JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY, 2017 http://dx.doi.org/10.1080/0167482X.2017.1294155
PERSONAL VIEW
Pelvic organ prolapse: the impact on quality of life and psychological well-being Antonio Simone Lagan!aa , Valentina Lucia La Rosab Salvatore Giovanni Vitalea
, Agnese Maria Chiara Rapisardac and
a Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Messina, Italy; bUnit of Psychodiagnostics and Clinical Psychology, University of Catania, Catania, Italy; cDepartment of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
ABSTRACT
The aim of this work is to propose a brief comment about the impact of pelvic organ prolapse on the quality of life and the psychological well-being of the affected women.
ARTICLE HISTORY
Received 28 October 2016 Revised 30 January 2017 Accepted 4 February 2017 KEYWORDS
Cystocele; pelvic organ prolapse; quality of life
Pelvic organ prolapse (POP) is a complex condition resulting from defects in the supporting structures of the vagina [1]. It is defined as the descent of anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina [2,3]. Urogenital prolapse affects about 45% of women after the menopause, with a lifetime prevalence of 30% to 50% [2,4]. The main causes of POP include aging, pregnancy, delivery and previous pelvic surgery. Moreover, among the high-risk factors there are conditions that increase intra-abdominal pressure, such as chronic pulmonary disease, constipation, obesity and heavy manual labor [2]. The prevalence of POP is increasing because of the progressive ageing of the population and the increasing use of surgical therapy in gynecology [2,5,6]. The treatment of POP includes non-surgical and surgical management. Although surgical management of POP is currently adopted, non-surgical treatments such as pessaries, pelvic floor muscle training, or both can be useful in symptomatic improvement [7,8] as well as weight loss in case of obesity. Nevertheless, most of these treatments are not helpful for women with severe prolapse; therefore, surgical therapy is more appropriate in these cases. The surgical management, depending on the type of POP, includes apical suspension (sacral colpopexy and sacrospinous ligament fixation), anterior and posterior (colporrhaphy, perineorrhaphy and obliterative procedures) vaginal prolapse repair. The aims of CONTACT Valentina Lucia La Rosa 78, 95123 Catania (CT), Italy
[email protected]
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prolapse repair are relief of patient’s symptoms, restoration of the normal anatomy and function of the pelvic structures, prevention of recurrences, and repair of concomitant intrapelvic defects [9]. Regarding the contraindications, surgical treatment of prolapse is not indicated for patients with local vaginal diseases, who are not surgically fit or have early-stage asymptomatic prolapse [9]. In this regard, the use of meshes radically changed the scenario and outcomes of POP surgery: many studies about this topic have demonstrated that the surgical treatment of prolapse with mesh is efficient and acceptably safe [10–12]. However, according to the International Urogynecological Association’s (IUGA) Grafts Roundtable [13] the use of vaginal mesh in POP surgery should not be recommended in case of Stage I–II, local/systemic pain syndromes, possibility of pregnancy and does not seem to be highly effective in case of prolapse of posterior compartment and patients younger than 50 years; conversely, mesh surgery seems to achieve the best results for patients !50 years old, prolapse of anterior compartment ! Stage 2, deficient fascia, chronic increase intra-abdominal pressure and combined condition or recurrence. In addition, the use of mesh may have some complications that may occur either during or after repair of a prolapse. Intraoperative complications include bleeding, injury to bladder, ureter or urethra, nerve or bowel injury, anesthesia-related complications and
Unit of Psychodiagnostics and Clinical Psychology, University of Catania, Via Santa Sofia
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! ET AL. A. S. LAGANA
deep venous thrombosis (DVT), with the subsequent risk of pulmonary embolism (PE) [9,10]. Postoperative complications include infections, erosion of the mesh through the vagina or mesh contraction, de novo voiding symptoms and sexual dysfunctions [9]. In this regard, we take the opportunity to underline that the patient should be clearly informed about the possible adverse outcomes (and consequences) of each type of management, and participate in the decision making with the urogynecologist. POP is a very complex condition because it includes both physical and functional aspects [5]; for this reason, it can have a significant impact on quality of life and psychological well-being of the affected women. Indeed, prolapse may be associated with a variety of urinary, bowel and sexual symptoms which may significantly compromise the quality of life of the patients [3–5]. In particular, sexual dysfunctions are very common in women with POP and cystocele [4,5,14]. These women frequently report disorders of sexual desire, arousal, orgasm, and pain and these problems can decrease the quality of life and affect the relationship between partners [4]. Recent studies about this topic have investigated the quality of life and sexual function changes of women affected by POP and cystocele undergoing surgical treatment with vaginal mesh, but results are controversial [3,4,5,14–18]. According to some studies, surgical management of POP and cystocele considerably improves quality of life and sexual function of the patients in a long-term period after surgery [4,5,14], while other studies have underlined that sexual function might worsen in dyspareunia and behavior domains after mesh treatment [15–18]. According to these data, we think that a multidisciplinary approach in the treatment of women with POP and cystocele is very important. General and specific questionnaires have been designed and can be utilized to assess sexual quality of life in women with POP before and after surgery. Among these questionnaires, the most feasible and widely used are the Short Form-36 (SF-36) to evaluate the quality of life [19], and the Female Sexual Function Index (FSFI) to assess the effects on sexual function [20]. Nevertheless, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) is the most specific questionnaire to evaluate the impact of POP on sexual life of affected women [21]. Recently, the IUGA developed a new sexual function scale based on the original PISQ-12 questionnaire. The IUGARevised (PISQ-IR) questionnaire is a condition-specific tool designed to evaluate the sexual function in women with POP and urinary incontinence and its use is recommended to assess the impact of pelvic floor
disorders on quality of life and sexuality of affected women [22]. Moreover, the use of questionnaires to find the relationship between psychological symptoms and POP is a very important part of preoperative assessment. For this purpose, it would be appropriate to use tests such as the Minnesota Multiphasic Personality Inventory–2 (MMPI-2) [23] or Symptoms Checklist-90-R (SCL-90-R) [24] that investigate not only the presence of psychopathological symptoms, but also the personality traits in order to evaluate the presence of psychological comorbidities. In conclusion, taking into account the literature that underlines the significant impact of POP on emotional health and subjective well-being, this assessment should become an integral part of the therapeutic process of women affected by POP in order to ensure them a more adequate physical and functional rehabilitation [25–28].
Disclosure statement The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. No specific funding was obtained.
ORCID Antonio Simone Lagan!a 2802 Valentina Lucia La Rosa 6777 Salvatore Giovanni Vitale 6097
http://orcid.org/0000-0003-1543http://orcid.org/0000-0002-6619http://orcid.org/0000-0001-6871-
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! Current knowledge on the subject " Pelvic organ prolapse (POP) is the descent of anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina. " Prolapse may be associated with a variety of urinary, bowel and sexual symptoms which may significantly compromise the quality of life of the patients. " General and specific questionnaires are used to evaluate the impact of POP on sexual function.
! What this study adds " We highlight some important aspects about the topic. " We underline the importance of a multidisciplinary approach in the treatment of women with POP. " We suggest that the assessment of quality of life and sexual functioning should become an integral part of the treatment of POP.
