The Australian Pelvic Floor Questionnaire (APFQ) is a validated patient-reported outcome (PRO) designed for routine urogynaecological evaluation and research of pelvic floor dysfunction (1-2). It consists of 42 questions divided into four domains for the assessment of bladder, bowel, prolapse and pelvic symptomatology, their severity, the bothersomeness detected amongst affected women as well as their impact on quality of life (QoL). Its main advantages are the variety of the encompassed domains (four in total), the thorough questioning of each domain as well as its ability to separately calculate each domain (along with a total score calculation). In Greek settings there is a great need to develop PTOs for pelvic floor dysfuntions. Thus, the aim of the current study was to develop the Greek version of the APFQ as well as test for its validity and reliability in a primary healthcare setting.

The cross-cultural translation was completed through a multistage forward and back-translation process by 3 bi-lingual translators, according to previously reported official adaptation guidelines (3). The validation process involved administering the adapted Greek APFQ (APFQ_GR) to women who visited a semirural primary healthcare centre within Greek mainland for a urogyneacological visit. Along with APFQ, two other health-related QoL measures for pelvic floor conditions were administered; the Pelvic Floor Distress Inventory (PFDI-20/UDI-6), including only the 6 questions of the Urinary Distress Inventory, and the Pelvic Floor Impact Questionnaire (PFIQ-7), consisting of 7 questions that needed to be answered 3 times each considering symptoms related to three domains (bladder, vagina, and bowel), all 3 separately scored, and their effect on function, social health, and mental health in the past three months. Test-retest reliability was explored by re-administering APFQ_GR after 2-4 weeks.

The Greek translation of the SBST was successfully performed with initial approval from K. Baessler, the original questionnaire’s investigator (1). No major inconsistencies were found in translations, as the questionnaire did not include any elements that could vary significantly among different cultures. No ceiling effects were detected whereas, floor effects were detected only in the domains where women reported no symptoms. 110 women (57.9±8.5 years-old) participated in the validation process. The majority (99%) suffered from urinary incontinence, only 1% had bowel problems and 24,5% reported having also been diagnosed with pelvic organ prolapse (POP) . Strong correlations were yielded between APFQ_GR (total score & bladder symptoms’ domain) with both, PFDI-20/UDI-6 and PFIQ-7 (Spearman’s ρ ranging between 0.627 to 0.793). Moderate to strong correlations were obtained between APFQ_GR (bowel and prolapse symptoms’ domain) with PFIQ-7 (Spearman’s ρ ranging between 0.398 to 0.622). Weaker correlations were reported between the other three domains of APFQ_GR (bowel, prolapse and sexual function) with PFDI-20/UDI-6, which appears logical as the latter evaluated only bladder domain problems. Also, no correlations (Spearman’s ρ of 0.019 & 0.061) were yielded between the sexual function domain of the APFQ_GR with both questionnaires, which again may be explained by the fact that none of the latter two evaluated sexual function. Test-retest reliability of the APFQ_GR explored in a smaller patient sample (n=32) yielded very good results for all domains except for bladder domain (ICC ranged between 0.734 and 0.978).  The low ICC value of the bladder domain (ICC= 0.202) was attributed to the reported changes detected over time on the sample (improvement of symptoms on second visit to the health centre). Finally, internal consistency of APFQ_GR was also satisfactory across all four domains as well as for the total score (Cronbach’s α ranging between 0.697 and 0.872).

Overall, the developed Greek version of the Australin pelvic floor quesiotnnaire (APFQ_GR) was proven to be appropriate, comprehensible, valid and reliable for the sample of women being tested.

The developed Greek version of the APFQ is recommended to be used for the evaluation and monitoring of Greek women with suspected pelvic floor dysfunction for cross-cultural rehabilitation research and clinical practice. However, more research is needed to explore the sexual function domain further, as well as the questionnaire's sensitivity and cut off values (minimal clinical important differences) for each domain.

Baessler K, O'Neill SM, Maher CF, Battistutta D. Australian pelvic floor questionnaire: a validated interviewer-administered pelvic floor questionnaire for routine clinic and research. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Feb;20(2):149-58.
Baessler K, O'Neill SM, Maher CF, Battistutta D. A validated self-administered female pelvic floor questionnaire. Int Urogynecol J. 2010 Feb;21(2):163-72.
Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. J Eval Clin Pract. 2011 Apr;17(2):268-74.