ABSTRACT: In women with a pelvic floor disorder, the relationship between their therapeutic goals (patient-centered goals) and subjective and objective measures of pelvic floor dysfunction and choice of treatment are unclear. Key elements of patient and clinician treatment decision making include symptoms and physical examination findings, quality-of-life estimates, anatomic measures of prolapse severity, and patient therapeutic goals.
The aim of this retrospective study was to investigate associations between patient-centered goals and objective and subjective measures of pelvic floor dysfunction and treatment choice. The study population was composed of women 18 years or older who were evaluated for a pelvic floor disorder by a single surgeon at a specialty clinic from January 2008 to December 2009. After the physician interview but before the physical examination, patients were asked to list their therapeutic goals, which were categorized as information-seeking, improvement across any of 6 pelvic floor symptom categories, and “other.” Validated surveys were used to assess pelvic floor symptom burden and health-related quality of life (HRQoL). Vaginal Pelvic Organ Prolapse Quantification points were assessed to determine the severity of prolapse. The relationship between each patient-reported goal with symptom burden, HRQoL, anatomic severity, and treatment choice (surgical vs nonoperative care) was determined.
A total of 90 patients met inclusion criteria. The mean (SD) age of the patients was 56 (14) years; 67% were younger than 65 years. Among the 90 patients, 23.3% reported a surgery treatment preference, and 30.7% had severe prolapse (defined as at least 1 Pelvic Organ Prolapse Quantification point ≥1 cm beyond the hymen). Across the 90 patients, 18% reported a single goal, with 28%, 37%, 14%, and 3.3% reporting 2, 3, 4, or 5 goals, respectively. Patient-reported goals reflected symptom burden for bowel and bladder complaints, whereas a cosmetic goal appeared to reflect both prolapse symptoms and impact as well as measurably worse anatomical prolapse. Improved cosmesis was the only goal associated with severe prolapse. Therapeutic goals related to sexual function reflected overall mental HRQoL but not symptoms or prolapse severity. Patients with an activity-based goal preferred surgical treatment; however, the sample size for women who chose to have surgery was too small to allow statistical significance.
These data suggest that patient therapeutic goals may be useful for understanding patient preferences, but they do not appear to be reliable indicators of symptom type, severity of prolapse, or treatment preference. Lack of a clear relationship between therapeutic goals and symptoms as well as anatomic severity of prolapse can make it difficult for patients to decide on a treatment strategy.
Department of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth, Lebanon, NH