Quality of Life Following Pelvic Organ Prolapse Treatments in Women: A Systematic Review and Meta-Analysis

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Abstract

Introduction: Quality of life (QoL) improvement is one of the main outcomes in the management of pelvic organ prolapse as a chronic illness in women. This systematic review aimed to investigate the impact of surgical or pessary treatment for pelvic organ prolapse (POP) on quality of life. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was applied. Electronic databases, including PubMed, Scopus, and Web of Science, were searched for original articles that evaluated the QoL before and after surgical interventions or pessary in pelvic organ prolapse from 1 January 2012 until 30 June 2022 with a combination of proper keywords. Included studies were categorized based on interventions, and they were tabulated to summarize the results. Results: Overall, 587 citations were retrieved. Of these, 76 articles were found eligible for final review. Overall, three categories of intervention were identified: vaginal surgeries (47 studies), abdominal surgeries (18 studies), and pessary intervention (11 studies). Almost all interventions were associated with improved quality of life. The results of the meta-analysis showed a significant association between the employment of surgical approach techniques (including vaginal and abdominal surgeries) and the quality of life (Pelvic Floor Distress Inventory (PFDI) (MD: −48.08, 95% CI: −62.34 to −33.77, p-value < 0.01), Pelvic Floor Impact Questionnaire (PFIQ) (MD: −33.41, 95% CI: −43.48 to −23.34, p < 0.01)) and sexual activity of patients with pelvic organ prolapse (Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) (MD: 4.84, 95% CI: 1.75 to 7.92, p < 0.01)). Furthermore, narrative synthesis for studies investigating the effect of the pessary approach showed a positive association between the use of this instrument and improvement in the quality of life and sexual activity. Conclusions: The results of our study revealed a significant improvement in the women’s quality of life following abdominal and vaginal reconstructive surgery. The use of pessary was also associated with increased patient quality of life.

Keywords: pelvic organ prolapse, quality of life, systematic review

1. Introduction

Pelvic organ prolapse (POP) occurs due to weakness of the supportive tissues of the pelvic organs, which may lead to prolapse of the anterior and/or posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy) [1]. The prevalence of POP is currently increasing due to extended life expectancies and childbearing in low-resource areas [2]. Pelvic prolapses are not always symptomatic and can lead to discomfort in the vagina and changes in bladder and bowel function that can greatly affect women’s quality of life [3], with general, social, psychological, and sexual impacts [4]. Therefore, improving the quality of life is one of the main outcomes in the management of pelvic organ prolapse in women [5].

Surgical interventions for POP include repairing with native tissue or mesh and minimally invasive surgeries such as laparoscopic or robotic techniques, which are increasing in popularity [6]. The selection of the intervention depends on several factors, such as the site and severity of the POP; additional symptoms that affect urinary, bowel, or sexual function; the wish to preserve the uterus; and the surgeon’s choice and ability. Surgical treatment options include vaginal or abdominal (laparotomy, laparoscopy, and, more recently, robotic approach) [7]. There are also conservative interventions, which are defined as non-surgical methods such as optimizing lifestyle (weight loss and avoiding heavy lifting or coughing) and physical therapies [8]. In the last decades, pessaries, which have existed since the beginning of recorded history, have also been used in women with POP [9]. These are removable devices that provide support after prolapse [9]. Various instruments have been designed to assess the quality of life (QoL). Some of them evaluate the general aspect, whereas others, such as the Pelvic Organ Prolapse Distress Inventory (POPDI-6) and Pelvic Organ Prolapse Impact Questionnaire (POPIQ-7), are specific for POP [10,11]. Some questionnaires are dedicated to the quality of sex life [12].

QoL studies for POP are very diverse, with different methods, instruments, and follow-ups. Therefore, studies that summarize the results and provide final recommendations are scarce. Performing a systematic review is the best way to summarize the effects of POP treatment on QoL. A similar study was performed in 2012 by Doaee et al. that examined articles over the past ten years [13]. Due to the advances in urogynecological surgery and other interventional methods such as pessaries, updating this data seems necessary. The current study aims to review those studies that have focused on changing the QoL by means of surgery or pessary for POP management.

2. Methods

The current systematic review was designed to review QoL in women before and after surgery or pessary intervention for POP management in English biomedical journals. The study is reported based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement [14].

2.1. Eligibility Criteria

The inclusion criteria were as follows: (1) study design: all original articles including randomized clinical trials, observational studies (cross-sectional, case-control, or cohort), and editorials/letters; (2) patient population and intervention: adult women with POP who received surgical treatments or pessary intervention for POP management; and (3) outcome: evaluated quality of life using available questionnaires. Review articles, opinions or guidelines, conference abstracts, non-peer-reviewed papers, case reports, unpublished reports, and articles in which the date and location of the study were not specified were excluded.

2.2. Information Sources

The initial search was undertaken in three main databases including articles published in MEDLINE (through PubMed), Scopus, and Web of Science from 1 January 2012 until 31 June 2022. Additionally, a manual search in the reference section of the relevant studies was done to obtain possible publications that were missed in our electronic search.

2.3. Search Strategy

To retrieve citations on the topic based on the medical subject heading (Mesh), a combination of the following keywords was used: ‘pelvic organ prolapses’, ‘quality of life’, and ‘treatment’. The study time frame was also applied to all databases. A full search strategy for each database is available in the Supplementary Materials.

2.4. Study Selection

Titles and abstracts were independently reviewed for eligibility by three authors (PJ, RH, and SP), and non-relevant or duplicate studies that did not meet the inclusion criteria were excluded. In cases of disagreement, the problem was resolved by discussion and the main author (ZG.). After initial screening, the full texts of the articles were reviewed, and the unrelated articles were removed.

2.5. Quality Assessment

NS and AS independently assessed the quality of the included studies using the National Heart, Lung, and Blood Institute (NHLBI) tools [15]. Based on the design of a study (whether a randomized controlled trial or a cohort), an individual checklist that contains 14 signaling questions for assessing the quality of each study was used. Briefly, studies scoring nine or more “Yes” answers were marked as “Good”, studies scoring between seven or eight were marked as “Fair”, and studies rating less than seven were marked as “Poor” quality.

2.6. Data Extraction

The data—including the first author, publication date and study design, intervention mode, using mesh or native tissue, sample size, stage of prolapse and prolapse type, main findings, and the instrument used to measure the QoL, as well as the follow-up duration and quality of papers—were extracted and tabulated.

2.7. Statistical Analysis

We used the mean difference (MD) of the total quality of life questionnaire values before and after the intervention. Using a random effect model, the quantitative values of each study were pooled separately. If the MD was not given in the specific study, an estimate was made using Excel calculators [16]. The Pelvic Floor Distress Inventory Questionnaire (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ-7) were used as the main measures for pooling the results of the studies regarding the QoL of patients. Furthermore, the PISQ and FSFI questionnaires were used to pool the data regarding the sexual activity of patients after the intervention. We used Cochran’s Q statistic (Q-test) and the I2 to assess heterogeneity. I2 value >75% indicated a high amount of heterogeneity. Publication bias was assessed by visual inspection of the funnel plot, and Egger’s test with a significance level of 0.05 was used to evaluate the publication bias. All analyses were statistically significant with a p-value < 0.05. The analyses were performed using R-4.1.3 software and the Meta package (R Core Team, Vienna, Austria; available at https://www.R-project.org/, accessed on 6 January 2022).

2.8. Registration Statement

We have written the protocol of this study, but due to the high diversity of studies and quality of life assessment methods, we did not register it due to the high possibility of changes in the protocol

3. Results

3.1. Statistics

Overall, 587 citations were found to be eligible. After excluding 435 duplicates, 122 studies were screened by the title and abstract. By excluding 21 citations, 100 full text articles were reviewed, and 76 articles were finally eligible for final evaluations. The flowchart of the study is depicted in Figure 1 .

An external file that holds a picture, illustration, etc. Object name is jcm-11-07166-g001.jpg

Flow diagram of the recruiting studies according to PRISMA.

3.2. Instrument Used

A wide variety of questionnaires were used to measure patient-reported outcomes, including QoL measures. Of these, some were the general measures, and several instruments were pelvic-specific QoL questionnaires. Some instruments are used for measuring sexual QoL in sexually active women. The most common general instruments were the 36-Item Short Form Survey (SF-36) and Patient Global Impression of Improvement (PGI-I), while the pelvic-specific measures were the Pelvic Floor Distress Inventory Questionnaire-20 (PFDI- 20), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12), Prolapse Quality of Life (P-QOL), and Pelvic Floor Impact Questionnaire-7 (PFIQ-7). The Sexual QoL was measured by the Female Sexual Function Index (FSFI). The questionnaires are listed in Table 1 .

Table 1

Questionnaires used in the recruited studies.

General Instruments References
World Health Organization Quality of Life Questionnaire-Brief version (WHOQOL-BREF)[17,18]
King’s Health Questionnaire (KHQ)[19,20,21,22]
Patient Health Questionnaire-9 (PHQ-9[23]
36-Item Short Form Survey (SF-36)[22,24,25,26,27,28]
12-Item Short Form Survey (SF-12)[29,30]
Patient Global Impression of Improvement (PGI-I)[23,31,32,33,34]
European quality of Life Five Dimension (Euro Qol EQ-5D)[9,21,33]
Satisfaction With Life Scale (SWLS)[35]
Patient Satisfaction Index (PSI)[21]
Pelvic-specific instruments
Pelvic Floor Distress Inventory Questionnaire-20 (PFDI- 20) *[9,27,31,33,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59]
Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12)[9,20,24,33,37,42,43,44,48,50,55,56,57,60,61,62]
Prolapse Quality of Life (P-QOL)[7,12,22,23,32,35,47,48,60,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79]
Pelvic Organ Prolapse Symptom Score (POP-SS)[23]
Body Image in the Pelvic Organ Prolapse (BIPOP)[23]
International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS)[28,30,32,49,66,80]
Pelvic Floor Impact Questionnaire-7 (PFIQ-7)[9,27,33,36,37,39,40,42,43,45,46,51,54,55,56,57,58,59,81]
International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF)[9,33,57,80]
International Consultation on Incontinence Questionnaire-Quality of Life[49]
Sheffield Prolapse Symptoms Questionnaire (SPSQ)[21]
Patient Assessment of Constipation Quality of Life Questionnaire (Pac-QOL)[9]
German Pelvic Organ Prolapse
Questionnaire
[82,83,84]
Sexual functioning instruments
Female Sexual Function Index (FSFI)[9,13,26,75,76]

* The PFDI-20 consists of three parts, including the Pelvic Organ Prolapse Distress Inventory (POPDI-6), the Urinary Distress Inventory (UDI-6), and the Colo-Rectal-Anal Distress Inventory (CRADI-8).

3.3. General Findings

To facilitate reporting the results, papers were classified into three categories: vaginal surgeries (47 articles), abdominal surgeries (18 articles), and pessary interventions (11 articles). These are categorized in Figure 2 .

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Categorization of the included studies.

3.3.1. Vaginal Surgeries

There were two main procedures for vaginal surgeries: reconstructive (in two subgroups, including repair with natural tissue [17,19,20,23,24,31,36,37,38,60,61,63,64,65,66] ( Table 2 ) and repair with mesh [7,9,12,21,25,26,29,32,35,39,40,41,42,43,44,55,62,67,68,69,78,82,83,85]) ( Table 3 ) and obliterative surgeries [18,27,60,71,72,73,86] ( Table 4 ). In one study, obliterative surgery and sacrospinous fixation in older postmenopausal women were compared, and the QoL was better in the sacrospinous group [18]. These results are the opposite of another article with the same method and population that showed that obliterative surgery versus reconstructive acted better in improving the QoL [28,72,79].

Table 2

The characteristics of the studies on the effectiveness of reconstructive vaginal surgeries by native tissue on the quality of life in women with pelvic organ prolapse.

Physical domain improved from 11.2 to 13.5; Psychological domain improved from 11.6 to 13.8; Social relationships domain improved from 13.6 to 15; Environmental domain improved from 12.9 to 14.

Table 3

The characteristics of the studies on the effectiveness of reconstructive vaginal surgeries with mesh on the quality of life in women with pelvic organ prolapse.

First Author [Ref]Year/Study DesignSample SizeQuestionnireProlapse Type and StageInterventionFollow UpResultQuality
El Haddad [44]2012/ Prospective observational study69PISQ-12 +
PFDI-20
Anterior ≥ 2Anterior vaginal mesh repair6 monthsSignificant decrease in QoL scores and significant increase in sexual activity.Fair
Yesil [83]2013/ Prospective observational study60German Pelvic Organ Prolapse
Questionnaire
Anterior ± Apical
≥ 2
Mesh +
anterior repair, anterior repair + posterior repair,
posterior repair
12 monthsSignificant decrease in QoL scores and significant increase in sexual activity.Fair
Thomin [55]2013/ Prospective observational study99PFDI-20 +
PFIQ-7 +
PISQ-12
Anterior
2 and 3
Anterior vaginal mesh repair6 months and then annuallyImprovement in PFDI and PFIQ after surgery (p < 0.001); PISQ did not change.Fair
Bartuzi [26] 2013/ Prospective observational study113SF-36All types
≥ 3
Anterior repair + posterior repair + mesh
anterior repair + mesh
posterior repair
+ mesh, total repair
6–8 weeks, 16–18 weeksImprovement in 3 individual domains (general health (GH), vitality (V) and mental health (MH)) and in one summary domain (MCS).Good
Hefni [21]2013/ Cross-sectional127Euro Qol EQ-5D +
SPSQ +
KHQ +
PSI
Anterior
NR
Anterior vaginal mesh repair6 weeks, 6 and 12 monthsPatients reported good current QoL and high patient satisfaction. Fair
Brocker [78]2015/ Prospective observational study69P-QOLAll types
≥ 2
Vaginal mesh repair12 monthsSignificant improvement in all domains of P-QoL.Good
Husch [32]2016/ Prospective observational study148PGI +
P-QOL +
ICIQ-VS
Anterior ± Apical
All stages
Anterior transvaginal mesh repair27.2 monthsThe results of the “prolapse-quality of life” questionnaire were comparable to asymptomatic women.Good
Buca [69]2016/ Prospective observational study116P-QOLAll types
≥ 2
Anterior repair + mesh,
anteroposterior repair + mesh, anteroposterior repair + hysterectomy +
mesh
24 monthsImprovement in “general state of patients health” (p < 0.05); physical, social, and psychological quality of life (p < 0.05); significant reduction in the percentage of patients with urinal disturbances (86.2% preoperative vs. 20.7% postoperative; p < 0.05); and an improvement in patient’s sexual activity.Fair
Lamblin [42]2016/Retrospective, nonrandomized study195PFDI-20 +
PFIQ-7 +
PISQ-12
Anterior + Apical
≥ 3
Anterior and apical repair12 and 24 monthsFunction improved, with significantly better PFIQ-7 (p = 0.03) and PFDI-20 (p = 0.02) scores in the mesh group.Good
Fünfgeld [68]2017/Prospective observational study289P-QOLAnterior
≥ 2
Cystocele correction36 monthsQuality of life scores improved significantly in all domains, including sexuality and personal relationships (p < 0.001, Wilcoxon test).Good
Rahkola-Soisalo [43]2017/ Prospective observational study207PFDI-20 +
PFIQ-7 +
PISQ-12
NR
≥ 2
Transvaginal mesh repair12 monthsOverall postoperative improvement in quality of life (p < 0.001).Fair
Kinjo [12]2018/Retrospective cohort237FSFI +
P-QOL
All types
≥ 2
Anterior trans vaginal mesh,
anteroposterior trans vaginal mesh,
C-trans vaginal mesh,
posterior trans vaginal mesh +- mid-urethral sling
12 monthsAll P-QOL dimensions were significantly improved after surgery. Overall, 79 patients completed the FSFI, and 14 (17.7%) were sexually active. The overall scores for sexual function were significantly improved after surgery. Fair
Alt [67]2018/ Prospective observational study130P-QOLAnterior ± posterior
≥ 2
Anterior, posterior,
or combined anterior/posterior mesh repair
12 weeks, 12 months,
60 months
Compared to the pre-surgical results, the scores are lowest (QOL increased) at 12 weeks after surgery and slightly increase up to 20–60% of the pre-surgical score results at the five-year follow-up (QOL decreased). Good
Altman [41]2018/ Prospective observational study207PFDI-20Apical ± anterior
≥ 2
Uphold™ vaginal support system12 monthsProlapse-related 15-dimensional instrument measures (excretion, discomfort, sexual activity, distress, and mobility) were significantly improved after surgery (p <0.05–0.001). Significant inverse associations were detected between increased 15D scores and a decrease in PFDI-20 and subscale scores (p < 0.001), indicating improvements on both instruments. Good
Cadenbach [7]2019/ Prospective observational study54P-QOLAnterior
≥ 2
Anterior repair12 monthsAn improvement in quality of life could be determined during the study in all domains investigated (p < 0.001, Wilcoxon test).Fair
Sukgen [25]2020/ Prospective observational study36SF-36NR
≥ 2
Not specified6–8 weeks-
16–18 months
Some quality-of-life domains (i.e., vitality and mental health), as well as physical and mental health summary scores, improved significantly. Fair
Zalewski [35]2020/Before after study60P-QOL +
SWLS
Apical
≥ 3
Sacrospinous ligament fixation12 monthsNearly all domains in questionnaires were statistically improved after surgery.Good
Sukgen [85] 2021/Prospective observational study72FSFINR
NR
Vaginal mesh surgery3 and 12 monthsPositive change in quality of life and sexual function of patients following the intervention. Significant increase according to FSFI score among all endpoints (16%, 86%, and 100% respectively, p = 0.001).Fair
Naumann [82] 2021/Retrospective cohort107German Pelvic Organ Prolapse
Questionnaire
Anterior ± apical
All stages
Anterior repair
± apical in recurrent or complex prolapse
18 monthsThe total score of the GPOP-Q decreased significantly by 6.4 (p < 0.001). Improvement in each domain was observed.Good
Deltetto [62] 2021/Prospective observational study15PISQ-12Posterior
2
Posterior vaginal repair12 monthsThe quality of life was significantly improved in the majority of patients (p < 0.05).Fair
Nakai [29] 2021/ Prospective observational study28SF-12Anterior or apical
≥ 3
Vaginal hysterectomy and utero-sacral ligament colpopexy12 monthsPostoperative QOL was improved in all eight domains after surgery in both synthetic polypropylene and polytetrafluoroethylene mesh groups.Good
Lo [39] 2021/Retrospective cohort83PFDI-20+
PISQ-12
Anterior or apical
≥ 3
Vaginal hysterectomy, mesh repair, posterior colporrhaphy 6 and 12 monthsSignificant improvement in QoL questionnares. Good
Chiang [40] 2021/Randomized controlled trial64PFDI-20 +
PFIQ-7
Anterior
≥ 2
Transvaginal mesh with concomitant midline fascial plication6, and 12
months
Both groups were improved regarding QoL.Fair
Lucot [9] 2022/Randomized controlled trial262PFDI +
PFIQ +
FSFI +
PISQ-IR +
EQ-5D-3L +
ICIQ-UI
Anterior
≥ 2
Transvaginal mesh surgery vs.
laparoscopic mesh sacropexy
18, 24, 36, and
48 months
Laparoscopic sacropexy acted better than trans-vaginal mesh surgery.Good

Table 4

The characteristics of the studies on the effectiveness of obliterative vaginal surgeries on the quality of life in women with pelvic organ prolapse.

First Author
[Ref]
Year/Study DesignSample SizeQuestionnaireProlapse Type and StageInterventionFollow UpMain FindingsQuality
Yeniel [73]2012/Prospective observational study10P-QOLNR
≥ 3
Le Fort colpocleisis6 monthsReduced scores of P-QoL, reflecting improvement in QoL following colpocleisis.Good
Katsara [86]2016/Retrospective study44Author’s designAll types
NR
Le Fort colpocleisis13 yearsOverall, 75% reported a positive impact on QoL, 10% a negative because of urinary problems, 10% could not report any change in the QoL, and 5% could not answer this question.Good
Petcharopas [72]2018/Retrospective cohort study295P- QOLNR
≥ 1
Le Fort colpocleisis
vs.
vaginal hysterectomy,
sling,
anterior repair, posterior repair, McCall culdoplasty,
vaginal vault suspension
23.87 monthsP-QOL scale revealed significantly less postoperative impairment in the obliterative surgery group (1.75 vs. 5.26, p = 0.023). There were no significant differences in other P-QOL domains. Le Fort acted better in elderly.Good
Ertas [71] 2021/Retrospective cohort study53P-QOLAll types
≥ 3
Le Fort colpocleisis1, 6, and 12
months
Significant improve in the postoperative P-QoL score (p < 0.001).Fair
Karaca [79]2021/Retrospective cohort study98P-QOLNR
NR
Le Fort colpocleisis vs. sacrospinus fixationImmediately after surgeryLe Fort acted better in elderlyFair
Farghali [18]2021/Prospective comparative study86WHOQOL-
BREF
All types
≥ 2
Le Fort colpocleisis vs. sacrospinous fixation6 weeks; 3, 6, 12 monthsSacrospinous fixation acted better than Le Fort. Psychological and social health domains were significantly higher in the sacrospinous fixation group compared to the Le Fort group (p2 = 0.04 and 0.02, respectively). General health satisfaction and total QoL scores were significantly higher in the sacrospinous fixation group compared to the Le Fort group (p2 = 0.03 and 0.01, respectively).Fair
Agacayak [27]2022/Prospective comparative study46SF-36 +
UDI +
PFIQ
Anterior ± Posterior
≥ 3
Le Fort colpocleisis vs. sacrospinus fixation6 months, 2 and 5 yearsLe Fort acted better than sacrospinus fixation. Pelvic Floor Impact Questionnaire and SF36 were found to be significantly better in the Le Fort group (p. = 0.039 and 0.042, respectively).

Overall, 60.5% (23/38) of the reconstructive studies used mesh for repairing. In a recent study, transvaginal mesh surgery and laparoscopic mesh sacropexy had similar results [9]. In addition, in one cohort study, QoL was measured after POP surgery with or without mesh and did not differentiate between individuals with and without mesh [31]. All studies investigated the QoL in the first surgery, except one, which evaluated the transvaginal bilateral sacrospinous fixation after the second recurrence of vaginal vault prolapse, which improved the QoL and sexual function [61].

3.3.2. Abdominal Surgeries

Overall, eight [33,47,48,56,74,75,76,87] and two studies [53,54] were dedicated to just laparoscopic or robotic approaches, respectively ( Table 5 ). Four citations compared vaginal-assisted laparoscopic sacrohysteropexy and vaginal hysterectomy with vaginal vault suspension for advanced uterine prolapse, which has similar results [45,49,50,55]. Another study compared two methods of laparoscopic and robotic ventral mesh rectopexy, and the results had no difference [51]. One study compared robotic and vaginal sacropexy with comparable results, and in one study, three methods were compared [46].

Table 5

The characteristics of the studies on the effectiveness of abdominal surgeries on the quality of life in women with pelvic organ prolapse.

First Author [Ref]Year/Study DesignSample SizeQuestionnaireProlapse Type and StageInterventionFollow UpMain FindingsQuality
Thibault [56]2013/Prospective observational cohort148PISQ-12+
PFDI-20+
PFIQ-7
All types
≥ 2
Laparoscopic sacrocolpopexy12 monthsImprovement in PISQ-12, PFDI-20, and PFIQ-7 total mean scores. (p < 0.05).Good
Majkusiak [88]2015/Observational study4010-point analogue scale-sex-QOLApical ≥ 3cAbdominal cervicosacropexy (laparotomy)18 monthsThe average score of the quality of sexual life was 5.75 (SD 2.52, 95% CI: 4.41–7.1) before and increased to 7.93 (SD 1.77, 95% CI: 6.9–8.95) after the procedure (p < 0.05). The mean score of the overall QoL in relation to POP before and after the surgery was 2.77 (SD 2.39, 95% CI: 1.87–8.64) and 9.03 (SD 1.08, 95% CI: 8.66–9.43), respectively (p < 0.001).Good
Linder [54]2015/Retrospective observational cohort84PFIQ-7 + PFDI-20Apical ≥ 3Robotic sacrohysteropexy72 months
Minimal postoperative pelvic floor complications and high rate of patient satisfaction achieved.Good
Grimminack [53]2016/Prospective observational cohort50PFDI-20Anterior ±
posterior
> 2
Robotic sacrohysteropexy60 monthsImprovement in the QoL following surgery (p < 0.05).Good
Nguyen [52]2018/Prospective observational cohort222PFDIAll types
≥ 1
Vaginal and abdominal repair12 monthsImprovement in QoL of both groups after 1 year. Vaginal group showed higher QoL scores (45.6 vs. 32.6, p = 0.032).Fair
Tahaoglu [76]2018/Observational study22FSFI +
P-QOL
All types
≥ 2
Laparoscopic pectopexy6 monthsFSFI and P-QOL scores improved significantly following surgery (p < 0.05).Fair
Pizzoferrato [33]2019/Observational study152PFDI-20 +
ICIQ-UI SF +
PFIQ-7 +
Euro Qol EQ-5D + PISQ-12 +
PGI-1
All types
≥ 2
laparoscopic sacrocolpopexy48 months Improvement in PFDI-20 (median: 47.4 before surgery vs. 34.4 afterwards, p = 0.002); improvement in PGI-I score = 1.8 ± 1.1.Fair
MäkeläKaikkonen [51]2019/Prospective randomized study30PFDI-20+
PFIQ-7
Posterior
≥ 2
Laparoscopic and robotic ventral mesh rectopexy 24 monthsBoth were comparableGood
Luque [87] 2020/Prospective observational cohort33Pac-QoLApical + posterior
≥ 3
Laparoscopic sacrocolpoperineopexy6, 12, and 36 monthsSignificant improvement in QoL scores at 6, 12, and 36 months following surgery. Fair
Zhu [45] 2021/Retrospective study50PFIQ-7 + PFDI-20Apical ≥ 2Modified laparoscopic uterine suspension and vaginal hysterectomy and sacrospinous ligament fixation12 monthsImprovement in QoL (P < 0.001 for PFIQ-7 and PFDI-20).Fair
Van Zanten [46] 2021/Prospective observational cohort77PFDI-20 +
PFIQ-7
Apical ≥ 2Robot-assisted sacrocolpopexy and supracervical hysterectomy with sacrocervicopexy 50 monthsImprovement in median UDI-6 scores (26.7 vs. 22.2, p = 0.048), and median PFIQ-7 scores (60.0 vs. 0, p = 0.008).Good
Sliwa [47] 2021/Observational cohort42P-QOL +
PFDI-20
All types
≥ 3
Laparoscopic anterior fixation with mesh12 monthsImprovement in P-QoL score, as well as PFDI-20, along with its 3 symptom scales.Fair
Karsli [48] 2021/Observational cohort31P-QOL +
PISQ-12 + PFDI-20
Apical ≥ 3Laparoscopic pectopexy3 monthsImprovement in P-QOL (from 83.45 ± 8.7 (64–98) to 8.61 ± 6.4 (0–23) (p < 0.05)); in PISQ-12 from 29.61 ± 4.8 (14–38) to 7.1 ± 3.2 (1–13)). Significant improvement in UDI-6 after procedure.Fair
Cengiz [49] 2021/Randomized controlled Study49ICIQ-VS+
ICIQ-QOL+
PFDI-20
Apical ≥ 2Vaginal assisted laparoscopic sacrohysteropexy vs. vaginal
hysterectomy with vaginal vault suspension
12 monthsICIQ-VS score, ICIQ-QOL, UDI-6, and IIQ-7 scores were improved for both groups.Good
Akbaba [74] 2021/Retrospective study37P-QOLAnterior + apical ≥ 3Laparoscopic lateral suspension with mesh20 monthsImprovement.Good
Okcu [50] 2021/Prospective observational cohort65PISQ-12+
PFDI-20
All types Any stagesVaginal hysterectomy with sacrospinous ligament
fixation, laparoscopic hysterectomy with sacrocolpopexy or abdominal
hysterectomy with sacrocolpopexy
36 monthsAbdominal group acted better (p = 0.047), while the sexual function was similar.Good
Obut [75]2021/ Prospective randomized study62FSFI +
P-QOL
Apical ≥ 2Laparoscopic pectopexy-hysterosacropexy12 monthsImprovement in all domains of POP-Q, P-QOL, and FSFI scores in both groups.Good
D’altilia [81] 2022/Prospective randomized study95PFIQ-7Anterior + Apical
NR
Laparoscopic, robotic or abdominal sacrocolpopexy 36 monthsSingle anterior vaginal mesh acted better than anterior/posterior mesh.Good

Only one study was on laparotomy [77], and another citation evaluated the difference between vaginal (using native tissue or with a mesh prolapse) and abdominal (open or robotic abdominal sacrocolpopexy), with results in favor of the abdominal group [78].

3.3.3. Pessary Intervention

Three studies compared pessary and surgery [79,80,81] ( Table 6 ). In one, the women who underwent surgery had better QoL [84], whereas in other studies, the QoL after two interventions had no differences. All studies used ring pessaries [28,77], except three citations that used Gellhorn/cube pessaries [58,59,89].

Table 6

The characteristics of the studies on the effectiveness of pessary on the quality of life in women with pelvic organ prolapse.

First Author
[Ref]
Year/Study DesignSample SizeQuestionnaireProlapse Type and StageInterventionFollow UpResultQuality
Manchana [77]2012/Retrospective observational study126P-QOLNR
≥ 2
Ring pessary12 monthsThe median score from all PQOL domains except personal relationships were significantly decreased after 1 year of ring pessary use. The median total scores at baseline and at 1 year were 40 and 8, respectively (p < 0.001).Good
Lone [80]2015/Prospective observational study287ICIQ-VS +
ICIQ-UI SF
NR
≥ 1
Pessary (ring/cub/Gellhorn) vs. surgery12 monthsBoth groups were improved regarding QoL. No statistically significant between-group difference was noted.Good
Tenfelde [59]2015/Observational cross-sectional study56PFDI-20 +
PFIQ-7
NR
NR
Pessary-Overall, women reported high levels of QOL. Health-related QoL scores correlated negatively with PFDI-20 scores (ρ = −0.55, p = 0.001). Women with higher QoL reported fewer pelvic floor symptoms for each of the subscales (urinary, colorectal, and prolapse).Fair
Coelho [28]2018/Prospective observational study19ICIQ-VS +
SF-36
Anterior±apical ≥ 3Ring pessary6 monthsSF-36 had significant improvement in three specific domains: general state of health (p = 0.090), vitality (p = 0.0497), and social aspects (p = 0.007). ICIQ-VS presented a reduction in the vaginal symptoms (p < 0.0001) and an improvement in QoL (p < 0.0001).Fair
Yang [58]2018/Retrospective study300PFDI-20 +
PFIQ-7
All types NRRing—Gellhorn6 monthsImprovement.Good
Mao [89]2018/Prospective observational study142PFDI-20 +
PFIQ-7
Anterior Posterior
≥ 3
Ring with support pessary, follow-up with Gellhorn if failed13–24 monthsImprovement in both questionnaires. All domains were improved significantly (p < 0.001). Good
Bradley [57] 2021/Cross-sectional analysis568PFDI-20 +
PFIQ-7 +
PISQ-12 +
ICIQ-UI-SF
All types Any stagePessary vs. surgery (both reconstructive and obliterative)36 monthsWomen choosing POP surgery vs. pessary had similar physical and mental generic QOL.Good
Mendes [22] 2021/Prospective observational study50SF-36 +
P-QOL +
KHQ
All types Any stagesRing pessary4 monthsImprovement in the general and specific quality of life of women.Fair
Thys [34]
2021/Prospective observational study291PGI-I +
DSQOL
All types ≥ 2Ring pessary with or without knob-space filling pessary12 monthsImprovement.Good
Carlin [84]
2021/Retrospective study130German Pelvic Organ Prolapse
Questionnaire
All types Any stagesPessary vs. surgery3 monthsSurgery acted better than pessary.Fair
Zeiger [30] 2022/Multicenter, longitudinal, prospective observational study97ICIQ-VS +
SF-12
NR
≥ 3
Ring pessary6 monthsImproved sexual function (78.6%), vaginal symptoms (91.8%), and quality of life (92.8%) (p < 0.01) after the intervention.Good

3.4. Overall Findings and Meta-Analysis

Almost all interventions, including surgery and pessary interventions, were associated with improved quality of life. In cases where two different surgical or surgical and pessary methods were compared, the results were inconsistent.

Among the included studies, fifteen studies used the PFDI questionnaire to estimate the QoL [9,31,33,36,37,40,41,42,45,47,51,52,55,56]. The pooled results showed a significant improvement in QoL after surgical interventions (MD: −48.06, 95% CI: −62.34 to −33.77, I2: 97%, p < 0.01) (Figure 3 ). Visual inspection of the funnel plot and results of Egger’s test for funnel plot asymmetry (p = 0.17) indicated no possible source of publication bias ( Figure 4 ).

An external file that holds a picture, illustration, etc. Object name is jcm-11-07166-g003.jpg

Pooled mean difference of the effect of surgical intervention (vaginal and abdominal surgery) on total quality of life score using the Pelvic Floor Distress Inventory Questionnaire (PFDI) [31,33,36,37,40,41,42,45,47,51,52,55,56].

An external file that holds a picture, illustration, etc. Object name is jcm-11-07166-g004.jpg

Funnel plot for the results of the effect of surgical intervention (vaginal and abdominal surgery) on total quality of life score using the Pelvic Floor Distress Inventory Questionnaire [PFDI].

Eleven studies used the PFIQ questionnaire to estimate the QoL [9,36,37,40,42,43,45,51,55,56]. The pooled results showed a significant improvement in QoL after surgical interventions (MD: −33.41, 95% CI: −43.48 to −23.34, I2: 99%, p < 0.01) (Figure 5 ). Visual inspection of the funnel plot and results of Egger’s test for funnel plot asymmetry (p = 0.52) indicated no possible source of publication bias ( Figure 6 ).

An external file that holds a picture, illustration, etc. Object name is jcm-11-07166-g005.jpg

Pooled mean difference of the effect of surgical intervention (vaginal and abdominal surgery) on total quality of life score using Pelvic Floor Impact Questionnaire (PFIQ) [9,36,37,40,42,43,45,51,55].

An external file that holds a picture, illustration, etc. Object name is jcm-11-07166-g006.jpg

Funnel plot for the results of the effect of surgical intervention (vaginal and abdominal surgery) on total quality of life score using Pelvic Floor Impact Questionnaire (PFIQ).

For estimating the effect of surgical intervention on sexual activity, 14 studies were included [9,12,20,24,37,39,42,43,55,56,61,75,76,85]. Among them, 10 studies used the PISQ questionnaire. The pooled results showed a significant improvement in sexual function after surgical interventions (MD: 4.84, 95% CI: 1.75 to 7.92, I2: 98%, p < 0.01) (Figure 7 ). Visual inspection of the funnel plot and results of Egger’s test for funnel plot asymmetry (p = 0.01) indicated a possible source of publication bias ( Figure 8 ).

An external file that holds a picture, illustration, etc. Object name is jcm-11-07166-g007.jpg

Pooled mean difference of the effect of surgical intervention (vaginal and abdominal surgery) on total quality of sexual activity. (PSIQ: Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, FSFI: Female Sexual Function Index) [9,20,24,37,39,42,43,55,56,61,75,76,85].

An external file that holds a picture, illustration, etc. Object name is jcm-11-07166-g008.jpg

Funnel plot for the results of the effect of surgical intervention (vaginal and abdominal surgery) on total quality of sexual activity.

4. Discussion

In this systematic review, we found that the QoL was significantly improved in women after surgical or pessary interventions for the management of POP. We performed a meta-analysis of QoL and sexual activity questionnaires. The results of the meta-analysis showed a significant association between surgical approach techniques (including vaginal and abdominal surgeries) and improved QoL and sexual activity of patients with POP. Due to vast heterogeneity in the pessary approach and QoL questionnaires used, we were not able to pool the results of studies regarding pessary. However, descriptive analysis showed an improved quality of life in these patients.

Interventional and observational studies dedicated to POP surgeries or using pessaries have grown significantly in the last decade [90,91]. On the other hand, with the emergence of specialized QoL questionnaires for pelvic organ prolapse and its symptoms, we encounter a significant amount of data concerning QoL in different methods [92].

As mentioned before, we divided the studies into three parts based on the intervention approach. In vaginal studies, we also dealt with reconstructive and obliterative methods. Increasing numbers of elderly women and their co-morbidities have increased the preference for obliterative vaginal surgery, due to high levels of durability with lower rates of morbidity. Obliterative methods seem to be a good method for older women who are not sexually active and could not tolerate major surgeries with good durability and relative ease of surgery [90,93]. Few studies evaluated the QoL of patients following obliterative methods. The results of these surgeries were satisfactory, and in two studies that were compared with other methods, the results were contradictory [18,72].

Reconstructive methods using synthetic meshes for pelvic organ prolapse and/or stress urinary incontinence have been popular since the mid-1990s [50]. Mesh repairs were effective as traditional repairs [81] and improve QoL [26]. Patients may benefit from anatomical stability when the risks are justifiable [7], with a low rate of recurrence and few complications [7]. However, reports of mesh-related complications are increasing [7,90], and the Food and Drug Administration (FDA) recently warned about using transvaginal mesh due to adverse events including vaginal erosion, dyspareunia, pain, and infection [57,92]. However, there is no consensus in this regard, and the use of mesh is recommended by some experts.

With regard to abdominal approaches, three different approaches were evaluated in the studies. Laparoscopic sacrocolpopexy and sacrohysteropexy have been demonstrated to be effective and safe with faster recovery time, shorter operating time, lower blood loss, lower scar tissue, lower pain, and minimally invasive nature compared to the abdominal approaches [94]. However, these procedures have been associated with some complications, such as stress urinary incontinence [95], defecation problems [96], and injuries of the presacral venous plexus [97]. On the other hand, robotic surgeries have recently been introduced with good results and improvement in QoL. A systematic review and meta-analysis showed less intraoperative bleeding, lower incidence of postoperative complications, and shorter hospital stay for RVMR compared with LVMR, but found no differences in rates of recurrence, conversion, or reoperation [98].

Finally, the vaginal pessary is a conservative treatment for pelvic organ prolapse and can be offered as the first-line treatment in most patients [99]. Non-surgical modalities such as pessary are the best choice for older women because most of them have some type of cardiovascular disease [100] or diabetes mellitus [101]. Among various vaginal pessaries, the ring pessary is the most common type because it is convenient to insert and remove and has acceptable continuation rate and manageable adverse events. In addition, a ring with support pessary is a safe and effective conservative treatment for POP; it not only relieves bothersome prolapse and urinary symptoms but also significantly decreases their impacts on health-related QoL. One-quarter of the patients discontinued using pessary mainly due to dissatisfaction with pessary effectiveness or adverse events such as vaginal discharge or vaginal erosion [102]. Some women also prefer surgery after a while. Pessary treatment is continued beyond 12 months after initial placement by 63% of patients [34]. Comparative studies between pessary and surgery are not numerous, and their results are contradictory. In one study, women had the same quality of life [80], while in another study, women who underwent surgery reported a better QoL than pessary users [34].

In this study, we also had some limitations. First, due to the differences in the questionnaires used, variation in follow-up duration, and different methods of surgery, there was a significant amount of heterogeneity in the results of our meta-analysis. Furthermore, we only investigate a limited number of questionnaires available for assessing QoL patients with POP in our quantitative synthesis. However, it is worth noting that the results of other questionnaires were in line with our meta-analysis, which showed improved QoL of these patients after the aforementioned approaches were used. The conclusions of the meta-analysis were made mostly from the results of a limited number of observational studies, which lowers the certainty of evidence because of their observational nature. However, the results of almost all studies included in this systematic review were in line with our findings. Pelvic floor surgeries are relatively new and have made great strides in the last decade. It is suggested that, in future studies, the methods used with mesh be analyzed in a more specialized way.

5. Conclusions

QoL is significantly improved in women after surgical or pessary interventions for management of POP. Due to the daily progress of urogynecological and modern technologies in surgery and less invasive treatments, long-term cohort studies are recommended to evaluate the QoL in these people.

Acknowledgments

We thank the personnel of Vali-E-Asr Reproductive Health Research Center for their kind help. The protocol of this study was registered with the review board of Tehran University of Medical Sciences.