Introduction

Pelvic organ prolapse (POP) is a common pelvic floor disorder in women. Women suffering from POP report symptomatic distress and impaired quality of life (QOL) [1, 2]. Their symptoms may be related to urinary or bowel systems or organ prolapse. A recent study reported considerable discrepancies between physician interview and patient self-assessment questionnaire on POP symptoms [3]. Using a condition-specific health-related QOL questionnaire can provide more objective and comprehensive assessment of women’s symptoms and QOL. Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) are reliable, valid, and comprehensive condition-specific and QOL instruments for women with pelvic floor disorders [4]. A validated Chinese version is available [5]. There are different treatment options for POP, namely, expectant management, vaginal pessary, or surgery. There is considerably more literature evaluating treatments and outcomes, especially surgical outcomes, than factors affecting women’s choice of treatment. The effect of POP on QOL of women could be one of these factors, as impairment of QOL of women suffering from urinary incontinence has been shown to be a factor in them preferring the surgical option [6, 7]. The aim of this prospective observational study was to investigate the symptoms and QOL of women suffering from POP. Factors affecting their decision on treatment choice were also studied. Ethics approval for the study was granted by the Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee on 4 December 2007 [CRE-2007.437].

Materials and methods

All women with POP presenting to the urogynecology clinic and who had not been treated prior to the initial consultation were invited to join the study. They could have recurrence of POP following previous surgery for prolapse. Exclusion criteria included mental incapacity or previous vaginal pessary. Written consent was obtained. All participants filled in the Chinese version of PFDI, PFIQ, and Short Form-36 (SF-36) before their consultation [5, 8]. The generic questionnaire SF-36 was used to assess the general health of these women. It was designed to measure health-related QOL. It comprises eight domains and measures physical functioning, role limitation due to physical problems, role limitation due to emotional problems, social functioning, mental health, energy/vitality, pain, and general health perception. A higher score indicates better QOL. A Hong Kong Chinese version has been validated for use [8]. Women were also asked independently to grade the overall severity of symptoms on a visual analogue scale (VAS) from 0 to 10, with a higher score indicating greater severity of symptoms. Following completion of these instruments, every woman was assessed by the attending gynecologist, who was blinded to the information obtained from the questionnaires. Clinical data and sociodemographic data, including age, gravidity, parity, and menstrual status, were obtained. The attending gynecologist then examined the participants and determined the type and staging of the POP according to the Pelvic Organ Prolapse Quantification (POP-Q) system [9]. All women who had urinary symptoms had uroflowmetry and cystometry, and diagnoses were made according to criteria of the International Continence Society [10]. Prolapse was reduced by vaginal ring pessary on the day of cystometry.

All women were counseled about their conditions, including prolapse type, POP stage, any concomitant urodynamic stress incontinence (USI), and management options available, namely, expectant management, vaginal pessary, and surgery. A two-page information sheet was also given to them that included a brief introduction to POP, treatment options (expectant management, vaginal pessary, and surgery), and the potential risks associated with the respective treatment options. The only active treatment provided on the day was a vaginal ring pessary. Surgical options available included vaginal hysterectomy and pelvic floor repair (VHPFR), vaginal mesh repair (VM), and laparoscopic sacrocolpopexy (LS). Pelvic floor repair included anterior colporrhaphy or posterior colporrhaphy and were offered where appropriate. Synthetic type I polypropylene mesh, anterior, posterior, or total where appropriate, were used in VM repair surgery. In general, women with stage I/II uterine prolapse were offered VHPFR, those with stage III/IV uterine prolapse were offered VHPFR with sacrospinous ligament fixation or VM, and those with stage III/IV vaginal vault prolapse were offered VM or LS [11]. Concomitant anti-incontinence surgery was offered if they had USI. Management was decided upon according to each woman’s condition and preferences.

Women who opted for expectant management or vaginal pessary were reviewed after 4–6 months. Symptoms of complications including vaginal bleeding, vaginal discharge that were not tolerable, vaginal discomfort or failure to retain vaginal pessary, and increase in SUI were assessed using a standardized data sheet and speculum examination. If complications arose, they were again counseled about the complications and treatment options of POP. Women could choose to continue with vaginal pessary if they wished. In case of failure to retain the vaginal pessary, another size was tried. Women who opted for surgical treatment at the first consultation or during follow-up were scheduled for the relevant operation. As the waiting time of surgery was long (generally 6–9 months) in our institution because of service demand, women could have expectant management or trial vaginal pessary before surgery. They might opt out of surgical treatment if they preferred to use vaginal pessary after the trial. Women who opted for expectant management but had concomitant urinary incontinence were offered pelvic floor exercises.

Statistics and sample size

Descriptive statistics were used to determine symptom prevalence. Chi-square or Fisher’s exact test was used for nonparametric data. Analysis of variance (ANOVA) was used to study the difference between PFDI and PFIQ scores and other variables between different groups. Direct logistic regression analysis was performed to identify factors predicting likelihood of women opting for surgical treatment. All analyses were performed with the Statistical Package for Social Science version 17.0 (SPSS Inc., IL, USA). Significance level was set at P < 0.05. Assuming a prevalence of a specific symptoms, e.g., SUI, was 50% and an accepted error was set at 5%, a sample size of >234 was needed.

Results

From September 2008 to May 2010, 354 women were seen on a consultation basis for POP; for this study, 20 (5.6%) were excluded, 26 (7.4%) refused to participate or did not complete the study, and 308 (87.0%) completed. Mean age was 59.9 ± 10.5 (range 34–87) years, and mean number of vaginal deliveries was 3.1 ± 1.5. In all, 215 (69.8%) were postmenopausal, and 33 (10.7%) previously had a hysterectomy. Whereas 247 (80.2%) women had a chief complaint of POP, 60 (19.5%) had urinary symptoms and one (0.3%) had fecal incontinence; 283 (91.9%), 261 (84.7%), and 183 (59.4%) had at least one type of urinary, prolapse, or bowel symptom respectively. According to the POP-Q assessment, 66 (21.4%), 164 (53.3%), and 78 (25.3%) had stage I, stage II, and stage III/IV prolapse, respectively; prolapse stage in each compartment is listed in Table 1. The prevalence of urinary or prolapse symptoms and complications and bowel symptoms are listed in Table 2. Women who had stage III/IV prolapse had significantly more prolapse symptoms compared with the stage I/II group. There was significantly more SUI in the stage I/II group.

Table 1 Overall staging of prolapse and in each compartment according to Pelvic Organ Prolapse Quantification (POP-Q)
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Table 2 Prevalence of different symptoms in women with pelvic organ prolapse (POP)
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PFDI, PFIQ, and SF-36 scores according to prolapse stage are shown in Tables 3 and 4. There were higher Urogenital Distress Inventory (UDI) obstructive subscale, Pelvic Organ Prolapse Distress Inventory (POPDI), and anterior and general subscale scores in the stage III/IV group compared with the stage I/II group. However, the Colorectal–Anal Distress Inventory (CRADI) total score and its rectal prolapse subscale scores were significantly higher in the stage I/II group. With regard to the impact on QOL, the emotional and physical activity subscales of POPIQ were statistically higher in the stage III/IV group compared with the stage I/II group. The stage I/II group regarded themselves as being more impaired in their general health according to the SF-36 (Table 4). There was greater impact on QOL from urinary symptoms than from prolapse or colorectal–anal symptoms {UIQ 67.6 ± 81.9 vs POPIQ 59.8 ± 78.4 vs Colorectal–Anal Impact Questionnaire (CRAIQ) 27.5 ± 60.1; P <0.05).

Table 3 Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) scoring in all women according to pelvic organ prolapse (POP) staging
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Table 4 Short-Form 36 (SF-36) scoring in all women and different stages of pelvic organ prolapse (POP)
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In all, 266 women had urodynamic studies: 155 (50.3%) had no abnormality detected, and 92 (29.9%), 13 (4.2%), and 6 (1.9%) had urodynamic stress incontinence (USI), detrusor overactivity (DO), and concomitant USI and DO, respectively. There was no difference in USI with prolapse staging (P = 0.52).

At the writing of this report, which was at least 1 year after the first consultation, 92 (29.9%), 57 (18.5%), and 159 (51.6%) women chose expectant management, vaginal pessary, and surgery, respectively. None in the expectant management or vaginal pessary group was still awaiting surgery. Overall, 197 women (64.0%) tried vaginal pessary, but 59 failed to retain the pessary; 70 (76.1%) and 41 (25.8%) of the expectant and surgery groups opted not to try vaginal pessary. Factors that affected the treatment received are shown in Table 5. Direct logistic regression analysis was performed to assess the impact of seven independent factors on the likelihood that women would opt for surgical treatment. The full model distinguished women who had surgical treatment for POP from those who declined surgery. Four factors made statistically significant contributions to the model. The strongest predictor was complications from the use of vaginal pessary, with an odds ratio (OR) of 4.02. OR of 1.01 for POPDI scoring indicated that for every additional POPDI score, women were 1.01 times more likely to opt for surgical treatment, controlling for other factors in the model (Table 6).

Table 5 Factors affecting treatment chosen at 1 year
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Table 6 Logistic regression predicting likelihood of women having surgical treatment for pelvic organ prolapse (POP)
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Discussion

Most literature on POP focused on treatment outcomes, and most pertains to women from the Western world. There may be ethnic differences in the experience of POP in Chinese women because hormonal replacement therapy usage is less common among Chinese women, and Western women tend to remain sexually active longer than Chinese women [12]. This study evaluated symptoms, QOL, and factors affecting women’s choice on treatment. This may be useful not only for health care providers referring women with POP to appropriate specialists for further care, but also for physicians offering treatment.

In our study, there was a high prevalence of urinary, prolapse, and colorectal–anal symptoms in women presenting with POP, although the prevalence of all three was lower than reported in the literature [13, 14]. As expected, SUI was more prevalent in the stage I/II POP group. Awareness of vaginal lump, dragging discomfort, subjective feeling of the prolapse affecting walking or daily activity was also expected to be greater in the stage III/IV group. In addition, symptoms of distress evaluated by UDI obstructive subscale and POPDI general and anterior subscales were significantly more important in the latter group. However, symptoms of distress arising from the bowel, as evaluated by CRADI total and rectal subscales, were more prominent in the stage I/II group.

There is little doubt that women with POP suffered impaired QOL. Their UIQ scores were higher than their POPIQ scores. Women may regard urinary symptoms as more bothersome, and in general, more urinary symptoms were reported than prolapse symptoms. Although the SF-36 is not a condition-specific health-related QOL instrument, its use in general health assessment allows comparison with the normal population. Age has a significant effect on SF-36 scoring [8, 15]. However, when compared with the local female population norm of the 41–64 year-old group, or even ≥65 years, women with POP had lower scores in all domains, except in general health subscales, when compared with ≥65-year-old group [8]. This indicates that POP had a substantial impact on QOL. It was noteworthy that stage I/II POP women scored significantly lower in general health compared with the stage III/IV group. This implies that stage I/II POP women regarded themselves as having poorer general health than women with a greater degree of prolapse. This apparently incongruous finding requires further study.

Rates of complications and failure to retain the vaginal pessary were comparable to reported rates in the published literature [16–18]. Reported discontinuation rate of vaginal pessary range from 8% to 56% [16, 18, 19]. It is understandable that women who had complications from vaginal pessary use or who failed to retain their pessary would be more likely to choose surgical treatment. After prolapse reduction by vaginal pessary, SUI may also increase [19]. Many women may decline vaginal pessary, especially if they regard SUI as more bothersome than prolapse symptoms. Women with concomitant USI were 3.3 times more likely to choose surgical treatment. Future study using incontinence pessary with knob in women with concomitant USI is important to further refine this information.

Three factors were found to predict the likelihood of women opting for surgery after consultation and vaginal pessary trial: USI and POP stage were clinical factors that might have influenced physician’s counseling on treatment options. However, complications arising from vaginal pessary use and the woman’s experience are both clinical factors. Where complications arose from vaginal pessary use and subsided, women were offered continuing use of vaginal pessary or other treatments, including surgery. Therefore, the final decision would include all remaining viable options, including vaginal pessary or expectant treatment. In such a situation, counseling and recommendation from the attending physician was not the only available option. The fourth factor, POPDI, was related to the degree of the woman’s symptomatic distress. For every point 1 increase in score, there was a, relatively minor, 1.01 increase in the likelihood of the women choosing surgery. Although the higher the POPDI score, the higher the likelihood of women choosing surgery, this factor had a relatively mild influence on women’s decisions to undergo surgery. Interestingly, QOL, as indicated by POPIQ, was not found to be a significant factor.

The decision-making process for managing POP by a woman with this condition is likely to be more complex than is possible to investigate in this study. It may well be that exploration of this process will require qualitative research, with its advantages and disadvantages. One of the limitations of this study was that choice of treatment by the woman is unlikely to be totally free from the influence of the attending physician, although as far as possible, nondirective and standardized counseling was offered to all women in this study. We evaluated the treatment type that women received at least 1 year after first consultation, and they may have tried expectant management or vaginal pessary before surgery. It would be interesting to study the treatment women received in a longer follow up as this is a continually evolving situation. It is inevitable that as follow-up duration increases, more women will eventually opt for some form of surgery. Understanding this process will require further research.

Women’s preferences may have been influenced by factors not considered in this study. Basu et al. showed that women with prolapse were less willing to risk potential complications for a greater chance of long-term cure [6]. Other factors, such as direct cost, may have an impact. In this study, VM repair was not commonly used. Conventional surgery had virtually no direct cost to patients in this study, but the VM device was paid for by the patient. Anterior or posterior VM costs about US $1,100, and total mesh costs about US $1,700; for some patients, this is a considerable expense. However, sacrocolpopexy was an alternative that could have been chosen, with little direct cost.

This study provides information at 1 year after initial presentation. There was lack of objective assessment using PFDI and PFIQ during follow-up. Whether there are changes affecting a woman’s decision regarding treatment options needs further study. Women with USI and detrusor overactivity had impaired marital relationship and sexual function [20]. However, the impact of POP on these issues was not explored in this study. At present, there is no satisfactory validated Chinese instrument in our locality to assess these issues.

Conclusion

Chinese women with POP have considerable symptomatic distress arising from urinary and bowel systems and from POP. They also have impaired QOL compared with the population norm of the same age. Complications with vaginal pessary, concomitant USI, POP stage, and POPDI scoring were factors associated with an increased likelihood of a woman opting for surgical treatment. This has some implication for counseling and may assist physicians in helping women to arrive at an informed choice in this troublesome yet seldom life-threatening condition.