CC BY
18
7. Suppiah V., Moldovan M., Ahlensiel M. et.al. IL-28B is association with response to chronic hepatitis C Interferon-alfa and ribavirin therapy//Nature Genet. - 2009. - № 41. - P. 1100-1104.
Nasimova Nigina, Samarkand State Medical Institute E-mail: [email protected]
Evaluation of women's life quality with genital prolapse before and after surgery
Abstract: Abstract cites the results of evaluation of life quality of reproductive age women with genital prolapse before and after surgical treatment with simultaneous voluntary surgical contraception (VSC). Keywords: genital prolapse, life quality.
Introduction
Under current conditions, considering the tendency to "rejuvenation" of the disease, genital prolapse appears not only medical, but also personal, family, social problem, affecting the sexual, professional, and many other spheres of patients' life, i. e. this pathology affects the quality of patients' life.
In the diagnosis of genital prolapse the main symptom is a detected neoplasm by the patient, which protrudes beyond the vulvar cleft [13; 16; 67; 79; 80]. The most common complaints ofpatients with genital prolapse are aching and/or feeling of heaviness in the abdomen, whites, foreign body sensation in the vagina, urinary incontinence and gases during exercise, coughing, sneezing, sexual dysfunction. On genital prolapse (GP) sexual life is possible only after reduction of fallen body [149; 157].
It was found that on urinary incontinence life quality loss consists up to 50 %, with urgency and mixed — up to 80 % [48; 54]. About 37 % of US women experience incontinence symptoms, 86 % of them noted a significant deterioration in life quality [13]. With the development of new surgical techniques in urogynecology, appears a need of rigorous evaluation of the results of the intervention, so as the development of modern methods of treatment are not always aimed at improving the life quality and reducing the probability of disease recurrence [10]. In this study, the question life quality (LQ) acts as forecast criteria, planned treatment, evaluation of the effectiveness of the treatment, the analysis of early and late rehabilitation.
Assessment of LQin the surgery is usually performed before and after surgery, which is an important criterion for the effectiveness of surgical intervention [81]. Practically, there are not works dedicated to women life quality section after correction of genital prolapse in conjunction with simultaneous VSC. Due to the development of new surgical techniques is appears a necessary to a strict evaluation of intervention results. Development of new methods of treatment in surgical practice do not always aims to increase survival or decrease the probability of disease recurrence [81, 92, 102]. The level of patients' LQ, established prior to surgery has prognostic value, and helps to provide useful additional information about the patient, allowing a different position to estimate the potential results of the upcoming surgery. As a result, on the basis of risk analysis and the use of a surgical correction the overall treatment strategy for a patient is determined. In the available literature data on the LQ in patients with O and VVPO are fragmentary, due to a small number of studies of this problem, and rather narrow implementation of the proposed questionnaire for the study of LQin daily practice. A certain negative role in the assessment of the quality of life plays a specificity of some of the issues affecting the intimate side of life
(sexual function). These questions are not acceptable for some patients, especially the older age group [39; 47; 154; 166; 201; 224].
Objective
To evaluate women life quality with genital prolapse before and after surgical intervention.
Materials and methods
The study of quality of life of patients with genital prolapse and simultaneously VSC produced in accordance with the information collected as a result of a questionnaire before and after surgery at 1 year. For comparison was recruited control group of 50 women without prolapsed, similar age composed 35.2 ± 3.2 years (control group).
It was used qualimetric method with application of questionnaire "Short Form 36 Health Quality Survey" (hereinafter — SF- 36), which allows to specify eight main indicators of LQ, presented in the form of points, taking into account the fact that a higher score indicates a better quality of life, except pain index. The method recommended by the WHO (1996) to quantify the basic parameters of quality of life (emotional sphere, the sphere of physical, general well-being):
1) general health (GH) — assessment of patients health status at the moment of treatment and prospects;
2) physical functioning (PF) — reflects the degree to which health limits in the implementation of physical activity (self-care, walking, climbing stairs, carrying heavy loads, etc.);
3) role-physical functioning (RFF) — impact on the physical condition of role functioning (work, perform everyday activities);
4) role-emotional functioning (REF) — the impact on the emotional state of role functioning, involves assessment of the degree to which emotional state obstructs the work or other daily activities (including an increase in the cost of time, reducing the amount of work done, impairment of quality of its performance and the like);
5) social functioning (SF) — social functioning, is defined by the degree to which physical or emotional state limiting social activity (communication);
6) pain intensity (PI) — the severity of pain and impact of pain on the ability to engage in daily activities, including work at home and outside the home;
7) the viability (V) — means feeling full of strength and energy, or, on the contrary, exhausted;
8) mental health (MH) — self-assessment of mental health, which characterizes the mood (the presence of depression, anxiety, an overall positive emotions).
To assess sexual function on genital prolapse was used a PISQ questionnaire (Pelvic organ prolapse/urinary incontinence sexual function questionnaire).
Evaluation of women's life quality with genital prolapse before and after surgery
Thus, before the operation the majority of women deliberately tried to limit sex because of GP. This could not affect the overall LQ The quality of the intimate life of patients is a factor that adversely affects the emotional sphere state. After 1 year of surgical treatment, women often answered confidently to the question of control over urination during intercourse. But their assessment of the sexual life limitations for fear of urine or stool incontinence has not changed practically. Women explained sex limiting by the fear of "disturbing the effect of the surgery". Negative emotions during intimacy diminished significantly. Women marked increase in the frequency of orgasms experienced, driving growth with a sexual partner. There was a trend to an increase in the frequency of sexual desire. All of these changes were accompanied by an increase in satisfaction with sex life. Marked tendency to improve the quality of sex life, talk about the positive effect of removing genital prolapse with simultaneous VSC on women LQ.
Discussion
The study of LQwas carried out by SF-36 questionnaire, which aimed at determining the status of all areas of LQ, and the PISQ questionnaire, to evaluate the state of sexual activity.
It was found that in all patients observed lower general self-rated health before surgery of GP, regardless of the degree of prolapse. However, the degree of GP effected on LQ self-esteem reducing depth. LQ of patients with a complete prolapse of internal genitals characterized by decrease in most indicators regarding appropriate age control, with the exception of self mental health, social functioning and emotional state influence on the role functioning.
The least, LQindicators' deterioration were observed in patients with uterine neck elongation. Perhaps, the reason was that the patients were generally younger. This assumption is confirmed by comparison with an appropriate control group for age, which showed no significant differences in LQ.
Already at the age of 45 years partial prolapse differed significantly from the control indicators of general health factors, influence of emotional state to role functioning, social functioning and vitality index.
In patients with elongation other LQindicators did not differ significantly from the control group. In patients with complete and incomplete GP detected decrease of LQfeatures more, so than in the group with the elongation, as compared with the control group.
The dependence of the LQof patients is undoubtly, but in our study were examined only women of reproductive age. So, Mant (1997), Nguen (2008), Paskulin (2009) pointed, that the age of patients — this is one of the key factors that reduce the patients' LQ.
It is noted, that with the age increasing, in LQwill dominate a sense of psychological comfort. So, LQis determined by the degree of GP and age [149; 209; 218; 223]. Comparative analysis of the LQof patients with genital prolapse before and 1 year after surgery showed, that 1 year after the operation appears increase in the level of psychological comfort, women vitality, reduce of pain severity and its impact on women daily activities. Self-assessment of the general state of health after surgery was significantly increased in all women. Reduced LQindexes, characterizing the physical condition, most likely are associated with limitations of plan recommendation, aimed at preserving the results of surgical treatment. However, when comparing different contraception methods, used after surgery in women found that, in this group compared with the control group, LQindex is characterized by increased physical activity, decrease of role functioning dependence on the physical and emotional condition.
It is noted that GP degree determines the dynamics of some LQ indicators recovery. Pain intensity score changed significantly, in comparison with the preoperative value. Operative treatment of prolapse influenced significant positive impact on the self-esteem of women's mental health.
Surgical removal of GP revealed a significant increase of many LQindicators' dependence from age, except for role emotional and social functioning. Taking into account the research results before and after surgery, it can be assumed that the severity of the underlying disease and the social position of women (education, position in society and the family, etc.) play a major role in reducing the LQindexes.
Assessment of LQindicators, depending on the type of surgical treatment in women with GP before and after surgery demonstrated, that colpoperineolevatoroplastics had a positive influence on the rate of general and mental health. A combination of GP surgery with vaginal tubal occlusion significantly increased almost all indicators of LQ. The operation had a positive effect on the emotional state of role functioning.
We looked at the dependence of LQchange from volume of undergone surgery at 1 year. It was observed significant improvement in all parameters on colpoperineolevatoroplastics and uterine neck amputation with fornix transplantation. Thus, after any GP surgery methods was marked increase in emotional state, self-esteem of viability. This is accompanied by varying degrees of reduction of physical activity level, which, however, may indicate the implementation of doctor's recommendation to restrict the exercise that more impact in the first year after surgery. Looking LQ dependence before and after surgery, depending on the place ofresidence of surveyed women (city and village), we have not identified significant differences.
One of the components of LQis a human sexual function. According to the literature, up to 40 % of women don't carry out sexually active life because of GP [153; 196; 197; 265; 274; 282]. In our study, many patients did not pay attention to this side of life and feel free to discuss the responses, explaining the peculiarities of education, public views on this side oflife in the formative period of their reproductive behavior. Our analysis of sexual function showed that at the time of the survey, most women were married — 67.3 % of cases and 32.7 % of patients did not have a sexual life because of the widow or her husband's disease. This affected the overall LQ, the state of emotional sphere.
As a positive outcome of GP surgery it should be considered that before the operation 35 % of the women pointed the lack of sexual desire sense and after surgery in 74 % of women a sense of sexual desire always observed. At the same time, women who have used permanent contraception method, noted satisfaction with sexual life, increase in the frequency of orgasms experienced, driving growth with a sexual partner.
Our research has shown that the removal of the prolapse is not playing fair value in the resumption of sexual activity in women who did not have it before surgery. Women of reproductive age have noted that the cause of discomfort during sexual intercourse disappeared, although «fear of disrupt the effect of surgery» remained for several months. There is a tendency to improve the LQ after surgical treatment ofprolapse in combination with VSC, indicating a positive effect removal of genital prolapse in conjunction with a reliable method of contraception on women LQwhich is formed by satisfaction in sexual field too. It contributes to the formation of the emotional and psychological evaluation of the LQ of patients and generally has a positive impact on public health indicators [39; 78; 106; 153; 201; 210; 222].
So our work is the first to show the importance of LQ studies in women with GP not only during surgery, but also impact of permanent contraception method on LQ, which does not require additional surgical procedures, and related costs, and also the physical and emotional trauma. In the era of evidence-based medicine using questionnaires for the study of LQbefore and after surgery is highly desirable. Since, it will allow estimating the place of different operations in modern obstetrics. In our study, LQ_ questionnaires allowed to make science-based conclusions on the effect of surgical correction of pelvic organ prolapse with simultaneous VSC on all aspects of patients' life.
Thus, in prolapse and partial GP, as well as the presence of this disease in combination with uterine neck elongation, our proposed methods of surgical treatment with simultaneous VSC are optimal for women of reproductive age, as far as they contribute preservation and restoration of specific functions of female body — menstrual and sexual, which positively affects LQ of these women.
Conclusions:
1. LQin GP depends on the severity of the underlying disease and the social status of women — 42.7 % of patients have uterine neck elongation, in which no significant differences were revealed in indexes of LQ compared to the control group.
Deterioration in general health observed regardless of the degree of prolapse. Reliably significant appeared the pain intensity index (p < 0.05).
2. The quality of sexual intercourse increased by 83 % during performing this method of contraception in women with prolapse of the vaginal walls, reflecting the positive impact of removing genital prolapse with simultaneous VSC on LQof women. Negative emotions during intimacy diminished significantly. It was observed a tendency to increase the frequency of sexual desire.
3. The effectiveness of surgical treatment, as well as characteristics of the LQof women after surgical treatment with simultaneous VSC, allows suggesting this method the most efficient in patients of reproductive age. The use of the proposed system of medical measures, including a new method ofVSC, can improve the results of surgical treatment and LQ. This system has a significant economic savings in direct medical costs.
Recommendations
In women of late reproductive age, suffering from prolapse of the vaginal walls for the prevention of unwanted pregnancies and with the written voluntary informed consent and presence of qualified surgeon-gynecologist, it is recommended to perform VSC with access to fallopian tubes through the front wall of the vagina simultaneously with surgical treatment of the underlying disease.
References:
1. Tegerstedt G., Miedel A., Schmidt M. M.et al. Obstetric riskfactors for symptomatic prolapse: Apopulation-based approach//Am.J. Obstet. Gynecol. - 2006. - Vol. 194, № 1. - P. 73-81.
2. Trivers K. F. et al. Oral contraceptives and survival in breast cancer patients aged 20 to 54 years//Epidem Biomarkers Prev. -2007. - 16, 9: 1822-1827.
3. The effect of age on short-term outcomes after abdominal surgery for pelvic organ prolapse/H. E. Richter, P. S. Good, K. Kenton et al.// J. Am. Geriatr. Soc. - 2007. - Vol. 55, № 6. - P. 857-863.
4. The surgical technique and early postoperative complications of the Gyncare Prolift pelvic floor repair system/A. Lucioni, D. E. Rapp, E. M. Gong et al.//Can. J. Urol. - 2008. - Vol.15, № 2. - P. 4004-4008.
5. Turkey Demographic and Health Survey 2003. Hacettepe University, Institute of Population Studies, General Directorate of Mother and Child Health/Family Planning, Ministry of Health, State Planning Organization and European Union Ankara, Turkey (in Turkish).
6. Validation of telephone administration of 2 condition-specific quality of- life questionnaires/E. J. Geller, E. R. Barbee, J. M. Wu et al.// Am. J. Obstet. Gynecol. - 2007. - Vol. 197, № 6. - P. 632.el-4.
7. Vessey M. et al. Mortality in relation to oral contraceptive use and cigarette smoking//Lancet. - 2003. - 362: 185-191.
8. Vessey M et al. Oral contraceptive use and cancer: Findings in a large cohort study 1968-2004//Br J Cancer. - 2006. - 95: 385-389.
9. Wadhwa A., Surendra J. B., Sharma A. et al. Laparoscopic repair of diaphragmatic hernias: experience of six cases//Asian J. Surg. -2005. - Vol. 28, № 2. - P. 145-150.
10. Ware J. E., Snow K. K., Kosinski M. et al. SF-36 health survey: Manual and Interpritation guide. - MA: Boston, 1993.
11. Ware J. E. The status of health assessment 1994//Public Health. - 1995. - Vol. 16. - P. 327-354.
12. Webster G. D. Management of type 3 stress urinary incontinence, using the artificial urinary sphincter//Urology. - 1992. - Vol. 39. - P. 499.
13. Weak VLPP and MUCP correlation and their relationship with objective and subjective measures of severity of urinary inconti-nence/Martan A. [et al.]//Int. Urogynecol. J. - 2007. - Vol. 18. - P. 267-271.
14. Whiteside J. L., Weber A. M., Meyn L. A., Walters M. D. Risk factors for prolapse recurrence after vaginal repair//Am. J. Obstet. Gynecol. - 2004. - Vol. 191. - P. 1533-1538.
15. Wildemeersch D., Schacht E., Wildemeersch P. Performance and acceptability of intrauterine release of levonorgestrel with a miniature delivery system for hormonal substitution therapy, contraception and treatment in peri and postmenopausal women//Maturitas. -2003. - 44: 237-245.
Otamuradov Furqat Abdukarimovich, Tashkent Pediatric Medical Institute E-mail: [email protected]
Rectovestibular fistula with normal anus
Abstract: The anorectal malformations are presented by wide spectrum of nosological forms. Many aspects of the surgical
treatment of the rectogenital fistulas in normally formed anus remain to be debatable because they are described insufficiency in
the literature.
