Available Qualityof Life Assessment Tools

A global assessment tool for pelvic floor dysfunction is not yet available. Although a single tool would be highly desirable, its required complexity may make it impractical. Frequently used global QOL assessment tools, such as the SF-36, do not lend themselves particularly well to pelvic floor dysfunction, because the various aspects of pelvic floor dysfunction are not well covered. Disease-specific QOL questionnaires are required to assess the various parameters involved in pelvic floor dysfunction. Therefore, we currently use a battery of QOL questionnaires to comprehensively evaluate QOL impact. This allows us to evaluate individual aspects of QOL impact.

Patients are asked to complete the questionnaires after their initial consultation visit. The data are then entered into the clinical database for later analysis and comparison to questionnaire responses after therapy. We have found the responses to individual questions to be of equal, if not greater, value than the overall calculated impact score for a given questionnaire.

A particular challenge is the use of QOL tools for outcomes assessment. Managing to get a patient to complete a questionnaire can be difficult, especially if follow-up visit appointments are not kept. We have found that simply mailing the questionnaires to patients and requesting the return of completed questionnaires is associated with a less than 50% response rate. The best time to have a patient complete a QOL questionnaire may be during a follow-up visit, before the clinician sees the patient. If overall questionnaire scores are to be used for assessment, care must be taken to ascertain that all questions have been answered.

We have learned much about the use of QOL assessment tools over the last few years. Factors of significant importance are listed below:

1. Despite questionnaire validation, many questions are not clear to patients. Thus, the individual interpretation of a question will affect its answer. In clarifying the nature of a question, a clinician may add bias, especially if the questionnaire is completed in front of the clinician who is providing the care.

2. Many questions are not applicable to many patients. Work and sex/intimacy-related questions are particularly affected by differences in lifestyle. If overall questionnaire scores will be used, care must be taken to adjust the score to reflect questions that are not appropriate to that particular patient.

3. Many behavior-related voiding patterns are not corrected by medical treatment. Urinary frequency and nocturia may be affected by a patient's desired large-volume fluid intake or caffeine-containing beverage intake, which may continue after therapy.

4. Male factor is frequently the principal reason a patient is not sexually active. Thus, questions related to sexual activity should be assessed as a change from preoperative baseline rather than an overall score.

5. Sexual function has significant generational differences. For many elderly patients, requesting information regarding their sexual activity is considered offensive. Many patients do not consider sex pleasurable, and their practices - even at sexual peak - were very conservative. For example, many elderly women are not comfortable with genital self-contact.

6. Coexistence of functional bladder or bowel pathology will affect QOL impact. This is particularly true in patients with chronic constipation, with a high degree of fixation on bowel function. Because QOL questionnaires do not collect this information and are not modified based on their presence, the clinician must keep these issues in mind when evaluating QOL impact.

Recognized limitations of the utilization of QOL assessment tools include language barriers, cognitive dysfunction, and comparison at two remote times such that life situation may have changed (i.e., death of a spouse or new onset disease process or pelvic floor symptoms complex).

Over the last 10 years, a multiplicity of QOL questionnaires have been reported, validated, used in clinical trials, and correlated with disease severity and outcomes. We have been using the questionnaires listed below on a routine basis, but do realize others have become available and may be of equal, or greater, utility in urogynecologic practice.

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