Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life

doi:10.1016/j.ajog.2006.01.060

American Journal of Obstetrics and Gynecology

Volume 194, Issue 5, May 2006, Pages 1455-1461

https://doi.org/10.1016/j.ajog.2006.01.060 Get rights and content

Objective

Women who seek treatment for pelvic organ prolapse strive for an improvement in quality of life. Body image has been shown to be an important component of differences in quality of life. To date, there are no data on body image in patients with advanced pelvic organ prolapse. Our objective was to compare body image and quality of life in women with advanced pelvic organ prolapse with normal controls.

Study design

We used a case-control study design. Cases were defined as subjects who presented to a tertiary urogynecology clinic with advanced pelvic organ prolapse (stage 3 or 4). Controls were defined as subjects who presented to a tertiary care gynecology or women's health clinic for an annual visit with normal pelvic floor support (stage 0 or 1) and without urinary incontinence. All patients completed a valid and reliable body image scale and a generalized (Short Form Health Survey) and condition-specific (Pelvic Floor Distress Inventory-20) quality-of-life scale. Linear and logistic regression analyses were performed to adjust for possible confounding variables.

Results

Forty-seven case and 51 control subjects were enrolled. After controlling for age, race, parity, previous hysterectomy, and medical comorbidities, subjects with advanced pelvic organ prolapse were more likely to feel self-conscious (adjusted odds ratio 4.7; 95% confidence interval 1.4 to 18, P = .02), less likely to feel physically attractive (adjusted odds ratio 11; 95% confidence interval 2.9 to 51, P < .001), less likely to feel feminine (adjusted odds ratio 4.0; 95% confidence interval 1.2 to 15, P = .03), and less likely to feel sexually attractive (adjusted odds ratio 4.6; 95% confidence interval 1.4 to 17, P = .02) than normal controls. The groups were similar in their feeling of dissatisfaction with appearance when dressed, difficulty looking at themselves naked, avoiding people because of appearance, and overall dissatisfaction with their body. Subjects with advanced pelvic organ prolapse suffered significantly lower quality of life on the physical scale of the SF-12 (mean 42; 95% confidence interval 39 to 45 versus mean 50; 95% confidence interval 47 to 53, P < .009). However, no differences between groups were noted on the mental scale of the SF-12 (mean 51; 95% confidence interval 50 to 54 versus mean 50; 95% confidence interval 47 to 52, P = .56). Additionally, subjects with advanced pelvic organ prolapse scored significantly worse on the prolapse, urinary, and colorectal scales and overall summary score of Pelvic Floor Distress Inventory-20 than normal controls (mean summary score 104; 95% confidence interval 90 to 118 versus mean 29; 95% confidence interval 16 to 43, P < .0001), indicating a decrease in condition-specific quality of life. Worsening body image correlated with lower quality of life on both the physical and mental scales of the SF-12 as well as the prolapse, urinary, and colorectal scales and overall summary score of Pelvic Floor Distress Inventory-20 in subjects with advanced pelvic organ prolapse.

Conclusion

Women seeking treatment for advanced pelvic organ prolapse have decreased body image and overall quality of life. Body image may be a key determinant for quality of life in patients with advanced prolapse and may be an important outcome measure for treatment evaluation in clinical trials.

Section snippets

Material and Methods

The Cleveland Clinic Foundation Institutional Review Board approved this study. This was a case-control study design. Subjects were currently enrolled in an ongoing, case-control study investigating functional bowel and anorectal disorders in patients with advanced pelvic organ prolapse. Ninety-eight subjects were enrolled at the time of this analysis. Cases were defined as subjects presenting to a tertiary urogynecology clinic with advanced pelvic organ prolapse stage 3 or 4 using the Pelvic

Results

Forty-seven case and 51 control subjects were enrolled. Demographic information of the case and control subjects are shown in Table I. Control subjects were more likely to be younger and nonwhite and have had more formal education. Cases were more likely to report higher vaginal parity and to have undergone previous hysterectomy.

Responses to the body image scale are shown in Table II. After controlling for age, race, parity, medical comorbidities, and previous hysterectomy, subjects with

Comment

Pelvic organ prolapse causes symptoms that have an impact on a woman's daily activities and negatively affect her quality of life. When these symptoms are severe enough, women seek care from health care providers. However, the relationship between these symptoms and pelvic organ prolapse is slightly more complex. For example, there are weak to moderate correlations between the degree of vaginal prolapse and the presence of specific symptoms such as vaginal bulge, heaviness, and voiding

References (26)

J.C. Lasry et al.
Depression and body image following mastectomy and lumpectomy
J Chronic Dis
(1987)
M.S. Lee et al.
Mastectomy or conservation for early breast cancer: psychological morbidity
Eur J Cancer
(1992)
M. Noguchi et al.
Psychologic and cosmetic self-assessments of breast conserving therapy compared with mastectomy and immediate breast reconstruction
J Surg Oncol
(1993)
W.S. Schain et al.
Mastectomy versus conservative surgery and radiation therapy. Psychosocial consequences
Cancer
(1994)
N. Yilmazer et al.
A comparison of body image, self-esteem and social support in total mastectomy and breast-conserving therapy in Turkish women
Support Care Cancer
(1994)
R.C. Bump et al.
The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction
Am J Obstet Gynecol
(1996)
J. Ware et al.
A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity
Med Care
(1996)
B. Gandek et al.
Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment
J Clin Epidemiol
(1998)
M. Barber et al.
Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7)
Am J Obstet Gynecol
(2005)
P. Hopwood et al.
A body image scale for use with cancer patients
Eur J Cancer
(2001)

R. Garry et al.

The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy

BMJ

(2004)

E.C. Samuelsson et al.

Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors

Am J Obstet Gynecol

(1999)

R.M. Ellerkmann et al.

Correlation of symptoms with location and severity of pelvic organ prolapse

Am J Obstet Gynecol

(2001)

Cited by (344)

Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it?
2024, American Journal of Obstetrics and Gynecology
Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor.
Long-term Results of Sexual Function and Body Image After Vaginoplasty With Acellular Dermal Matrix in Women With Mayer-Rokitansky-Küster-Hauser Syndrome
2024, Journal of Minimally Invasive Gynecology
To describe the long-term anatomic and sexual functional results of vaginoplasty with acellular dermal matrix (ADM) in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) and to evaluate the changes in body image pre- and postoperatively in these patients.
A retrospective study from March 2015 to September 2021.
A tertiary teaching hospital.
Forty-two patients with MRKH syndrome who underwent vaginoplasty with ADM (the MRKH group) and 30 sexually active, nulliparous, aged-matched women (the control group).
The relevant data were retrospectively collected via our electronic medical record system and were analyzed statistically.
Vaginal length was assessed using a 3-cm-diameter mold. The Chinese version of the Female Sexual Function Index questionnaire was used to evaluate sexual function. The Chinese version of the modified body image scale was applied to evaluate body image. The median follow-up time was 57 months (range, 13–91 months). Granulomatous polyps in the neovagina were the most common postoperative complication (7 of 42, 16.7%). Patients with MRKH syndrome can achieve long-term satisfactory outcomes both anatomically and functionally after vaginoplasty with ADM, comparable with those of healthy control women. The vaginal length in the MRKH group was comparable to that in the control group ( 8.04 ± 0.51 cm vs. 8.15 ± 0.46 cm, respectively). The FSFI scores were similar between the MRKH (26.54 ± 3.44) and control (26.80 ± 2.23) groups. The modified body image scale score was significantly decreased after vaginoplasty with ADM.
Vaginoplasty with ADM is a minimally invasive and effective procedure for patients with MRKH syndrome.
Clinical effectiveness of vaginal pessary self-management vs clinic-based care for pelvic organ prolapse (TOPSY): a randomised controlled superiority trial
2023, eClinicalMedicine
Prolapse affects 30–40% of women. Those using a pessary for prolapse usually receive care as an outpatient. This trial determined effectiveness and cost-effectiveness of pessary self-management (SM) vs clinic-based care (CBC) in relation to condition-specific quality of life (QoL).
Parallel-group, superiority randomised controlled trial, recruiting from 16 May 2018 to 7 February 2020, with follow-up to 17 September 2021. Women attending pessary clinics, ≥18 years, using a pessary (except Shelf, Gellhorn or Cube), with pessary retained ≥2 weeks were eligible. Limited manual dexterity; cognitive deficit; pregnancy; or requirement for non-English teaching were exclusions. SM group received a 30-min teaching session; information leaflet; 2-week follow-up call; and telephone support. CBC group received usual routine appointments. The primary clinical outcome was pelvic floor-specific QoL (PFIQ-7), and incremental net monetary benefit for cost-effectiveness, 18 months post-randomisation. Group allocation was by remote web-based application, minimised on age, user type (new/existing) and centre. Participants, intervention deliverers, researchers and the statistician were not blinded. The primary analysis was intention-to-treat based. Trial registration: https://doi.org/10.1186/ISRCTN62510577.
The requisite 340 women were randomised (169 SM, 171 CBC) across 21 centres. There was not a statistically significant difference between groups in PFIQ-7 at 18 months (mean SM 32.3 vs CBC 32.5, adjusted mean difference SM-CBC −0.03, 95% CI −9.32 to 9.25). SM was less costly than CBC. The incremental net benefit of SM was £564 (SE £581, 95% CI −£576 to £1704). A lower percentage of pessary complications was reported in the SM group (mean SM 16.7% vs CBC 22.0%, adjusted mean difference −3.83%, 95% CI –6.86% to −0.81%). There was no meaningful difference in general self-efficacy. Self-managing women were more confident in self-management activities. There were no reported suspected unexpected serious adverse reactions, and 31 unrelated serious adverse events (17 SM, 14 CBC).
Pessary self-management is cost-effective, does not improve or worsen QoL compared to CBC, and has a lower complication rate.
National Institute for Health and Care Research, Health Technology Assessment Programme (16/82/01).
Management of female pelvic organ prolapse—Summary of the 2021 HAS guidelines
2023, Journal of Gynecology Obstetrics and Human Reproduction
When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life and rule out other pelvic pathologies. The prolapse should be described compartment by compartment, indicating the extent of the externalization for each. The diagnosis of POP is clinical. Additional exams may be requested to explore the symptoms associated or not explained by the observed prolapse. Pelvic floor muscle training and pessaries are non-surgical conservative treatment options recommended as first-line therapy for pelvic organ prolapse. They can be offered in combination and be associated with the management of modifiable risk factors for prolapse. If the conservative therapeutic options do not meet the patient's expectations, surgery should be proposed if the symptoms are disabling, related to pelvic organ prolapse, detected on clinical examination and significant (stage 2 or more of the POP-Q classification). Surgical routes for POP repair can be abdominal with mesh placement, or vaginal with autologous tissue. Laparoscopic sacrocolpopexy is recommended for cases of apical and anterior prolapse. Autologous vaginal surgery (including colpocleisis) is a recommended option for elderly and fragile patients. For cases of isolated rectocele, the posterior vaginal route with autologous tissue should be preferentially performed over the transanal route. The decision to place a mesh must be made in consultation with a multidisciplinary team. After the surgery, the patient should be reassessed by the surgeon, even in the absence of symptoms or complications, and in the long term by a primary care or specialist doctor.
Primary care providers practice patterns regarding female pelvic floor disorders
2024, Family Medicine and Community Health
Oestrogen therapy for preventing pelvic organ prolapse in postmenopausal women
2024, Cochrane Database of Systematic Reviews

View all citing articles on Scopus

View full text

Transactions from the Twenty-Sixth Annual Meeting of the American Urogynecologic SocietyWomen seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life

Objective

Study design

Results

Conclusion

Section snippets

Material and Methods

Results

Comment

Depression and body image following mastectomy and lumpectomy

J Chronic Dis

Mastectomy or conservation for early breast cancer: psychological morbidity

Eur J Cancer

Psychologic and cosmetic self-assessments of breast conserving therapy compared with mastectomy and immediate breast reconstruction

J Surg Oncol

Mastectomy versus conservative surgery and radiation therapy. Psychosocial consequences

Cancer

A comparison of body image, self-esteem and social support in total mastectomy and breast-conserving therapy in Turkish women

Support Care Cancer

The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction

Am J Obstet Gynecol

A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity

Med Care

Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment

J Clin Epidemiol

Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7)

Am J Obstet Gynecol

A body image scale for use with cancer patients

Eur J Cancer

The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy

BMJ

Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors

Am J Obstet Gynecol

Correlation of symptoms with location and severity of pelvic organ prolapse

Am J Obstet Gynecol

Transactions from the Twenty-Sixth Annual Meeting of the American Urogynecologic Society
Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life