Objective
To describe perceptions of prolapse-specific body image in women with symptomatic prolapse.
Study Design
Women with symptomatic pelvic organ prolapse quantification stage ≥ II prolapse participated in semistructured focus groups or self-report questionnaire. Transcripts were independently reviewed and body image themes were identified and confirmed by consensus.
Results
Twenty-five women participated in focus groups and 27 in online questionnaires. Transcript analysis revealed 3 central themes and 25 body-image related subthemes. Women living with prolapse were more likely to feel self-conscious, isolated, “different,” less feminine, and less attractive. Women often changed sexual intimacy practices because of embarrassment or discomfort, and many avoided intimacy all together. Prolapse greatly affected women’s personal and professional activities causing some women to adjust routines or stop activities. Women reported loss of interest in activities, distraction while performing daily/work-related tasks, and embarrassment when asking for help with activities.
Conclusion
Themes identified in this qualitative study demonstrate the profound effect of prolapse on a woman’s body image.
Symptomatic pelvic floor disorders are estimated to affect up to 24% of the female population over 20 years of age and symptomatic pelvic organ prolapse (POP) is estimated to affect up to 3% of this population. These disorders can greatly affect a woman’s quality of life, including social, psychological, occupational, domestic, physical, and sexual well being. POP can be treated conservatively with a pessary or surgically with either reconstructive or obliterative procedures. Historically, outcome studies in urogynecology focused on anatomic and functional changes after surgical intervention. The development of condition-specific health-related quality of life (HRQOL) instruments and patient satisfaction measures have improved our ability to assess the impact of pelvic floor disorders on women. However, current prolapse-specific HRQOL measures do not assess the impact of these conditions on a woman’s body image.
Body image (BI) is a psychologic construct that refers to an individual’s perceptions of and attitudes towards her own body. BI affects many aspects of psychosocial functioning and body dissatisfaction is associated with anxiety and depression. Studies in the plastic surgery literature suggest that the anxiety and depression attributed to body dissatisfaction may motivate patients to pursue corrective surgery. We believe this same phenomena may be occurring in women with prolapse.
Prolapse can result in dramatic changes to the urogenital tract. Prolapse is a hidden disfigurement that only the woman and her intimate contacts are aware of and may negatively affect a woman’s BI. This can lead to shame, embarrassment, and a decrease in feelings of sexual attractiveness that may negatively impact her quality of life. There are few studies assessing the impact of POP on BI. Jelosevek et al used a modified version of a BI questionnaire validated for patients with cancer and demonstrated that women with prolapse have poorer body image compared with controls. In a recent study using validated general BI questionnaires, we showed that BI significantly improved after surgery. Ideally, a pelvic floor disorder- or prolapse-specific BI questionnaire would have been used for both of these studies; however, such an instrument does not exist.
Using BI measures as a tool in POP research may allow us to understand the full impact of prolapse on women and better assess treatment outcomes. The goal of this study is to describe perceptions of prolapse-specific body image in women experiencing this condition using qualitative research methods as a first step toward developing a prolapse-specific BI questionnaire.
Materials and Methods
Study sample
We approached women seeking care at the Women’s Center for Bladder and Pelvic Health at University of Pittsburgh Medical Center Magee-Womens Hospital to participate in this study. Women who were ≥40 years of age with ≥ stage II symptomatic prolapse by POP quantification (POPQ) examination were offered participation. Symptomatic prolapse was defined as 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 (2) “Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?” Symptomatic women were chosen to maximize the chance of identifying prolapse-specific body image themes in this initial study. Women who were asymptomatic or unable to complete informed consent or participate in data collection or focus groups as determined by clinician judgment were excluded. The University of Pittsburgh Institutional Review Board approved this study, and participants signed informed consent at time of enrollment. After being screened and consented, eligible women were invited to participate in either 1 structured focus group session or to complete an online questionnaire. We chose to offer either participation in a focus group or completion of an online questionnaire to maximize enrollment by providing options for women to participate who may not feel comfortable in a focus group setting or could not participate because of transportation/scheduling issues.
Focus groups
Qualitative research allows investigators to explore topics in which little data exists. As a popular qualitative research method, focus groups promote a more natural conversation among participants and create an environment suitable for self-disclosure. A facilitator (C.N.) trained in qualitative research methodology and focus group moderation conducted all the focus group discussions. The facilitator explained study details using an introductory script at the start of the group discussions and followed an interview guide created by the study team during the focus group sessions. The facilitator asked additional probe questions when necessary to obtain supplementary information. A research assistant served as a note-taker during each of the discussions and recorded general comments and nonverbal communication. Each focus group discussion was audio-recorded and transcribed verbatim with the exception of any names or other identifying information to aid in the data analysis process.
Self-report online questionnaire
The online questionnaire was created using Survey Monkey PRO software and was available through a uniform resource locator (URL) created via the Survey Monkey PRO account used for this study. The URL was emailed as a link to participants who chose to complete the online questionnaire. Subjects used a unique subject identification number and no personally identifiable information was disclosed in the online questionnaire. The questions asked on the online questionnaire were identical to the 7 interview guide questions used by the facilitator during focus group discussions. Several preformulated probes were also included under each major question to obtain additional information. The open-ended question prompt was followed by a text box with an unlimited character count to allow subjects to respond in an unrestricted fashion.
Focus group and online questionnaire analysis
A grounded theory approach was used to facilitate data analysis. After the first focus group recording was transcribed and reviewed, a codebook of major themes emerging from the discussion was created. As each subsequent transcript from the focus group and online questionnaire was reviewed, the codebook was amended to reflect new themes or ideas. Each transcript was coded independently by 2 coders to ensure reliability of the coding scheme. The 2 sets of coded transcripts were compared and any differences were discussed until a final consensus was reached. If an agreement could not be attained by the coders, a third investigator acted as arbitrator until a final code was chosen. After the codebook was finalized, the focus group and online questionnaire transcripts were coded and compiled by theme.
After the finalized coding scheme was applied to each transcript, the resulting analysis was reviewed for major themes pertaining to POP and its effect on BI. Thematic saturation was reached and only minimal changes were made to the codebook by the sixth focus group. Atlas.ti 5.0 was used to categorize and organize data from the focus groups and online questionnaires (Scientific Software Development GmbH, Berlin, Germany).
Study measures
The POPQ examination was used to assess prolapse to determine baseline stage and maximum leading edge. The POPQ scoring system is a standardized method of assessing site-specific pelvic floor defects through 9 measurements of the vagina and perineum obtained during a routine pelvic examination. The POPQ was performed as described by Bump et al.
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