Pelvic organ prolapse patients’ attitudes and preferences regarding their uterus: comparing German- and Russian-speaking women

The study questionnaire included information on demography, level of education, previous experience with POP, and symptom severity. A 4-point scoring system was used to assess symptom severity (Pelvic Floor Questionnaire) [10]. Patients were also asked whether they had been seeking information about POP through printed sources, the Internet, broadcast media, family, friends, or healthcare providers. The Knowledge About Pelvic Organ Prolapse Questionnaire, validated for German- and Russian-speaking patients, was used to assess level of knowledge about POP (score 0–16) [11]. Sexually active patients were asked to complete the Female Sexual Function Index (FSFI) questionnaire written in their respective language [12, 13].

To assess uterus-related preferences and attitudes toward hysterectomy versus uterus-preserving prolapse surgery, we developed two structured 5-point-Likert scales: benefit of uterus (BOU) and benefit of not having uterus (BNU), each consisting of 12 items (Supplementary appendix). These scales were developed with the assistance of K. Leithner-Dzubias, head of the psychosomatic outpatient clinic at the Medical University of Vienna, based on existing surveys about women’s perceptions about hysterectomy and body image [7, 14‐19]. Five items were taken from the scoring system used by Good et al. [5], five from the survey composed by Frick et al. [1], and three from the study by Kuppermann et al. [19]. Patients were asked if the uterus was important for their sexual function and emotional state or if removing the uterus would worsen their relationship or their body image. A higher median score on the BOU scale indicated greater benefit for uterine preservation. The higher median score on the BNU scale indicated greater benefit of removing the uterus. Finally, patients were asked if they would prefer to preserve or remove their uterus when undergoing prolapse surgery. The 5-point Control Preference Scale (CPS) validated by Sung et al. [20] was used to assess patients’ preferences regarding their role in making a decision about the treatment of POP.

We categorized patients as active in their treatment decision-making process if they responded they preferred to make the final decision or the final decision after seriously considering the doctor’s opinion. Those who responded yes were categorized as taking a collaborative role. Those responding that they preferred the doctor make the decision or that they would like the physician to make the decision after considering their opinion were categorized as taking a passive role [1, 20]. Logistic regression analysis was applied to identify the contribution of demographic variables, level of knowledge about POP, and scores of uterus-related benefit scales.

Assuming the equal functional outcome of uterus-preserving surgery and hysterectomy, there was no significant difference in patients’ preferences between groups: 40% of German- and 54% of Russian-speaking patients preferred to retain their uterus; 44 and 32%, respectively, preferred hysterectomy (p > 0.05) (Fig. 1).

The proportion of women who stated that the uterus was important for their sexuality, body image, or partnership was lower in the German-speaking group (Table 3). Russian-speaking women were mostly concerned about feeling older and being sad about losing their fertility and body image when undergoing hysterectomy.

With a mean BOU score of 32.5 ± 9.1, Russian-speaking patients saw a greater benefit for uterine preservation than German-speaking patients [20.6 ± 6.7, (p < 0.01)]. The Russian-speaking group had significantly higher mean scores on domains sexuality, body image, and partnership of the BOU scale [2.6 ± 1.0 vs. 1.8 ± 0.9 for sexuality; 2.4 ± 1.1 vs. 1.5 ± 0.7 for body image, 2.6 ± 0.9 vs. 1.6 ± 0.7 for partnership domains (p < 0.05)](Fig. 2).

Mean BNU scale scores did not differ between the German- and Russian-speaking women (29.6 ± 6.9 vs. 31.0 ± 6.5; p > 0.05). A psychometric analysis of the BOU and BONU scales showed an acceptable reliability in both groups. Cronbach’s alpha coefficient was 0.904 for the German the BOU scale and 0.916 for the Russian. Cronbach’s alpha coefficients for the BNU scale were 0.769 and 0.876, respectively.

Forty-one percent of German-speaking patients with POP preferred an active and 42% to a collaborative role in decision making. Russian-speaking patients mostly preferred the doctor to make a treatment decision (55% passive patients) (Table 4).

Logistic regression analysis demonstrated that significant predictors for a patient’s decision to preserve her uterus were higher BOU scores, higher level of education, higher POP knowledge scale scores, and use of the Internet. Predictors for decision to remove the uterus were being older, higher BNU scores, and history of cancer. Predictable values for all variables are presented in Table 5.