University of Virginia Health System

U.VA. RESEARCHERS MEASURE PATIENT GOAL ACHIEVEMENT AFTER FEMALE PELVIC SURGERY

The goals of women who opt for surgery to correct pelvic floor disorders and their surgeons' goals may differ, according to results of a pilot study reported by researchers at the University of Virginia Health System in the current issue of the American Journal of Obstetrics and Gynecology.

According to principal investigator Dr. Kathie L. Hullfish, a urogynecologist and assistant professor of obstetrics and gynecology at U.Va., the term pelvic floor dysfunction encompasses at least three disorders: urinary incontinence, pelvic organ prolapse and fecal incontinence. Pelvic pain and sexual dysfunction can occur as part of the condition as well, she said.

Success traditionally has been defined by pelvic surgeons from the standpoint of anatomical correction, with less emphasis on patient function and quality of life, Hullfish said. But suppose, for example, one surgically repairs a prolapse such as a fallen bladder, and the repaired tissue looks great, but the patient returns with new problems like incontinence. Is that successful surgery?

Although several quality-of-life questionnaires do exist for patients with pelvic floor dysfunction, Hullfish said her objective was to ask patients their individual concerns and goals before surgery occurred, to categorize those goals and then follow patients after surgery to find out the degree of individual goal attainment.

Not everybody has the same set of problems causing the symptoms, although the symptoms may be the same, she said. I want to ask patients about their goals - not my goals, not a prepared checklist of goals, but their own, related to their lives.

In the study, 33 women who elected to have surgery at U.Va. each listed several goals they wished to achieve. Of the total 119 goals listed, nearly 43 percent concerned urinary or bowel symptoms, 30.6 percent dealt with improving activity, 12.6 percent with general health concerns, 11.8 percent with social relationships and self-image and 2.5 percent with physical appearance. At six and 12 weeks after their surgery, the participants answered a survey rating achievement of their goals. At six weeks, all of the women agreed that a majority of their goals had been met for activity, symptoms, general health and appearance, but the social or self-image goals had not been met. However, by 12 weeks, the women agreed that a majority of goals had been met in all categories, the researchers reported.

Sorting out the quality of life issues is the important thing - seeing what's important to a woman and what they want surgery to do for them. For some women, surgery is not a good choice. It is a large commitment that takes time out of their lives, their work and their family. And for some women, surgery may not be able to adequately fix their problems and may even make them worse. I always counsel patients about their non-surgical options when it comes to problems of the pelvic floor. Many options exist - such as medication, physical therapy or devices like pessaries.

One out of three women who deliver a baby vaginally experience urinary incontinence due to weakened pelvic floor tissue, and five to six percent have problems with fecal incontinence after delivery, Hullfish said. Post-menopausal women frequently experience urinary incontinence as well. Yet research shows that women endure incontinence symptoms for an average of nine years before they seek help from a health care provider.

I think that more and more women are willing to talk about embarrassing disorders like incontinence and prolapse, probably as a result of several factors. First the disorders are common, as they tend to occur in the fastest growing segment of our patient population, which is women over the age of 65. Plus, patients are more informed and more willing to bring up the subject if they have a good relationship with their provider, Hullfish said.

Hullfish conducted the study with senior researcher Dr. William D. Steers, chairman, Department of Urology and Viktor Bovbjerg, assistant professor, Department of Health Evaluation Sciences. Because research data on pelvic floor disorders are relatively new and rapidly evolving, Hullfish said she and her team hope to do a larger study with more patients and a longer follow-up period.

July 15, 2002