Patient-Reported Outcome Measures (PROMs) in Pelvic Floor Disorders

Pelvic floor muscle training patient reported Outcome Measures (PROM) (PFMT-P): Turkish adaptation and its validity and relibiality

OBJECTIVE

Although there are several patient reported outcome measures (PROM) regarding knowledge, source of knowledge and practice about pelvic floor muscle training (PFMT), there is a lack of a valid and reliable PROM that includes the practice component of PFMT along with knowledge and source of knowledge. There is no valid and reliable measurement tool in Turkish used for this purpose. In this context, the aim of our study is to evaluate the psychometric properties of Pelvic Floor Muscle Training Patient Reported Outcome Measures (PROM) (PFMT-P) and to test whether it is a valid and reliable measurement tool for Turkish women.

STUDY DESIGN

This study has been carried out psychometric testing (validity and reliability) of a new assessment tool concerning PFMT-P. A total of 170 female healthcare professionals (midwives, nurses, doctors, physiotherapists) who were between the ages of 23 and 49 and who volunteered to participate were included in the study. SPSS 25.0 and LİSREL 8.80 statistical programs were used for the analysis of data. Descriptive statistics were evaluated with numbers, percentages and means. Content validity index and confirmatory factor analysis were used for validity. Cronbach Alpha value and test-retest were used for reliability. Level of significance was p < 0.05.

RESULTS

Content validity index (CVI) was found to be 0.96 for the overall scale. Model fit indices were found as perfect and good matched. Cronbach's alpha coefficient was found as 0.813 for the overall scale. Test-retest correlation was found as 0.658, it was 0.998 for practice component and 0.997 for source of knowledge component and a positive, significant and high correlation was found.

CONCLUSIONS

It has been determined that PFMT-P is a valid and reliable measurement tool suitable for Turkish culture. With this, it is a short, comprehensive and useful tool that can be used in both pregnancy and the postpartum period for women of reproductive age or menopause.

Risk and protective factors for pregnancy-related urinary incontinence until 1 year postpartum: A cohort study using patient-reported outcome measures in Italy

OBJECTIVE

To investigate the epidemiology of pregnancy-related urinary incontinence (UI) and the related risk factors, focusing also on women's characteristics related to maternity pathway utilization.

METHODS

In this prospective cohort study, we used patient-reported data obtained from the systematic survey on the maternity pathway that all pregnant women in Tuscany, Italy, can join. We selected 8410 women who completed-between March 2019 and November 2022-all five follow-up questionnaires from the first trimester until 12 months postpartum, each including a UI-specific patient-reported outcome measure. We performed panel regression models to explore the related risk factors.

RESULTS

Prevalence of UI was 4.4% at the first trimester, 23.7% at the third trimester, and 15.6%, 12.6%, and 12.4% at 3, 6, and 12 months postpartum. UI occurrence and severity were higher in older, overweight/obese, and unemployed women. High-risk pregnancy and discomfort during pregnancy were risk factors. Receiving a cesarean section reduced the risk, while spontaneous tears, episiotomy, and high birth weight increased it. Women who experienced delays in pregnancy examinations because of long waiting times and women who had planned pregnancy had a higher risk, while performing during-pregnancy pelvic-floor-muscle training was protective.

CONCLUSION

Besides confirming the classic risk and protective factors for UI, we also found novel determinants related to the proper maternity pathway utilization.

Evaluation and acceptability of patient-reported outcome measures in women following pelvic organ prolapse procedures

BACKGROUND

The Australasian Pelvic Floor Procedure Registry (APFPR) captures clinical and surgical data in women undergoing pelvic floor procedures. The inclusion of patient reported outcome measures (PROMs) in the APFPR is a critical activity providing the additional patient perspective of their condition prior to surgery as well as monitoring beyond the usual post-surgical follow-up time. This study aimed to evaluate the acceptability of seven PROMs for women with pelvic organ prolapse (POP) and to determine the most suitable instrument for the APFPR.

METHODS

Semi-structured qualitative interviews were conducted with women with POP (n = 15) and their treating clinicians (n = 11) in Victoria, Australia. Interview topics covered appropriateness, content, and acceptability of seven POP-specific instruments identified through the literature to determine their suitability and acceptability for inclusion in the APFPR. We analysed the interview data using conventional content analysis.

RESULTS

All study participants agreed that PROMs were needed for the APFPR. Both women and clinicians suggested that some of the instruments were ambiguous, too long and confusing. The Australian Pelvic Floor Questionnaire was accepted widely amongst women and clinicians and recommended for inclusion in the APFPR. All participants agreed it would be appropriate to capture PROMs before surgery, and then followed up post-surgically. Email, phone call or postal mail-out were the preferred options for PROMs data collection.

CONCLUSION

Most women and clinicians supported incorporating PROMs in the APFPR. Study participants believed that capturing PROMs would have potential use in individual care and improve outcomes of women with POP.

Influence of the COVID-19 pandemic on self-reported urinary incontinence during pregnancy and postpartum: A prospective study

OBJECTIVE

To explore how the COVID-19 pandemic influenced self-reported occurrence and severity of pregnancy-related urinary incontinence (UI) in the maternity pathways of Tuscany, Italy.

METHODS

In this prospective pre-post cohort study, we selected a pre-pandemic (n = 1018) and a post-pandemic (n = 3911) cohorts of women that completed, from the first trimester until 3 months postpartum, three surveys including validated patient-reported outcome measures for UI. Data were obtained from systematic surveys on the maternity pathways of Tuscany from March 2019 to June 2021. We performed panel regression models to explore how UI risk differed between COVID-19 groups.

RESULTS

UI occurred less frequently and less severely in post-pandemic patients-especially stress/mixed UI in women never performing pelvic floor muscle training (PFMT)-whereas no difference emerged in women performing during-pregnancy PFMT. During COVID-19, obese women had higher risk of UI, whereas women undergoing operative delivery had lower risk. The post-pandemic group reported more severe UI symptoms at the third trimester, but less severe UI postpartum in women suffering from UI during pregnancy.

CONCLUSIONS

During the COVID-19 pandemic, women reported fewer UI symptoms because they might have lacked chances to identify UI symptoms as a result of pandemic-related sedentarism and inactivity. The risk in women performing during-pregnancy PFMT was not increased, but just six of 26 health districts organized remote PFMT sessions, thus revealing limited resilience to the pandemic in Tuscany.

Analysis of the Structural Characteristics and Psychometric Properties of the Pelvic Floor Bother Questionnaire (PFBQ): A Systematic Review

BACKGROUND

The Pelvic Floor Bother Questionnaire is a validated and reliable questionnaire that studies the presence and degree of pelvic floor discomfort, providing a global vision of pelvic floor dysfunction. This questionnaire assesses urinary stress incontinence, urinary urgency, urinary frequency, urge urinary incontinence, pelvic organ prolapses, dysuria, dyspareunia, defecatory dysfunction, fecal incontinence, and the disability it causes to the respondent.

AIM

The aim of the present study was to analyze the structural characteristics and psychometric properties of the different versions of the pelvic floor bother questionnaire, as well as the methodological quality, the quality of evidence, and the criteria used for good measurement properties.

METHODS

A systematic review was carried out in different databases, such as PubMed, SCOPUS, Web of Science, Dialnet, ScienceDirect, and CINAHL, on studies adapting and validating the pelvic floor bother questionnaire in other languages. The data were analyzed taking into account the guidelines of the preferred reporting item statement for systematic reviews and meta-analyses (PRISMA) and following the COSMIN guidelines, considering articles published up to 28 February 2022, and registered in the PROSPERO database.

RESULTS

Initially, a total of 443 studies were found, from which a total of four studies were analyzed with regard to structural characteristics and psychometric properties, such as reliability, internal consistency, construct validity, and criterion validity.

CONCLUSIONS

The different versions of the questionnaires show basic structural characteristics and psychometric properties for the evaluation of patients with pelvic floor dysfunctions. Most of the analyzed versions present criteria for good measurement properties qualified as sufficient, inadequate-adequate methodological quality, and low-moderate quality of evidence.

International Urogynecology Consultation: Patient Reported Outcome Measures (PROs) use in the evaluation of patients with pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Patient-reported outcome measure instruments include patient-reported outcomes (PROs) and patient-reported goals (PRGs), which allow practitioners to measure symptoms and determine outcomes of treatment that matter to patients.

METHODS

This is a structured review completed by the International Urogynecology Consultation (IUC), sponsored by the International Urogynecological Association (IUGA). The aim of this working group was to evaluate and synthesize the existing evidence for PROs and PRGs in the initial clinical work-up/evaluation and research arena for patients with pelvic organ prolapse (POP).

RESULTS

The initial search generated 3589 non-duplicated studies. After abstract review by 4 authors, 211 full texts were assessed for eligibility by 2 writing group members, and 199 studies were reviewed in detail. Any disagreements on abstract or full-text articles were resolved by a third reviewer or during video meetings as a group. The list of POP PROs and information on PRGs was developed from these articles. Tables were generated to describe the validation of each PRO and to provide currently available, validated translations.

CONCLUSIONS

All patients presenting for POP should be evaluated for vaginal, bladder, bowel and sexual symptoms including their goals for symptom treatment. This screening can be facilitated by a validated PRO; however, most PROs provide more information than needed to provide clinical care and were designed for research purposes.

Patient-reported outcome measures for pain in women with pelvic floor disorders: a systematic review

INTRODUCTION AND HYPOTHESIS

Patient-reported outcome measures (PROMs) are helpful instruments when measuring and reporting changes in patient health status (Al Sayah et al. J Patient Rep Outcomes 5 (Suppl 2):99, 2021) such as the health-related quality of life (HrQoL) of women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The Australasian Pelvic Floor Procedure Registry (APFPR) aims to increase capacity for women to report surgical outcomes through the collection of HrQoL data (Ruseckaite et al. Qual Life Res. 2021) but currently lacks a pain-specific PROM for women with pelvic floor disorders (PFDs), particularly POP and SUI. This review aims to systematically review the existing literature and identify instruments that measure pain in women with POP and SUI for inclusion within the APFPR, which reports on complications from these conditions.

METHODS

We conducted a literature search on OVID MEDLINE, Embase, CINAHL, PsycINFO and EMCARE databases in addition to Google Scholar and grey literature to identify studies from inception to April 2021. Full-text studies were included if they used PROMs to measure pain in women with POP and SUI. Two authors independently screened articles, extracted data and assessed methodological quality.

RESULTS

From 2001 studies, 23 publications describing 19 different PROMs were included for analysis. Eight of these instruments were specific to the pelvic floor; four were only specific to pain and used across multiple disorders; three were generic quality of life instruments and four were other non-validated instruments such as focus group interviews. These instruments were not specific to pain in women with POP or SUI, as they did not identify all relevant domains such as the sensation, region and duration of pain, or incidents where onset of pain occurs.

CONCLUSIONS

The findings of this review suggest there are no current PROMs that are suitable pain-specific instruments for women with POP or SUI. This knowledge may inform and assist in the development of a new PROM to be implemented into the APFPR.

Extension and Evaluation of the PROMIS Sexual Function and Satisfaction Measures for Use in Adults Living With Multiple Sclerosis

BACKGROUND

Sexual dysfunction is a common symptom of multiple sclerosis (MS). Clinically meaningful and psychometrically sound measures of sexual function validated in people with MS are necessary to identify people with MS who experience problems with sexual function.

AIM

To evaluate the Patient-Reported Outcomes Measurement Information System (PROMIS) Sexual Function and Satisfaction (SexFS) v2.0 measure in people with MS and to extend the PROMIS SexFS Brief and Full Profiles to include additional aspects of sexual function relevant to people living with MS.

METHODS

A convenience sample of MS clinicians and sexually active individuals with MS ranked relevance of 26 items that listed specific factors that interfere with sexual function. Rankings were used to select items to include in the modified SexFS for Multiple Sclerosis (SexFS-MS) profiles. Sex-FS Brief and Full profiles along with the top 22 ranked interfering factor items underwent cognitive interviews (CI) to assess whether the items were understandable and meaningful.

OUTCOMES

The SexFS as originally published functioned well in people with MS after minor modifications.

RESULTS

Twelve MS clinicians and 26 people with MS ranked items. The 10 highest ranked questions about factors that interfere with sexual function most relevant to people with MS were added to the SexFS-MS Brief profiles and 18 to the Full profiles. Ten men and 12 women with MS participated in CIs and found most items to be clear and meaningful. However, important changes were made to the profile instructions, some response sets, and to some items to improve clarity and function. New items to assess numbness and reasons why sexually active people choose at times not to engage in sexual activity were added.

CLINICAL IMPLICATIONS

Brief and Full profiles are freely available and are recommended for research and clinical practice that include people with MS.

STRENGTHS & LIMITATIONS

This study is the first to provide validity evidence for the PROMIS SexFS in people living with MS. Though the PROMIS SexFS was tested in people who identify as lesbian, gay, or bisexual, only individuals who identified as heterosexual participated in this study. Results may not represent views of people with MS who identify as other sexual orientations who may have different concerns and priorities related to sexual function.

CONCLUSION

This study extended the PROMIS SexFS Brief and Full profiles to create the SexFS-MS by adding items that measure most relevant issues related to sexual function in individuals living with MS. Amtmann D, Bamer AM, Salem R, et al. Extension and Evaluation of the PROMIS Sexual Function and Satisfaction Measures for Use in Adults Living With Multiple Sclerosis. J Sex Med 2022;19:719-728.

Patient-Reported Outcome measures for pregnancy-related urinary and fecal incontinence: a prospective cohort study in a large Italian population

OBJECTIVE

To investigate prevalence and risk factors of pregnancy-related urinary/fecal incontinence (UI/FI) in a large Italian population.

METHODS

This is a prospective cohort study analyzing patient-reported outcome (PRO) measures obtained from the systematic longitudinal survey on the maternity pathway of Tuscany from March 2019 to April 2021. Four questionnaires were completed by 6,023 women from the beginning of pregnancy until six months postpartum, each including two PRO measures - Wexner scale for FI and ICIQ-SF for UI -, and questions investigating sociodemographic/clinical factors. After assessing UI/FI prevalence at each time-point, we run panel regressions to explore the related risk factors.

RESULTS

Women reporting UI and FI were, respectively, 24.3% and 6.2% in the third trimester, and 12.6% and 4.2% six months postpartum. UI occurrence and severity were higher in highly-educated, aged > 30, and overweight/obese women. Spontaneous tears or episiotomy were risk factors for postpartum UI, while receiving cesarean-section and performing pelvic-floor-muscle-training during pregnancy were protective, mainly in specific groups. Finally, higher FI prevalence and severity emerged in overweight, aged > 40, highly-educated, non-Italian women and in those undergoing tears.

CONCLUSION

We employed PRO measures to investigate the epidemiology of pregnancy-related UI/FI and detect the main risk groups. Pelvic-floor-muscle-training may be recommended in women with peculiar sociodemographic/clinical features.

Evaluation of the acceptability of patient-reported outcome measures in women following pelvic floor procedures

PURPOSE

Patient-reported outcome measures (PROMs) are valuable tools in evaluating the outcomes of surgical treatment health-related quality of life (HRQoL) of women with stress urinary incontinence (SUI) and may be incorporated into related clinical quality registries. The aim of this study was to assess the feasibility and acceptability of incorporating PROMs into the Australian Pelvic Floor Procedure Registry (APFPR).

METHODS

Semi-structured qualitative interviews were conducted with women with SUI (N = 12) and their managing clinicians (N = 11) in Victoria, Australia. Interview topics covered content and face validity, appropriateness, and acceptability of three incontinence-specific, two pain, one anxiety and depression, one sexual function and one patient global impression of improvement instruments identified through the literature to determine their suitability and acceptability for the APFPR. We analysed interview data into topics using conventional content analysis.

RESULTS

Study participants agreed that PROMs were needed for the APFPR. Both participant groups suggested that some of the instruments were ambiguous, therefore only three instruments (one incontinence-specific, sexual function and patient global impression of improvement) will be included in the APFPR. Both clinicians and women agreed it would be appropriate to answer PROMs at baseline and then at 6- and 12-month postsurgically. Email, phone call and mail-out of the instruments were the preferred options for administration.

CONCLUSION

Most women and clinicians supported the feasibility of incorporating PROMs in the APFPR. Participants believed the PROMs would demonstrate useful aggregate HRQoL data and have potential for use in individual care.

Three-year follow-up of a self-administered Australian pelvic floor questionnaire validated in Chinese pregnant and postpartum women

INTRODUCTION AND HYPOTHESIS

The aim of this study was to verify whether the Chinese version of the self-administered Australian Pelvic Floor Questionnaire (APFQ) can assess the changes in symptoms over a long time period (responsiveness) and to verify the reliability and validity of the questionnaire after 3 years of follow-up.

METHODS

The questionnaire was completed by 146 women using the WeChat platform after 3 years of follow-up. Reliability was assessed through internal consistency (Cronbach's alpha). Construct validity was evaluated by significantly distinguished differences in symptom scores between women who did and did not subjectively suffer bothersome symptoms. Responsiveness was evaluated in 146 women. The effect size (ES) and standardized response mean (SRM) were used to assess the degree of responsiveness.

RESULTS

Of the 146 women, all completed the questionnaire through the WeChat platform without missing any items. Reliability, Cronbach's alpha for the four domains and total APFQ were: bladder function 0.78, bowel function 0.71, pelvic organ prolapse 0.78, sexual function 0.68 and total APFQ 0.84. Concerning construct validity, the APFQ significantly distinguished the symptom scores between women who did and did not subjectively suffer from bothersome symptoms, and the score difference was 1.1-1.6 points, 1.2 points, 2.0-3.7 points and 1.4 points, respectively. For responsiveness, three domains showed slight (bowel domain) to moderate (bladder domain, sex domain) sensitivity to change. ES and SRM ranged from 0.21 to 0.75 and 0.16 to 0.60, respectively.

CONCLUSIONS

The Chinese version of the self-administered APFQ is reliable and valid and can monitor the changes in symptoms over time.

Maternal risk factors of urinary incontinence during pregnancy and postpartum: A prospective cohort study

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Urinary incontinence after delivery affects every fifth woman.

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Urinary incontinence before pregnancy is a risk factor of postpartum incontinence.

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Primiparous women are at a greater risk of urinary incontinence after birth.

Introduction

Urinary incontinence (UI) during pregnancy is a common health problem. Vaginal delivery in particular affects the pelvic floor and increases the risk of pelvic floor dysfunctions. This prospective cohort study was conducted to investigate the incidence of UI during pregnancy and three months postpartum and determine the risk factors underlying UI.

Methods

In total, 547 volunteer women were recruited from the maternity clinic of a tertiary hospital. The participants filled out a questionnaire twice, one in the second trimester and the other three months after delivery. A multivariate logistic regression model with forward stepwise selection was used to analyze known risk factors for UI.

Results

The prevalence of UI during pregnancy was 39.5% and three months after childbirth 16.1%. Twenty-two percent of participants had pre-existing UI compared to 41.0% of the 88 women with UI three months postpartum. UI before pregnancy (OR 2.2), during pregnancy (OR 3.8) and primiparity (OR 2.3) were significantly associated with postpartum UI.

Conclusions

Women with UI before or during pregnancy and who are primiparous are at increased risk for postpartum UI. To prevent and reduce the risk factors contributing to UI, pregnant women should be routinely counseled.

Transanal Irrigation for Neurogenic Bowel Disease, Low Anterior Resection Syndrome, Faecal Incontinence and Chronic Constipation: A Systematic Review

Transanal irrigation (TAI) has received increasing attention as a treatment option in patients with bowel dysfunction. This systematic review was conducted according to the PRISMA guidelines and evaluates the effect of TAI in neurogenic bowel dysfunction (NBD), low anterior resection syndrome (LARS), faecal incontinence (FI) and chronic constipation (CC). The primary outcome was the effect of TAI on bowel function. Secondary outcomes included details on TAI, quality of life (QoL), the discontinuation rate, adverse events, predictive factors for a successful outcome, and health economics. A systematic search for articles reporting original data on the effect of TAI on bowel function was performed, and 27 eligible studies including 1435 individuals were included. Three randomised controlled trials, one non-randomised trial, and 23 observational studies were included; 70% of the studies were assessed to be of excellent or good methodological quality. Results showed an improvement in bowel function among patients with NBD, LARS, FI, and CC with some studies showing improvement in QoL. However, discontinuation rates were high. Side effects were common, but equally prevalent among comparative treatments. No consistent predictive factors for a successful outcome were identified. Results from this review show that TAI improves bowel function and potentially QoL; however, evidence remains limited.

Validation of the Chinese version of the Pelvic Organ Prolapse Symptom Score (POP-SS)

OBJECTIVE

The objective of the present study was to translate the Pelvic Organ Prolapse Symptom Score (POP-SS) into Chinese and validate it in a population of Chinese women.

METHODS

The POP-SS questionnaire was translated into simplified Chinese language following an intercultural adaptation procedure. One hundred forty-six patients who met the inclusion criteria were recruited. Among the enrolled patients, 63 underwent surgery for POP and 50 underwent pessary management. They completed the questionnaires at baseline (T1), 1 to 2 weeks later (T2), and 3 months after intervention (T3). Evaluation for psychometric properties was conducted following with the COnsensus-based Standards for the selection of health Measurement INstruments checklist, including internal consistency, test-retest reliability, measurement error, content validity, criterion validity, construct validity, responsiveness, and interpretability.

RESULTS

The POP-SS was successfully translated into a Chinese version and achieved good content validity. Internal consistency (Cronbach's alpha = 0.796) was good, and test-retest reliability was excellent (intraclass correlation coefficients = 0.98; P < 0.001). The construct validity was verified by factor analysis and consistent with the theoretical structure of the original questionnaire. The POP-SS score was also significantly correlated with Pelvic Floor Distress Inventory-20 (Spearman's correlation coefficient = 0.89, P < 0.001). The confirmatory factor analysis identified two factors: physical symptoms and evacuation symptoms. The mean changes among the participants in very much better (9.80 ± 5.36) and much better (5.67 ± 2.99) groups were larger than those among the participants in the no change group (0.43 ± 2.07). The effect size responsiveness parameter in the much better group (>0.80) was larger than that in the no change group (<0.20). The values of the minimal important change for surgery and pessary groups were both larger than the smallest detectable change, indicating sufficient responsiveness.

CONCLUSIONS

The Chinese version of POP-SS is a reliable and valid instrument and has good sensitivity to change in the population studied.