Comparison of mood state in severe pelvic organ prolapse patients before and after surgery

1 Introduction

Pelvic organ prolapse (POP) refers to the descent of one or more of the anterior vaginal wall, posterior vaginal wall, uterus (cervix), or apex of the vagina (vaginal vault or cuff scar after hysterectomy).¹ POP is a common disorder in parous women. The prevalence of POP is highly varied and is approximately between 3% and 50% according to different studies.^2–6 The number of patients suffering from symptomatic POP is predicted to increase to 46%, over 5 million individuals, by 2050 as the demographic of women over 65 years old increases in the USA.^7–9 Surgical treatment remains the mainstream therapeutic strategy for POP, and more than 1/10 patients may undergo POP repair surgery during their lifetime.¹⁰ Most studies have focused on the clinical efficacy of POP repair surgery, which has been confirmed to be effective for controlling POP symptoms. Although POP is generally not life-threatening, it severely impairs an individual's physical and psychological health, resulting in a significant public health burden.⁷ Moreover, the psychosocial dysfunctions caused by POP are usually underdiagnosed and undertreated.¹¹ Mood state is a chronic or transitory psychological state experienced as a feeling or emotion that influences function and wellbeing.¹² However, several recent studies have demonstrated that mood state is closely related to pelvic floor disorders and many POP patients have elevated negative mood states like anxiety and depressive mood.^13–16 Thus, this study aimed to compare the mood state of patients with severe POP before and after surgery.

2 Materials and methods

This single-center prospective study included a total of 100 patients who underwent surgical treatment for severe POP in the First Affiliated Hospital of Kunming Medical University from October 2016 to February 2019. The inclusion criteria were as follows: a) the ability to live independently and communicate verbally; b) protrusion of any part of the six defined points (Aa, Ba, Ap, Bp, C, and D) to 1cm equal to or lower than the hymenal ring¹⁷; and c) complete follow-up data. Patients with a history of psychiatric diseases, serious complications, or opioid use were excluded.¹⁸ This study was approved by the Ethics Committee of Kunming Medical University (LunShen L No.13). Signed informed consent was obtained from each participant.

Anxiety and depression scores were assessed using the Hamilton Anxiety Scale (HAMA) and the Hamilton Depression Scale (HAMD), respectively.^19–23 The HAMA scale consists of 14 symptom elements (including: anxious mood; tension; fears; insomnia; cognitive changes; depressed mood; somatic symptoms; sensory; cardiovascular; respiratory; gastrointestinal; genitourinary; autonomic; observed behaviour at interview), including both psychological and somatic symptoms.²⁴ Each item is scored from 1 to 5 depending on the severity of the symptoms, and the total scores are 70 points. Patients are classified into four levels according to the total points: normal (0–6), mild anxiety (7−13), moderate anxiety (14–20), and severe anxiety (≥21). We used the 17 item HAMD scale to evaluate the severity of depression symptoms. The 17 items including: depressed mood (0–4); low self-esteem (0–4), feelings of guilt (0–4); suicide (0–4); insomnia early (0–2); insomnia middle (0–2); insomnia late (0–2); work and activities (0–4); retardation (0–4); agitation (0–4); anxiety, psychic (0–4); anxiety, somatic (0–4); somatic symptoms gastrointestinal (0–2); somatic symptoms general (0–2); genital symptoms (0–2); hypochondriasis (0–4); loss of weight within the last week (0–2); insight (0–4). Each item is scored from 0 to 2 or 0 to 4, depending on the severity of the symptoms and the total scores are 54 points. According to the total scores, patients are divided into four categories: normal (0–7), mild depression (8−16), moderate depression (17–23), and severe depression (≥24).

The clinical severity of POP was evaluated using with the POP Quantification (POP-Q) staging system that was introduced in 1996 as an objective and accurate scale for describing the pelvic floor anatomy in women with POP.²⁵ This scale is composed of 9 measurements regarding the vagina and perineum anatomy via a routine pelvic examination, and POP was divided into five stages (0∼IV).²⁵ In this study, all examinations were performed by trained physicians, in which patients were asked to take a deep breath and then hold the breath as if they are bearing down. Recurrence was defined as a postoperative POP-Q stage of ≥ Ⅱ (the point of the most distal prolapse is between 1 ​cm above and 1 ​cm below the hymenal plane).²⁶

Clinical and psychological evaluations were performed preoperatively and at 3 and 6 months postoperatively. The individual clinical profiles of the patients were collected. Afterward, individualized surgical treatment was planned according to the POP-Q stage, medical history, and subjective consideration.

SPSS 22.0 software (IBM Corp., Armonk, NY, USA) was used for statistical analyses. The enumeration data are expressed in percentage, and the measurement data are expressed as mean ​± ​standard deviation. Normally distributed numerical variables were compared by the t-test, and those with skewed distribution by the rank-sum test. Probability (P) values ​≤ ​0.05 were considered significant.

3 Results

In this study, a total of 98 patients completed the assessments (one patient developed urinary leakage 1 month after surgery and another patient experienced recurrence 3 months postoperatively; these two patients were eventually excluded from the study due to incomplete follow-up data). Among the patients, 10 underwent vaginal total hysterectomy plus total colpectomy and four underwent Le Fort-style partial colpocleisis; these 14 patients could not complete the POP-Q examination postoperatively. The study design flowchart is showed in Fig. 1. The other 84 patients received the POP-Q examination and the results are showed in Fig. 2. The POP-Q stage was significantly improved 3 and 6 months postoperatively (P ​< ​0.05).

The mean age of the participants was 60.59 ​± ​11.68 years (range, 34–93 years) and the mean parity was (2.5 ​± ​1.50) times. The combined symptoms included mild incontinence (n ​= ​12; 12%); hypertension (n ​= ​39; 39%); diabetes (n ​= ​11; 11%); ovarian cyst or uterine myoma (n ​= ​17; 17%); and history of hysterectomy (n ​= ​5; 5%).

Preoperatively, all patients had varying degrees of anxiety symptoms (all >7 points; mean HAMA score, 11.94 ​± ​5.59 points). Among these participants, 18 (18.37%) had mild anxiety symptoms, 23 (23.50%) had moderate anxiety symptoms, and 57 (58.13%) had severe anxiety symptoms. Three months postoperatively, the mean anxiety score was 4.67 ​± ​2.02 points; 5 (5.10%) patients had mild anxiety symptoms, 3 (3.10%) had moderate anxiety symptoms, and none had severe anxiety symptoms. After 6 months, the mean anxiety score was 4.89 ​± ​2.57 points; 2 (2.00%) patients had mild anxiety symptoms and 15 (15.30%) had moderate anxiety symptoms, and none had severe anxiety symptoms. Compared to the preoperative baseline level, the anxiety scores were significantly decreased 3 and 6 months postoperatively (both P ​< ​0.05). However, compared to the condition 3 months postoperatively, the anxiety scores were higher after 6 months (P ​< ​0.05). In this study, the preoperative mean anxiety score was 11.94 ​± ​5.59 points, indicating that the patients had anxiety symptoms. Three months postoperatively, the mean anxiety score was 4.67 ​± ​2.02 points, indicating that the patients’ anxiety scores had decreased to normal levels. At the 6-month follow-up, the mean anxiety score was 4.89 ​± ​2.57 points, indicating an increase in anxiety symptoms. The HAMA scores showed a slight increase from the 3-month evaluation to the 6-month evaluation; this result was statistically significant. The detailed data is presented in Table 1.

According to the surgical approaches used, we divided patients into a traditional prolapse surgery group (n ​= ​46) and a mesh pelvic reconstruction group (n ​= ​52) and compared the HAMA scores in the two groups. The respective mean anxiety scores of HAMA and HAMD had no significant difference between traditional prolapse surgery group and mesh pelvic reconstruction group before and after surgery (P ​> ​0.05). The detailed data is presented in Table 2.

Preoperatively, the mean HAMD score was 5.56 ​± ​2.58 points. Among the patients, 20 (20.40%) had mild depression symptoms and none had moderate or severe depression symptoms. Three months postoperatively, the mean depression score was 3.58 ​± ​1.61 points, which was significantly lower than the preoperative baseline level (P ​< ​0.05). After 6 months, the mean depression score was 3.37 ​± ​1.60 points, which was also significantly lower than the preoperative baseline level and the 3-month data (P ​< ​0.05). The mean depression score was 5.56 ​± ​2.58 points preoperatively and decreased to 3.58 ​± ​1.61 and 3.37 ​± ​1.60 points after 3 and 6 months, respectively. The postoperative mean depression scores were less than 7 points, meaning that our patients were within the normal range for depression symptoms. The detailed data is presented in Table 1. In the traditional prolapse surgery and mesh pelvic reconstruction groups, the respective mean depression scores were 5.59 ​± ​2.92 and 5.56 ​± ​3.06 points preoperatively (P ​> ​0.05), 3.52 ​± ​1.73 and 3.63 ​± ​1.62 points 3 months postoperatively (P ​> ​0.05), and 3.33 ​± ​1.33 and 3.40 ​± ​1.36 points 6 months postoperatively (P ​> ​0.05). The detailed data is presented in Table 2.

4 Discussion

POP may cause various health problems and could significantly impacts the mood health and subjective well-being of women.¹⁴ Vrijens et al. conducted a cross-sectional cohort study and noted that POP was associated with anxiety and depression symptoms.¹⁵ In the current study, we used the HAMA and HAMD rating scales to evaluate the severity of anxiety and depression symptoms. We also found that patients with severe POP presented varying degrees of anxiety and depression symptoms preoperatively. We speculate that the occurrence of anxiety and depression symptoms may be correlated with a poor understanding of POP among patients and an unwillingness to see a doctor. The patients may feel ashamed when talking about POP and may refuse to participate in daily social activities. Furthermore, Khan et al. found that pelvic floor muscle training is an effective strategy for improving POP symptoms and was most beneficial for patients without moderate-to-severe anxiety or depression. Patients with moderate-to-severe anxiety or depression may not benefit from the training.¹⁶ In this study, 15 different surgery approaches were used for POP and the POP-Q stage was significantly improved 3 and 6 months postoperatively. The founding supported that individualized surgery is an effective treatment for POP. Further, the anxiety and depression scores significantly decreased postoperatively in patients with severe POP, which may provide theoretical evidence for further psychological interventions. Although we found that the depression was continuously improved with time, the anxiety seemed to be aggravated after a 6-month follow-up. The determination of the clinical relevance requires further studies. The HAMA scores and HAMD scores in the traditional prolapse surgery group and mesh pelvic reconstruction group were almost the same at the time points. In other words, the two different surgical approaches involving native tissue repair or mesh pelvic reconstruction improved the effect on anxiety and depression equally. This study provides valuable information for better understanding of psychological symptoms in patients with severe POP. Thus, clinicians should pay more attention to psychological disorders in patients at different stages of severe POP. Early diagnosis and management are important to improve the patient's health and quality of life. However, this study still has the following limitations. First, the anxiety questionnaires were administered 2 days before the surgery, which can be a very stressful time associated with higher levels of anxiety. In future studies, we will assess HAMA during the patient's initial consultation with the physician rather than before surgery. In addition, the definitive mechanisms underlying POP-related anxiety and depression symptoms remain unclear. We will enroll more POP patients and create a regression model to investigate the relationship between the variance of depression and anxiety in future studies.

In conclusion, clinicians should be aware of the presence of psychological disorders in patients with severe POP. Individualized surgical treatment might be correlated with the remission of anxiety and depression symptoms.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.