and found to be safe, but there is a paucity of information regarding robotic-assisted sacrocolpopexy in this population. Data are only beginning to emerge regarding the safety and efficacy of robotic surgery in the elderly, with most studies focusing on oncologic procedures. Preliminary studies in this setting suggest that elderly patients may benefit from a minimally invasive approach, although given their limited physiologic reserves, appropriate patient selection is essential. The purpose of this review article is to evaluate the stepwise management of POP in the elderly female, with a focus on the safety and feasibility of a robotic approach.

Sleep quality in women seeking care for pelvic organ prolapse

OBJECTIVES

To identify the prevalence of sleep disturbance in women seeking treatment for pelvic organ prolapse (POP) and identify correlates of poor sleep quality in this population by using a validated sleep scale.

STUDY DESIGN

This is a cohort study of female patients with pelvic organ prolapse.

MAIN OUTCOME MEASURES

Pittsburgh Sleep Quality Index (PSQI), Pelvic Floor Disorders Inventory (PFDI), and Pelvic Floor Impact Questionnaire (PFIQ) measures were completed. Demographic data, medical comorbidities, medications, and physical examinations were also recorded.

RESULTS

407 Women were enrolled. Analysis was performed on the 250 subjects who completed all PSQI components. Subjects were predominantly white, with a mean age of 61 ± 11 years and mean BMI of 28 ± 5 kg/m(2). The majority (71%) had Stage III prolapse. Half (N=127) had poor sleep quality (PSQI > 5). Women with poor sleep quality were younger, had more medical comorbidities, more pelvic floor symptoms, more nocturia, more depressive symptoms, and took more time to fall asleep. Factors associated with sleep quality were evaluated using multivariable linear regression models. Worse sleep scores were associated with each of the PFDI subscores (urinary, prolapse, bowel), depressive symptoms, severe nocturia symptoms, and number of comorbidities.

CONCLUSIONS

Poor sleep is prevalent in women with prolapse. Pelvic floor symptoms as measured by PFDI sub-scales, were associated with poor sleep quality. Future studies are needed to better understand how sleep disturbances may contribute to the impact of pelvic floor symptoms on quality of life.

Validation of the Spanish-language version of the Prolapse Quality of Life questionnaire in Chilean women

INTRODUCTION AND HYPOTHESIS

The Prolapse Quality of Life (P-QOL) questionnaire is a specific health-related quality of life (HRQL) instrument to assess the impact of POP on women. It has been validated in English-speaking women and to date has been translated into several other languages. However, currently there is no Spanish translation of the P-QOL questionnaire. The aim of this study was to translate the P-QOL questionnaire into Spanish and to assess its feasibility, validity, and reliability.

METHODS

Following a forward- and back-translation of the original English P-QOL questionnaire into Spanish language, the translated questionnaire was reviewed by a group of patients as well as an expert panel to assess its comprehensibility. In this cross-sectional study women with POP symptoms were recruited from a tertiary referral teaching hospital. Women were defined as symptomatic if they report feeling a lump/bulge/pressure in the vagina. The Spanish translated P-QOL questionnaire was self-administered to all women. Reliability, content, and construct validity were evaluated using the Cronbach's alpha coefficient, ANOVA, and Spearman's correlation tests.

RESULTS

One hundred and twenty-eight women were studied. There were no missing items. The Cronbach's alpha ranged from 0.626 to 0.866 across domains, demonstrating the good reliability of the Spanish P-QOL. The severity of symptoms was related to the worst quality of life, but the severity of POP was not related to poorer QoL.

CONCLUSIONS

The Spanish translated version of the P-QOL is a reliable, consistent and valid instrument to assess symptom severity and QoL impact in Chilean women with POP.

Prolapse symptoms in overweight and obese women before and after weight loss

OBJECTIVE

The objective of this study was to estimate the association between body mass index (BMI) and pelvic organ prolapse symptoms and bother among overweight and obese women with urinary incontinence before and after weight loss.

METHODS

Women (N = 338) were randomized to either an intensive 6-month weight loss or educational program (control); they were evaluated for prolapse symptoms at baseline and 6 months. Symptomatic prolapse was defined as a positive response to at least 1 prolapse subscale question of the Urogenital Distress Inventory. "Bother" was defined as responses of slight, moderate, or great. Women with prolapse symptoms were analyzed by baseline BMI category: overweight, obese, and severely obese at baseline and at 6 months. Proportional odds regression and χ tests for trend were used for analysis.

RESULTS

Age mean was 53 (SD, 10) years, BMI mean was 36 (SD, 6) kg/m, and 78% were white. A higher proportion of obese women reported feeling vaginal bulging compared with overweight women (13% vs 0%, P = <0.01). At baseline, 37% (n = 124) reported bothersome "lower abdominal pressure"; 18% (n = 62), bothersome "heaviness in the pelvic area"; and 14% (n = 48), bothersome "pelvic discomfort when standing." Nine percent (n = 31) reported bothersome "feeling," and 2% (n = 6) reported bothersome "seeing a bulge" in the vagina. At 6 months, there were no significant differences in improvement of self-reported bothersome prolapse symptoms in women in the weight loss or the control group.

CONCLUSIONS

In this study of overweight and obese women, increasing BMI was associated with only "feeling" a vaginal bulge. Weight loss did not improve bothersome prolapse symptoms.

Correlation between anatomical findings and symptoms in women with pelvic organ prolapse using an artificial neural network analysis

INTRODUCTION AND HYPOTHESIS

The aim of the present study was to assess the relationship between lower urinary tract symptoms, anatomical findings, and baseline characteristics in women with pelvic organ prolapse (POP).

METHODS

A cross-sectional observational study was performed, enrolling consecutive women seeking cares for lower urinary tract symptoms (LUTS) with evidence of POP. Data regarding baseline characteristics, LUTS, and physical examination were gathered for each patient. Multivariate analysis (multiple linear regression (MLR)) and artificial neural networks (ANNs) were performed to design predicting models.

RESULTS

A total of 1,344 women were included. Age, BMI, pelvic organ prolapse quantification (POP-Q) stage I, and previous surgery for urinary incontinence resulted predictors of urgency and stress incontinence. POP-Q stages III-IV were related to voiding dysfunction and POP symptoms. Age, BMI, and menopausal status resulted predictors for sexual dysfunction. Receiver operating characteristic comparison confirmed that ANNs were more accurate than MLRs in identifying predictors of LUTS.

CONCLUSIONS

LUTS result from a fine interaction between baseline characteristics and anatomical findings. ANNs are valuable instrument for better understanding complex biological models.

The prevalence of anal incontinence in post-partum women following obstetrical anal sphincter injury

INTRODUCTION AND HYPOTHESIS

The primary objective of this study was to determine the prevalence of anal incontinence (AI) in post-partum women following obstetrical anal sphincter injury (OASI). We also assessed quality of life and prevalence of other pelvic floor symptoms.

METHODS

Women who had third or fourth degree OASI were asked to complete the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7).

RESULTS

Survey response rate was 25% (n = 1,383). Average patient age was 33.4 years. Of the patients, 10.2% had a fourth degree tear, and 89.8% had a third degree tear. Prevalence of AI was 7.7% (formed stool), 19.7% (loose stool), and 38.2% (flatus). Average PFDI and PFIQ scores were significantly higher in the fourth degree tear group.

CONCLUSIONS

The community prevalence and impact of AI have not been well-studied. Establishment of a perineal clinic and an increase in resources may help educate women and expedite treatment for OASI.

Symptoms of combined prolapse and urinary incontinence in large surgical cohorts

OBJECTIVE

To estimate whether prolapse severity is a major contributor to urinary incontinence severity, as measured by validated incontinence questionnaires.

METHODS

We analyzed data from two large female stress urinary incontinence (SUI) surgical cohorts: the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) study (N=655) and the subsequent Trial of Mid-Urethral Slings (TOMUS) study (N=597). All participants completed a standardized baseline assessment including validated measures of symptom severity, quality of life, objective measures of urine loss (Urogenital Distress Inventory [UDI], Medical, Epidemiologic, and Social Aspects of Aging questionnaire, Incontinence Impact Questionnaire, and pad test), as well as the Pelvic Organ Prolapse Quantification assessment. Groups were compared using the chi; test (categorical measures) or the one-way analysis of variance (continuous measures). Statistical significance was defined as P<.05.

RESULTS

The SISTEr and TOMUS samples were similar for many variables including age (52 and 53 years, respectively), nulliparity (9% and 12%), prior urinary incontinence (UI) surgery (14% and 13%), and prior hysterectomy (31% and 28%), but other differences necessitated separate analysis of the two cohorts. There was not a statistically significant difference in UDI scores according to prolapse stage in either study population. Patients with prior surgery for pelvic organ prolapse and SUI had more incontinence symptoms and were more bothered by their UI regardless of prolapse stage.

CONCLUSION

Prolapse stage is not strongly or consistently associated with incontinence severity in women who select surgical treatment of SUI. Prior pelvic organ prolapse and UI surgery is associated with worse UI severity and bother.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00064662 and NCT00325039.

LEVEL OF EVIDENCE

II.

Validity, reliability and responsiveness of a Dutch version of the prolapse quality-of-life (P-QoL) questionnaire

INTRODUCTION AND HYPOTHESIS

We aimed to test validity, reliability and responsiveness of a Dutch version of a prolapse quality-of-life questionnaire (P-QoL).

METHODS

P-QoL was translated into Dutch and adjusted by a panel of five experts. The scores of the final version were compared between symptomatic (n = 160) and asymptomatic (n = 80) patients and with findings on vaginal examination (pelvic organ prolapse quantification (POP-Q)). In terms of reliability, Cronbach's alpha was calculated, and a test-retest (n = 20) was performed. Responsiveness to treatment was assessed by comparing pre- and postoperative scores in 45 patients.

RESULTS

Total scores for each P-QoL domain were different between symptomatic and asymptomatic women (p < 0.001). Severity according to P-QoL correlated well with POP-Q findings. Cronbach's alphas showed internal consistency within the domains. Test-retest reliability was high. Pre- and postoperative scores for each domain were significantly different (p < 0.001).

CONCLUSION

The Dutch version of P-QoL is valid, reliable and responsive to assess quality-of-life and symptoms in Dutch-speaking patients with urogenital prolapse.

A single nucleotide polymorphism in the promoter of the LOXL1 gene and its relationship to pelvic organ prolapse and preterm premature rupture of membranes

Pelvic organ prolapse and preterm premature rupture of membranes, the 2 conditions which have in common weakening of the tensile strength of tissues, are thought to be caused, in part, by abnormal extracellular matrix synthesis and/or catabolism. We identified a new single nucleotide polymorphism (NT_010194(LOXL1):g.45008784A>C) in the promoter of the LOXL1 gene, which is essential for elastin synthesis. Promoter studies showed that the minor "C'' allele had significantly greater activity than the major "A'' allele. Case-control studies examined the association of the alleles of this single nucleotide polymorphism with pelvic organ prolapse and preterm premature rupture of membranes. When comparing allele frequencies and genotypes in pelvic organ prolapse cases versus controls, no significant associations were found. A case-control study conducted in African American neonates also found no significant associations between the promoter alleles and preterm premature rupture of membranes. We conclude that a functional single nucleotide polymorphism exists in the promoter region of the LOXL1 gene. Association studies suggest that the promoter single nucleotide polymorphism does not contribute significantly to risk of pelvic organ prolapse or preterm premature rupture of membranes.

Paper versus web-based administration of the Pelvic Floor Distress Inventory 20 and Pelvic Floor Impact Questionnaire 7

Web-based questionnaires are increasingly employed for clinical research. To investigate whether web-based and paper versions of the Pelvic Floor Distress Inventory 20 (PFDI-20) and Pelvic Floor Impact Questionnaire 7 (PFIQ-7) yield similar results, we compared results obtained with these two modes of administration. Women with pelvic floor disorders completed both versions of these questionnaires. Scores between modes of administration were compared using the paired t test and the intraclass correlation coefficient (ICC). Among the 52 participants, there were no significant differences in scores or scale scores between the web-based and paper questionnaires. The ICC was 0.91 for the PFDI-20 score and 0.81 for the PFIQ-7 score (p < 0.001 for each). The web-based format was preferred by 22 participants (53%), ten (24%) preferred the paper format, and nine (21%) had no preference. The acceptability and score equivalence recommend these web-based questionnaires as an alternative to paper questionnaires for clinical research.