Qualityof Life Assessment Tools

G.Willy Davila

The nature of pelvic floor dysfunction as multifactorial with involvement of multiorgan systems makes severity and impact assessment an exceedingly challenging aspect of the evaluation of a symptomatic patient. Various factors such as organ system function, anatomic alterations, lifestyle impact, and psychological well-being may be impacted differently by the disease process, and more importantly, by the therapy received by a patient with pelvic floor dysfunction. Historically, outcome assessment was limited to continence and normal anatomy restoration. As recently as 10 years ago, outcome assessment was focused solely on objective parameters such as urodynam-ics. Aspects of day-to-day living of great importance to the patient, such as lifestyle alterations, work capability, and interpersonal intimacy, were not addressed by clinicians. It is inappropriate to assess outcomes of a multiorgan system dysfunction by assessing only one-dimensional factors. This is particularly true in the assessment of surgical outcomes. For example, a woman who undergoes reconstructive surgery for exteriorized vaginal prolapse, in whom the anatomic surgical result is very satisfactory, but who has resultant postoperative fecal incontinence caused by progressive denervation injury, will likely complain of a greater negative quality-of-life (QOL) impact after her surgical procedure. Fortunately, clinicians are beginning to question their patients regarding multiple aspects of pelvic floor symptomatology. Other examples of outcome variables that are appropriately evaluated using global or disease-specific instruments such as QOL questionnaires include the impact of surgical therapy on sexual function and the impact of pharmacologic therapy on other bodily functions. A clear example of the latter is the impact of anticholinergic therapy for overactive bladder on bowel function, particularly the well-recognized side effects of dry mouth and constipation.

Certain aspects of pelvic floor function that are best addressed in a questionnaire format include sexual and bowel function. It is not uncommon for a urogynecologic patient presenting with genital prolapse or urinary incontinence to not report fecal incontinence symptoms because of their perceived embarrassment during a face-to-face interview. Frequently, these patients do not report symptoms of fecal incontinence, although they are asked about them during their initial visit, until their evaluation is well underway and surgery has been scheduled. This can result in a delay in performance of the surgical procedure because of the need for evaluation of the patient's fecal incontinence. An even greater challenge is encountered in the evaluation of the impact of pelvic floor dysfunction on sexual function. It has been only recently that validated QOL questionnaires have been available to assess sexual function and the various aspects of sexual dysfunction. Because of the great variability in sexual function "normality," an individual perception of satisfactory, versus unsatisfactory, sexual function is best served by the use of a QOL questionnaire with subjective responses.

We routinely use QOL questionnaires as measures of disease severity, individual impact, and outcome assessment. We find these tools to be invaluable in the assessment of patients with pelvic floor dysfunction and recommend their use on a routine basis.

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