Objective
The objective of the study was to describe the basic knowledge about prolapse and attitudes regarding the uterus in women seeking care for prolapse symptoms.
Study Design
This was a cross-sectional study of English-speaking women presenting with prolapse symptoms. Patients completed a self-administered questionnaire that included 5 prolapse-related knowledge items and 6 benefit-of-uterus attitude items; higher scores indicated greater knowledge or more positive perception of the uterus. The data were analyzed using descriptive statistics and multiple linear regression.
Results
A total of 213 women were included. The overall mean knowledge score was 2.2 ± 1.1 (range, 0–5); 44% of the items were answered correctly. Participants correctly responded that surgery (79.8%), pessary (55.4%), and pelvic muscle exercises (34.3%) were prolapse treatment options. Prior evaluation by a female pelvic medicine and reconstructive surgery specialist (beta = 0.57, P = .001) and higher education (beta = 0.3, P = .07) was associated with a higher mean knowledge score. For attitude items, the overall mean score was 15.1 (4.7; range, 6–30). A total of 47.4% disagreed with the statement that the uterus is important for sex. The majority disagreed with the statement that the uterus is important for a sense of self (60.1%); that hysterectomy would make me feel less feminine (63.9%); and that hysterectomy would make me feel less whole (66.7%). Previous consultation with a female pelvic medicine and reconstructive surgery specialist was associated with a higher mean benefit of uterus score (beta = 1.82, P = .01).
Conclusion
Prolapse-related knowledge is low in women seeking care for prolapse symptoms. The majority do not believe the uterus is important for body image or sexuality and do not believe that hysterectomy will negatively affect their sex lives.
Pelvic organ prolapse (POP) is a prevalent disorder, with 37% of the female population in the United States affected by stage 2 or greater prolapse. Prolapse has been found to have a negative impact on a woman’s perceived body image, physical and sexual attractiveness, and femininity. Additionally, prolapse may affect a woman’s ability to engage in personal and professional activities.
Lack of knowledge regarding pelvic floor disorders may lead to hesitancy in seeking medical care and dissatisfaction with care. In fact, patients with urinary incontinence may not discuss their problems with a physician because of a lack of understanding and the perception that pelvic floor disorders are a normal consequence of aging. Many options exist for the treatment of POP including pelvic floor muscle exercises, pessary, and surgery. Commonly, surgical treatment for prolapse includes hysterectomy. However, it is unknown whether women with POP consider their uterus to be an integral part of their sexual function and femininity.
Limited research exists that assesses patient knowledge of POP treatment options and attitudes regarding the relationship of the uterus and hysterectomy with sexuality/femininity in women seeking care for POP symptoms. Increased understanding of patients’ attitudes and expectations may potentially lead to improved counseling and education. Thus, the objectives of this study were to describe patient knowledge about POP and POP treatment and patient attitudes regarding the uterus in women seeking care for prolapse symptoms.
Materials and Methods
We conducted an ancillary analysis of a multicenter, cross-sectional survey study through the Society of Gynecologic Surgeons Fellows Pelvic Research Network. Nine academic centers throughout the United States with Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellowships participated. Institutional review board approval was obtained from all participating sites.
English-speaking women with POP symptoms seeking care from an FPMRS specialist at a participating site between May 2011 and August 2012 were eligible. Women with prior hysterectomy and inability to complete written questionnaires were excluded. Patients who answered with an affirmative response to question 3 on the Pelvic Floor Distress Inventory questionnaire (Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?) were invited to participate. Clinical and demographic information was collected.
Prior to consultation with the FPMRS specialist, eligible participants were approached about the study, and if interested, informed consent was obtained. Participants completed a 38-item study questionnaire that included knowledge and attitude questions about POP treatment options, the uterus, and hysterectomy. The knowledge domain consisted of 5 items modified from a previously validated questionnaire and included the following: (1) surgery is a treatment option for POP, (2) pessary is a treatment option for POP, (3) pelvic floor muscle exercises are a treatment option for POP, (4) hysterectomy reduces the risk of uterine cancer, and (5) prolapse causes incontinence. Knowledge items were scored correct for questions 1-4 if the participant responded strongly agree/agree (score = 1) or incorrect if the participant responded unsure/disagree/strongly disagree (score = 0); and question 5 had reverse scoring. The points were summed (range, 0–5) and higher scores indicated greater knowledge.
There were 6 attitude items that determined a benefit-of-uterus score: “the uterus is important for …” (1) sexual function and (2) sense of self; and “hysterectomy would …” (3) make me feel less feminine, (4) make me feel less whole, (5) worsen my partner’s sexual experience, and (6) worsen my sexuality. Attitude items were scored on a 5 point Likert scale that ranged from strongly agree (score = 5) to strongly disagree (score = 1). Higher scores indicated a more positive perception of the uterus (range, 6–30).
Descriptive statistics were used to summarize participant demographic and clinical information. Associations between patient characteristics and overall knowledge and uterine attitude scores were obtained using χ 2 and Fisher exact tests and analysis of variance. Multiple linear regression was used to determine predictors of higher knowledge and attitude scores. P < .05 was considered statistically significant. All statistical analyses were conducted using SAS, version 9.2 (SAS Institute, Cary, NC).
Results
A total of 217 patients completed the survey; 4 were excluded because they completed the questionnaire after the consultation with the FPMRS specialist. There were no missing responses to the questionnaire. Demographic characteristics of the study group are provided in Table 1 . All subjects were presenting to the participating center in this study for the first time with POP symptoms. In our cohort, 57 women (26.8%) had previously seen a FPMRS specialist at a different institution for prolapse, and 53 (24.9%) had previous prolapse treatment. Current sexual activity was reported in 106 patients (49.1%). The majority of patients had not had previous abdominal/pelvic (64.4%) or vaginal surgery (95.6%).
| Characteristic | (n = 213) |
|---|---|
| Age , y | 58.9 ± 14.1 |
| Race | |
| White | 183 (85.9) |
| Black | 12 (5.6) |
| Asian | 3 (1.4) |
| Other | 5 (2.3) |
| Unknown | 10 (4.7) |
| Ethnicity | |
| Hispanic | 24 (11.2) |
| Non-Hispanic | 188 (88.3) |
| Unknown | 1 (0.5) |
| Menopausal status | |
| Premenopause (n = 50) | 50 (23.5) |
| Perimenopause (n = 31) | 31 (14.6) |
| Postmenopause (n = 132) | 132 (62.0) |
| Education level | |
| Less than high school | 13 (6.1) |
| High school/GED | 61 (28.6) |
| Some college | 52 (24.4) |
| College degree | 46 (21.6) |
| More than college | 39 (18.3) |
| Unknown | 2 (0.9) |
| Income level | |
| Less than $20,000 | 39 (18.3) |
| $20,001-40,000 | 45 (21.1) |
| $40,001-60,000 | 32 (15.0) |
| $60,001-80,000 | 23 (10.8) |
| More than $80,001 | 67 (31.5) |
| Unknown | 11 (5.2) |
| Geographic location in United States | |
| Northeast | 91 (42.7) |
| South | 44 (20.7) |
| Midwest | 57 (26.8) |
| West | 21 (9.9) |
The overall mean knowledge score was 2.2 ± 1.1 of 5, indicating on average only 44% of items were correctly answered. Regarding treatment options for prolapse, 80% correctly answered that surgery was an option, 56% correctly answered pessary was an option, and 34% correctly answered pelvic muscle exercises were an option. Hysterectomy decreases uterine cancer risk was correctly answered in 42%, and 90% incorrectly responded that prolapse causes urinary incontinence.
Table 2 presents the knowledge scores and correlations with patient characteristics. As education increased from less than high school to greater than college level, the mean knowledge score increased from 1.8 ± 1.2 to 2.8 ± 0.8 ( P = .006). On multiple linear regression, education level continued to be correlated with knowledge scores (beta = 0.3, P = .07). However, even college-educated women on average answered less than 50% of the questions correctly. Prior evaluation by a FPMRS specialist was also associated with a higher mean knowledge score (beta = 0.57, P = .001).
| Variable | Univariate analysis | Multiple linear regression | |||
|---|---|---|---|---|---|
| Knowledge score Mean ± SD | P value | Parameter estimate | Adjusted means | Adjusted P value | |
| Race | |||||
| White (n = 183) | 2.2 ± 1.1 | 2.31 (white) | .46 | ||
| Black (n = 12) | 1.8 ± 1.3 | .04 | –0.194 | 2.51 (others) | |
| Other (n = 8) | 3.1 ± 0.6 | ||||
| Ethnicity | |||||
| Hispanic or Latina (n = 24) | 2.1 ± 1.1 | .53 | |||
| Not Hispanic/Latina (n = 188) | 2.2 ± 1.2 | ||||
| Education level | |||||
| HS grad/GED or less (n = 74) | 2.0 ± 1.2 | .02 | 0.30 | 2.26 | .07 |
| Some college or more (n = 137) | 2.4 ± 1.1 | 2.56 | |||
| Income level | |||||
| Less than $20,000 (n = 39) | 2.0 ± 1.2 | ||||
| $20,001-40,000 (n = 45) | 2.0 ± 1.0 | .15 | |||
| $40,001-60,000 (n = 32) | 2.6 ± 1.2 | ||||
| $60,001-80,000 (n = 21) | 2.3 ± 1.1 | ||||
| More than $80,001 (n = 65) | 2.4 ± 1.2 | ||||
| Prior treatment for prolapse | |||||
| Yes (n = 53) | 2.7 ± 1.0 | .0001 | |||
| No (n = 160) | 2.0 ± 1.1 | ||||
| Previously seen FPMRS for prolapse | |||||
| Yes (n = 57) | 2.7 ± 1.2 | .0005 | 0.57 | 2.69 | .001 |
| No (n = 156) | 2.1 ± 1.1 | 2.13 | |||
| Sexually active? | |||||
| Yes (n = 103) | 2.3 ± 1.1 | .15 | |||
| No (n = 109) | 2.1 ± 1.2 | ||||
| POPQ stage | |||||
| Stage 0-1 (n = 11) | 1.5 ± 0.9 | .15 | |||
| Stage 2 (n = 96) | 2.2 ± 1.1 | ||||
| Stage 3-4 (n = 94) | 2.3 ± 1.2 | ||||
The overall mean benefit-of-uterus attitude score was 15.1 ± 4.7 out of 30, indicating that women had relatively neutral attitudes on whether the uterus was beneficial for sexuality or femininity. However, the majority of respondents disagreed that the uterus was important for body image and sex. Attitude item responses are described in Table 3 .
| Attitude (n = 213) | Strongly agree/agree | Unsure | Disagree/ strongly disagree |
|---|---|---|---|
| The uterus is important for … | |||
| Sexual function/sexuality | 44 (20.7) | 68 (31.9) | 101 (47.4) |
| Sense of self | 44 (20.7) | 41 (19.2) | 131 (60.1) |
| Hysterectomy would … | |||
| Make me feel less feminine | 25 (11.7) | 52 (24.4) | 136 (63.9) |
| Make me feel less whole | 25 (11.7) | 46 (21.6) | 142 (66.7) |
| Worsen partner’s sexual experience | 6 (2.8) | 89 (41.8) | 118 (55.4) |
| Improve my sexuality | 21 (9.9) | 99 (46.5) | 93 (43.7) |
Univariate analysis as depicted in Table 4 supports that a higher mean benefit-of-uterus score is associated with patients who had seen a FPMRS specialist previously, 16.5 ± 5.6 vs 14.6 ± 4.2 ( P = .01). Additionally, patients who lived in the western (18.0 ± 6.6) or southern (15.8 ± 4.5) regions of the United States had higher mean benefit-of-uterus scores than the northeast (14.9 ± 4.4) or midwest (13.8 ± 4.0) ( P = .003). On multiple linear regression analysis, previous consultation with an FPMRS specialist was again associated with a higher mean benefit-of-uterus score (beta = 1.82, P = .01), and nonwhite race was associated with a lower mean benefit-of-uterus attitude score (beta = 2.0, P = .06).
