Patient characteristics
A total of 249 patients underwent POP surgery during the study period. Twenty-three patients with primary vaginal vault POP after the previous hysterectomy were excluded. Of the 226 patients enrolled for primary POP surgery, 11 revoked their consent before the operation, leaving 215 (97.7%) took part in the baseline interview. The follow-up questionnaires were received from 193 (89.7%) patients at 3 months and 185 (86.0%) at 6 months after the operation. The primary reasons for leaving the follow-up schedule included declined further participation (n = 8), lost to follow-up for unknown reasons (n = 8), relocation (n = 10), died for reasons not related to complication of prolapse treatment (n = 2), or incomplete data (n = 2). There was no difference in the symptom (POP-SS and PHQ), body image, POP stage, or P-QoL scores between the patients that did not participate and participated in the follow-up (p > 0.05, Supplementary Table 1).
A large number had had POP for a long time before seeking treatment (median = 5.2; range 1–26 years). Reasons reported as the main barriers to seek early treatment were lack of money (21.2%), fear of disclosure (15.9%), the perception that POP is incurable (13.6%), fear of treatment outcome (12.1%), lack of accompanying support (8.6%), distance from a health facility (requiring 2 days or more to reach health facility; 6.2%), and lack of transportation (5.0%). Three out of five patients (59.5%) had decision making power to visit health care when getting sick.
Patients' characteristics are shown in Table 1. The mean age at the time of surgery was 49.3±9.4 (range 35-70) years. Preoperatively, 148 (68.8%), 134 (62.3%), and 72 (33.5%) patients had anterior, central, and posterior descent ≥III stages, respectively. These defects were associated with variable degrees of loss of support at the other vaginal sites considered: 131 patients (60.9%) showed descent in all three compartments, 50 (23.3%) in two compartments, and 34 (15.8%) in only one compartment (18 anterior descent and 16 apical descent).
Intraoperative and postoperative results were collected. The median operative time for all the surgical interventions was 65 (47-127) minutes, and the median postoperative hospital stay was 2 days (range, 2-4 days). There was no intraoperative complications like severe hemorrhage or rectal, bladder, or ureteric injury occurred. However, some women developed mild to moderate postoperative complications: seven cases (3.2%) fever and 11 (5.1%) urinary tract infection. Late complications were also reported and included two cases (1.1%) of gluteal pain, four cases (2.5%) of dyspareunia, five cases (2.7%) of stress urinary incontinence, six cases (3.2%) of recurrent urinary tract infections, and five cases (2.7%) of constipation.
Impact of POP surgery on HRQoL
A significant improvement in the quality of life was reported throughout the study (Figure 1 and Table 2). In Figure 1, the bar chart shows the figures (Mean±SD) for P-QoL, POP-SS, BIPOP, and PHQ at 3 and 6 months after surgery compared to patients’ scores before surgery. The internal consistency (Cronbach’s alpha) of the P-QoL, POP-SS, BIPOP, and PHQ instrument in this study was 0.92, 0.75, 0.81, and 0.71, respectively.
Prolapse Quality of Life
Preoperatively, the negative effects on the personal relationship (76.7/100 points), the negative impact on physical impairment, and roles (75.5 and 74.5/100 points) were the areas of patients’ HRQoL which were the most affected. A significant improvement was reported after 3 months follow-up for the above-listed domains. However this improvement was not reproduced in the personal relationship domain score during this follow-up period, and the patient had a worse score (15.0±12.6 to 20.0±18.3, p = 0.005, paired t-test). The 6-month follow-up demonstrated a further significant improvement as compared to the baseline. Similar improvement also reported in the other P-QoL areas (GHP, SE, and SM) in both follow-ups (baseline vs. 6-month follow-up, out of 100 points in each case: 60.5 vs. 21.8; 46.7 vs. 14.4; 46.2 vs. 8.5; Supplementary Table 2).
P-QoL was also higher as measured by PRC, PC, and PSC at baseline. But, a marked improvement was observed in a 6 month follow-up (mean change baseline and 6 month with 95% CI in each case: −58.1 (−61.8, −54.4), − 49.4 (− 51.5, − 47.2) and − 40.1 (− 43.6, − 36.4), Table 2).
Prolapse Symptoms Score
A significant reduction in POP symptoms was detected (Table 2). The POP-SS score decreased both at the 3 months and the decrease sustained at a 6-month follow-up (mean decrease 5.2 and 2.1 points, respectively). At baseline, discomfort/pain that worsens when standing (85.1%), feeling of something coming down (82.7%), and feeling of heaviness around the lower abdomen (81.4%) were reported. These symptoms were reduced significantly after surgery. A total of 14.0% (n = 166) patients reported a bothersome bulge symptom at 3 months after surgery, and 97.3% (n = 180) did not report this symptom at 6 months postoperatively (Supplementary Table 2).
Depressive Symptoms
Total PHQ-9 scores > 10 occurred in 42.8% (92/215) of the patients at baseline. After 6 months, the PHQ-9 scores were significantly decreased. The mean change PHQ from baseline to 6 months was −8.8 (95%CI: −9.9, −7.7) points, Table 2). The postoperative prevalence of depressive symptoms was 7.0% (13/185), which was six-fold lower from baseline. Items representing alterations in doing things, energy, and hope were the most commonly reported items at baseline (Supplementary Table 2).
Body Image
Improvement in the BIPOP score was observed, indicating a better BI perception after surgery. Before surgery, 115 patients (53.8%) reported having regular sexual intercourse; 18 (15.6%) of them had dyspareunia. Conversely, at 6 months after surgery, 159 (85.9%) patients reported having regular sexual intercourse and 4 (2.5%) had dyspareunia (Supplementary Table 2). The BIPOP score (mean with 95%CI) was 33.9 (33.0, 35.2) versus 17.4 (16.6, 18.2) at preoperative and at 6 months follow-up, respectively (p < 0.001, Table 2).
Patient Global Impression of Improvement
Response to the surgical treatment measured by the PGI-I is shown in Figure 2. Altogether 97.8% of the patients considered their condition to be better and 1.1% considered it to be worse compared to the preoperative situation at 6-month follow-up (PGI-I scales 1-3, Figure 2). At the 6-month follow-up, 171 (92.4%) of the patients recommended the operation to a close friend suffering POP.
Goal Attainment
Two hundred and ten women completed preoperative goal assessment (97.6%). The most common patient goal was to reduce condition-specific symptoms (prolapse (186, 88.5%), urinary (174, 82.5%), and bowel symptoms (96, 45.7%)) followed by improving intimate relationships (74, 35.2%), activities and social life (66, 31.4%), body image/physical appearance (60, 28.5%), and general health (47, 22.3%). Living happily (74, 35.2%), reduced discomfort/pain (14, 6.7%) and other (22, 10.5%) were also reported. One hundred sixty-six (89.7%) of 185 women achieved their goal of reducing prolapse symptoms (defined as score ≥6/10) at 6 months follow-up.
Predictors of Quality of Life Change during Follow-up
Linear Mixed Model (LMM) analysis was performed to examine the longitudinal effects of sociodemographic, POP-SS, BIPOP, and PHQ on P-QoL domains and/or components (Table 3). The change in P-QoL after surgery was associated with the change in POP-SS, PHQ, and BIPOP scores (p < 0.001). There was a change in PC and PRC score overtime for a point change in the POP-SS, PHQ, and BIPOP scores (p < 0.001). Being married resulted in a 5.7 point increase in the PRC score (p < 0.01). However, age, parity, type of surgery, and prolapse stage were not associated with the improvement of P-QoL scores (Table 3).