Abstract
Background
We compared short- and long-term patient-reported satisfaction and outcomes after hysterectomy between women with and without pelvic floor dysfunction at the time of hysterectomy.
Methods
The nationwide prospective FINHYST cohort was divided into two groups according to the indication for hysterectomy: those with pelvic organ prolapse (POP) with or without urinary incontinence (POPUI) (n = 1323) and those with other benign indications (non-POPUI, n = 2641). Outcomes were assessed via questionnaires at two months for all women and at ten years for the Helsinki University Hospital (HUH) subgroup (n = 838). The primary outcome was patient satisfaction measured by a visual analogue scale (VAS, 0-100); secondary outcomes included patient-reported outcomes and adverse events.
Results
Satisfaction was high at two months (mean VAS 88.1 POPUI vs. 89.8 non-POPUI, n.s) and remained high at ten years (89.2 POPUI vs. 92.5 no POPUI, p < 0.01). Women without POPUI reported greater satisfaction at ten years. At two months, fewer women in POPUI group had VAS scores under 70 compared to those in non-POPUI group (9.0% vs. 11.5%, p < 0.02). In both groups, the strongest predictors of dissatisfaction were reoperation, wound infection, and inadequate pain relief. At ten years, women with POPUI reported more frequently low VAS scores, (VAS < 70: 11.7% vs. 7.0%), persisted pelvic floor symptoms (86.7% vs. 64.0%, p < 0.01), and reoperations for POP (20.7% vs. 2.3%, p < 0.01).
Conclusions
Short- and long term satisfaction following hysterectomy is high. Hysterectomy due to POP was associated with recurrent patient-reported pelvic floor symptoms, reoperations and higher risk of complications, reducing long-term satisfaction.
Keywords: Patient-reported outcome, Satisfaction, Pelvic organ prolapse, Urinary incontinence, Dissatisfaction, Visual analogue scale
Introduction
Hysterectomy for benign indication and POP (pelvic organ prolapse) surgery are common, with 30% of women undergoing hysterectomy and 12–19% POP surgery [1, 2]. If the indication for hysterectomy is benign, the risks and benefits must be weighed carefully, and the most important end points should be improved symptoms and quality of life. Subjective and objective outcomes are not always in concordance, and recent data suggest that subjective outcomes are more important [3]. Adverse events are known to have a marked impact on subjective outcome, although patient’s’ and surgeons’ perception of adverse events may differ [3].
The most common benign indications for hysterectomy are POP, myoma, abnormal uterine bleeding (AUB), pelvic pain, and endometriosis [1, 4], all of which may cause several symptoms affecting health-related quality of life (HRQoL). Hysterectomy and POP or UI (urinary incontinence) surgeries are known to improve HRQoL [5–8], but if subjective expectations are not fulfilled women may perceive the surgery as a failure [3]. Moreover, any adverse event during or after the operation may cause shame among women [3].
Hysterectomy may cause damage to the pelvic floor, and thus, increase risk for POP [9, 10]. POP is a dynamic process that evolves over time, and it may be influenced by several factors such as age, menopause, obesity, vaginal deliveries, pregnancies, parity, and congenital connective tissue abnormalities [11–13]. Additionally, both POP and UI can significantly impair HRQoL [14, 15], and outcomes may be further negatively affected by de novo symptoms, reoperations, or pre-existing conditions [7, 14]. Given this, rather than focusing solely on anatomical outcomes, it is crucial to assess subjective long-term outcomes, including symptom improvement and patient satisfaction. However, data on these aspects remains limited.
This study aimed to evaluate short- and long-term patient-reported outcomes after hysterectomy for benign indications, with a focus on comparing patient satisfaction and the factors associated with satisfaction between women who underwent hysterectomy for POP and those with other benign indications.
Materials and methods
We used a nationwide prospective survey of 5279 hysterectomies for benign indications (FINHYST) performed in Finland during 2006 [4]. All women received a postoperative questionnaire two months after the hysterectomy. The study included a subgroup of women (n = 838) undergoing hysterectomy in the Helsinki University Hospital region (HUH subgroup). These women received a second questionnaire ten years after their hysterectomy. The study flow is shown in Fig. 1.
Fig. 1.
Flowchart of the study population. HUH Helsinki University Hospital district, POP pelvic organ prolapse, UI urinary incontinence, VAS visual analogue scale
The cohort and the HUH subgroup were linked to the Finnish Care Register to detect any POP or UI-related outpatient visits and surgical operations. This register contains information on hospital admission and discharge dates, diagnoses coded according to the International Classification of diseases (ICD), and operation codes based on the Nordic Classification of Surgical Procedures (NSCP) for all clinical in- and outpatient visits in specialized health care facilities throughout Finland. The diagnoses and operation codes included were N81.* (female genital prolapses), N39.3 (stress urinary incontinence), N39.4 (other specified urinary incontinence), and LEF* (prolapse procedures).
We divided the FINHYST cohort with completed two-month questionnaire (n = 3964) into subgroups according to the primary indication of hysterectomy. The study group comprised women with POP and with or without UI (POPUI group), and the comparison group women with other indications (non-POPUI group).
Other indications for hysterectomy in the comparison group included myoma, abnormal uterine bleeding, dysmenorrhea, endometriosis, and adnexal mass. All women underwent total hysterectomy, and those with POPUI indication also underwent POP repair concurrently (anterior and/or posterior repair, sacrospinous ligament fixation, mesh repair). The choice of hysterectomy approach, abdominal (AH), laparoscopic (LH), or vaginal (VH), was made by the surgeon.
The two-month follow-up questionnaire assessed satisfaction with hysterectomy using a 10-cm VAS scale, ranging from very unsatisfied to very satisfied, and converted to a 0–100 mm score. In addition, the questionnaire inquired about the adequacy and duration of sick leave, hospital readmissions, and outpatient visits. Women who experienced surgery-related minor complications requiring treatment indicated one or more of the following: wound infection, urinary tract infection (UTI), wound dehiscence, heavy vaginal bleeding, postoperative anemia requiring transfusion, pelvic hematoma or infection, inadequate pain control, or other specified problems. Surgeons completed a postoperative questionnaire covering procedural details, short-term minor complications (wound infection, UTI, postoperative anemia requiring blood transfusion, pelvic hematoma or infection, other specified problem and fever of unknown origin) and major complications (deep vein thrombosis, pulmonary embolism, bladder/ureter/bowel/vascular injury or any other reason making a reoperation necessary) length of hospital stay, and sick leave. Complications requiring readmission were confirmed through electronic medical records. Responses were compared between the two study groups. All hysterectomy-related minor and major complications are described in detail in a previous study [16].
The HUH subgroup also received a non-validated 10-year follow-up questionnaire that contained questions on the following: satisfaction with VAS, effect on quality of life, whether the patient would choose hysterectomy again (yes/no), urinary problems and their treatments, defecation problems and their treatments, symptoms of vaginal bulging, prolapse treatment (conservative and surgical), pain before and after hysterectomy, sexual activity, and surgical or gynecological operations performed after hysterectomy.
These outcomes of patient satisfaction were analyzed between POPUI and non-POPUI groups among the whole cohort and in the HUH subgroup. A cut-off point of 70 was set to define patient dissatisfaction with hysterectomy, based on earlier literature [17, 18]. Dissatisfaction (defined as VAS score under 70) and related factors were assessed at two months for the entire cohort and at ten years for the HUH subgroup. We also compared patient-reported outcomes, complications, and symptoms with those reported by the surgeons at two months. In the HUH subgroup, we further evaluated the occurrence of new symptoms, outpatient visits, and surgical procedures ten years after hysterectomy.
Data were analyzed using SPSS for Windows statistical software version 29.0 (SPSS, Inc., Chicago, IL, USA). Categorical variables were compared by the Chi-square or Fisher exact tests, as appropriate. Continuous variables were compared using either Student’s T-test or the Mann–Whitney U test. When comparing more than two groups, one-way ANOVA was employed, and when comparing one continuous and two categorical variables the two-way ANOVA was used. Binary logistic regression model was used to identify independent predictors of visual analogue scale scores under 70. This analysis was performed on factors with a p-value < 0.10 in univariate analysis. A significance level of p < 0.05 was used for all analyses.
We initially attempted to generate a propensity score matched cohort; however, due to a significant reduction in sample size and persistent imbalance with standard matching, we utilized Inverse Probability of Treatment Weighting (IPTW) to estimate the causal effect.
To evaluate the robustness of our findings and control for the potential confounding effect of the surgical method and complications, a sensitivity analysis was performed excluding patients with early complications and stratifying by hysterectomy route (AH, LH, VH). A generalized linear model was fitted, adjusting for age, BMI, parity, and occupational status.
Additionally, we attempted multiple imputation to address missing data, but this yielded unstable estimates due to high missingness (Fraction Missing Info > 0.78). Therefore, 10-year results (HUH-subgroup) are reported based on complete case analysis (n = 554).
Results
The two-month questionnaire was completed by 75% of FINHYST participants (n = 3964): 1323 women with POPUI and 2641 women without POPUI. In the HUH subgroup, 66.1% (n = 554) of study participants answered the ten-year questionnaire: 57.7% (n = 128) of POPUI and 69.1% (n = 426) of no POPUI women.
The demographics of the study groups are presented in Table 1. The groups had significant differences in age, parity, method of hysterectomy, occupational status, and postoperative (short-term) complications. The differences were similar in the HUH subgroup.
Table 1.
Demographics of the 3964 women in this study divided into two groups according to the benign indication for hysterectomy (POPUI = pelvic organ prolapse with or without urinary incontinence and non-POPUI = other indication)
| n (%) | All | POPUI | non-POPUI | p |
|---|---|---|---|---|
| 3964 (100) | 1323 (33.4) | 2641 (66.6) | ||
| Age mean (Sd) | 52.0 (10.5) | 59.1 (11.4) | 48.9 (7.9) | < 0.01 |
| BMI mean (Sd) | 26.5 (4.7) | 26.5 (4.1) | 26.5 (4.9) | |
| Parity | ||||
| No deliveries* n (%) | 671 (16.9) | 79 (6.0) | 592 (22.4) | < 0.01 |
| One to two n (%) | 2058 (51.9) | 681 (51.5) | 1377 (52.1) | < 0.01 |
| Three or more n (%) | 1235 (31.2) | 563 (42.6) | 672 (25.4) | < 0.01 |
| Hysterectomy approach | ||||
| AH | 947 (23.9) | 30 (2.3) | 917 (34.7) | < 0.01 |
| LH | 1234 (31.1) | 95 (7.2) | 1139 (43.1 | < 0.01 |
| VH | 1783 (45.0) | 1198 (90.6) | 585 (22.2) | < 0.01 |
| Any complication^ | 577 (14.6) | 155 (11.7) | 422 (16.0) | < 0.01 |
| Employed | 152 (3.8) | 26 (2.0) | 126 (4.8) | < 0.01 |
BMI Body mass index, AH Abdominal hysterectomy, LH Laparoscopic hysterectomy, VH Vaginal hysterectomy, * no deliveries or status unknown, ^ reported by doctors. The difference between the groups is calculated using Chi-square test for categorical variables and Mann-Whitney U-test for continuous, numerical, and categorical variables
Short-term PROMs – two-month outcomes
At two months post-hysterectomy, 98% of women (n = 3,886) completed the VAS assessment, with a mean satisfaction score of 89.5 (SD 16.7) (Table 2). Mean satisfaction after the two-month follow-up did not differ between groups in the entire cohort (88.1 POPUI and 89.8 no POPUI) or in the HUH subgroup (88.3 and 90.8) (Table 2). Evaluation of dissatisfaction (VAS < 70) showed a minor difference in the whole cohort. The POPUI group scored less dissatisfaction in crude comparison (9.0% vs. 11.5%, p = 0.02). In a separate crude analysis using IPTW, the weighted difference between POPUI (21%) and non-POPUI (11.8%) women was 9.2% and OR 0.56 (95% CI 0.5–0.6). After standard multivariable regression risk difference for dissatisfaction for two months was − 1.0% (95% CI -5.0-2.0, p = 0.452) indicating that after adjusting for baseline imbalances, there was no significant difference in short-term dissatisfaction between POPUI and non-POPUI women. However, after rigorous adjustment for confounding using IPTW, women with POP as an indication for a hysterectomy had a significantly higher adjusted probability of dissatisfaction (20%) compared to those with other benign indications (17%). The adjusted risk difference was 2.0% points (95% CI 0.0-5.0, p = 0.021). Importantly, a separate model demonstrated that a mere history of POPUI (without POP being the primary indication for a hysterectomy) was not associated with dissatisfaction (p = 0.772) (Table 3). In the sensitivity analysis excluding patients with complications and stratified by hysterectomy route, the significant association between groups and VAS scores observed in the primary analysis was no longer present. The adjusted mean difference between the groups was negligible (mean difference 1%, 95%CI-0.02-0.04, p = 0.678). However, BMI (p = 0.04) and VH (p = 0.02) remained a significant predictor of the dissatisfaction. The HUH subgroup did not show a significant difference in dissatisfaction two months after hysterectomy in either the crude or IPTW analysis.
Table 2.
Crude and IPTW adjusted comparison of patient-reported satisfaction by VAS scores from 0 (very unsatisfied) to 100 (very satisfied). A subgroup of Helsinki university hospital district (HUH) participants is shown separately. Differences between groups were analyzed using Pearson’s Chi-square test or T-test
| Whole cohort 2 mo | All | POPUI | non-POPUI | p |
|---|---|---|---|---|
| n = 3964 | n = 1323 | n = 2641 | ||
| Answered VAS question, n (%) | 3886 (98.0) | 1288 (97.4) | 2598 (98.4) | |
| VAS (mean, Sd) | 89.5 (16.7) | 88.1 (19.9) | 89.8 (16.3) | n.s. |
| VAS (crude under) 70, n (%) | 415 (10.7) | 116 (9.0) | 299 (11.5) | 0.02 |
| VAS (IPTW adjusted) under 70, n (%) | 2185 (18.3) | 420 (11.8) | 1765 (21.0) | <0.001 |
| HUH subgroup 2 mo | n = 838 | n = 222 | n = 616 | |
| Answered VAS question, n (%) | 673 (80.3) | 179 (80.6) | 494 (80.2) | n.s. |
| VAS (mean, Sd) | 90.2 (16.0) | 88.3 (18.7) | 90.8 (15.0) | n.s. |
| VAS under 70, n (%) | 74 (11.0) | 22 (12.3) | 52 (10.5) | n.s. |
| HUH subgroup 10 yrs | ||||
| Answered 10 yrs, n (%) | 554 (66.1) | 128 (57.6) | 426 (69.2) | n.s. |
| VAS (mean, Sd) | 91.7 (1.4) | 89.2 (1.5) | 92.5 (1.3) | < 0.01 |
| VAS under 70, n (%) | 45 (8.1) | 15 (11.7) | 30 (7.0) | n.s. |
| Would choose hysterectomy again? | ||||
| Yes, n (%) | 521 (94.0) | 117 (91.4) | 404 (94.8) | < 0.01 |
| No | 24 (4.3) | 9 (7.0) | 15 (3.5) | n.s. |
Sd Standard deviation, Mo Months, VAS Visual analogue scale, POPUI Pelvic organ prolapse with or without urinary incontinence. The difference between the groups is calculated using Chi-square test for categorical variables and Mann-Whitney U-test for continuous, numerical, and categorical variables
Table 3.
Adjusted predictors of short-term patient dissatisfaction (VAS < 70) following hysterectomy: A doubly robust analysis using inverse probability of treatment weighting (IPTW)
| Predictor Variable | Adjusted OR | 95% CI | P-value |
|---|---|---|---|
| Surgical Indication | |||
| Other Benign Indications (Ref) | 1.00 | — | — |
| POP Indication | 1.18 | 1.03–1.36 | 0.020 |
| Surgical Approach | |||
| Abdominal (Ref) | 1.00 | — | — |
| Vaginal | 0.57 | 0.48–0.67 | < 0.001 |
| Laparoscopic | 0.35 | 0.29–0.41 | < 0.001 |
| Patient Characteristics | |||
| Age (per year increase) | 0.96 | 0.95–0.97 | < 0.001 |
| BMI (per unit increase) | 1.17 | 1.05–1.08 | < 0.001 |
| Employed / Working (vs. No) | 4.35 | 3.41–5.53 | < 0.001 |
| Clinical Factors | |||
| Complications (Yes vs. No) | 1.32 | 1.12–1.57 | 0.001 |
| Parity (vs. Nulliparous) | |||
| Parity 1 | 2.11 | 1.69–2.63 | < 0.001 |
| Parity 2+ | 1.34 | 1.04–1.73 | 0.023 |
| POPUI history (non-POPUI ref) | 0.98 | 0.85–1.13 | 0.772 |
VAS Visual analogue scale, BMI Body mass index, POPUI Pelvic organ prolapse with or without urinary incontinence, OR Odds ratio, CI Confidence interval
At two months, minor complications were reported by 29.3% (n = 387) of women in the POPUI group and 34.3% (n = 907) in the non-POPUI group, (p < 0.01). Among all women, the most common complication was urinary tract infection (UTI) (6.1%), followed by wound infection (4.4%) and pelvic hematoma with or without infection (4.3%). Women in the POPUI group experienced more UTIs than those in the non-POPUI group (7.9% vs. 5.1%, p < 0.01) whereas women in the non-POPUI group had a greater rate of pelvic hematomas (2.9% vs. 5.0%, p < 0.01). Pain relief was reported as inadequate by 2.3% (n = 90) of women, with no significant difference between the groups. Women in the POPUI group underwent fewer reoperations (n = 20, 1.5% vs. n = 74, 2.8%, p < 0.01) and experienced fewer major complications (n = 30, 2.3% vs. n = 105, 4.0%, p < 0.01). VAS scores were generally lower in women who experienced any complications than in those without complications. The lowest VAS scores (69.1, Sd 27.7) were observed in women who underwent reoperation or had other major complication (69.6, Sd 29.3) after hysterectomy. Women who experienced inadequate pain relief also had markedly lower VAS scores (73.7, Sd 26.7).
At two months, BMI over 30 kg/m2 and parity (one or more) were associated with decreased dissatisfaction risk (VAS under 70) among all women and among women in the non-POPUI group (Table 3). Conversely, among the same women, urinary infection, pelvic hematoma, and older age were associated with increased risk for dissatisfaction. The greatest risk for dissatisfaction was observed among women who experienced reoperation (OR 3.4, 95% CI 1.7–7.1), wound infection (OR 2.8, 95% CI 1.9–4.1), or inadequate pain relief (OR 4.0, 95% CI 2.5–6.6) (Table 4).
Table 4.
Risk factors for VAS scores under 70 at two months after hysterectomy identified in both the POPUI and non-POPUI groups
| All | POPUI | non-POPUI | ||||
|---|---|---|---|---|---|---|
| VAS < 70 | p | VAS < 70 | p | VAS < 70 | p | |
| n (%) | 415 (10.7) | 116 (9.0) | 299 (11.5) | 0.02 | ||
| OR (95% CI) | OR (95% CI) | OR (95% CI) | ||||
| Age over 50 (under 50 ref) | 1.2 (1.0–1.5) | 0.9 (0.6–1.5) | 1.3 (1.0–1.7) | 0.05 | ||
| BMI over 30 (under 30 ref) | 0.6 (0.5-0.0.8) | < 0.01 | 0.6 (0.3–1.0) | 0.7 (0.5–0.9) | 0.02 | |
| Parity (zero or status unknown ref) | ||||||
| One to two | 0.7 (0.5–0.9) | < 0.01 | 0.6 (0.3–1.2) | 0.7 (0.5–1.0) | 0.04 | |
| Three or more | 0.7 (0.5–1.0) | 0.04 | 0.7 (0.3–1.4) | 0.7 (0.5–1.0) | n.s. | |
| Hysterectomy approach (AH/LH ref) | ||||||
| VH | 0.9 (0.6–1.6) | 1.5 (0.7–3.3) | 0.8 (0.6–1.1) | n.s. | ||
| Reoperation (no reoper ref) | 3.4 (1.7–7.1) | < 0.01 | 7.0 (2.5–19.2) | < 0.01 | 5.1 (3.0–8.6) | < 0.01 |
| Infection (no infection ref) | 1.0 (0.6–1.7) | 1.1 (0.4–2.9) | 0.9 (0.5–1.6) | n.s. | ||
| Urinary infection (no UTI ref) | 1.7 (1.2–2.5) | < 0.01 | 1.4 (0.7–2.7) | 1.9 (1.2–3.0) | < 0.01 | |
| Wound opening (no opening ref) | 1.6 (0.9–3.1) | 2.0 (0.5–7.4) | 1.4 (0.7–3.0) | n.s. | ||
| Wound infection (no wound inf. ref) | 2.8 (1.9–4.1) | < 0.01 | 4.1 (2.0–8.4) | < 0.01 | 2.4 (1.5–3.8) | < 0.01 |
| Heavy vaginal bleeding (no bleeding ref) | 1.6 (0.9–2.8) | 2.4 (0.8–7.3) | 1.4 (0.7–2.7) | n.s. | ||
| Pelvic hematoma (no hematoma ref) | 2.5 (1.7–3.7) | < 0.01 | 1.5 (0.6–3.8) | 2.9 (1.8–4.6) | < 0.01 | |
| Inadequate pain relief (adequate ref) | 4.0 (2.5–6.6) | < 0.01 | 3.9 (1.4–11.0) | < 0.01 | 4.1 (2.3–7.2) | < 0.01 |
Multivariate logistic regression analysis: each minor complication was adjusted for classified age, classified BMI, hysterectomy approach, parity, reoperation, and postoperative infection. VAS Visual analogue scale, BMI Body mass index, AH Abdominal hysterectomy, VH Vaginal hysterectomy, LH Laparoscopic hysterectomy, POPUI Pelvic organ prolapse with or without urinary incontinence, OR Odds ratio, CI Confidence interval
The comparison of patient- and surgeon-reported complications showed that patients reported more minor complications (29–34% vs. 12–16%). Both reported the same complication (agreement score) only in 40–58% of cases (p < 0.01). UTI was the most common complication not reported by surgeons, whereas pelvic hematoma with or without infection and wound infection demonstrated the highest agreement rates.
Long-term PROMs – ten-year outcomes
Ten years after hysterectomy, women in the POPUI group scored lower mean VAS scores (89.2 vs. 92.5, p < 0.01) and reported more dissatisfaction than women in the non-POPUI group (11.7% vs. 7.0%). The latter did not reach statistical significance. Adjusted IPTW analysis and adjusted original data analysis after imputation demonstrated a statistically significant difference in continuous 10-year satisfaction scores between the groups (mean difference − 0.37, 95% CI -0.73 to -0.01, p = 0.042 and (mean difference − 0.42; 95% CI -0.79 to -0.05; p = 0.027). This confirms the robustness of the primary findings. Overall, 94% of women would still choose to undergo hysterectomy (91.4% in the POPUI group and 94.8% in the non-POPUI group, p < 0.01) (Table 2).
Ten years after hysterectomy, among the HUH subgroup, 47.7% (n = 264) of participants reported urinary symptoms, 30.5% (n = 169) problems with defecation, and 15.3% (n = 85) symptoms of bulging. Women in the POPUI group reported more of these symptoms than those in the non-POPUI group (any POPUI symptoms: 86.7%, n = 111 vs. 64.0%, n = 273, p < 0.01). Constipation (32.0%, n = 41 vs. 21.1%, n = 90, p < 0.01) and urinary incontinence (32.8%, n = 42, vs. 23.9%, n = 102, p = 0.04) were the most common symptoms in both groups. Among women reporting bulging, urinary symptoms, or defecation problems, 61% to 75% experienced mild to severe bother with excretion while 30 to 37% reported mild to severe bother with sexual activity. In the adjusted model, women with POPUI were significantly more likely to report prolapse symptoms at the 10-year follow-up compared to non-POPUI women (mean difference 12.0%; 95% CI 1.0–24.0; p = 0.038). This association persists even after adjusting for parity, age, BMI, and complications. Women in the POPUI group underwent more reoperations (20.7%, n = 46 vs. 2.3%, n = 14, p < 0.001) and had more health care visits due to POP or UI (31.1%, n = 69 vs. 6.2%, n = 38, p < 0.001). The concordance between patient-reported bulging and registry-based outpatient visits was negligible (Cohen’s kappa = 0.03). Similarly, the agreement between bulging and registry-recorded reoperations was slight (kappa = 0.10). Additionally, women in the POPUI group reported significantly lower VAS scores than women in the non-POPUI group when experiencing urinary symptoms (87.3 vs. 90.1, p < 0.01) or bulging (83.8 vs. 86.4, p = 0.02). However, the need for a urinary incontinence operation significantly reduced VAS scores in the non-POPUI group (90.6 vs. 77.8, p < 0.001).
After ten years, older age and symptoms of bulging were associated with an increased risk of dissatisfaction, indicated by VAS scores under 70, among all women and among the women in the POPUI group (Table 5). Conversely, a larger BMI and parity with three or more children decreased dissatisfaction risk, while complications after hysterectomy increased the risk by 5-fold (OR 5.1, 95% CI 1.4–18.9, p = 0.02). Across the women in the non-POPUI group, any urinary or prolapse symptoms were associated with an increased risk of VAS scores under 70 (OR 2.3, 95% CI 1.1–5.1, p = 0.03 and OR 4.0, 95% CI 1.4–11.9, p = 0.01, respectively).
Table 5.
Risk factors associated with VAS scores under 70 at ten years after hysterectomy identified in both the POPUI and non-POPUI groups (HUH subgroup)
| All | POPUI | non-POPUI | ||||
|---|---|---|---|---|---|---|
| VAS < 70 | p | VAS < 70 | p | VAS < 70 | p | |
| n (%) | 45 (8.1) | 15 (11.7) | 30 (7.0) | |||
| OR (95% CI) | OR (95% CI) | OR (95% CI) | ||||
| Age (continuous) | 1.1 (1.0–1.1) | 0.02 | 1.2 (1.0–1.5) | 0.03 | 1.0 (0.9–1.1) | n.s. |
| BMI (continuous) | 0.9 (0.8–1.0) | < 0.01 | 0.5 (0.3–0.9) | < 0.01 | 0.9 (0.8–1.0) | n.s. |
| Parity (0–2 ref) | ||||||
| Three or more | 1.3 (0.5–3.4) | 0.7 (0.3–0.9) | < 0.01 | 1.0 (0.4–3.1) | n.s. | |
| Complications (ref no compl) | 1.5 (0.7–3.3) | 5.1 (1.4–18.9) | 0.02 | 1.4 (0.5–3.4) | n.s. | |
| Hysterectomy approach (AH/LH ref) | ||||||
| VH | 0.8 (0.2–3.3) | ns | 0.5 (0.1–2.6) | n.s. | ||
| Working (ref no working) | 0.8 (0.3–2.5) | 2.3 (0.5–11.0) | 0.4 (0.1–1.1) | n.s. | ||
| Bulging (ref no bulking) | 3.4 (1.7–7.1) | < 0.01 | 4.1 (1.1–15.9) | 0.04 | 2.8 (1.0–7.7) | 0.04 |
| Any urinary symptoms (ref no symptom) | 1.8 (0.9–3.4) | 0.6 (0.2–2.4) | 2.3 (1.1–5.1) | 0.03 | ||
| Any prolapse symptom (ref no symptom) | 4.0 (1.5–10.5) | < 0.01 | 2.8 (0.3–25.2) | 4.0 (1.4–11.9) | 0.01 | |
| Any defecatory symptom (ref no symptom) | 2.1 (1.1–3.9) | 0.03 | 3.0 (0.9–10.2) | 2.0 (0.9–4.4) | n.s. | |
| POPUI visit in register (ref no visit) | 2.4 (1.1–5.4) | 0.04 | 2.6 (0.8–8.8) | 1.9 (0.5 (6.8) | n.s. | |
| POPUI operation register (ref no oper) | 2.4 (0.9–6.4) | 2.1 (0.5–8.0) | 2.6 (0.2–45.2) | n.s. | ||
Multivariate logistic regression analysis: each variable was adjusted for age, BMI, hysterectomy approach, parity, complications, and working status. VAS Visual analogue scale 0-100, BMI Body mass index, AH Abdominal hysterectomy, VH Vaginal hysterectomy, LH Laparoscopic hysterectomy, SUI Stress urinary incontinence, POPUI Pelvic organ prolapse with or without urinary incontinence, OR Odds ratio, CI Confidence interval, HUH Helsinki University Hospital district
Discussion
We assessed patient satisfaction following hysterectomy for benign indications at two distinct intervals: short-term (two months) and long-term (ten years). The results showed that patient satisfaction measured by VAS was high (88–90) two months after surgery. Notably, this level of satisfaction remained stable, even ten years post-surgery (88–91), and is consistent with a previous study [19]. A large majority (94%) of women stated they would choose to undergo hysterectomy again if faced with the same decision. Additionally, our study was able to assess the influence of pre-existing POP on satisfaction after hysterectomy and examined the contribution of additional pelvic floor symptoms to dissatisfaction (VAS scores < 70). Separate analysis of the POPUI and non-POPUI groups enabled a more precise evaluation of surgical effectiveness, risk profiles, and the extent to which satisfaction and QoL outcomes depend on surgical indication rather than procedure alone. However, given the large sample size, small differences in continuous variables may reach statistical significance without necessarily implying clinical relevance. The 3.3-point difference in VAS scores between POPUI and non-POPUI women after ten years, while statistically distinct, falls below the threshold typically considered perceptible to patients (usually defined as 5–10 points on a 0–100 scale) [20, 21].
When evaluating the entire cohort at two months post-hysterectomy, women in the POPUI group demonstrated significantly greater short-term satisfaction in crude comparison (more VAS scores over 70) than women in the non-POPUI group, but this was not seen after adjusted analysis or at the ten-year follow-up in the HUH subgroup. Likely the persistence or recurrence of pelvic floor symptoms led to a decline in satisfaction [22], although the mean satisfaction in all women remained high. However, these excellent short- and long-term satisfaction rates were comparable to findings in previous reports, despite the different study set-ups [5, 7].
Interestingly, according to doubly robust analysis women undergoing hysterectomy for POP as a primary indication had 1.18 times the odds of being dissatisfied after two months compared to women with other benign indication. This finding contrasts with the previous studies [5, 19, 22, 23], suggesting that when confounding and likely protective factors (such as age, parity, and surgical approach) are fully balanced, the POP with itself carries a slightly higher inherent risk of short-term dissatisfaction that is masked in less rigorous analyses. Additionally, this may be attributable to a mismatch between patient expectations and surgical outcomes, whereby the achieved result does not align with pre-operative anticipations, resulting in patient disappointment [3]. When excluding complications the crude difference in VAS scores between the groups disappeared suggesting that the higher dissatisfaction observed in the non-POPUI group in the primary analysis may also be mediated by the occurrence of complications and surgical approach (AH). The adjusted model revealed LH and VH being strongly protective against dissatisfaction compared to AH. However, Belayneh et al. [23] reported that improvement in the patient satisfaction and QoL is independently associated with reductions in prolapse symptoms, not with age, surgery approach or prolapse stage.
Complications most strongly reduced short-term satisfaction, varying significantly across groups due to the predominance of VH and related surgical differences. UTIs were associated with dissatisfaction only among women in the non-POPUI group. Preoperative POP and urinary symptoms may influence UTI perception: symptomatic women view postoperative UTIs as expected, while probably more asymptomatic non-POPUI women report them distinctly. Additionally, vaginal approach often involves more pelvic floor manipulation and may prolong catheterization, increasing noticeable dysuria and pyuria often misinterpreted as infection. A higher rate of abdominal hysterectomy may lead to more wound healing problems.
Notably, physicians reported only one-fourth of the minor complications identified by patients. Many minor complications were likely managed in primary health care and were not documented in hospital records. However, these findings suggest that complications and adverse events that have impact to the patient may be underrecognized or underreported by healthcare professionals [3, 24, 25]. It has been previously noted [3] that patients may consider functional outcomes, such as incontinence, sexual dysfunction, and symptom recurrence, as severe adverse events. This phenomenon likely occurred in our study as well since both the recurrence of pelvic floor symptoms and complications were found to decrease satisfaction among women in the POPUI group, even ten years postoperatively.
Although pain relief was adequate in 98% of women, inadequate pain relief was associated with patient dissatisfaction across all groups, consistent with previous studies linking effective postoperative pain management to improved satisfaction and lower mortality [26]. Notably, there is no pain-specific instrument for assessing patient-reported outcomes in women with POP or SUI [27, 28]. After hysterectomy or transvaginal POP surgery, insufficient pain control increases the risk of chronic pain [29, 30], which women rate as a particularly severe adverse outcome [3]. This may explain the higher rates of dissatisfaction seen in our study among women in the POPUI group, especially among those with persistent complications even ten years after surgery.
After ten years, experienced recurrent or de novo pelvic floor symptoms were common, and decreased satisfaction was observed among all women. These findings corresponded with objective healthcare utilization patterns, suggesting that the results are not driven solely by reporting bias. The relapse rates of POP symptoms in previous studies have ranged from 12.5% to 36.7% [19, 31, 32], which is consistent with our observed rate of bulging symptoms. Women in the POPUI group who experienced bulging symptoms reported the lowest VAS scores and the highest levels of dissatisfaction, although bulging was associated with a higher risk for dissatisfaction across all women. This finding is supported by earlier research showing that the absence of postoperative vaginal bulge symptoms is one of the most consistent predictors of improvement [7, 33]. Furthermore, it is well established that a history of hysterectomy for POP is a significant risk factor for subsequent reoperation for POP [9, 10]. This was particularly notable in our study, as nearly one-fifth of women in the POPUI group underwent reoperation for POP, compared with only 2.3% of women in the non-POPUI group. Additionally, nearly twice as many women in the study were managed conservatively. It is possible that the symptoms of POP or UI themselves, rather than the surgery, contribute to decreased long-term satisfaction. Although this aspect was not directly examined here, previous research suggests that this is likely one of the main reasons for decreased satisfaction [34, 35].
Contrary to some previous studies, we found associations of older age, larger BMI, and parity with satisfaction [34–36]. Age over 60 years is a significant predictor of POP progression [37], and it likely explained decreased long-term satisfaction among older women in our study. Of course, it is possible that age as such had a negative effect on quality of life, thus also affecting the measured satisfaction. In contrast, higher BMI and three or more deliveries both had positive effects on long-term satisfaction. The explanation for these findings remains unclear but may be linked to overall satisfaction with family life. Moreover, the number of deliveries might influence the severity of prolapse [38], and these women likely got more relief for their symptoms. In contrast to our findings, obesity has been associated with increased risk of prolapse [39] and lower satisfaction following prolapse surgery [40]. However, the associations are probably more complex since conflicting results have also been reported by others [41, 42].
A strength of this study is the long (over ten-year) study period, allowing short- and long-term outcomes to be captured. The combination of patient-reported outcomes and registry-based data provides a comprehensive picture of pelvic floor prolapse outcomes that neither source can achieve independently (only slight/minimal agreement in Cohen’s kappa). The rather high response rate to the questionnaires adds to the reliability of the findings. Importantly, this study provides the patient perspective to hysterectomy outcomes in relation to the feared risks of urinary incontinence and prolapse. To our knowledge, this is the first study of hysterectomy to compare the perceptions of both patients and their surgeons. The study design also enriched a prospective FINHYST study performed in 2006 by including two-month and ten-year questionnaires, which were linked to comprehensive registry data. However, we did not examine the gynecological status of participants, and minor complications not requiring secondary surgery or hospitalizations may have been missed, especially if treated outside the specialized health care system.
A limitation of our study is the use of non-validated questionnaires, which are prone to bias, including incomplete data and response bias, potentially limiting the generalizability of our findings. This may partly explain the discrepancies in complication reporting between patients and physicians, as documentation required completion of a specific form. Notably, Barber et al. [33] found a higher rate of missing data (25%) with validated questionnaires than with simpler patient-reported outcomes. VAS scores are widely used in urogynecologic research and provide reliable, reproducible measures of patient satisfaction; however, they are not fully validated for this specific application [43, 44]. Additionally, various cut-off points for dissatisfaction have been reported [17, 18], and no consensus exists regarding the appropriate threshold. Finally, although women in the POPUI group underwent significantly more reoperations compared to controls (20.7% vs. 2.3), a key limitation is our reliance on patient-reported experience. The questionnaire data cannot distinguish between the recurrence of original symptoms and the development of de novo conditions, making it difficult to determine if reported dissatisfaction stems from the failure of previous repairs or the onset of new pelvic floor disorders.
Conclusion
This study demonstrates that long-term satisfaction after hysterectomy is generally high and enduring, regardless of the indication for the procedure. However, both minor and major postoperative complications tend to reduce patient satisfaction, not only short-term but probably also long-term. Additionally, women undergoing hysterectomy for POP, face a higher risk of urinary and pelvic floor symptoms as well as additional surgical interventions. These issues can negatively affect long-term satisfaction. Therefore, it is essential to thoroughly discuss both short- and long-term consequences of hysterectomy for POP with patients before surgery. These results enhance our understanding of the patient perspective of the benefits and challenges associated with hysterectomy and concurrent POP repair.
Acknowledgements
We gratefully acknowledge Juuso Saavalainen for his meticulous management and processing of the original FINHYST database and for data entry.
Abbreviations
- VAS
Visual analogue scale
- POP
Pelvic organ prolapse
- UI
Urinary incontinence
- HUH
Helsinki University Hospital district
- BMI
Body mass index
- HRQoL
Health-related quality of life
Authors’ contributions
Kuittinen: Protocol and project development, data collection and management, data analysis, manuscript writing and editing Tulokas: Protocol and project development, manuscript writing and editing Rahkola-Soisalo: Protocol and project development, manuscript writing and editing Brummer: Data collection and management, manuscript writing and editing Härkki: Protocol and project development, data collection and management, manuscript writing and editing Mentula: Protocol and project development, manuscript writing and editing.
Funding
Open Access funding provided by University of Helsinki (including Helsinki University Central Hospital). TK acknowledges research grants from the Women’s Clinic at Helsinki University Hospital, the Orion Research Foundation sr., the Finnish Society of Gynecological Surgery and the Finnish Society of Obstetrics and Gynecology.
Data availability
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The FINHYST research adhered to the principles outlined in the Declaration of Helsinki and local statutory requirements. All women provided written informed consent before the study. The study protocol was approved by the Ethics Committee of the Helsinki and Uusimaa Hospital District (Dnro 457/E8/04 and 343/13/03/03/2015) and was registered in the ClinicalTrials (NCT00744172). The use of data from the Care Register was authorized by the national health authorities, and all data were used in accordance with national and institutional regulations. Institutional approval was obtained from each participating hospital.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.