Over time, hospital stays after surgery have become much shorter, leaving much of the acute recovery phase to occur outside the monitored hospital setting. Postoperative pain in hospitalized women has been the subject of many reports.1–5 However, there is a paucity of information relating to a patient's experience and recovery after her discharge from the hospital. In one study, approximately 40% of patients after gynecologic laparoscopic surgery have inadequate pain control after being discharged from the hospital, whereas in another, fewer than 40% could resume normal role functions such as shopping or laundry washing 1 week after surgery.6,7 Frequently asked questions from patients include: How long will I need pain medications after my surgery? When will I be able to return to my normal activities? How much pain after surgery is normal? The counsel physicians offer their patients in response to these questions, and others, is based largely on anecdotal evidence and may be grossly inadequate. Recognizing the frequency of inadequate pain control and predictors of such after gynecologic surgery may be useful in altering practice habits to ensure improved pain management.
The aims of this study are to describe, in women undergoing major abdominal or vaginal gynecologic surgery for benign disease, their pain experience and recovery during the first 2 weeks after hospital discharge and their satisfaction with postoperative recovery 2 and 6 weeks after surgery. Additionally, we sought to estimate the prevalence of inadequate pain control on recovery days 3, 7, and 14 between women undergoing vaginal compared with abdominal surgery.
MATERIALS AND METHODS
This is a prospective cohort study involving patients undergoing benign gynecologic surgery. This study was approved by the University of Utah institutional review board and all women completed an informed consent process. Eligible participants include all English-speaking women aged 18 years or older admitted at least overnight to the hospital after benign abdominal or vaginal gynecologic surgery at a tertiary care academic center. Additional exclusion criteria included concomitant laparoscopy of any kind, a primary surgical indication of chronic pelvic pain, reoperation for complications relating to prior surgeries, or a patient's inability to complete study instruments independently. Those requiring more than 4 postoperative days in the hospital were withdrawn from the study to exclude people with postoperative complications associated with long length of stay. We excluded laparoscopic approaches in an attempt to better understand “traditional” surgical approaches.
Participants were approached during their inpatient recovery and given a 2-week study diary to complete. From the day after hospital discharge (recovery day 1) to 14 days after surgery, participants completed a daily evaluation of pain and pain medication use during the first 2 weeks after surgery. Pain was evaluated using a validated four-item Surgical Pain Scale in which participants indicate the average amount of pain during that day at rest, during normal activities, and during exercise (if applicable) and rate how unpleasant the worst pain they experienced that day was.8 A rating scale of 0–10 is used with zero being no pain sensation and 10 representing the most intense pain imaginable. Inadequate pain control was defined as a score greater than 4 on the Surgical Pain Scale.
On postoperative days 7 and 14, participants also provided information about their recovery using a 15-item validated instrument in which participants indicate how they feel on a scale of 1–10 with 10 representing feeling closest to complete recovery.9 Questions relate to various daily activities, including working, moving around, leaving the house, and sleeping, and also query how recovered people feel and whether they feel “back to normal.” We contacted participants by telephone between 2 and 4 days after discharge to remind them to complete the study instruments, 2 weeks after discharge to remind them to return the pamphlets, and 6 weeks after discharge to administer the recovery scale as well as questions about their satisfaction with their recovery and pain management. A maximum of four attempts was made to contact study participants for each scheduled follow-up call. Those patients who did not complete the study diary were included in the 6-week follow-up phone calls. From the electronic medical record, we abstracted demographic information, medical conditions, details relating to surgery, preoperative and postoperative pain scores, and details from the preoperative nursing assessment.
Although this is primarily a descriptive study, we calculated our sample size based on detecting a twofold difference (25% compared with 50%) in inadequate pain control between abdominal and vaginal surgery groups. Assuming α=.05 and power=80%, we required 58 women per group (116 total). Based on our surgical trends, we assumed that half of enrollees would have vaginal and half abdominal surgery and further assumed that 90% would complete the 2-week outcome measure and thus planned to enroll at least 127 women. Categorical variables were analyzed with χ2 or Fisher's exact tests and continuous variables with t tests (for parametric) or Wilcoxon signed rank tests (for nonparametric data). Stepwise logistic regression analysis was used to determine the predictors of inadequate pain control; however, the number of women with any given risk factor was small and these results should be considered exploratory. P<.05 was considered statistically significant.
Of 185 patients approached for participation in the study between May 2010 and April 2011, 158 (85%) consented to participate. We later excluded 18 as a result of hospital stays longer than 4 days. Of the remaining 140 participants, 13 completed no study instruments and were lost to follow-up, 89 completed both the 2-week diary and the 6-week follow-up, 15 completed only the 2-week diary, and 23 completed only the 6-week follow-up. Of this sample of 127 women, 80 (63%) underwent surgery using a vaginal approach and 47 (37%) using an abdominal approach. Mean hospital stay was 1.1 days for women undergoing vaginal surgery and 2.2 days for those undergoing abdominal surgery. Patients undergoing vaginal surgery were older than those undergoing abdominal surgery (mean 54 compared with 47 years, respectively) but were similar in all other demographic variables examined, including body mass index (calculated as weight (kg)/[height (m)]2). The study population is summarized in Table 1.
On recovery day 3, 45.0% and 51.1% of women undergoing vaginal and abdominal surgery, respectively, had inadequate pain control (P=.5). On recovery day 7, the proportion with inadequate pain control decreased to 22.5% and 29.8% in women after vaginal and abdominal surgery, respectively (P=.4). On recovery day 14, only 5.0% of women reported inadequate pain control after vaginal surgery; however, 23.4% of patients reported inadequate pain control after abdominal surgery (P<.005). Trends in pain scores over the first 2 weeks are summarized in Figure 1.
As expected, the use of narcotic pain medications decreased over time and patients in the vaginal group required less narcotic pain medication overall. The proportion of women in each group that reported using narcotic pain medications were: 91.9% abdominal and 66.7% vaginal on recovery day 3; 66.7% abdominal and 32.4% vaginal on recovery day 7; and 32.4% abdominal and 10.1% vaginal on recovery day 14 (P<.01 for all comparisons). There were no differences between groups in the proportion using nonnarcotic pain medications: 81.0% abdominal and 88.4% vaginal on recovery day 3; 82.9% abdominal and 77.9% vaginal on recovery day 7; and 69.4% abdominal and 55.9% vaginal on recovery day 14.
The mean recovery scale score at 2 weeks was 6.77 in the vaginal and 5.91 in the abdominal group. (Higher scores indicate a greater level of recovery with 10 indicating return to usual function.) At 6 weeks, mean recovery score was 7.69 in the vaginal and 8.23 in the abdominal group. We analyzed three key clinical questions from this scale separately and grouped responses of 8, 9, or 10 on the 10-point scale together to signify a good outcome. In response to the statement, “I feel completely recovered from surgery,” few women felt recovered after 2 weeks of home recovery and approximately half of the women in either group felt recovered by 6 weeks. Similar results are seen when patients are asked about their ability to participate in their usual activities. After 6 weeks of recovery at home, two-thirds of the women surveyed felt “back to normal” (Table 2).
When asked about the management of their pain during their home recovery, the vast majority of patients found their pain management to be “very successful” (68.9% and 75.8% at 2 and 6 weeks, respectively) or “moderately successful” (18.5% and 12.1% at 2 and 6 weeks, respectively). Only 2.9% and 3.0% reported their pain management to be “not at all successful” at 2 and 6 weeks, respectively. Approximately four of five patients felt their recovery was what they anticipated or easier at both time points (Fig. 2). Between routes of surgery, there were no differences in perception of pain management at 2 weeks (P=.15) or at 6 weeks (P=.54) or in perception of recovery at 2 weeks (P=.56) or 6 weeks (P=.97).
Stepwise logistic regression analysis was used to identify predictors of inadequate postoperative pain control on recovery day 14. Of these, in our limited population, only route of surgery was significant as a predictor of inadequate pain control (odds ratio [OR]5.67; 95% confidence interval 1.68–19.15). Variables that were not significant on univariate analysis included age (younger than 50 years compared with older than 65 years, OR 0.81, 0.10–6.36); body mass index (less than 30 compared with 30 or higher, OR 2.91, 0.60–14.19); smoking (no compared with yes, OR 1.09, 0.26–4.60); alcohol use (no compared with yes, OR 0.86, 0.26–2.86); preoperative pain score 0–2 compared with more than 2 (OR 0.63, 0.14–2.86); depression or anxiety or both (no compared with yes, OR 0.36, 0.11–1.14); payer type (Medicare compared with private, OR 1.29, 0.30–5.53); number of prescription medications preoperatively (OR 1.0 per medication, 0.89–1.12); and postoperative hematocrit (OR 0.97 per unit, 0.81–1.18).
Pain control after vaginal surgery is suboptimal during the 3–7 days after hospital discharge with one of five patients experiencing inadequate pain control. Results for patients after abdominal surgery were more concerning: one in two women reported inadequate pain control at 3 days, one in three at 7 days, and one in four 2 weeks after hospital discharge despite the fact that one-third still used narcotic pain medications 2 weeks after discharge. The recovery scale demonstrates an average overall recovery score of 7–8 at 6 weeks, indicating that on average, patients feel almost recovered at this time point with regard to their return to normal activities and behavior. However, only half of the women in either group felt fully recovered after 6 weeks. Despite the patients' reported inadequate pain control, the vast majority of patients was satisfied with management of their pain and felt that their recovery was similar to what they anticipated or easier.
There is surprisingly little information about pain control and recovery at home after abdominal and vaginal gynecologic surgery. Our data provide some concrete information that can be used to counsel patients undergoing vaginal or abdominal surgery. The data also indicate there is room for improvement.
We specifically excluded women undergoing laparoscopic surgery in this study to focus on the traditional approaches. Similar to available data about recovery after traditional surgeries, literature on laparoscopic or robotic approaches focuses on pain control during hospitalization; rigorous evaluation of postdischarge pain and recovery using standardized instruments is lacking. Some outcomes such as return to work are hampered by differential counseling of women undergoing different surgical approaches. Given that fully half of our patients undergoing vaginal surgery did not feel fully recovered by 6 weeks, a similar study of women undergoing other types of minimally invasive surgery would be useful. It is also clear from our results that future research should extend beyond the 6-week period currently considered the classic “recovery period.”
With a shift in postoperative practice toward earlier hospital discharge, it is essential that we ensure our patients are well cared for at home. Interventions are needed to improve both postoperative pain and recovery. These might include more extensive patient education regarding optimal use of pain medications (narcotic and nonnarcotic), optimizing bowel regimens to decrease pain associated with constipation or bowel discomfort, and complementary medicine such as massage, stretching exercises, or other physical therapy at home to improve musculoskeletal pain.
Strengths of our study include its prospective nature, use of validated instruments to assess pain and recovery, and high participation and follow-up rates. Surgeons were not involved in data collection. We excluded conditions that may lead to a poorer recovery to provide a picture of what the average woman experiences after surgery; however, further study would be useful to evaluate patients with confounding conditions because they may be at the most risk of having an unfavorable experience postoperatively. Although our recruitment strategy of enrolling women after, rather than before, surgery may have introduced a healthy participant bias, this seems unlikely given the 85% participation rate. Other limitations of our study include the heterogeneous group of procedures examined, the single-site nature of the patient population making our results less generalizable, and the fact that only 70% of participants completed all the study instruments at every time point. Our sample size was too small to detect small differences between groups or in preoperative predictors of poor pain control; in particular, very few women had conditions such as anxiety and depression, which others have found associated with postoperative pain during hospitalization for gynecologic problems.10 Finally, postoperative counseling was left to the discretion of individual providers and was not standardized.
In conclusion, our findings demonstrate that postoperative pain control and recovery at home are suboptimal for many patients. Health care providers need to focus more on the at-home experience of our patients in this era of early hospital discharge.
1. Roy KK, Goyal M, Singla S, Sharma JB, MAlhotra N, Kumar S. A prospective randomised study of total laparoscopic hysterectomy, laparoscopically assisted vaginal hysterectomy and non-descent vaginal hysterectomy for the treatment of benign diseases of the uterus. Arch Gynecol Obstet 2011;284:907–12.
2. Drahonovsky J, Haakova L, Otscenasek M, Krofta L, Kucera E, Feyereisl J. A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease. Eur J Obstet Gynecol Reprod Biol 2010;148:172–6.
3. Garry R, Fountain J, Brown J, Manca A, Mason S, Sculpher M, et al.. EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy. Health Technol Assess 2004;8:1–154.
4. Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: systematic review and meta-analysis of randomized controlled trials. BMJ 2005;24:330:1478.
5. Nieboer TE, Johnson N, Lethaby A, et al.. Surgical approach to hysterectomy for benign gynaecological disease. The Cochrane Database of Systematic Reviews 2009, Issue 8. Art No.: CD003677. DOI: 10.1002/14651858.CD003677.pub4.
6. Lovatsis D, José JB, Tufman A, Drutz HP, Murphy K. Assessment of patient satisfaction with postoperative pain management after ambulatory gynaecologic laparoscopy. J Obstet Gynaecol Can 2007;29:664–7.
7. Horvath KJ. Postoperative recovery at home after ambulatory gynecologic laparoscopic surgery. J Perianesth Nurs 2003;18:324–34.
8. McCarthy M Jr, Chang CH, Pickard AS, Giobbie-Hurder A, Price DD, Jonasson O, et al.. Visual analog scales for assessing surgical pain. J Am Coll Surg 2005;201:245–52.
9. Kleinbeck SV. Self-reported at-home postoperative recovery. Res Nurs Health 2000;23:461–72.
10. Kain ZN, Sevarino F, Alexander GM, Pincus S, Mayes LC. Preoperative anxiety and postoperative pain in women undergoing hysterectomy. A repeated-measures design. J Psychosom Res 2000;49:417–22.