Patient-reported goal attainment and comprehensive functioning outcomes after surgery compared with pessary for pelvic organ prolapse

Abstract

Background: Pelvic organ prolapse can have a negative impact on a woman's overall functioning. When choosing between surgery or pessary, many women have information needs about long-term expectations. Whereas it has been shown that both surgery and pessary can improve prolapse symptoms, there is less information comparing comprehensive functioning outcomes and goal attainment between the 2 treatments.

Objective: Our primary objective was to compare patient-reported goal attainment and comprehensive physical, social, and emotional functioning outcomes after surgery vs pessary for symptomatic prolapse.

Study design: We conducted a prospective, observational, cohort study including women choosing surgery or pessary for symptomatic stage 2 or greater prolapse. Women undergoing any modality of prolapse surgery or those anticipating using a pessary long-term to avoid surgery were eligible. Women completed questionnaires at baseline (before treatment) and up to 12 months after treatment including the following: (1) pretreatment goals and actual posttreatment goals achieved; (2) 5 functioning outcomes encompassing physical, social, and emotional function using the Patient-Reported Outcomes Measurement Information System surveys; and (3) validated symptom and quality-of-life questionnaires. Treatment goals were categorized into symptom goals (prolapse, urinary, bowel, pain) and function goals (physical, social, emotional, sexual). Goals achieved were compared using a χ2 test. Multiple logistic regression was used to identify variables associated with not achieving all pretreatment goals. Mean improvements in functioning scores were compared within groups and between groups using paired and independent Student t tests. Assuming 80% of women would achieve complete goal attainment in the surgery group, 64 women per group would be needed to detect a 20% difference at an alpha of 0.05. We recruited 80 women per group to account for dropout.

Results: A total of 160 women were enrolled and 72 surgical (90%) (mean follow-up 12 months) and 64 pessary patients (80%) (mean follow up 8 months) had posttreatment data. Fourteen discontinued pessary use and 8 ultimately crossed over to surgery. At follow-up, a higher proportion of women in the surgery arm reported successfully achieving symptom goals and function goals compared with women who chose pessary (P < .05). Women who continued pessary use had comparable goal attainment with women in the surgery group for almost all goal categories, whereas women who discontinued the pessary or crossed over to surgery had significantly lower goal attainment compared with both the surgery and pessary continuation groups. On multiple logistic regression, only college education or higher was associated with an increased odds of not achieving all pretreatment goals (odds ratio, 2.70, 95% confidence interval, 1.1-6.6, P = .03). Regarding functioning outcomes, within groups, there were statistically significant improvements between pre- and posttreatment Patient-Reported Outcomes Measurement Information System functioning scores in all 5 domains for the surgery group and 4 of 5 domains in the pessary group (P < .05). When comparing between groups, women who had surgery reported significantly greater improvements in the physical function, social roles, and depression domains compared with the pessary group (P < .05).

Conclusion: Women undergoing either surgery or pessary for symptomatic prolapse experience goal attainment and improvements in physical, social, and emotional functioning, although surgery is associated with greater improvements.

Keywords: goal; patient-reported outcomes; pelvic floor disorders; pelvic prolapse; pessary; surgical treatment.

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