Pain and activity after vaginal reconstructive surgery for pelvic organ prolapse

Abstract

Objectives To describe postoperative pain and functional activity after transvaginal native tissue reconstructive surgery with apical suspension and retropubic synthetic midurethral sling (MUS) and to compare these outcomes between patients receiving uterosacral ligament suspension (USL) and sacrospinous ligament fixation (SSLF). Materials and Methods This planned secondary analysis of a 2x2 factorial randomized trial included 374 women randomized to receive ULS (n=188) or SSLF (n=186) to treat both Stages 2-4 apical vaginal prolapse and stress incontinence between 2008 and 2013 at 9 medical centers. Participants also randomized to receive perioperative pelvic muscle therapy or usual care. All patients received transvaginal native tissue repairs and a MUS. Participants completed the Surgical Pain Scales (0-10 numeric rating scales; higher scores = greater pain) and Activity Assessment Scale (AAS) (0-100; higher score = higher activity) prior to surgery and at 2 weeks, 4-6 weeks, and 3 months postoperatively. The SF-36 was completed at baseline, 6, 12, and 24 months after surgery; the Bodily Pain, Physical Functioning, and Role-Physical subscales were used for this analysis (higher scores = less disability). Self-reported pain medication use was also collected. Results Before surgery, average pain at rest and during normal activity were (adjusted mean ± standard error) 2.2+0.2 and 2.8+0.3 (range 0-10 and 0-9, respectively); both increased slightly from baseline at 2 weeks (+0.7 for both, p<0.01 compared to pre-surgery) then decreased below baseline at 3 months (-0.9 and -1.1 respectively, p<.001), with no differences between surgical groups. Pain during exercise/strenuous activity and worst pain decreased below baseline levels at 4-6 weeks (-1.3, p=.01 and -1.0, p=.002) and 3 months (-2.0 and -1.5, p<.0001) without differences between surgical groups. Functional activity as measured by the AAS improved from baseline at 4-6 weeks (+9.2, p<.0001) and 3 months (+13.8, p<.0001). SF-36 Bodily Pain, Physical Functioning and Role-Physical Scales demonstrated significant improvements from baseline at 6, 12, and 24 months with no differences between groups (24 months: +5.6, +5.8 and +4.7 respectively, p<.0001 for each). Use of narcotic pain medications was reported by 14% of participants prior to surgery, 54% at 2 and 26% at 4-6 weeks post-operatively; thereafter, use was similar to baseline rates until 24 months when it decreased to 7%. Use of non-narcotic pain medication was reported by 48% of participants prior to surgery, 69% at 2 weeks and similar to baseline at 3 months; thereafter use dropped steadily to 27% at 2 years. Conclusion Pain and functional activity improve for up to 2 years after native tissue reconstructive surgery with ULS or SSLF and MUS for stage 2-4 pelvic organ prolapse. On average, immediate postoperative pain is low and improves to below baseline levels by 4-6 weeks.