Women's experiences of receiving care for pelvic organ prolapse: a qualitative study

Pain and other complications of pelvic mesh: a systematic review of qualitative studies and thematic synthesis of women's accounts

OBJECTIVES

Synthesis of the experience of women with pain from pelvic or vaginal mesh or its removal, to identify pain-related problems and to formulate psychological aspects of pain.

DESIGN

Systematic review and thematic analysis of qualitative studies of pain from pelvic or vaginal mesh, or mesh removal, in women over 18 years, using individual interviews, focus groups, free text, or written or oral contributions to formal enquiries.

DATA SOURCES

Medline, Embase and PsycINFO, from inception to 26 April 2023.

ELIGIBILITY CRITERIA

Qualitative studies of pain and other symptoms from pelvic or vaginal mesh or its removal; adults; no language restriction.

DATA EXTRACTION AND SYNTHESIS

Line-by-line coding of participant quotations and study author statements by one author to provide codes that were applied to half the studies by another author and differences resolved by discussion. Codes were grouped into subthemes and themes by both authors, then scrutinised and discussed by a focus group of mesh-injured women for omissions, emphasis and coherence. Studies were appraised using an amalgamation of the CASP and COREQ tools.

RESULTS

2292 search results produced 9 eligible studies, with 7-752 participants, a total of around 2000. Four recruited patients, four totally or partially from mesh advocacy groups, and two were national enquiries (UK and Australia). Four major themes were as follows: broken body, broken mind; distrust of doctors and the medical industry; broken life and keeping going-a changed future. Psychological content mainly concerned the loss of trust in medical care, leaving women unsupported in facing an uncertain future. Mesh-injured women strongly endorsed the findings.

CONCLUSIONS

Pain and other problems associated with pelvic mesh are profound and far-reaching for women affected. Worse, they feel subject to continued gaslighting, including denial of their mesh-related problems and dismissal of their concerns about continued mesh insertion.

PROSPERO REGISTRATION NUMBER

CRD42022330527.

Overlooked by the obstetric gaze - how women with persistent health problems due to severe perineal trauma experience encounters with healthcare services: a qualitative study

BACKGROUND

During the first year postpartum, about 25 per cent of Swedish women with severe perineal trauma (SPT), i.e., a third- or fourth-degree perineal laceration at childbirth, are unsatisfied with their healthcare contacts. Further, there is a lack of research on the more long-term experiences of healthcare encounters among women with persistent SPT-related health problems. This study explores how women with self-reported persistent SPT-related health problems experience their contact with healthcare services 18 months to five years after childbirth when the SPT occurred.

METHODS

In this descriptive qualitative study, a purposive sample of twelve women with self-reported persistent health problems after SPT were individually interviewed from November 2020 - February 2022. The data was analysed using inductive qualitative content analysis.

RESULTS

Our results showed a paradoxical situation for women with persistent health problems due to SPT. They struggled with their traumatised body, but healthcare professionals rejected their health problems as postpartum normalities. This paradox highlighted the women's difficulties in accessing postpartum healthcare, rehabilitation, and sick leave, which left them with neglected healthcare needs, diminished emotional well-being, and loss of financial and social status. Our results indicated that these health problems did not diminish over time. Consequently, the women had to search relentlessly for a 'key person' in healthcare who acknowledged their persistent problems as legitimate to access needed care, rehabilitation, and sick leave, thus feeling empowered.

CONCLUSIONS

Our study revealed that women with persistent SPT-related health problems experienced complex health challenges. Additionally, their needs for medical care, rehabilitation, and sick leave were largely neglected. Thus, the study highlights an inequitable provision of SPT-related healthcare services in Sweden, including regional disparities in access to care. Hence, the authors suggest that Swedish national guidelines for SPT-related care need to be developed and implemented, applying a woman-centered approach, to ensure equitable, effective, and accessible healthcare.

A Randomised Trial on the Effects of the Addition of Uterosacral Ligament Plication to Pectopexy Operation on Anatomical Restoration and Female Sexual Functions

INTRODUCTION AND HYPOTHESIS

The objective was to determine whether the addition of uterosacral ligament plication to pectopexy for pelvic organ prolapse increases anatomical improvement and female sexual functioning.

METHODS

This is a prospective randomised study. Forty patients who underwent laparoscopic pectopexy (LP) and laparoscopic pectopexy with uterosacral ligament plication (LPUSL) were included in the study. A total of 38 patients were evaluated in the study. Patients were assessed by the Pelvic Organ Prolapse Quantification (POP-Q) system and the patients who had symptomatic apical prolapse POP-Q ≥ II were included in the study. Patients were evaluated preoperatively and postoperatively at the 3rd, 6th and 12th month, with respect to anatomical changes as well as sexual function.

RESULTS

A statistically significant difference was found when the preoperative C points was compared with the C points postoperatively, at 3rd, 6th and 12th months in both the LP and LPUSL groups (p < 0.001). Additionally, there were statistically significant difference between the LP and LPUSL groups in terms of C and Aa points at the 6th and 12th postoperative months in favour of the LPUSL group (p = 0.007, p = 0.005 respectively). There was also a statistically significant difference when Ba points were compared between the two groups at the 12th postoperative month, in favour of the LPUSL group (p = 0.002). There were no statistically significant differences between the groups with respect to the variables of the Female Sexual Function Index. Additionally, all parameters were significantly better in both groups at the 3rd and 12th months than the preoperative values in post hoc analysis; only desire also had a significant improvement between the 3rd and 12th months in the LPUSL group in post hoc analysis.

CONCLUSION

Pectopexy operation seems to be a successful surgical approach as an alternative to sacrocolpopexy. The addition of uterosacral ligament plication to pectopexy operation improves the anatomical restoration more drastically than with LP on its own. Moreover, either LP or LPUSL has improved the majority of sexual function indices.

A mixed methods systematic literature review of barriers and facilitators to help-seeking among women with stigmatised pelvic health symptoms

BACKGROUND

Women's pelvic health is a globally important subject, included in international and United Kingdom health policies, emphasising the importance of improving information and access to pelvic health services. Consequences of pelvic symptoms are intimate, personal, and varied, often causing embarrassment and shame, affecting women's quality of life and wellbeing.

AIM

To understand the experience of seeking healthcare for stigmatised pelvic health symptoms by synthesising all types of published primary research and mapping the results to behavioural theory, to identify potential targets for intervention.

METHODS

Systematic search of MEDLINE, CINAHL, PsycINFO, SocINDEX, PubMED databases, CDSR and CENTRAL registers, from inception to May 2023 for all types of research capturing women's views and experiences of seeking help with stigmatised urogenital and bowel symptoms. Studies only reporting prevalence, predictors of help-seeking, non-health related help-seeking, or written in languages other than English, German, French, Spanish and Swedish were excluded. Reference checking and forward citation searching for all included studies was performed. A results-based synthesis approach was used to integrate quantitative and qualitative data. Themes were mapped to the Common-Sense model and Candidacy framework. The Mixed Methods Appraisal Tool was used for critical appraisal. Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research for assessing certainty of review findings.

RESULTS

86 studies representing over 20,000 women from 24 high income countries were included. Confidence was high that barriers to help-seeking were similar across all study types and pelvic symptoms: stigma, lack of knowledge, women's perception that clinicians dismissed their symptoms, and associated normalising and deprioritising of low bother symptoms. Supportive clinicians and increased knowledge were key facilitators.

CONCLUSIONS

Using the Common-Sense Model to explore women's help-seeking behaviour with stigmatised pelvic symptoms reveals problems with cognitive representation of symptom identity, emotional representations of embarrassment and shame, and a subjective norm that women believe their symptoms will be trivialised by clinicians. Together these barriers frustrate women's identification of their candidacy for healthcare. Addressing these issues through behavioural change interventions for women and clinicians, will help to achieve universal access to pelvic healthcare services (United Nations Sustainable Development Goal 3.7).

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021256956.

A Qualitative Exploration of the Perceptions of Women Living with Pelvic Floor Disorders and Factors Related to Quality of Life

Background: Pelvic floor dysfunction encompasses conditions like urinary and fecal incontinence, pelvic organ prolapse, and pelvic pain, significantly affecting women's quality of life. Despite its prevalence, few studies have adopted a qualitative approach to understanding women's perceptions and emotions regarding these issues. This study aims to delve into how women with pelvic floor disorders perceive their condition and its impact on their daily lives. Methods: We analyzed qualitative data from interviews with 160 women suffering from pelvic floor dysfunctions. Using inductive qualitative content analysis, we systematically examined the data to identify variations, differences, and similarities. Results: The analysis revealed four primary themes in the women's narratives: "Physical Impacts", "Emotional and Psychological Impacts", "Social and Relational Impacts", and "Sexual Health Impacts", along with 12 subthemes. The findings predominantly highlight how pelvic floor dysfunctions detrimentally affect women's quality of life and emotional well-being, instilling fear and insecurity in daily activities, compounded by sleep disturbances and sexual dysfunction. Conclusions: Women living with pelvic floor dysfunction face multifaceted challenges that adversely affect various aspects of their lives, diminishing their overall quality of life. This includes notable impacts on sleep, physical, and sexual activities. However, not all affected women report these issues, often due to fear of stigma, choosing instead to conceal their struggles in an effort to maintain an appearance of normalcy.

Primary care providers practice patterns regarding female pelvic floor disorders

INTRODUCTION

Pelvic floor disorders (PFDs) pose substantial physical and psychological burdens for a growing number of women. Given the ubiquity of these conditions and known patient reluctance to seek care, primary care providers (PCPs) have a unique opportunity to increase treatment and provide appropriate referrals for these patients.

METHODS

An online survey was administered to PCPs to assess provider practices, knowledge, comfort managing and ease of referral for PFDs. Logistic regression was used to assess the association between demographic/practice characteristics of PCPs and two primary outcomes of interest: discomfort with management and difficulty with referral of PFDs.

RESULTS

Of the 153 respondents to the survey, more felt comfortable managing stress urinary incontinence (SUI) and overactive bladder (OAB), compared with pelvic organ prolapse (POP) and faecal incontinence (FI) and were less likely to refer patients with urinary symptoms. Few providers elicited symptoms for POP and FI as compared with SUI and OAB. Provider variables that were significantly associated with discomfort with management varied by PFD, but tended to correlate with less exposure to PFDs (eg, those with fewer years of practice, and internal medicine and family physicians as compared with geriatricians); whereas the factors that were significantly associated with difficulty in referral, again varied by PFD, but were related to practice characteristics (eg, specialist network, type of practice, practice setting and quantity of patients).

CONCLUSION

These findings highlight the need to increase PCPs awareness of PFDs and develop effective standardised screening protocols, as well as collaboration with pelvic floor specialists to improve screening, treatment and referral for patients with PFDs.

Two variants of 'constrained participation' in the care of vulnerable adults: A proof-of-concept study

There has been a radical turn towards ideals of patient autonomy and person-centred care, and away from historically entrenched forms of medical paternalism, in the last 50 years of nursing practice. However, along the way, some shades of grey between the areas of ideal patient participation and of outright patient non-participation have been missed. The current article constitutes an exploratory proof-of-concept study of the real-world traction of a distinction-straddling concept of 'constrained participation' and its two sub-concepts of 'fought-for participation' and 'forced-to participation'. In order to concretise these additions to the conceptual terrain of person-centred participation and its anti-theses, we apply them to themes in the care of vulnerable older adults. In the final section, we close by eliciting some characterological, educational and clinical implications of adding these new tools also to the conceptual repertoire of nursing practice and education.

Co-Design of a website for women with pelvic organ prolapse: A study protocol

Background

Despite high reported prevalence of pelvic organ prolapse (POP), women report difficulties accessing evidence-based and reliable information about the condition. Many rely on social media and other popular and highly visible internet platforms which have been found to contain poor quality information that is difficult for the average patient to understand. The aim of the study is to co-design an information website for premenopausal women with POP. The website design will be based on the Website Developmental Model for the Healthcare Consumer (WDMHC) framework.

Methods

A four phase process will be utilised as per the WDMHC framework: 1) User, task and environmental analysis; 2) Functional and representational analysis; 3) Cognitive walkthrough, keystroke level model, heuristic testing; 4) Content based testing, expert testing and user-based testing.Ethics approval has been obtained (LS-23-19-Carroll-Ful). Two groups of stakeholders will be recruited (i) patient group (ii) healthcare professional (HCP) group. Patient participants will be recruited from an online pelvic floor dysfunction (PFD) support group (n=950 members). A website designer and HCP stakeholders involved in the multidisciplinary team caring for women with POP will be invited to participate.Both groups will participate in separate co-design online workshops. Focus group workshops will be video-recorded, transcribed and imported into NVivo. Themes and subthemes will be developed.The website will be designed and disseminated to all participants for feedback. Cognitive walkthrough and heuristic testing will be undertaken. Following this, necessary modifications will be made to the website. Participants will then complete a modified System Usability Scale (SUS) and the eHealth Impact Questionnaire, while five HCPs will complete the DISCERN instrument.

Conclusion

This study will inform the design and testing of an information website for women with POP. The website design and content will be informed by patient and HCP stakeholder voices and the health literacy literature.

The influence of the combined impairments and apical mesh surgery on the biomechanical behavior of the pelvic floor system

Objective: The prolapse mechanism of multifactorial impairment of the female pelvic floor system and the mechanics of the pelvic floor after apical suspension surgery are not yet understood, so we developed biomechanical models of the pelvic floor for the normal physiological state (0°) and 90° pathological state. Methods: Under different types and levels of the impairments and uterosacral suspensions, the possible changes in the morphometric characteristics and the mechanical characteristics of suspension and support functions were simulated based on the biomechanical models of the pelvic floor. Results: After the combined impairments, the descending displacement of the pelvic floor cervix and the stress and displacement of the perineal body reached maximum values. After surgical mesh implantation, the stresses of the normal pelvic floor were concentrated on the uterine fundus, cervix, and top of the bladder and the stresses of the 90° pathological state pelvic floor were concentrated on the uterine fundus, uterine body, cervix, middle of the posterior vaginal wall, and bottom of the perineal body. Conclusion: After the combined impairments, the biomechanical support of the bladder and sacrococcyx in the anterior (0°) and 90° pathological state pelvic floor system is diminished, the anterior vaginal wall dislodges from the external vaginal opening, and the posterior vaginal wall forms "kneeling" profiles. The pelvic floor system may evolve with a tendency toward the cervical prolapse with anterior and posterior vaginal wall prolapse and eventually prolapse. After surgical mesh implantation, the cervical position can be better restored; however, the load of combined impairment of the pelvic floor is mainly borne by the surgical mesh suspension, the biomechanical support function of pelvic floor organs and sacrococcyx was not repaired by the physiological structure, and the results of uterosacral suspension alone may be poor.

Pelvic organ prolapse: Women's experiences of Accessing Care & Recommendations for improvement

Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life.Many women with POP symptoms present initially to primary care settings. Research has shown these interactions are often unsatisfactory, with women reporting their health care professional (HCP) trivialized their symptoms or appeared to have poor knowledge about pelvic floor dysfunction (PFD).Aim The aim of this qualitative study was to explore experiences of younger women seeking treatment for POP and their recommendations for improvements.Methods Ethics approval was obtained (LS-21-01-Carroll-Ful). Women with POP were recruited from an online support group (n = 930 members). Inclusion criteria: adult women, diagnosed with POP and aware of their POP stage. Following informed consent, a demographic questionnaire, interview questions and the Central Sensitization Inventory (CSI) were forwarded. Semi-structured zoom audio-recorded interviews were conducted. Thematic analysis was undertaken; transcripts coded, and themes identified.Results Fourteen women aged 32-41, parity 1-3, with POP Grade 1-3 participated. Many women reported HCPs as dismissive or not appreciative of the impact of their condition. Others described interactions with HCPs who they felt listened, understood the impact of their POP, gave simple explanations, a positive prognosis and outlined a realistic treatment plan.Current antenatal education, post-partum care and primary HCP screening for PFD were identified by women as deficient. Many highlighted delays in accessing specialist care for POP. Women made several recommendations for improvements to the current model of care.Conclusions Increased focus on person-centred care, particularly emotional support, information and education may improve younger women's experiences when seeking care for POP.

Advanced flexible transvaginal mesh with high visibility under computerized tomography (CT) scan

Pelvic floor disorders, including pelvic organ prolapse (POP) and stress urinary incontinence (SUI), are serious and very common. Surgery is commonly undertaken to restore the strength of the vaginal wall using transvaginal surgical mesh (TVM). However, up to 15% of TVM implants result in long-term complications, including pain, recurrent symptoms, and infection.Clinical Relevance- In this study, a new bioengineered TVM has been developed to address these issues. The TVM is visible using noninvasive imaging techniques such as computed tomography (CT); it has a highly similar structural profile to human tissue and potential to reduce pain and inflammation. These combined technological advances have the potential to revolutionize women's health.

Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Wolaita zone, Southern Ethiopia: Hospital based mixed method study

BACKGROUND

Despite increasing efforts to improve access to diagnosis and treatment services, women with pelvic organ prolapse tend to stay at home for years before getting treatment. A large number of women, particularly in rural areas do not get early diagnosis and treatment, and they come with an advanced stage; but the reason for this appears unclear. Thus, this study aimed to determine the proportion and associated factors of delay in seeking treatment among women with pelvic organ prolapse (POP) in the Wolaita zone, Southern Ethiopia.

METHODS

A hospital-based cross-sectional study mixed with qualitative method was conducted in the Wolaita zone, Southern Ethiopia, from September to October 2021. A total of 422 women with pelvic organ prolapse were selected by systematic random sampling for quantitative data. The women recruited for in-depth interviews were purposefully selected until data saturation reaches via phenomenological study design. The quantitative data were collected by interviewer-administered questionnaire and reviewing clients' medical records via an open data kit and then exported to and analyzed with a statistical package for social science version 25. The associated variables were determined by conducting a logistic regression model and are presented with the crude odds ratio (COR) and adjusted odds ratio (AOR) with their respective 95% confidence intervals (95%CI). All statistical tests were conducted at a 5% level of significance. The interview was first transcribed, coded, and categories and themes were generated by applying thematic analysis.

RESULTS

The study showed that 82.0% (95% CI: [74.8-89.3%]) of women with POP delayed seeking treatment. The delay to seek treatment was associated with a lack of support (AOR = 4.9; 95% CI [1.8-13.2]), low-income (AOR = 6.4; 95% CI [2.2-19.2]), fear of disclosure (AOR = 5.0; 95% CI [1.3-19.2]) and fear of social stigma (AOR = 4.6; 95% CI [1.5-14.2]). The reasons for the delay were feeling shameful to disclose, fear of stigma and cultural and spiritual beliefs.

CONCLUSIONS

More than three-fourths of women with POP delayed seeking treatment, and improving support, improving the economy, raising awareness, and involving influential people in interventions are all necessary to avert it.

Factors affecting women's decision between uterine-preserving versus hysterectomy-based surgery for pelvic organ prolapse

BACKGROUND

Given the prevalence of women seeking surgical treatment for pelvic organ prolapse (POP), there is a need to understand women's decision-making regarding uterine-preserving versus hysterectomy-based surgeries. Historically, hysterectomy-based surgeries have been the preferred treatment for pelvic organ prolapse; however, contemporary evidence supports uterine-preserving surgeries as equivalent. At present, the lack of information available to the general public and limited options presented at surgical consultation for pelvic organ prolapse may hinder women's autonomy as they navigate surgical treatment.

OBJECTIVES

To examine the factors affecting women's decision-making processes regarding uterine-preserving or hysterectomy-based surgery for pelvic organ prolapse.

DESIGN

This is a qualitative study.

METHODS

We conducted semi-structured, qualitative interviews with women seeking surgery for pelvic organ prolapse to explore the factors affecting women's decision-making between hysterectomy-based and uterine-preserving surgeries.

RESULTS

Women (n = 26) used clinical and personal factors to determine which surgery was best. Women noted that the lack of evidence (clinical and/or anecdotal) available to them hindered their decision-making, causing them to rely more on their own interpretations of the evidence, what they perceived to be "normal," and what their surgeon recommended. Even with standardized discussion regarding the existing clinical equipoise between surgeries at the clinical consultation, some women still had misperceptions that hysterectomy-based surgery would convey the lowest risk of prolapse recurrence and be best for severe prolapse.

CONCLUSION

There is a need for more transparency in discussions about prolapse and the factors affecting women's decision-making for surgical repair of pelvic organ prolapse. Clinicians should be prepared to offer the option of hysterectomy-based or uterine-preserving surgeries and to clearly explain the clinical equipoise between these procedures.

Prevalence and sociodemographic correlates of urinary incontinence in Japanese women: A web-based cross-sectional study

BACKGROUND

Epidemiological studies on urinary incontinence that used a validated international standard questionnaire are limited in Japan, and few studies have examined the sociodemographic and behavioral correlates of urinary incontinence.

OBJECTIVE

The aim of this study was to estimate the prevalence of urinary incontinence according to the Japanese version of the International Consultation on Incontinence Questionnaire-Short Form, and its sociodemographic and behavioral correlates among Japanese women.

DESIGN

A web-based cross-sectional study.

METHODS

A randomly sampled cross-sectional Internet survey was conducted in Japan among 3030 women aged 20-64 years. The International Consultation on Incontinence Questionnaire-Short Form score, sociodemographic, body mass index, medical and childbirth history, practice of pelvic floor muscle training, and medical care use were obtained. Descriptive statistics, the chi-square test, and forced-entry logistic regression analysis were used in data analysis.

RESULTS

Participants' average age was 43.4 years, and the response rate was 32.9%. The prevalence of urinary incontinence was 25.5%, and it increased with age. Stress urinary incontinence was the most common subtype (57.4%), followed by urge urinary incontinence (20.3%) and mixed urinary incontinence (16.7%). Less than 5% of those with urinary incontinence had experience with pelvic floor muscle training and medical care use. Middle-aged and older (p < 0.001), overweight and obesity (p < 0.001), vaginal delivery status (p < 0.001), low back pain (p = 0.008), and previous pelvic floor muscle training engagement (p < 0.001) were significantly associated with urinary incontinence.

CONCLUSION

Increasing population awareness of urinary incontinence from an early age and developing effective interventions for the identified at-risk groups, such as the middle-aged and older, those with overweight and obesity, and those with previous pregnancies, are urgently needed.

Development of a conceptual framework for a new patient-reported outcome measure for pain in women following mesh surgery for pelvic floor disorders: a qualitative study

Introduction and hypothesis

The Australasian Pelvic Floor Procedure Registry (APFPR) collects both clinical and health-related quality of life (HRQoL) data on women undergoing surgery using a prosthesis such as mesh for pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The registry lacks a suitable instrument to assess pain in women following mesh surgery for SUI and POP. This qualitative study describes the views on pain following mesh surgery in women and clinicians through the development of a conceptual framework, which may inform the development of a new instrument for the APFPR.

Methods

We conducted semi-structured interviews with women following mesh surgery for POP and SUI (n=17) and clinicians (n=6) in Victoria, Australia. We sought to reveal aspects of any sort of pain after a pelvic floor procedure. Interviews covered sensation, region, continuity of pain, triggers, and the mode and method of administration for a new pain-specific patient-reported outcome measure. Data were analysed using thematic analysis.

Results

We identified the important components of pain felt by women with POP and SUI after surgery using mesh. From the seven themes outlined, a conceptual framework was developed compiling related components of pain into six specific domains.

Conclusions

This study identifies the important components of pain felt by women following mesh surgery. It is hoped that the development of a pain-specific PROM, as supported by clinicians, will assist in the timely and appropriate diagnosis and management of POP and SUI.

Conservative non-pharmacological interventions in women with pelvic floor dysfunction: a systematic review of qualitative studies

BACKGROUND

Women's adherence is essential to physiotherapeutic treatment of pelvic floor dysfunction, but its related factors are not usually considered in the development of treatment approaches. This study aims to understand how women with pelvic floor dysfunction experience pelvic floor conservative non-pharmacological treatment options.

METHODS

A systematic review of qualitative studies. The electronic search was performed in MEDLINE/PubMed, CINAHL, Lilacs, SCOPUS, and Web of Science databases. Primary articles on qualitative methods focused on the experience of women regarding pelvic floor conservative non-pharmacological interventions, i.e., pelvic floor muscle training (PFMT), either associated or not with biofeedback, perineal massage, vaginal dilators, and others. A meta-aggregation was performed.

RESULTS

It was included 22 manuscripts in this review. It was found seven studies about the use of vaginal devices, two about manual intervention and 14 studies on women's experience with PFMT. The findings were synthesized as follows: I) women's experience of manual interventions; II) women's experience using vaginal devices changes according to health professional attitudes; III) women's experiences using vaginal devices varied depending on their pelvic floor dysfunction; IV) reported side effects due to the use of vaginal devices; V) external factors influencing PFMT performance; VI) women's perception of their own personal factors influencing PFMT performance; VII) PFMT characteristics influencing women's adherence; VIII) strategies used by women to include PFMT in their routine.

CONCLUSION

Women's experience with pelvic floor conservative non-pharmacological treatment options is a complex phenomenon that involves many more variables than simply personal aspects. This is a systematic review of qualitative studies registered in the PROSPERO (CRD42018080244).

Pelvic organ prolapse: The lived experience

BACKGROUND

Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life. This study explores the lived experience of women with POP.

METHODOLOGY

A qualitative study was undertaken. Following institutional ethical approval women from an online peer support group (n = 930 members) were recruited to participate in semi-structured interviews. Inclusion criteria stipulated women (> 18years), pre-menopausal, at least one-year post-partum, diagnosed with POP and aware of their diagnosis. Semi-structured interviews were undertaken with a clinician specialising in pelvic health. A battery of questions was designed to elicit discussion on their experience of being diagnosed with POP and its impact on daily life and relationships. Interviews were carried out via Zoom, recorded and transcribed. Thematic analysis was undertaken.

FINDINGS

Fourteen women (32-41 years), para 1-3 participated. All had at least one vaginal birth; three had vacuum, four had forceps operative births. All had Grade 1-3 POP. Interviews lasted 40-100 minutes. Three core themes with subthemes were identified; biological/physical, psychological and social. Women were particularly affected in terms of sport and exercise participation, their own perceptions of their ability as mothers and fear of their condition worsening. They described societal attitudes, reporting stigma around POP and women's pelvic health in general, expectations placed on women to put up with their symptoms and an idealised perception of new motherhood.

CONCLUSIONS

The impact of POP from a biopsychosocial perspective reflects other chronic conditions. Prevention, early education and supports for developing strong self-management approaches would be beneficial for long term management of this condition.

International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor muscle training

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 3 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) describes the current evidence and suggests future directions for research on the effect of pelvic floor muscle training (PFMT) in prevention and treatment of POP.

METHODS

An international group of four physical therapists, four urogynecologists and one midwife/basic science researcher performed a search of the literature using pre-specified search terms on randomized controlled trials (RCTs) in Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro and Scopus databases for publications between 1996 and 2021. Full publications or expanded abstracts in English or in other languages with abstracts in English were included. The PEDro rating scale (0-10) was used to evaluate study quality. Included RCTs were reviewed to summarize the evidence in six key sections: (1) evidence for PFMT in prevention of POP in the general female population; (2) evidence for early intervention of PFMT in the peripartum period for prevention and treatment of POP; (3) evidence for PFMT in treatment of POP in the general female population; (4) evidence for perioperative PFMT; (5) evidence for PFMT on associated conditions in women with POP; (6) evidence for the long-term effect of PFMT on POP. Full publications in English or in other languages with abstracts in English and expanded abstracts presented at international condition specific societies were included. Internal validity was examined by the PEDro rating scale (0-10).

RESULTS

After exclusion of duplicates and irrelevant trials, we classified and included 2 preventive trials, 4 trials in the post-partum period, 11 treatment trials of PFMT for POP in the general female population in comparison with no treatment or lifestyle interventions, 10 on PFMT as an adjunct treatment to POP surgery and 9 long-term treatment trials. Only three treatment studies compared PFMT with the use of a pessary. The RCTs scored between 4 and 8 on the PEDro scale. No primary prevention studies were found, and there is sparse and inconsistent evidence for early intervention in the postpartum period. There is good evidence/recommendations from 11 RCTs that PFMT is effective in reducing POP symptoms and/or improving POP stage (by one stage) in women with POP-Q stage I, II and III in the general female population, but no evidence from 9/10 RCTs that adding PFMT pre- and post -surgery for POP is effective. There are few long-term follow-up studies, and results are inconsistent. There are no serious adverse effects or complications reported related to PFMT.

CONCLUSIONS

There are few studies on prevention and in the postpartum period, and the effect is inconclusive. There is high-level evidence from 11 RCTs to recommend PFMT as first-line treatment for POP in the general female population. PFMT pre- and post-POP surgery does not seem to have any additional effect on POP. PFMT is effective and safe but needs thorough instruction and supervision to be effective.

“Broken”—How Identities as Women, Mothers and Partners Are Intertwined with the Experience of Living with and Seeking Treatment for Pelvic Organ Prolapse

Pelvic Organ Prolapse (POP) occurs when one or more pelvic organs descend into or through the vaginal opening, significantly impacting physical and mental health. POP affects the female reproductive tract and, overwhelmingly, people who identify as women. However, little research has examined the impact of gendered expectations on women’s treatment-seeking for POP and their decision-making around surgery for POP. To address this gap, we conducted semi-structured interviews with 26 women seeking surgery for POP in Alberta, Canada. Data were analyzed from a gender-based lens, using the Framework Method. Participants reported the need to balance their identities as women, partners, and mothers in their pursuit of treatment and faced many barriers to treatment related to their gendered responsibilities. Findings highlight the gendered experiences of prolapse in the context of healthcare needs and can inform policies and practices which promote more equitable access to prolapse treatment.

Women’s Experiences with Compliance with Pelvic Floor Home Exercise Therapy and Lifestyle Changes for Pelvic Organ Prolapse Symptoms: A Qualitative Study

In this study, we aimed to investigate women’s experiences with compliance with prescribed pelvic floor muscle exercises (PFMEs) and lifestyle changes 6–12 months after completing an individual pelvic floor physiotherapy program. This study was targeted to understanding factors affecting adherence to PFMEs and lifestyle changes to deal with pelvic organ prolapse (POP) symptoms. We designed this research as a descriptive qualitative study. We conducted this study from December 2016 to September 2017 in Madrid, Spain. Twenty-six women with symptomatic POP selected using a purposive sampling method participated in six focus groups and three one-to-one semi-structured interviews. Three authors coded and inductively analyzed transcript contents with iterative theme development. A thematic analysis revealed three main themes: (1) symptoms change; (2) PFMEs and lifestyle changes performance; and (3) a health practitioner–patient relationship. Women identified as adherent reported improvement in physical symptoms and emotional and general state as a result of the new knowledge achieved. Fear also promoted compliance with performing PFMEs and adopting lifestyle changes. Likewise, PFMEs preference and routine, integration of PFMEs and lifestyle changes into activities of daily living, support guides, therapeutic alliance, individual supervision, follow-up, and feedback were also identified as adherence facilitators. One of the biggest barriers that we identified was responsibility. Compliance with prescribed PFMEs and lifestyle changes can be improved with effective individual, women-centered, and supervised physiotherapy programs reducing symptoms, including exercises aligned with women’s preferences that are easy to integrate in daily living, promoting knowledge and awareness of their condition, providing written or electronic guidelines, with routine follow-up visits offering both positive feedback and clear and consistent messages, and enhancing therapeutic alliance.

Mini-review: Modern Concept of Pelvic Organ Prolapse

Symptomatic pelvic organ prolapse (POP) has been increasing in recent years for both developed and developing countries. By 2050, as the adult population grows, the number of women with symptomatic POP will increase by 46%. Due to the increasing number of complications after surgery among women with POP, the current understanding of treatment has become extremely important for researchers and practitioners. There are many novel conservative and surgical treatment approaches under investigation. However, some primary surgical treatments show an approximate 30–50% risk of repeated pelvic floor reconstruction. Therefore, the review aims to summarize several conservative treatment options and identify critical areas of need for future research.

Gender expression is associated with selection of uterine preservation or hysterectomy for pelvic organ prolapse surgery: Novel methodology for sex- and gender-based analysis in gynecologic research

OBJECTIVE

To explore whether patient characteristics were associated with gender expression, and to further determine impact of gender expression on patient selection of hysterectomy or uterine-preservation in pelvic organ prolapse (POP) surgery.

METHODS

Within a prospective cohort, a self-reported gender expression tool classified patients as expressing gender polar (i.e., reporting only feminine traits) or non-polar gender scores (i.e., reporting feminine and masculine traits). Multivariate modeling explored associations of gender expression with traditional socio-demographic variables, and with selection of hysterectomy or uterine-preserving surgery. Descriptive statistics of socio-demographic variables were reported by frequency, proportion and mean (SD).

RESULTS

177 participants completed the gender score questionnaire. Overall, the sample had a more feminine gender expression with the majority of respondents classified as gender polar (67.23%, n = 119). Participants with non-polar gender scores were 2.53 times (95% 1.05-6.09) more likely to choose uterine preservation versus hysterectomy-based surgery. Gender polarity was weakly associated with age, but no other sociodemographic variables.

CONCLUSION

Gender expression is not tightly associated with socio-demographic variables, and is thus a novel measurement in gynecologic research. Gender polarity appears to be associated with choice to undergo hysterectomy. Further research is required to understand this relationship and implications in clinical outcomes.

Experiences of urinary tract infection: A systematic review and meta-ethnography

AIM

To understand the experience of urinary tract infection (UTI) by synthesizing primary qualitative research findings and developing a conceptual model that illustrates this experience.

METHOD

A systematic search of Medline, PsychInfo, Embase, and CINAHL from inception to August 2020 to find qualitative research exploring the experience of UTI. Qualitative evidence synthesis in the form of meta-ethnography was undertaken. Findings are reported in keeping with eMERGe guidance.

RESULTS

We included 16 qualitative studies in the synthesis of evidence, providing data from over 1038 participants aged 13-97 years. We developed nine themes: the impact of UTI on my whole body; impact on quality of life, activities, and the associated psychological toll; I know my body and my experience has taught me when I need to seek care; worry and the transition to medicalization; antibiotics are a valuable treatment approach; antibiotics are a last resort; being heard, seen, and cared for with dignity; self-judgment; and the end of the road, a need for information and cure. These themes supported a conceptual model to illustrate the patient experience of UTI.

CONCLUSIONS

The conceptual model communicates the wide and varied symptoms of patients' UTI experiences and how they process this and make care decision based on past health experiences. For some, there appears to be a sense of hopelessness and frustration. This model may be used to highlight the need for improvements in diagnostic and treatment pathways. Future research to further understand the nuances of acute, recurrent, and persistent UTI is needed.

Simulation of vaginal uterosacral ligament suspension damage, mimicking a mesh-augmented apical prolapse repair

Synthetic implants were used for repair of anterior compartment prolapses, which can be caused by direct trauma resulting in damaged pelvic structures. The mechanical properties of these implants may cause complications, namely erosion of the mesh through the vagina. In this study, we evaluated, by modeling, the behavior of implants, during Valsalva maneuver, used to replace damaged uterosacral ligaments (USLs), mimicking a sacrocolpopexy repair. For this purpose, two synthetic implants (A®, for prolapse repair and B®, for Hernia repair) were uniaxially tested, and the mechanical properties obtained were incorporated in the computational models of the implants. The computational model for the implant was incorporated into the model of the female pelvic cavity, in order to mimic the USLs after its total rupture and with 90% and 50% impairment. The total rupture and impairments of the USLs, caused a variation of the supero-inferior displacement and displacement magnitude of the vagina, with higher values for the total rupture. With total rupture of the USLs, when compared to healthy USLs, supero-inferior displacement and displacement magnitude of the vagina increased by 4.98 mm (7.69 mm vs 12.67 mm) and 6.62 mm (9.38 mm vs 16.00 mm), respectively. After implantation (A® and B®) a reduction of the supero-inferior displacements of the anterior vaginal wall occurred, to values found in the case of the model without any impairment or rupture of the ligaments. The simulation was able to mimic the biomechanical response of the USLs, in response to different implants stiffnesses, which can be used in the development of novel meshes.

A web-based fuzzy risk predictive-decision model of de novo stress urinary incontinence in women undergoing pelvic organ prolapse surgery

Background:

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are common conditions affecting women's health and quality of life. In 50% of cases, SUI occurs after POP surgery, which is called de novo SUI. Predicting the risk of de novo SUI is a complex multi-attribute decision-making process. The current study made available a Decision Support System in the form of a fuzzy calculator web-based application to help surgeons predict the risk of de novo SUI.

Materials and methods:

We first identified 12 risk factors and the diagnostic criteria for de novo SUI by means of a systematic review of the literature. Then based upon an expert panel, all risk factors were prioritized. A set of 232 fuzzy rules for the prediction of de novo SUI was determined. A fuzzy expert system was developed using MATLAB software and Mamdani Inference System. The risk prediction model was then evaluated using retrospective data extracted from 30 randomly selected medical records of female patients over the age of 50 without symptoms of urinary incontinence who had undergone POP surgery. Finally, the proposed results of the predictive system were compared with the results of retrospective medical record data review.

Results:

The results of this online calculator show that the accuracy of this risk prediction model, at more than 90%, compared favorably to other SUI risk prediction models.

Conclusions:

A fuzzy logic-based clinical Decision Support System in the form of an online calculator for calculating SUI prognosis after POP surgery in women can be helpful in predicting de novo SUI.

Pregnant women's experiences with a pelvic floor muscle training program in Nepal

BACKGROUND

In Nepal, pelvic floor disorders affect about 24% of the women in reproductive age whereof 10% suffer from pelvic organ prolapse (POP). Still, many do not seek health care. Strengthening exercises for the pelvic floor muscles for prevention and treatment of POP has shown strong evidence internationally, but for women in Nepal surgery is primarily offered. To amend this, a novel pelvic floor muscle training (PFMT) program for pregnant women was introduced.

OBJECTIVE

To learn about how the PFMT-program was received by the participating women, their understanding of the importance of doing the exercises, and the constraints of daily life for performing the program.

METHODS

A qualitative study design based on a sub-sample (N = 10) from a strategic sample (N = 235) who participated in the PFMT-program. Ten semi-structured in-depth interviews were interpreted according to a phenomenological analytical tradition.

RESULTS

The 10 women were representative for the women who had participated in the PFMT-program with regard to urban residence, socioeconomic, and educational standing. The program was well received and compliance satisfactory. In line with the PFMT's learning outcomes, the women described risk factors, showed knowledge about the pelvic floor muscles, and understood the importance of doing the exercises. They had managed to fit the exercises into their busy daily routines. Meeting peers in exercise groups and understanding from family were positive factors for compliance.

CONCLUSION

The Nepalese women appear interested in self-care and are making an effort to fit the exercises into their busy schedule. Although the communicative validity was satisfactory, the pragmatic validity cannot be generalized to women in rural areas and under less fortunate socioeconomic and educational circumstances.

Assessment of the effect of Mulabandha yoga therapy in healthy women, stigmatized for pelvic floor dysfunctions: A randomized controlled trial

Background

In developing countries, women do not reveal their perineum related health issues because most of the time they are stigmatized by the society. Multiparity, mostly found in women of rural areas is one of the major causes of pelvic floor dysfunctions (PFDs) like pelvic organ prolapse, urinary incontinence, rectal incontinence, etc. Usually, they visit health centres in the advanced stage of diseases, and then medical treatment is not the only choice left. Many research studies show that yoga practices promote health conditions, contribute to enhancing endurance, flexibility, and muscular strength, and improving quality of life.

Objective(s)

The study was conducted to assess the impact of Mulabandha yoga therapy (MYT) in healthy woman participants as a preventive measure.

Material and methods

The study was a prospective and randomized controlled trial. Fifty healthy woman participants were allocated in two groups viz., MYT group and No MYT group. Mulabandha yoga was conducted for the MYT group for 12 weeks. No MYT group was advised not to do yoga. Pelvic floor muscle strength was internally evaluated by employing the PERFECT scheme score (P = power, E = endurance, R = repetitions, F = fast contractions, ECT = every contraction timed). For eligible samples, MYT sessions were held for 12 weeks. Data interpretation was done with SPSS software 20.0 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY, USA).

Results

Fifty healthy woman participants were allocated for analysis. There was no statistically significant difference in between the groups comparison in terms of age, socio-economic status, occupation, education, parity and mode of delivery. PERFECT scheme score significantly improved in participants after 12 weeks of regular MYT. No statistically significant differences were observed between the groups comparison in terms of PERFECT scheme score.

Conclusion

The current study shows that regular practice of MYT for 12 weeks is a better means to reinforce the strength of pelvic floor muscles in women. This MYT procedure will establish evidence for women who are reluctant towards their pelvic organ-related issues. Women must incorporate the MYT practice in their routine life as a preventive measure to refrain from pelvic floor dysfunctions.

A Preference-Sensitive Online Instrument to Support Shared Decision Making for Patients With Pelvic Organ Prolapse: A Pilot Multicenter Randomized Controlled Trial

A preference-sensitive instrument for women with pelvic organ prolapse was developed to increase shared decision-making. This study aimed to assess the feasibility of a randomized controlled trial to measure the effectiveness of the instrument. A pilot randomized controlled trial was conducted at three Danish gynecological clinics to assess feasibility through recruitment rates, per-protocol use and women's perception of (1) support for decision-making, (2) shared decision-making (Shared Decision-Making Questionnaire), and (3) satisfaction with their decisions. In addition, a focus group interview with participating gynecologists (five gynecologists) was conducted. We invited 226 women and recruited 46 (20%). The most common reason (45%) for nonparticipation was overlooking the invitation in their online public mailbox. Shared Decision-Making Questionnaire showed high data completeness (96%) but indicated a ceiling effect. Women felt the developed instrument supported their decision-making and more so if it was used interactively during consultations. Despite finding the instrument generally useful, gynecologists tended to apply the instrument inconsistently and not per protocol (41%), and some used it as a template for all consultations. This pilot study indicates that recruitment methods, for a future randomized controlled trial, for example, nurse-led preconsultations, need reconsideration due to low recruitment rates and inefficient per-protocol use. In a future randomized controlled trial, cluster randomization should avoid the carryover effect bias.

Mesh-less laparoscopic treatment of apical prolapse

The pelvic organ prolapse (POP) is a common gynaecological problem, affecting nearly 50% of women over 40. The sacrocolpopexy using a synthetic mesh is now considered the “gold standard” for management of women with apical prolapse. In April 2019 the FDA placed a ban on the production of transvaginal meshes for prolapse due to late complications. The meshes for abdominal repair of POP are still used, but in future they may also be prohibited. The goal of the following video is to present a mesh-less modification of two techniques used for apical organ prolapse, the sacrocolpopexy and the pectopexy.

Women's experiences and perception of symptomatic pelvis organ prolapse: A Cross sectional study from Uttarakhand, India

Background

Pelvic Organ Prolapse (POP) negatively affects the health of a woman in terms of physical, social and emotional wellbeing.

Objective

The aim of this study was to elucidate the experience of living with prolapse and its impact on daily life.

Methods

Women undergoing surgery for pelvic organ prolapse were interviewed to evaluate their sociodemographic profile with subsequent impact on their daily life.

Results

Among the 45 cases with POP, 80% belonged to rural areas. Mean age of study group was 53.68 years. Young age at marriage (mean age 17.31), early first child birth (mean age being 20.5 years) and increased parity (86.66% had parity 3 and above) with majority of children born at home under supervision of untrained dais (77.78%) could probably attribute to their prolapse. Approximately 51% thought that prolapse occurs as a result of hard manual work and 64% cases considered it non treatable. POP was associated with poor quality of life in terms of physical, social and sexual life. Decreased sexual frequency was seen in 86.67% cases. 50% cases reported bladder problems. Sense of incomplete evacuation was seen in nearly 35% and constipation was reported by 37%.

Conclusion

Though there exists a social stigma associated with pelvic organ prolapse, this study showed that in majority, it was the woman herself who delayed medical help. Health care providers should take initiative in educating women regarding prolapse and to make them aware that it is a treatable condition which can improve their quality of life.

The relationship between pelvic organ prolapse and short birth intervals in a rural area of Nepal

Background

Pelvic organ prolapse (POP) is one of the main contributors to reproductive health problems that affect women’s quality of life. Previous studies have reported the risk factors and prevalence of POP. The aim of this study is to examine the association between POP and short birth intervals in a rural area of Nepal.

Methods

A cross-sectional study was conducted in Panchapuri municipality, located in Surkhet District of Karnali Province in Nepal. A questionnaire was used to collect information on POP, birth intervals, and other known confounding factors, such as age and parity. Multiple logistic regression analysis was used to examine the association between minimum birth intervals and POP.

Results

The study recruited 131 women. The prevalence of POP was 29.8%. The mean (SD) of maternal age was 32.3 (0.7) years. The median parity was 2, with a range of 2–6 children. More than half (64.9%) of the women reported a minimum birth interval of less than 2 years. Maternal age at birth, minimum birth interval, parity, and latest birth interval were significantly associated with POP in univariate analyses. After adjusting for the potential confounding factors such as age and occupation, the minimum birth interval was significantly associated with POP [AOR = 3.08, 95% CI 1.04–9.19].

Conclusion

The prevalence of POP was high in this rural area of Nepal. Age, parity, occupation, and minimum birth interval were significantly associated with POP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41182-021-00298-z.

Pelvic organ prolapse and treatment decisions- developing an online preference-sensitive tool to support shared decisions

Background

Female patients with pelvic organ prolapse and clinicians need to take decisions regarding treatment that are often unpredictable in relation to how they impact the future everyday lives of the patients.

This study formed the developmental phase of a larger study to develop and test an online tool to support shared decision-making.

Methods

Patients, health care professionals and other stakeholders participated in the development and evaluation process of this tool. The collected data was generated from observational studies, exploratory interviews with prompt cards and workshops with end users from four Danish gynecology outpatient clinics.

Results

Content analysis led to important themes. For the patients three themes emerged: 1) how the impact of symptoms on everyday life affected the need for relief, 2) their bodily perception and sex life and 3) their worries about the future. For clinicians the different symptoms and their severity was a main theme.

Conclusions

This article provides an overall description and discussion of the development methodology. It demonstrates how user involvement informed the prototyping process and how patients’ preferences were included in the final prototype. Whether the tool actually increases SDM, remains to be tested in a pilot feasibility study.

Implementing pelvic floor muscle training for women with pelvic organ prolapse: a realist evaluation of different delivery models

BACKGROUND

Pelvic Floor Muscle Training (PFMT) has been shown to be effective for pelvic organ prolapse in women, but its implementation in routine practice is challenging due to lack of adequate specialist staff. It is important to know if PFMT can be delivered by different staff skill mixes, what barriers and facilitators operate in different contexts, what strategies enable successful implementation and what are the underlying mechanisms of their action. PROPEL intervention was designed to maximise the delivery of effective PFMT in the UK NHS using different staff skill mixes. We conducted a realist evaluation (RE) of this implementation to understand what works, for whom, in what circumstances and why.

METHODS

Informed by the Realist and RE-AIM frameworks, the study used a longitudinal, qualitative, multiple case study design. The study took place in five, purposively selected, diverse NHS sites across the UK and proceeded in three phases to identify, test and refine a theory of change. Data collection took place at 4 time points over an 18 month implementation period using focus groups and semi-structured interviews with a range of stakeholders including service leads/managers, senior practitioners, newly trained staff and women receiving care in the new service models. Data were analysed using thematic framework approach adapted to identify Context, Mechanism and Outcome (CMO) configurations of the RE.

RESULTS

A heightened awareness of the service need among staff and management was a mechanism for change, particularly in areas where there was a shortage of skilled staff. In contrast, the most established specialist physiotherapist-delivered PFMT service activated feelings of role protection and compromised quality, which restricted the reach of PFMT through alternative models. Staff with some level of prior knowledge in women's health and adequate organisational support were more comfortable and confident in new role. Implementation was seamless when PFMT delivery was incorporated in newly trained staff's role and core work.

CONCLUSION

Roll-out of PFMT delivery through different staff skill mixes is possible when it is undertaken by clinicians with an interest in women's health, and carefully implemented ensuring adequate levels of training and ongoing support from specialists, multi-disciplinary teams and management.

A qualitative evidence synthesis using meta-ethnography to understand the experience of living with pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) affects the lives of many people. We aimed to systematically search for, identify and synthesize qualitative research that explores what it is like to live with POP and make this knowledge available for healthcare improvement.

METHODS

We systematically searched Medline, PsychInfo, Embase and CINAHL, from inception to March 2020, for qualitative research exploring the experience of living with POP. We used meta-ethnography to synthesize findings. This is a conceptual approach to qualitative evidence synthesis. We used the recent guidelines for reporting meta-ethnography.

RESULTS

We screened 3103 titles and 255 abstracts and included 37 primary studies. These incorporated the experience of 777 women, (aged 18 to 95 years) from a range of countries. We organized 162 ideas into 27 conceptual categories and 10 themes. We developed a conceptual model that helps us to understand the experience of pelvic organ prolapse. This model indicates that (1) the physical losses of POP are intricately linked to loss of identity; (2) women conceptualized POP as part of womanhood, yet also its thief; (3) there is a vicious cycle of taboo, silence and misunderstanding about POP and its treatment; (4) this silence is exacerbated by a feeling that POP is not taken seriously in healthcare.

CONCLUSIONS

This meta-ethnography helps us to understand the experience of living with a POP. Our model illustrates the complex process of healthcare decision making. Further studies to explore the complexity of decision making from the perspective of patient and health professional are timely.

Pelvic organ prolapse management

Pelvic organ prolapse describes the loss of support and subsequent descent of pelvic organs into the vagina. It is common, affecting up to 50% of parous women, and can be accompanied by a number of burdening symptoms. Prolapse has been thrown into the spotlight secondary to mesh-related complications. There are a number of effective treatment options to consider when managing pelvic organ prolapse and most do not require mesh. Patients' choice, comorbidities and likelihood of treatment success should be considered when making decisions about their care. Vaginal mesh surgery is currently on hold in the UK and even prior to this there has been a reduction both in the number of all prolapse surgeries and the number of women seeking surgery to manage their symptoms. This article reviews the current evidence for the management of pelvic organ prolapse, providing an update on the current state of mesh in prolapse surgery and summarises the key evidence points derived from the literature.

'What research was carried out on this vaginal mesh?' Health-related concerns in women following mesh-augmented prolapse surgery: a thematic analysis

OBJECTIVE

To understand health-related issues in women following mesh-augmented prolapse surgery.

DESIGN

Inductive thematic analysis of free-text comments from participants in a cross-sectional study of laparoscopic mesh sacrohysteropexy.

SETTING

Tertiary urogynaecology centres, United Kingdom.

POPULATION

Women who underwent laparoscopic mesh sacrohysteropexy by surgeons based at two tertiary urogynaecology centres between 2010 and 2018.

METHODS

A total of 1766 potential participants were contacted by post and invited to complete paper, online or telephone questionnaires containing a free-text comments section. Of 1121 participants (response proportion 63.5%), 752 (67.1%) provided such comments. These were analysed with a six-stage inductive thematic analysis, using NVivo 11® software.

MAIN OUTCOME MEASURES

Themes developed from free-text comments.

RESULTS

Following familiarisation, 29 codes and 189 sub-codes were identified. These defined six themes: pelvic floor symptoms, health status, treatment success, mesh, pain and care received. The majority of comments centred on the first of these six themes. There were concerns about mesh use and a desire for more information. A range of pain symptoms were mentioned, often associated with pelvic floor symptoms, prolapse surgery or mesh.

CONCLUSIONS

Despite the mesh controversy, pelvic floor symptoms and their impact on quality of life remain the principle concern of women following mesh-augmented prolapse surgery. There is a need for quality, accessible and evidence-based information sources for those women with concerns, and for those considering such surgery in the future, particularly regarding mesh safety and postoperative recovery. The relationships between pain, prolapse, mesh and pelvic floor surgery require further study.

TWEETABLE ABSTRACT

Following mesh-augmented prolapse surgery, pelvic floor symptoms remain women's main focus; pain deserves further research.

Barriers to seeking consultation for abnormal uterine bleeding: systematic review of qualitative research

Background

Although Abnormal Uterine Bleeding (AUB) can have serious medical consequences and significantly impacts daily life, the overall trend is that most women do not seek care for these symptoms. The objective of this review was to synthesise factors impeding women’s access care for AUB.

Methods

Systematic literature review of qualitative studies (interview and focus group) regarding the lived in experiences of women with abnormal menstrual symptoms, followed by a thematic analysis of these studies. We screened CINAHL, SCOPUS, ProQuest, OVID and Pubmed for qualitative studies. Studies were assessed using the Clinical Appraisal Skills Programme checklist and thematic synthesis was used to develop themes from the findings of the studies.

Results

The review yielded 12 studies that satisfied the inclusion criteria. Three themes were developed that described barriers for women seeking care for AUB: health literacy (understanding of normal periods, role of cervical Pap smears and lack of access to appropriate information), taboo/normalisation (fear and embarrassment of symptoms, prioritising others) and health care provider (lack of accessible and trusted female GPs and poor experiences with GPs).

Conclusions

For 20 years women have consistently reported poor experiences in accessing care for AUB. The findings from our review indicate that drivers to impeding access are multiple; therefore any approaches to improve access will need to be multi-level – from comprising local sociocultural considerations to improved GP training.

A systematic review and meta-synthesis of qualitative studies on pelvic organ prolapse for the development of core outcome sets

AIMS

In the current climate of evidence-based health care, the aim of this meta-synthesis was to collect and systematically analyse data from primary qualitative studies on pelvic organ prolapse (POP), to identify patient-centered perspectives on the natural course of POP. Information acquired in this study may be useful for ongoing research towards the development of core outcome sets (COS) in pelvic floor disorders.

METHODS

A CHORUS Working Group performed a standardized search of three different databases (Medline, Embase, Scopus), from inception to October 2019. We selected qualitative studies on women's perspectives on POP that were published in the English language. Three reviewers independently evaluated the quality of eligible papers and highlighted recurrent themes based on patient perspectives.

RESULTS

Eighteen qualitative studies including a total of 497 patients were assessed in this analysis. Our study revealed five superordinate themes, recurrently encountered in qualitative studies on POP: awareness of POP (6 studies), communication (9 studies), treatments (10 studies), effects on quality of life (6 studies), and self-image (3 studies). Five out of 10 quality criteria were met by all the studies included, based on an assessment performed using the critical appraisal skills program.

CONCLUSIONS

This is the first synthesis of qualitative studies that address POP-related experiences of women, highlighting five superordinate themes, of which treatment was the most commonly reported one. This synthesis' findings may guide quantitative research priorities and will hopefully contribute to the development of a COS for POP.

Vaginal Pessaries for Pelvic Organ Prolapse and Their Impact on Sexual Function

INTRODUCTION

Pelvic organ prolapse (POP) is a common condition among parous women and its prevalence increases with age. Vaginal pessaries are one of the management options for women with prolapse. In the current health climate, where there are controversy surrounding surgical procedures, an increasing number of women are considering a pessary over surgical management.

AIM

This article aims to provide an overview of POP, its associated symptoms, and the different types of pessaries available. It will go on to describe how sexual activity (SA) and sexual function (SF) needs to be considered as part of the pessary selection discussion, and common concerns expressed by women.

METHODS

A literature review was undertaken to record the current evidence regarding SA and pessary use, and clinical practice and experience are discussed.

MAIN OUTCOME MEASURES

The main outcome of this study was to consider the preservation or restoration of SF in women using a pessary for prolapse.

RESULTS

There are several pessaries available on the market that enable women to maintain SA, and for many of these it will not be noticeable to their partners. If, however, the woman or their partner finds the pessary uncomfortable or obstructing during intercourse, women can be trained to remove and reinsert their pessary as necessary. The evidence suggests that, for those women who are sexually active with their pessaries in situ, they are happy and continue with this form of management in the long term.

CONCLUSION

Health care professionals need to ensure that SF or the desire to be sexually active (in whatever form that may be) is assessed and discussed as part of routine care and is considered in all decision making. Rantell A. Vaginal Pessaries for Pelvic Organ Prolapse and Their Impact on Sexual Function. Sex Med Rev 2019;7:597-603.