Between hope and fear: patient's expectations prior to pelvic organ prolapse surgery.

Abstract

The aim of our study was to analyse the patient's expectations (fears and goals (hopes)) in women who are scheduled for pelvic organ prolapse (POP) surgery.
All consecutive women awaiting surgery for POP in a tertiary urogynaecological centre were included. A short questionnaire with two open questions on goals and fears with regard to the operation was used.
Ninety-six out of 111 distributed questionnaires (86%) were analysed. Goals and fears were categorized into five groups. De novo symptoms (63%), POP recurrence (34%) and surgical complications (29%) were the most important fears. Symptom release (96%), improved lifestyle (physical capabilities; 30%) and improved sexual life (18%) were important goals.
A wide variety of expectations both positive and negative can be found in women before POP surgery and should be an integral part of preoperative counselling. Achieving the individual goals as based on expectations, positive (goals) and negative (fears), should be part of the POP surgery evaluation.

Full text

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ORIGINAL ARTICLE
Between hope and fear: patient’s expectations prior to pelvic
organ prolapse surgery
Sameh S. S. Lawndy & Mariella I. Withagen &
Kirsten B. Kluivers & Mark E. Vierhout
Received: 11 December 2010 /Accepted: 2 May 2011 /Published online: 21 May 2011
# The Author(s) 2011. This article is published with open access at Springerlink.com
Abstract
Introduction and hypothesis The aim of our study was to
analyse the patient’s expectations (fears and goals (hopes))
in women who are scheduled for pelvic organ prolapse
(POP) surgery.
Methods All consecutive women awaiting surgery for POP
in a tertiary urogynaecological centre were included. A
short questionnaire with two open questions on goals and
fears with regard to the operation was used.
Results Ninety-six out of 111 distributed questionnaires
(86%) were analysed. Goals and fears were categorized into
five groups. De novo symptoms (63%), POP recurrence
(34%) and surgical complications (29%) were the most
important fears. Symptom release (96%), improved lifestyle
(physical capabilities; 30%) and improved sexual life (18%)
were important goals.
Conclusions A wide variety of expectations both positive
and negative can be found in women before POP surgery
and should be an integral part of preoperative counselling.
Achieving the individual goals as based on expectations,
positive (goals) and negative (fears), should be part of the
POP surgery evaluation.
Keywords Pelvic organ prolapse.POP surgery.Hopes.
Fears.Expectations
Abbreviations
POPPelvic organ prolapse
UI Urinary incontinence
Introduction
Pelvic organ prolapse (POP) and urinary incontinence
(UI) are common disorders in women and have a great
impact on quality of life (QoL) [1–4]. There is an 11%
lifetime risk of undergoing at least one operation for POP
or UI, and there is a high prevalence of reoperations [5].
POP surgery is an important treatment for POP. There is
no consensus regarding the best method of outcome
assessment of POP surgery, but the achievement of
patient-oriented goals gains importance [6, 7]. Traditional
physician-determined measures of treatment success
appeared to be insufficient to determine the quality of
surgical outcomes and patient satisfaction [7–9]; this may
be explained by the fact that surgeons and patients had
different goals and expectations on the outcomes of
surgery [10]. This has led to the introduction of disease-
specific QoL questionnaires in order to determine the
quality of surgical outcomes in a more patient-oriented
manner [11]. But disease-specific QoL questionnaires may
also lack the sensitivity to assess individual symptoms
[12], and they disregard the goals of the individual patient
[13–16]. Realistic and achievable goals may prevent
dissatisfaction with surgical outcomes [17].
Goal achievement is now regarded as an important
predictor for success after surgery. In the present study, we
were specifically interested in the fears or negative expect-
ationsofourpatients.Fears,justifiedorunjustified,maymake
S. S. S. Lawndy (*):M. I. Withagen:K. B. Kluivers:
M. E. Vierhout
791 Department of Obstetrics and Gynaecology,
Radboud University Nijmegen Medical Centre,
P.O. Box 9101, 6500 HB Nijmegen, the Netherlands
e-mail: s.lawndy@hotmail.com
Int Urogynecol J (2011) 22:1159–1163
DOI 10.1007/s00192-011-1448-6

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patients refrain from effective treatment. In the literature, this
subject has been given hardly any attention, neither in
gynaecological surgery nor in the other specialties.
In this study, we summarize the patient’s goals and fears
before surgery in a group of women scheduled for POP
surgery.
Materials and methods
Women were recruited from a tertiary urogynaecological
centre in the Netherlands, the Radboud University Nijme-
gen Medical Centre. All consecutive women who were
waiting for POP surgery during the study period from
December 2008 till October 2009 were requested to
complete a short questionnaire and return with a reply
envelope. Outpatient counselling was performed by the
outpatient gynaecologist who is in generally also the
operating gynaecologist. In our study, the women were
counselled by four gynaecologists who work with the same
protocols and in the same group; most of the women in our
study 68 (71%) were counselled by one gynaecologist
(MV). The preoperative counselling before the operation
was not altered for this study. Counselling generally started
by the referring general practitioner, but we have no
information on this. Outpatient counselling consisted of
counselling about the various possible therapies, a brief oral
explanation of the operation supported by the handout of a
standardized folder as advised by the Dutch Society for
Obstetrics and Gynecology (www.NVOG.nl). Patients were
standardly offered the possibility for an additional counsel-
ling consult, but this is seldom used.
The one-page questionnaire contained an introduction
and two short open questions. The introduction of the
questionnaire was as follows: “You are scheduled to
undergo POP surgery. We are studying the reasons for
undergoing such surgery. Therefore we would like to ask
you to answer as accurate as possible the following two
questions.” The first question was “What are the most
important goals you want to accomplish with the surgery?
In other words what do you hope to achieve by the
operation? You can, but need not necessarily, give a
maximum of 5 targets, let your imagination run free!” The
second question was “What are the most important things
or situations that you would not want to reach by the
surgery? In other words what do you fear a situation you
are concerned about that could occur after the operation?
You can, but need not necessarily, give a maximum of 5
things or situations. Let your imagination run free!”
The answers were collected, transferred into a database
and categorized. Categorization was based on the answers
and not on pre-existent categories. Simple statistical
frequencies were used to describe the answers. Spearman’s
correlation coefficient test was used to test for potential
correlations between the number of answers in the 10
categories (five hope categories and five fear categories). P
values<0.05 were considered statistically significant. Sta-
tistical analyses were performed using SPSS version 16.0
(SPSS, Inc., Chicago, IL, USA). This study was not
submitted for ethics approval since the procedures and
questionnaires used are part of daily clinical practice.
Results
One hundred eleven women (n=111) were asked to answer
our questionnaire, of whom 99 patients (89%) replied; one
of those had cancelled the operation. Two questionnaires
contained no useful information, and thus, 96 question-
naires (86%) were available for analysis.
The mean number of answers to the hope question was
2.9 (range 1–6), and the mean number of answers to the
fear question was 1.8 (range 0–5). The demographics and
surgical procedures for the participating women are shown
in Table 1, and all women included are native Dutch
women. The answers to the two questions are listed in
POP patients (n=111)
Age (years)
BMI (kg/m2)
Parity
Postmenopausal (yes)
First POP surgery (yes)
Planned surgical procedures
Anterior and/or posterior repair
Modified Manchester with anterior and/or posterior repair
Vaginal hysterectomy with anterior and/or posterior repair
Abdominal sacrocolpopexy
Prolift operations (with or without anterior and/or posterior repair)
60 (23; 88)
27 (17; 63)
2 (0; 5)
65 (68%)
80 (83%)
32 (33%)
41 (43%)
11 (11%)
3 (3%)
9 (9%)
Table 1 Demographics and
surgical procedures of the
study population
Data presented as number
(percentage) or median (range)
as appropriate
n number of cases, BMI body
mass index, POP pelvic organ
prolapse
1160 Int Urogynecol J (2011) 22:1159–1163

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Tables 2 and 3, respectively. Most women (63 women,
66%) had more goals than fears; a minority had more fears
than goals (10 women, 10%). The number of answers on
goals correlated positively with the number of fears (r=0.303
(P<0.01)). Further, the hope of getting a better lifestyle
category correlates positively with emotional health category
(r=0.254 (P<0.05)); the hope of getting a better sexual life
category correlates positively with the fear from deterioration
of sexuality category (r=0.232 (P<0.05)).
Discussion
To our best knowledge, our study is the first on fears,
besides goals, in relation to POP surgery. Fears and goals
can influence decision making. Goals, certainly erroneous
ones, may allow patients to go forward, with surgery when
it would not be reasonable to expect those goals, but fears
can also greatly influence decision making in patients and,
although often heard during consultations, has been given
little attention in the available literature. Our results show
that besides hopes (goals), there are also a significant
number of fears in the patients when specifically asked for.
It was, however, notable that the number of answers
regarding fears was less as compared with the answers
regarding goals. The number of goals and fears were,
however, positively correlated. This may be simply a result
of the ability of some women to verbalize their expectations
better than others
One previous study in 1993 has studied fear for cataract
operations in aged persons [18]. This study has found that
33% of the patients had fear and 32% felt tension about the
operation; women feared the operation significantly more
than men. Fears were associated with hypochondriasis,
hysteria and hypomania.
The most striking finding in our study is that almost all
women feared de novo symptoms, particularly UI. This
finding matches well with our clinical experience. The fear
Table 2 Categorized answers on the first question “What are your most important goals, you want to accomplish with the surgery? In other words
what you hope eventually to have achieved by the operation?”
Category Characteristic answern (%)
1. Symptoms
Urinary symptoms
Disappearing of urine incontinence
Disappearing of urgency/frequency
Normalize micturation
No need for sanitary napkin
Prolapse symptoms
Disappearing of prolapse sensation
No more need for vaginal pessary
Pain symptoms
Improvement of the pain (generally)
Improve back pain
Bowel symptoms
Improvement of defecation
Disappear of faecal incontinence
2. Lifestyle
Improve physical capabilities
3. Sexual life
Improvement sexuality
Disappear of dyspareunia
4. Emotional health
Improve body image
Improve fatigue symptoms
5. Other
Disappear of menstruation
Decrease the chance to get cancer
92 (96)
67 (70)
38 (40)
26 (27)
18 (19)
10 (10)
50 (52)
50 (52)
5 (5)
29 (30)
20 (21)
9 (9)
20 (21)
17 (18)
4 (4)
29 (30)
29 (30)
17 (18)
14 (15)
3 (3)
16 (17)
9 (9)
8 (8)
6 (6)
4 (4)
2 (2)
“I do not get wet every time”
“That I can walk for two hours as before without having to pee 3 times”
“That I can pee normally as before”
“That I can go out without Tena lady (sanitary napkin)”
“That no more flesh comes from my vagina”
“No need for using pessary”
“Reduction in the abdominal pain”
“No more back pain”
“That I can defecate normally as before”
“No involuntary stool loss moments”
“To do my work and sport optimally without all those problems”
“That I can have sex normally as before without hinder”
“Sex without pain”
“That I become a young woman again”
“No more feeling tired”
“No more bleeding, no more periods”
“Prevent the risk of womb cancer, I use Tamoxifen for 4 years”
Data are presented as n (percentage)
n number of times reported
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of becoming incontinent after POP surgery may be a reason
for refraining from POP surgery. The occurrence of stress
UI (SUI) after POP surgery may be associated with the
presence of occult stress incontinence before surgery [19, 20]
which is estimated to be 36–80% in advanced POP [20]. The
occurrence of postoperative SUI is, however, difficult to
predict, and all studies on the subject show that the
percentage of occult incontinence preoperatively is far higher
as compared with the actual percentage of SUI after surgery
[21]. The expectations of the women with regard to UI are
thus somewhat discrepant with the reality. Furthermore,
postoperative SUI can be managed rather effectively with
tension-free mid-urethral sling operations [22]. This makes
UI a crucial item for proper counselling before the operation.
In a recent study, the use of photos and videos to explain
what patients could expect during and after the operation
has reduced significantly preoperative anxiety [23]. Recur-
rence and failure after POP surgery were important issues
women fear; this is more justified because the failure rate of
POP surgery is high [5]. The patient’s fear of surgical
complications on the other hand seems rather high because
the complication rates during POP surgery are in general
low [21, 24].
The effect of POP surgery on sexuality, both fear for
deterioration as well as hope for improvement, was an
important subject in the women included in this study. We
do not know how many women in our group were sexually
active before or after the operation. A recent study reported
a significant improvement in the sexual function 2 years
after POP and stress UI surgery [25]. In another recent
study is concluded that the POP surgery with additional
incontinence surgery resulted in decreased vaginal wall
sensibility; there was no influence of the decreased vaginal
wall sensibility on sexual well-being [26].
In our study, we did not use a predefined system to
categorize the expectations, and previous studies had used
different categories [15–17, 27]. There is no widely accepted
system to categorize the goals for treatment. Lowenstein et al.
[27] have categorized the goals into five categories: (1) goals
related to symptom resolution, (2) goals related to lifestyle
and/or quality of life improvement, (3) goals related to
emotional outcome, (4) goals related to information seeking
(aimed to gain more information about symptoms, treatment,
or prognosis) and (5) other. Differences in goals between
populations may be explained by differences in social and
cultural environment. Factors such as age, culture, place and
religion will affect the goals and fears of the patients who are
going to be operated for pelvic floor dysfunctions.
Although it is known that POP is not a cause of pelvic or
low back pain [28], 30% of the women in our population
wished resolution pain as result surgery wish may be an
unrealistic aim of the surgery.
It could be expected to find that the hope to get a better
sex life positively correlates with the fear from deterioration
and that the hope of getting a better lifestyle correlates
positively with emotional health.
Table 3 Answers on the second question “What are your most important things or situations that you just would not want to reach by the
surgery? In other words what you want to avoid, a situation where you are concerned that could occur through the operation?”
CategoryCharacteristic answern (%)
1. Getting new symptoms
Urine incontinence
Pain
Urine retention/incomplete urination
Faecal incontinence
2. Recurrence
Failure of the surgery
Recurrence (soon in the future)
3. Surgical complications
Surgical complications
Complications of the general/spinal anaesthesia
Rejection of the mesh
4. Deterioration of sexual life
Getting dyspareunia
Sexually deterioration
5. Lifestyle deterioration
Physical deterioration
60 (63)
50 (52)
12 (13)
9 (9)
5 (5)
33 (34)
22 (23)
14 (15)
28 (29)
20 (21)
8 (8)
3 (3)
16 (17)
9 (9)
7 (7)
8 (8)
8 (8)
“To become incontinent”
“New pain complaints”
“That I use catheter to pee”
“Damage to the anal sphincter”
“That it has not helped”
“That I soon get recurrence”
“That there are complications during or after the operation”
“I get no adverse effects after anesthesia”
“I hope that no rejection of the mesh occurs”
“That my vagina become narrow that sex become impossible”
“That sexual sense become less”
“That hinders me in the daily activities”
Data are presented as n (percentage)
n number of times mentioned
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In conclusion, negative patient’s expectations (fears)
were present besides positive expectations (goals or hopes).
Both and especially, sometimes erroneous, fears are
important and should be an integral part of preoperative
counselling. Further, the fears should be part of a
comprehensive informed consent. Achievement of the
expectations, both positive (hopes) and negative (fears),
should be part of the evaluation of the outcome after
surgery.
Conflicts of interest
with and are on the Speaker’s Bureau of Ethicon Women’s Health &
Urology. MV is a member of the European OAB faculty of Astellas.
This study, however, was entirely instigated by the responsible
researchers and funded by university-administered research funds.
No commercial partner was involved in the study setup, study design,
data collection, or whatsoever. The other authors have no conflicts of
interest to declare.
MW and MV have a consultancy agreement
Open Access
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
This article is distributed under the terms of the
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