Predicting Treatment Choice for Patients With Pelvic Organ Prolapse

Abstract

This study was conducted to identify clinical factors that are predictive of treatment choice for pelvic organ prolapse. One hundred forty-six women diagnosed with pelvic organ prolapse were educated about their conditionand possible treatments before being offered one of three different treatment choices: expectant management (any choice other than pessary or surgery, including pelvic muscle exercises), pessary, or surgery. Data were recorded for all factors that might be predictors of treatment choice, including age (mean, 62 years); weight (mean body mass index, 26.5); vaginal parity (mean, 3.23); history of incontinence and prolapse surgery; pelvic and lower back pain scores; pelvic organ prolapse severity; pain medication use; prior hysterectomy; presence of cystocele, rectocele, enterocele, or uterovaginal-vaginal vault prolapse on examination; and presence of ovaries. Prior surgery included hysterectomy 68.5%, prolapse surgery 32.9%, and incontinence procedures 43.2%. The ovaries were intact in 71% of patients. Approximately 40% of participants reported no lower back or pelvic pain. Lower back and pelvic pain scores, as measured on a scale of 1 to 5 based on facial expressions, were at level 1 for 15% and 18% of participants, and at level 2 for 30% and 21% of participants, respectively. Ten percent of patients reported level 3 pain in both lower back and pelvic area, and lower back and pelvic pain were reported by approximately 5% each in both level 4 and level 5. Cystoceles were diagnosed in 65% of the women, rectoceles in 41%, enteroceles in 55%, and uterovaginal-vaginal vault in 88% of women. Nearly two thirds of the women (65%) were diagnosed with cystocele, 41% and 55% had rectocele and enterocele, respectively, and most (88%) had uterovaginal-vaginal vault prolapse with the leading edge descending a mean 2.2 cm beyond the introitus. Pelvic organ prolapse quantification (POP-Q) system scores were stage I in 4.8% of patients, stage II in 29.7%, stage III in 53%, and stage IV in 2.1% of patients. Overall, expectant management was the treatment choice for 11% of the participants, 19.4% chose pessary, and 69.4% elected to be treated with surgery. Factors that attained a significant influence in the choice of treatment were age (P <0.001), enterocele (P = 0.004), lower back pain (P = 0.040), pelvic pain (P = 0.022), descent of leading edge of prolapse (P = 0.002), and POP-Q stage (P <0.001). These factors were used for logistic regression analysis comparing expectant management and pessary with surgery. The chance of a patient choosing expectant management over surgery improved as the pelvic pain score increased (odds ratio [OR], 1.6; P = 0.024), but decreased with greater descension of the leading edge of prolapse (OR, 0.46; P = 0.001). The likelihood of choosing pessary over surgery increased with age (OR, 1.1; P <0.001) but decreased with increased length of prolapse descension (OR, 0.77; P = 0.0420), and decreased with prior prolapse surgery (OR, 0.23; P = 0.017). A regression model was developed for predicting management choice: expectant management versus surgery; y = 0.47 (pelvic pain score) - 0.78 (descent of leading edge of prolapse) - 2.04: pessary versus surgery; y = 0.096 (age) - 0.26 (descent of leading edge of prolapse) - 1.48 (prior prolapse surgery) - 6.381.