Hypothesis / aims of study
Pelvic floor disorders significantly impact a woman’s quality of life and well-being. While women often report adopting new behaviors to cope with pelvic floor disorders, little is known about relationship of these behaviors to symptom bother. The Adaptive Behavior Index was developed and validated by the Pelvic Floor Disorders Network. The aim of this study was to describe the behavioral adaptations used by women with symptomatic pelvic organ prolapse and to assess the change in these adaptations following surgical treatment for pelvic organ prolapse. We hypothesized that the adaptive behaviors women use to cope with pelvic organ prolapse will be significantly decreased following surgery for pelvic organ prolapse at three and six months.
Study design, materials and methods
This is a prospective cohort study of women presenting to an academic urogynecologic 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. Women unable to complete the informed consent process, participate in data collection were excluded. Demographic data, medical comorbidities, medications were assessed at baseline. The primary outcome was Adaptive Behavior Index score. The Adaptive Behavior Index is composed of two domains, a Hygiene domain and Avoidance domain. Secondary outcomes included: Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ), and Pelvic Organ Prolapse Quantification (POP-Q) examination. Assessments were performed at baseline, three and six months. Descriptive statistics and univariate analyses were performed.
One hundred fifty seven subjects had complete baseline, 3 and 6-month post-operative adaptation data. Mean subject age was 61.8 years, body mass index 27.9 kg/m2, and mean leading edge of prolapse was 2.8 cm. Twenty six percent of subjects had undergone prior POPUI surgery. The majority of subjects were white, post menopausal (86%), sixty six percent were never smokers, one third had more than one social problem, fifteen percent had a concomitant urinary incontinence surgery at the time of pelvic organ prolapse surgery. Subjects had a median of eight comorbidities. Median baseline Adaptive Behavior Index scores were 25 for the Hygiene domain 25 and 18 for the Avoidance domain.
Three and 6-month adaptations scores in both Hygiene and Avoidance domains were significantly lower than baseline scores. Subjects with improved Hygiene or Avoidance adaptation subscale scores at three months had lower UIQ and UDI scores; the other PFDI and PFIQ subscales were not significantly different. Subjects with improved Hygiene domain were significantly more likely to have had a concomitant UI surgery at time of their POP surgery compared to subjects without improvement. There was no difference in UI surgery in subjects with and without improvement in Avoidance domain.
In the 114 subjects with improved scores, the four items with greatest improvement were in the Avoidance domain: “ I urinate whenever possible whether I need to or not.” (n=65, 57.0%); “I avoid standing for long periods of time because of my prolapse or incontinence problems.” (n=63, 56.8%); “I try to drink less fluids or limit my fluid intake.” (n=56, 49.6%); “I limit or avoid physical activities because of my prolapse or incontinence problems (including strenuous exercise, heavy lifting, or swimming).” (n=56, 49.6%).
Interpretation of results
In women undergoing surgery for pelvic organ prolapse, Adaptive Behavior Index scores improve after surgical treatment. There appears to be a relationship between improved scores in both domains and improved urinary symptoms. Overall the greatest improvements in adaptations appear to relate to urinary symptoms and impact of symptoms on physical activity.