Hypothesis / aims of study
Major depression and depressive symptoms are prevalent and disproportionally affect women. Anxiety symptoms are often comorbid to depressive symptoms. Pelvic floor disorders (PFDs) significantly impact a woman’s quality of life and well being. Depressive symptoms are been shown to be highly prevalent in women with urinary incontinence, however, little is known regarding the relationship of mood symptoms on pelvic floor symptom bother and postoperative well being. The aims of this study are to determine postoperative depressive and anxiety symptoms in women undergoing surgery for pelvic organ prolapse at three months and six months postoperatively and describe subjects with persistent depression or anxiety at six months. Our hypothesis is that women with persistent depressive and anxiety symptoms will have worse pelvic floor quality of life scores.
Study design, materials and methods
This is a prospective cohort study of women with symptomatic POP presenting for care at an academic urogynecology practice with symptomatic prolapse and choosing to undergo surgical management for pelvic organ prolapse. Eligible participants included women answering “Yes” to one or both of the following questions from the Pelvic Floor Distress Inventory: 1. Do you usually have a sensation of bulging or protrusion from the vaginal area? and/or 2. Do you usually have a bulge or something falling out that you can see or feel in the vaginal area? on new patient intake forms. Women were included who demonstrated prolapse Stage II or greater as documented by POPQ examination. Following informed consent, subjects completed self-administered measures and the Personal Health Questionnaire-9 (PHQ9) screening questionnaire. Women unable to complete the informed consent process, participate in data collection, scoring <20 on the mini- mental status examination, or women who were actively suicidal by our screening protocol were excluded. Demographic data, medical comorbidities, medications condition-specific questionnaires including: Patient Health Questionnaire-9 (PHQ9), Beck’s Anxiety Inventory (BAI), Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ), and Pelvic Organ Prolapse Quantification (POP-Q) and physical examination were assessed at baseline, three, and six months. Descriptive statistics were performed. Continuous data were compared using T test or Mann-Whitney U test, and categorical data were compared using χ² test or Fisher’s exact test.
A total of 275 women had surgery for pelvic organ prolapse. Of these, 167 had depression and anxiety data for all 3 time points and are included in this analysis. Subjects were predominantly white, had a mean age of 62 years, BMI 27.9 kg/m2, mean leading edge prolapse of 3 cm, and median of 8 comorbidities. Subjects reported a median of 2 years with prolapse symptoms and 24% had prior POPUI surgery. Twenty five percent of subjects reported a history of depression and twenty two percent reported a history of anxiety. Subjects who had all 3 time points were older, more likely to be post menopausal, had statistically lower POPIQ scores, had fewer social problems and were more independent in instrumental activities of daily living, compared to subjects who had only one or 2 time points. Prevalence of depression symptoms at each time point is shown in Table 1.
Of the subjects depressed at baseline, 6 remained depressed at 6 months. At 6 months, 6 of the depressed subjects had not been depressed at baseline. Subjects with baseline depression were more likely to have higher PHQ9 scores at 3 and 6 months. Compared to non-depressed subjects, those who were depressed at 6 months post operatively were younger, had greater number of medical comorbidities, more likely to have baseline depression and anxiety, more likely to have had a history of depression and anxiety and past use of antidepressants and anxiolytics. Subjects with depressive symptoms at 6 months had statistically higher UIQ, UDI, POPDI, and CRADI scores.
Interpretation of results
The prevalence of depressive and anxiety symptoms appears to decrease following surgery for pelvic organ prolapse with 55% improvement in depressive symptoms post operatively. Depressive symptoms postoperatively seem to be associated with higher PFIQ and PFDI scores.