Abstract
Objective:
Body image (a woman’s perceptions and attitudes about her body) likely plays a role in pelvic organ prolapse treatment satisfaction and post-operative sexual function. The primary aim of this study was to describe changes in body image after surgical repair of vaginal vault prolapse. The secondary aim was to evaluate whether changes in sexual function are correlated with changes in body image.
Methods:
This was a planned secondary analysis of a randomized three-arm trial comparing surgical approaches for vaginal vault prolapse. Women with symptomatic post-hysterectomy vault prolapse were randomized to: transvaginal native tissue repair (NTR), mesh placed abdominally (Sacrocolpopexy; SC), or mesh placed transvaginally (TVM). Body image was measured using the validated Body Image in Pelvic Organ Prolapse (BIPOP) questionnaire at baseline, 6-, 12-, 24- and 36-months. Sexual activity and function were measured using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA revised (PISQ-IR) at similar time points. Longitudinal analysis for changes from baseline in mean BIPOP score and the proportion of women who met a distribution-based estimate of the minimally important difference (MID) was performed using general mixed models for repeated measures. The same method was used as a model to predict change in sexual function based on body image.
Results:
A total of 335 women were included in the analysis: NTR = 123, SC=107, TVM = 105. Mean age was 66.1±8.5 years and a majority (242, 72%) had Stage 3 prolapse. Baseline total and subscale BIPOP scores were not significantly different by treatment arm. All arms improved by 6-months, and this improvement was sustained to 36-months with no significant differences between the groups for change in BIPOP score nor MID-equivalent improvement.
99(30%) women reported being sexually active at all visits, 131(39%) reported they were not sexually active at all visits, and the remainder changed sexual activity status throughout the study. Amongst sexually active participants, there were no baseline differences in PISQ-IR scores between groups (NTR, 54 women, 3.2±0.7; SC, 43 women, 3.3±0.7; TVM, 46 women, 3.1±0.6). In sexually active women, change in BIPOP and PISQ-IR scores were correlated at each visit and a significant association between these measures (p<0.001) remained after adjustment for baseline sexual function, site, age, surgical treatment arm, and baseline dyspareunia.
Conclusions:
Body image improves following repair of vaginal vault prolapse, regardless of the surgical approach. Improvements in body image and sexual function are positively correlated among sexually active women.
Tweetable statement:
Body image improves and is correlated with improved sexual function following vaginal vault prolapse repair
INTRODUCTION
Body image is a multidimensional concept that involves an individual’s positive and negative perception, thoughts, behaviors and attitudes towards their body and its appearance. (1) Studies demonstrate that individuals with poor body image are more likely to experience depression, loss of self-confidence, poor sexual health and have impact on several other facets of life. (2,3) Body image has previously been demonstrated to be an important factor in quality of life in women with pelvic organ prolapse (POP). (4) Specifically, women with prolapse are at risk for both poorer genital body image and overall body image. (5,6)
The improvement of body image and sexual function with treatment of POP has previously been demonstrated. (7–9) However, there is limited data available regarding whether a particular method of treatment is superior to another with respect to improvement of body image and sexual health. A secondary analysis of the Study of Uterine Prolapse Randomized (SUPeR) trial compared body image outcomes using validated questionnaires in patients who underwent vaginal hysterectomy with uterosacral ligament suspension or mesh sacrospinous ligament suspension hysteropexy. Results indicated that body image improved following surgery and this improvement was sustained at 3 years in women that underwent surgical repair of uterovaginal prolapse. Some limitations of this secondary analysis were the comparison of a uterine preserving vs non-uterine preserving POP repair as well as the fact that all subjects were masked, both of which could potentially impact results of patient body image. Additionally, that analysis was unable to assess the impact of change in body image on sexual function. (7)
The Apical Suspension Repair for Vault Prolapse in a Three-Arm Randomized Trial (ASPIRe) was a multicenter randomized clinical trial that compared the efficacy and safety of 3 apical repair approaches for vaginal vault prolapse. (10,11) Women with symptomatic post-hysterectomy vault prolapse were randomized to: transvaginal native tissue repair (NTR), mesh placed abdominally (Sacrocolpopexy; SC), or mesh placed transvaginal (TVM). The standardized surgical procedures have previously been published. (10) For NTR, either a sacrospinous ligament fixation or a uterosacral ligament suspension was allowed and required attachment of 2 permanent and 2 delayed absorbable monofilament sutures to the vagina. SC could be performed open, laparoscopic or robotically using monofilament polypropylene mesh with standardized characteristics. The mesh was attached with a minimum of 4 attachment sites each on the anterior and posterior arm and a minimum of 2 permanent suture or anchor/tacks on the sacrum. The TVM used the Uphold LITE support system (Boston Scientific). The primary outcome of success for the parent trial was a composite measure of failure defined as any retreatment for prolapse or any Pelvic Organ Prolapse-Quantification (POP-Q) measure beyond the hymen or a positive response (any degree of bother) to the Pelvic Floor Distress Inventory (PFDI) question “Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?” As a planned secondary analysis of the ASPIRe trial, we aimed to describe changes in body image in women undergoing surgical repair of vaginal vault prolapse during the first three years of follow up. The secondary objective was to evaluate whether changes in sexual function are correlated with changes in body image.
METHODS
The ASPIRe study was conducted at 9 US clinical sites of the National Institutes of Health Pelvic Floor Disorders Network with the approval of each site’s institutional review board. All clinical trial participants provided written informed consent. Participants were only masked to treatment assignment until completion of the surgery and study visits were conducted at 6-month intervals.
Body image was measured using the Body Image in Pelvic Organ Prolapse (BIPOP) questionnaire at baseline, 6-, 12-, 18-, 24-, 30- and 36-months. The BIPOP is a 10-item validated instrument assessing how pelvic organ prolapse affects how women perceive body image. (12) There are 2 versions of the BIPOP-one for partnered women and one for non-partnered women, where the non-partnered version phrases partner-dependent questions as hypotheticals (e.g., “I worry” vs. “I would worry”). Each of the 10 questions in the BIPOP has five possible answers and are scored as follows: “strongly disagree (1)”, “disagree (2)”, “neither agree nor disagree (3)”, “agree (4)”, “strongly agree (5)”. The BIPOP questionnaire yields a mean total score and 2 subscale scores: “attractiveness subscale” & “partner subscale”. The range of the scores are 1–5 for both the total and subscales, with higher BIPOP scores representing worse prolapse-related body image. The minimally important difference (MID) was estimated via the distribution-based approach, which was estimated at one-half the standard deviation of the analysis population’s baseline BIPOP scores. (13) Individual BIPOP items were dichotomized as signifying poor body image (strongly agree/agree) or not (strongly disagree / disagree / neither agree nor disagree).
Self-reported sexual activity status (“Are you sexually active?”, Yes/No) was captured at baseline and each followup visits. Sexual function was measured using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA revised (PISQ-IR) at baseline and the same time points as the BIPOP. The validated PISQ IR questionnaire allows calculation of a summary score for sexually active women with range of 1–5, higher score represents better sexual function. (14)
For this analysis, surgical arm refers to the intervention actually received. Analyses that compared treatment effects were repeated on two dichotomies of surgical type: Mesh (TVM or SCP) vs. No Mesh (NTR) and Vaginal Route (TVM or NTR) vs. Abdominal (SCP). Dichotomized treatment comparisons are presented as supplemental materials. The randomization scheme was stratified by clinical site (10 sites) and age group (<65 vs. ≥ 65 years old).
Statistical Analysis
The analysis population included women enrolled and treated in the ASPIRe trial who had baseline as well as at least one post-baseline BIPOP score assessment.
Change in mean BIPOP score and the proportion of women with MID improvement from baseline were analyzed longitudinally to capture the treatment impact on overall Body Image at 6M, 12M, 24M, and 36M follow-up visits (change/improvement relative to baseline). Mixed linear models were applied for continuous endpoints and generalized linear mixed models were applied for dichotomous outcomes. Mixed models adjusted for received intervention, visit, the interaction of intervention and visit, a pooled version of clinical site (7 pooled sites), and randomization age strata. To simplify the clinical interpretation which also resulted in a simpler statistical model, the dichotomized “poor” body image BIPOP questions were used to analyze the overall impact of prolapse surgery (regardless of arm) on individual components of Body Image. These endpoints were analyzed using a McNemar’s test for paired data, comparing “poor” body image at 12M against baseline, 24M against baseline, and 36M against baseline for the full analysis population.
Sexual activity statuses were summarized for the full analysis population, and participants who were sexually active at baseline and at least once post-baseline were included in the sexual function analyses (PISQ-IR average scores are restrictive to sexually active individuals). Change in mean PISQ-IR score was analyzed longitudinally to assess the surgical arm impact on sexual function among sexually active individuals; modeling methods mirrored the BIPOP mean score models.
The correlation of longitudinal changes in body image and sexual function were analyzed using general linear mixed models for repeated measures. Here, the modeled relationship assessed post-surgery change in body image as a predictor for change in sexual function, adjusting for baseline sexual function, as well as visit, the interaction of visit and change in body image, clinical site, received intervention, and randomization age strata. The model and the associated correlation plot used a REVERSE scored BIPOP to simplify the results presentation (i.e., higher BIPOP score represented better body image and higher PISQ IR score represented better sexual function). Again, PISQ-IR endpoint availability limited the models to women who were sexually active at baseline and at least one follow-up visit. A similar correlative analysis was conducted to examine the effect of surgical success through 36M on change in body image at the 36M follow-up. This model was restricted to participants with known surgical success status at 36M and adjusted for baseline BIPOP score.
Confidence intervals and p values were calculated at the 0.05 significance level and there were no adjustments made for multiple comparisons. All statistical analyses were conducted using SAS Version 9.4 (SAS Institute, Cary, NC, USA).
RESULTS
In the primary study, 376 participants were randomized and 360 were treated, with 296 (82%) completing the 36M follow-up; 335 women (NTR = 123, SCP=107, TVM = 105) baseline and at least one post-baseline BIPOP score assessment and were included in this secondary analysis. Baseline demographics, clinical characteristics, BIPOP, and PISQ-IR scores are summarized for the full population and the 3 groups in Table 1. The mean age was 66.1±8.5 years, most (242, 72%) had Stage 3 pelvic organ prolapse, the majority were White (283, 84%), and married living with a partner (230, 69%). At baseline, 44% (146) of women identified themselves as sexually active. No statistically significant differences were noted in baseline characteristics or mean total and subscale BIPOP scores or summary PISQ-IR score by treatment arm. (Table 1)
Table 1:
Baseline Demographic and Medical History, 3 arms
| Outcome | NTR (N=123) |
SC (N=107) |
TVM (N=105) |
Total (N=335) |
|---|---|---|---|---|
| Demographics | ||||
| Age in years, Mean (SD) | 65.9 (8.3) | 65.4 (8.6) | 66.9 (8.7) | 66.1 (8.5) |
| Age >65 yrs, n (%) | 73 (59.3%) | 61 (57%) | 65 (61.9%) | 199 (59%) |
| Race, n (%) | ||||
| White | 104 (84.6%) | 89 (83.2%) | 90 (85.7%) | 283 (84%) |
| Black | 11 (8.9%) | 12 (11.2%) | 10 (9.5%) | 33 (10%) |
| American Indian/Alaskan Native | 2 (1.6%) | 1 (0.9%) | 0 (0%) | 3 (1%) |
| Asian | 1 (0.8%) | 1 (0.9%) | 1 (1%) | 3 (1%) |
| More than 1 | 2 (1.6%) | 0 (0%) | 1 (1%) | 3 (1%) |
| Other | 3 (2.4%) | 4 (3.7%) | 3 (2.9%) | 10 (3%) |
| Hispanic or Latina, n (%) | 18 (15.1%) | 14 (13.5%) | 9 (8.6%) | 41 (13%) |
| Marital Status, n (%) | ||||
| Single | 8 (6.5%) | 6 (5.6%) | 3 (2.9%) | 17 (5%) |
| Married/Living with partner | 83 (67.5%) | 70 (65.4%) | 77 (73.3%) | 230 (69%) |
| Divorced, separated | 24 (19.5%) | 18 (16.8%) | 11 (10.5%) | 53 (16%) |
| Widowed | 8 (6.5%) | 12 (11.2%) | 14 (13.3%) | 34 (10%) |
| Other | 0 (0%) | 1 (0.9%) | 0 (0%) | 1 (0%) |
| Education, n (%) | ||||
| Less than high school | 10 (8.1%) | 8 (7.5%) | 9 (8.6%) | 27 (8%) |
| High school/GED | 47 (38.2%) | 34 (31.8%) | 35 (33.3%) | 116 (35%) |
| Associate College Degree | 30 (24.4%) | 30 (28%) | 32 (30.5%) | 92 (27%) |
| 4-year college | 21 (17.1%) | 22 (20.6%) | 22 (21%) | 65 (19%) |
| Graduate degree | 12 (9.8%) | 11 (10.3%) | 5 (4.8%) | 28 (8%) |
| Unknown/Not reported | 3 (2.4%) | 2 (1.9%) | 2 (1.9%) | 7 (2%) |
| Health Insurance, n (%) | ||||
| Medicaid/Medicare | 67 (54.5%) | 58 (54.2%) | 62 (59%) | 187 (56%) |
| Private | 47 (38.2%) | 42 (39.3%) | 38 (36.2%) | 127 (38%) |
| Other | 9 (7.3%) | 7 (6.5%) | 5 (4.8%) | 21 (6%) |
| Medical History | ||||
| Gravidity, Median (IQR) | 3 (2 – 4) | 3 (2 – 4) | 3 (2 – 4) | 3 (2 – 4) |
| Vaginal parity, Median (IQR) | 3 (2 – 3) | 2 (2 – 3) | 2 (2 – 3) | 2 (2 – 3) |
| BMI (kg/m2), Mean (SD) | 28.0 (4.7) | 29.5 (6.5) | 28.5 (4.3) | 28.6 (5.3) |
| History of Smoking, n (%) | 43 (35%) | 38 (35.5%) | 39 (37.1%) | 120 (36%) |
| Prior stress urinary incontinence surgery, n (%) | 14 (11.4%) | 20 (18.7%) | 16 (15.2%) | 50 (15%) |
| Prior pelvic organ prolapse surgery, n (%) | 35 (28.5%) | 31 (29%) | 19 (18.1%) | 85 (25%) |
| Type of hysterectomy, n (%) | ||||
| Abdominal Open | 49 (39.8%) | 39 (36.4%) | 45 (42.9%) | 133 (40%) |
| Laparoscopic | 14 (11.4%) | 8 (7.5%) | 9 (8.6%) | 31 (9%) |
| Vaginal | 56 (45.5%) | 53 (49.5%) | 46 (43.8%) | 155 (46%) |
| Robotic | 2 (1.6%) | 3 (2.8%) | 4 (3.8%) | 9 (3%) |
| Unknown | 2 (1.6%) | 4 (3.7%) | 1 (1%) | 7 (2%) |
| Post void residual volume in mL, Median (IQR) | 30 (10 – 60) | 24 (10 – 50) | 30 (12 – 75) | 28 (10 – 65) |
| POP-Q Stage, n (%) | ||||
| II | 26 (21.1%) | 17 (15.9%) | 25 (23.8%) | 68 (20%) |
| III | 86 (69.9%) | 85 (79.4%) | 71 (67.6%) | 242 (72%) |
| IV | 11 (8.9%) | 5 (4.7%) | 9 (8.6%) | 25 (7%) |
| Sexually active, n (%) | 56 (45.9%) | 44 (41.1%) | 46 (44.2%) | 146 (44%) |
| BIPOP Score, Mean (SD) [N] | 3.1 (1.1) [123] | 3.3 (1.2) [107] | 3.2 (1.3) [105] | 3.2 (1.2) [335] |
| Attractive Subscale, Mean (SD) [N] | 3.1 (1.2) [123] | 3.3 (1.3) [107] | 3.2 (1.3) [105] | 3.2 (1.3) [335] |
| Partner Subscale, Mean (SD) [N] | 3.1 (1.2) [123] | 3.3 (1.3) [107] | 3.1 (1.3) [105] | 3.2 (1.3) [335] |
| PISQ-IR Sexually Active Average Score, Mean (SD) [N] | 3.2 (0.7) [54] | 3.3 (0.7) [43] | 3.1 (0.6) [46] | 3.2 (0.7) [143] |
NTR = Native Tissue Repair; SC = Sacrocolpopexy; TVM = Transvaginal Mesh; SD = standard deviation; IQR = Interquartile Range; POP-Q = Pelvic Organ Prolapse Quantification; BIPOP = Body Image Pelvic Organ Prolapse; PISQ-IR = Pelvic Organ Prolapse Incontinence Sexual Questionnaire.
Total and subscale BIPOP scores in all arms improved by 6-months, and this improvement was sustained over 36-months; however, no significant differences between the groups for change in BIPOP scores (Table 2, Figure 1) nor MID improvement (Table 3) were observed. When individual BIPOP items were dichotomized, the proportion of women reporting poor body image decreased on all 10 BIPOP items compared to baseline, and those improvements were sustained through 36M (p < 0.0001 for all 10 measures, Table 4). BIPOP models repeated for Mesh vs. No Mesh and Vaginal vs. Abdominal comparisons mirrored results of the 3-arm analysis (Supplemental Tables 1–6).
Table 2:
Body Image Pelvic Organ Prolapse (BIPOP) Score Estimated Baseline or Change from Baseline, Adjusted Means, 3 arms
| Mean (SD) or Adjusted Mean Change from Baseline (95% CI) |
Mean Difference (95% CI), P-value |
||||||||
|---|---|---|---|---|---|---|---|---|---|
| Month | N | NTR | N | SC | N | TVM | NTR vs. SC | NTR vs. TVM | SC vs. TVM |
| Score | |||||||||
| 0 | 123 | 3.1 (1.1) | 107 | 3.3 (1.2) | 105 | 3.2 (1.3) | 0.1738 | 0.4840 | 0.5502 |
| 6 | 115 | −1.1 (−1.3, −0.8) | 99 | −1.3 (−1.6, −1.1) | 99 | −1.3 (−1.5, −1.0) | 0.3 (−0.1, 0.6) 0.1045 |
0.2 (−0.1, 0.5) 0.2625 |
−0.1 (−0.4, 0.3) 0.6287 |
| 12 | 111 | −1.1 (−1.4, −0.9) | 96 | −1.3 (−1.6, −1.1) | 94 | −1.3 (−1.5, −1.0) | 0.2 (−0.1, 0.5) 0.2380 |
0.2 (−0.2, 0.5) 0.3755 |
−0.1 (−0.4, 0.3) 0.7798 |
| 24 | 99 | −1.1 (−1.3, −0.8) | 83 | −1.3 (−1.6, −1.1) | 92 | −1.4 (−1.6, −1.1) | 0.2 (−0.1, 0.6) 0.1664 |
0.3 (−0.1, 0.6) 0.1182 |
0.0 (−0.3, 0.4) 0.8764 |
| 36 | 96 | −1.2 (−1.4, −0.9) | 83 | −1.3 (−1.6, −1.1) | 80 | −1.5 (−1.8, −1.2) | 0.1 (−0.2, 0.5) 0.4247 |
0.3 (0.0, 0.7) 0.0864 |
0.2 (−0.2, 0.5) 0.3737 |
| Attractive | |||||||||
| 0 | 123 | 3.1 (1.2) | 107 | 3.3 (1.3) | 105 | 3.2 (1.3) | 0.1542 | 0.4051 | 0.6258 |
| 6 | 115 | −1.1 (−1.3, −0.8) | 101 | −1.4 (−1.6, −1.1) | 99 | −1.3 (−1.6, −1.1) | 0.3 (−0.1, 0.6) 0.1123 |
0.3 (−0.1, 0.6) 0.1570 |
0.0 (−0.4, 0.3) 0.8745 |
| 12 | 113 | −1.2 (−1.4, −0.9) | 96 | −1.4 (−1.6, −1.1) | 94 | −1.3 (−1.6, −1.1) | 0.2 (−0.2, 0.6) 0.2968 |
0.2 (−0.2, 0.5) 0.3920 |
0.0 (−0.4, 0.3) 0.8597 |
| 24 | 99 | −1.1 (−1.4, −0.9) | 83 | −1.4 (−1.7, −1.1) | 93 | −1.4 (−1.7, −1.2) | 0.3 (−0.1, 0.6) 0.1590 |
0.3 (−0.1, 0.7) 0.1028 |
0.0 (−0.3, 0.4) 0.8439 |
| 36 | 97 | −1.2 (−1.5, −0.9) | 83 | −1.4 (−1.7, −1.1) | 81 | −1.5 (−1.8, −1.2) | 0.2 (−0.2, 0.6) 0.3647 |
0.3 (0.0, 0.7) 0.0825 |
0.2 (−0.2, 0.6) 0.4220 |
| Partner | |||||||||
| 0 | 123 | 3.1 (1.2) | 107 | 3.3 (1.3) | 105 | 3.1 (1.3) | 0.2697 | 0.8217 | 0.4383 |
| 6 | 115 | −1.0 (−1.3, −0.8) | 99 | −1.3 (−1.6, −1.1) | 99 | −1.2 (−1.4, −0.9) | 0.3 (−0.1, 0.6) 0.1406 |
0.1 (−0.2, 0.5) 0.4866 |
−0.1 (−0.5, 0.2) 0.4530 |
| 12 | 111 | −1.1 (−1.3, −0.8) | 96 | −1.3 (−1.6, −1.0) | 94 | −1.2 (−1.5, −1.0) | 0.2 (−0.2, 0.6) 0.2669 |
0.1 (−0.2, 0.5) 0.4580 |
−0.1 (−0.4, 0.3) 0.7251 |
| 24 | 99 | −1.1 (−1.3, −0.8) | 83 | −1.3 (−1.6, −1.0) | 92 | −1.3 (−1.6, −1.0) | 0.2 (−0.1, 0.6) 0.2275 |
0.2 (−0.1, 0.6) 0.2056 |
0.0 (−0.4, 0.4) 0.9662 |
| 36 | 96 | −1.1 (−1.4, −0.9) | 83 | −1.3 (−1.6, −1.0) | 80 | −1.5 (−1.8, −1.2) | 0.1 (−0.3, 0.5) 0.4955 |
0.3 (−0.1, 0.7) 0.0983 |
0.2 (−0.2, 0.6) 0.3461 |
NTR = Native Tissue Repair; SC = Sacrocolpopexy; TVM = Transvaginal Mesh; SD = standard deviation; BIPOP = Body Image Pelvic Organ Prolapse.
Figure 1:
BIPOP Score Change from Baseline Over Time, Adjusted Means
Table 3:
Body Image Pelvic Organ Prolapse (BIPOP) Score Change of at least 0.6 points decrease (improvement) from Baseline, Adjusted Proportions of Participants, 3 arms
| Adjusted Proportion (95% CI) | Odds Ratio (95% CI), P-value |
||||||||
|---|---|---|---|---|---|---|---|---|---|
| Month | N | NTR | N | SC | N | TVM | NTR vs. SC | NTR vs. TVM | SC vs. TVM |
| Score | |||||||||
| 6 | 115 | 55% (45%, 65%) | 99 | 67% (57%, 76%) | 99 | 64% (54%, 73%) | 0.59 (0.34, 1.05) 0.0725 |
0.69 (0.39, 1.22) 0.2006 |
1.17 (0.64, 2.11) 0.6118 |
| 12 | 111 | 65% (55%, 73%) | 96 | 74% (65%, 82%) | 94 | 69% (59%, 78%) | 0.64 (0.35, 1.16) 0.1412 |
0.81 (0.45, 1.46) 0.4883 |
1.28 (0.68, 2.39) 0.4467 |
| 24 | 99 | 62% (52%, 71%) | 83 | 70% (60%, 79%) | 92 | 72% (62%, 80%) | 0.69 (0.38, 1.27) 0.2378 |
0.64 (0.35, 1.18) 0.1525 |
0.93 (0.49, 1.76) 0.8208 |
| 36 | 96 | 68% (57%, 76%) | 83 | 73% (62%, 81%) | 80 | 72% (61%, 81%) | 0.78 (0.41, 1.48) 0.4455 |
0.81 (0.43, 1.54) 0.5239 |
1.04 (0.53, 2.05) 0.9055 |
| Attractive | |||||||||
| 6 | 115 | 59% (49%, 68%) | 101 | 71% (61%, 79%) | 99 | 66% (56%, 75%) | 0.58 (0.33, 1.04) 0.0662 |
0.72 (0.41, 1.27) 0.2547 |
1.23 (0.68, 2.25) 0.4954 |
| 12 | 113 | 69% (59%, 77%) | 96 | 72% (62%, 80%) | 94 | 70% (60%, 78%) | 0.85 (0.47, 1.53) 0.5803 |
0.96 (0.53, 1.72) 0.8807 |
1.13 (0.61, 2.10) 0.6969 |
| 24 | 99 | 63% (53%, 72%) | 83 | 66% (56%, 76%) | 93 | 76% (66%, 84%) | 0.88 (0.49, 1.59) 0.6687 |
0.55 (0.30, 1.02) 0.0572 |
0.63 (0.33, 1.19) 0.1527 |
| 36 | 97 | 66% (56%, 75%) | 83 | 73% (63%, 82%) | 81 | 75% (65%, 83%) | 0.73 (0.39, 1.37) 0.3271 |
0.65 (0.34, 1.23) 0.1874 |
0.89 (0.45, 1.76) 0.7380 |
| Partner | |||||||||
| 6 | 115 | 57% (47%, 66%) | 99 | 64% (54%, 73%) | 99 | 60% (50%, 70%) | 0.74 (0.42, 1.30) 0.2994 |
0.88 (0.50, 1.53) 0.6384 |
1.18 (0.66, 2.11) 0.5811 |
| 12 | 111 | 61% (51%, 70%) | 96 | 69% (59%, 78%) | 94 | 65% (55%, 74%) | 0.70 (0.39, 1.25) 0.2292 |
0.84 (0.47, 1.48) 0.5432 |
1.19 (0.65, 2.18) 0.5636 |
| 24 | 99 | 57% (47%, 67%) | 83 | 66% (55%, 75%) | 92 | 66% (56%, 75%) | 0.69 (0.38, 1.25) 0.2259 |
0.67 (0.37, 1.20) 0.1750 |
0.96 (0.52, 1.78) 0.9043 |
| 36 | 96 | 61% (50%, 70%) | 83 | 71% (60%, 80%) | 80 | 72% (61%, 81%) | 0.63 (0.34, 1.17) 0.1427 |
0.60 (0.32, 1.13) 0.1116 |
0.96 (0.49, 1.86) 0.8984 |
NTR = Native Tissue Repair; SC = Sacrocolpopexy; TVM = Transvaginal Mesh; SD = standard deviation; BIPOP = Body Image Pelvic Organ Prolapse.
Table 4:
Body Image Pelvic Organ Prolapse (BIPOP) Item Response Indication of Poor Body Image at Baseline, 12-, 24-, and 36-Months, 3 arms
| Participants indicating poor body image, n (%) | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Question and Month | N | NTR | N | SC | N | TVM | N | Total | P-value |
| BIPOP Q1: Because of my prolapse, I [worry/would worry] that my partner might avoid being intimate with me. | |||||||||
| 0 | 123 | 43 (35.0%) | 107 | 51 (47.7%) | 105 | 43 (41.0%) | 335 | 137 (40.9%) | |
| 12 | 113 | 17 (15.0%) | 96 | 14 (14.6%) | 97 | 9 (9.3%) | 306 | 40 (13.1%) | <0.0001 |
| 24 | 100 | 16 (16.0%) | 83 | 11 (13.3%) | 92 | 6 (6.5%) | 275 | 33 (12.0%) | <0.0001 |
| 36 | 98 | 9 (9.2%) | 84 | 14 (16.7%) | 81 | 4 (4.9%) | 263 | 27 (10.3%) | <0.0001 |
| BIPOP Q2: I [am/would be] embarrassed for my partner to touch my genitals due to my prolapse. | |||||||||
| 0 | 123 | 57 (46.3%) | 107 | 58 (54.2%) | 105 | 48 (45.7%) | 335 | 163 (48.7%) | |
| 12 | 113 | 19 (16.8%) | 96 | 16 (16.7%) | 96 | 11 (11.5%) | 305 | 46 (15.1%) | <0.0001 |
| 24 | 100 | 15 (15.0%) | 83 | 14 (16.9%) | 92 | 10 (10.9%) | 275 | 39 (14.2%) | <0.0001 |
| 36 | 98 | 13 (13.3%) | 84 | 13 (15.5%) | 81 | 5 (6.2%) | 263 | 31 (11.8%) | <0.0001 |
| BIPOP Q3: I [avoid/would avoid] intimate situations or sexual activity with my partner because of my prolapse. | |||||||||
| 0 | 123 | 54 (43.9%) | 107 | 57 (53.3%) | 105 | 46 (43.8%) | 335 | 157 (46.9%) | |
| 12 | 113 | 21 (18.6%) | 96 | 13 (13.5%) | 96 | 8 (8.3%) | 305 | 42 (13.8%) | <0.0001 |
| 24 | 100 | 20 (20.0%) | 83 | 14 (16.9%) | 92 | 10 (10.9%) | 275 | 44 (16.0%) | <0.0001 |
| 36 | 98 | 13 (13.3%) | 84 | 11 (13.1%) | 81 | 2 (2.5%) | 263 | 26 (9.9%) | <0.0001 |
| BIPOP Q4: Because of my prolapse, I [become/would become] anxious in intimate situations. | |||||||||
| 0 | 123 | 61 (49.6%) | 107 | 57 (53.3%) | 105 | 51 (48.6%) | 335 | 169 (50.4%) | |
| 12 | 113 | 21 (18.6%) | 97 | 16 (16.5%) | 96 | 13 (13.5%) | 306 | 50 (16.3%) | <0.0001 |
| 24 | 99 | 16 (16.2%) | 83 | 15 (18.1%) | 92 | 8 (8.7%) | 274 | 39 (14.2%) | <0.0001 |
| 36 | 96 | 12 (12.5%) | 84 | 15 (17.9%) | 81 | 6 (7.4%) | 261 | 33 (12.6%) | <0.0001 |
| BIPOP Q5: I feel less attractive due to my prolapse. | |||||||||
| 0 | 123 | 51 (41.5%) | 107 | 54 (50.5%) | 105 | 55 (52.4%) | 335 | 160 (47.8%) | |
| 12 | 114 | 14 (12.3%) | 97 | 14 (14.4%) | 96 | 13 (13.5%) | 307 | 41 (13.4%) | <0.0001 |
| 24 | 99 | 16 (16.2%) | 83 | 9 (10.8%) | 93 | 8 (8.6%) | 275 | 33 (12.0%) | <0.0001 |
| 36 | 97 | 11 (11.3%) | 84 | 12 (14.3%) | 81 | 5 (6.2%) | 262 | 28 (10.7%) | <0.0001 |
| BIPOP Q6: I feel less feminine due to my prolapse. | |||||||||
| 0 | 123 | 48 (39.0%) | 107 | 51 (47.7%) | 105 | 46 (43.8%) | 335 | 145 (43.3%) | |
| 12 | 114 | 14 (12.3%) | 97 | 12 (12.4%) | 95 | 12 (12.6%) | 306 | 38 (12.4%) | <0.0001 |
| 24 | 99 | 14 (14.1%) | 83 | 10 (12.0%) | 93 | 9 (9.7%) | 275 | 33 (12.0%) | <0.0001 |
| 36 | 97 | 8 (8.2%) | 84 | 8 (9.5%) | 81 | 4 (4.9%) | 262 | 20 (7.6%) | <0.0001 |
| BIPOP Q7: I feel less confident about my body due to my prolapse. | |||||||||
| 0 | 123 | 65 (52.8%) | 107 | 58 (54.2%) | 105 | 60 (57.1%) | 335 | 183 (54.6%) | |
| 12 | 114 | 23 (20.2%) | 97 | 16 (16.5%) | 95 | 12 (12.6%) | 306 | 51 (16.7%) | <0.0001 |
| 24 | 99 | 16 (16.2%) | 83 | 10 (12.0%) | 93 | 9 (9.7%) | 275 | 35 (12.7%) | <0.0001 |
| 36 | 97 | 15 (15.5%) | 84 | 13 (15.5%) | 81 | 6 (7.4%) | 262 | 34 (13.0%) | <0.0001 |
| BIPOP Q8: My prolapse affects how I feel about the rest of my body. | |||||||||
| 0 | 123 | 37 (30.1%) | 107 | 46 (43.0%) | 105 | 40 (38.1%) | 335 | 123 (36.7%) | |
| 12 | 113 | 11 (9.7%) | 96 | 9 (9.4%) | 95 | 5 (5.3%) | 304 | 25 (8.2%) | <0.0001 |
| 24 | 99 | 13 (13.1%) | 83 | 10 (12.0%) | 93 | 7 (7.5%) | 275 | 30 (10.9%) | <0.0001 |
| 36 | 97 | 10 (10.3%) | 83 | 5 (6.0%) | 82 | 2 (2.4%) | 262 | 17 (6.5%) | <0.0001 |
| BIPOP Q9: I [try/would try] to hide my prolapse from my partner during intimate situations. | |||||||||
| 0 | 123 | 37 (30.1%) | 107 | 37 (34.6%) | 105 | 40 (38.1%) | 335 | 114 (34.0%) | |
| 12 | 111 | 11 (9.9%) | 96 | 9 (9.4%) | 94 | 5 (5.3%) | 301 | 25 (8.3%) | <0.0001 |
| 24 | 99 | 14 (14.1%) | 83 | 7 (8.4%) | 92 | 8 (8.7%) | 274 | 29 (10.6%) | <0.0001 |
| 36 | 97 | 11 (11.3%) | 83 | 7 (8.4%) | 81 | 3 (3.7%) | 261 | 21 (8.0%) | <0.0001 |
| BIPOP Q10: I feel older than my age due to my prolapse. | |||||||||
| 0 | 123 | 46 (37.4%) | 107 | 53 (49.5%) | 105 | 47 (44.8%) | 335 | 146 (43.6%) | |
| 12 | 113 | 17 (15.0%) | 96 | 14 (14.6%) | 95 | 11 (11.6%) | 304 | 42 (13.8%) | <0.0001 |
| 24 | 99 | 16 (16.2%) | 83 | 15 (18.1%) | 93 | 10 (10.8%) | 275 | 41 (14.9%) | <0.0001 |
| 36 | 97 | 14 (14.4%) | 83 | 12 (14.5%) | 82 | 4 (4.9%) | 262 | 30 (11.5%) | <0.0001 |
NTR = Native Tissue Repair; SC = Sacrocolpopexy; TVM = Transvaginal Mesh; BIPOP = Body Image Pelvic Organ Prolapse.
Ninety-nine (30%) women reported being sexually active at all visits; 131(39%) reported they were not sexually active at all visits; 56 (17%) were non-sexually active and became sexually active at least once post-surgery; and the remainder changed sexual activity status throughout the study. (Supplemental Table 7) Among sexually active women, sexual function (PISQ-IR total score) improved after surgery in all groups (Figure 2); however, mean change in sexual function did not differ by arm. (Table 5) PISQ-IR models repeated for Mesh vs. No Mesh and Vaginal vs. Abdominal comparisons produced similar findings (Supplemental Tables 8–9).
Figure 2:
PISQ-IR Average Score Change from Baseline Over Time, Adjusted Means
Table 5:
PISQ-IR Average Score Estimated Baseline or Change from Baseline, Adjusted Means, 3 arms
| Mean (SD) or Adjusted Mean Change from Baseline (95% CI) |
Mean Difference (95% CI), P-value |
||||||||
|---|---|---|---|---|---|---|---|---|---|
| Month | N | NTR | N | SC | N | TVM | NTR vs. SC | NTR vs. TVM | SC vs. TVM |
| 0.0 | 48 | 3.2 (0.7) | 41 | 3.3 (0.7) | 43 | 3.1 (0.6) | 0.3068 | 0.6810 | 0.1439 |
| 6.0 | 42 | 0.4 (0.2, 0.5) | 37 | 0.4 (0.2, 0.6) | 39 | 0.5 (0.3, 0.6) | 0.0 (−0.2, 0.2) 0.8143 |
−0.1 (−0.3, 0.1) 0.2240 |
−0.1 (−0.3, 0.1) 0.3407 |
| 12.0 | 40 | 0.4 (0.3, 0.5) | 35 | 0.4 (0.3, 0.6) | 38 | 0.6 (0.4, 0.7) | 0.0 (−0.2, 0.2) 0.8092 |
−0.2 (−0.4, 0.0) 0.1141 |
−0.1 (−0.3, 0.1) 0.1978 |
| 24.0 | 35 | 0.4 (0.2, 0.5) | 31 | 0.5 (0.3, 0.6) | 37 | 0.5 (0.4, 0.7) | −0.1 (−0.3, 0.1) 0.3277 |
−0.2 (−0.4, 0.0) 0.1023 |
−0.1 (−0.3, 0.2) 0.5560 |
| 36.0 | 32 | 0.4 (0.2, 0.5) | 29 | 0.5 (0.3, 0.7) | 31 | 0.5 (0.4, 0.7) | −0.1 (−0.4, 0.1) 0.2286 |
−0.2 (−0.4, 0.1) 0.1320 |
0.0 (−0.3, 0.2) 0.7929 |
NTR = Native Tissue Repair; SC = Sacrocolpopexy; TVM = Transvaginal Mesh; SD = standard deviation; PISQ-IR = Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised.
Note: Baseline P-values are from a t-test.
In sexually active women, improved body image (BIPOP reversed scores) and improved sexual function (PISQ-IR scores) were positively correlated at each visit (Figure 3) and improved body image (BIPOP reversed) had a significant modeled effect on change in PISQ-IR score (p<0.0001). Thirty-seven percent (108/295) of women in this analysis met predetermined criteria for surgical failure by 36 months (similar rates were observed in the parent study: 36%, 130/360). Surgical failure was statistically associated with poorer body image (increased BIPOP scores) at 36M (Supplemental Table 10, p=0.0015, effect estimate and 95% CI = 0.4117 (0.1595, 0.6639)).
Figure 3:
Correlation of changes from baseline in body image and sexual function at 6-, 12-, 24-, and 36-months post-surgery
DISCUSSION
Principal findings
The current study affirms that both body image and sexual function improve after surgical repair of post-hysterectomy vaginal vault prolapse. Improvements in body image and sexual function were not different across the 3-arms, nor the Mesh/Comparator or Vaginal/Comparator dichotomies. Furthermore, we found that improvement in body image was correlated with improvement in sexual function. The data presented help inform our understanding of the nuance and complexity of female sexual function and suggests that prolapse and body image play an important role.
Results in the context of what is known
The current study found that BIPOP and sexual function scores in all arms improved by 6-months post-procedure, and these improvements were sustained at 3 years postoperatively, with no differences between groups. Similar to results of prior studies, successful treatment was associated with improved body image. However, the current results add to the growing body of literature supporting that prolapse treatment with surgery is also consistently correlated with improved sexual function. (15–17) This is in contrast to the conflicting data regarding sexual function amongst patients with prolapse who are treated with a pessary. (15, 16, 18, 19) While treatment with a pessary has been shown to provide symptomatic relief and improved body image on the BIS scale, sexual function outcomes are not as consistently improved.
The current study also found that improved body image and improved sexual function were positively correlated, while surgical failure was associated with poorer body image. This is consistent with prior studies that have correlated worse sexual function to lower body image perception and more bothersome prolapse. (20) However, prior studies have not found sexual function to be independently associated with prolapse stage or compartment. (20,21).
Clinical implications
Amongst patients seeking treatment for post-hysterectomy vaginal vault prolapse, those who are looking to improve body image and sexual function have multiple surgical options to choose from. There were no differences in outcomes between the groups in this surgical trial, nor differences in the time to reach improvement nor the extent of improvement achieved. The addition of mesh-augmentation to prolapse repairs plausibly has the potential to impact body image, sexual function, and prolapse outcomes. A prior masked study, supports that body image and sexual function both improve after vaginal reconstructive surgery, and this is not impacted by use of mesh in a masked setting. (7) However, the current study contributes data from a non-masked setting that shows body image and sexual function are not adversely impacted by mesh-augmented repair. This is consistent with prior studies that have noted mesh-augmentation has not been associated with adverse sexual function outcomes. (22,23) In masked and unmasked settings, prolapse symptoms more so than stage appear to be associated with worse sexual function, and surgical treatment, regardless of route or mesh-augmentation, appears to be associated with improved sexual function (7, 22–26).
Research implications
The current study adds valuable information regarding body image and sexual function outcomes amongst patients with post-hysterectomy vaginal vault prolapse, including that surgical approach and mesh-augmentation do not appear to impact results. This data helps to resolve some of the controversy related to mesh-augmentation and sexual function in prolapse repair. However, this study raises important unanswered questions as well. While the failure rate was higher in the transvaginal group in the primary analyses and we found that surgical failure was associated with poorer body image, we did not find overall significant differences between postoperative body image in the transvaginal group compared to the other groups. This suggests that there are other factors that need to be elucidated beyond our current categorization of surgical failure that impact postoperative body image. There is still inadequate data regarding the impact of hysterectomy versus uterine preservation and body image and sexual function outcomes in patients with apical prolapse. The impact of mesh and/or suture exposure on body image and sexual function is still incompletely understood. Furthermore, the BIPOP is a newer scale than the modified Body Image Scale that has been used in many prior studies, and the differences in their performances are insufficiently described. (27) Both of these scales have been validated to assess body image amongst patients with pelvic organ prolapse. However, the BIPOP scale used in this study has undergone a more rigorous characterization of its validity properties, and not only assesses body image, but also elements of life-impact. (27)
Strengths and limitations
This study has many strengths, including its multi-center randomized design, standardized procedures, rigorous outcome measures, methodologically robust analysis consistent with the SUPeR study (i.e. mean score, MID shift, and dichotomized item response), and relatively large sample size with little loss to follow-up. (28) Furthermore, this study adds to sparse data regarding body image and sexual function after prolapse repair, and suggests that mesh-augmented reconstruction is not associated with adverse body image or sexual function outcomes. However, this study has weaknesses as well. Despite the multicenter design, the trial participants are not representative of the United States population, and cultural influences on associations between prolapse, body image, sexual function and vaginal mesh may not be adequately captured. Additionally, oscillating sexually active status and sexual function forced us to limit analyses to those sexually active at baseline. We also did not capture data on reasons for sexual inactivity at anytime point. Furthermore, very few patients had mesh and/or suture exposure, so we had insufficient data for subgroup analysis of these events, body image, and sexual function. Finally, while the BIPOP has undergone more rigorous validation than other instruments for assessing body image, it has not previously undergone validation for responsiveness to change and in this study, we used a distribution-based method for determining responsiveness which is less ideal than use of anchor-based approaches. (29)
Conclusions
Body image and sexual function improve following repair of vaginal vault prolapse, regardless of the surgical approach. Improvements in body image and sexual function are positively correlated among sexually active women.
Supplementary Material
Supplemental Table 1: Body Image Pelvic Organ Prolapse (BIPOP) Score Estimated Baseline or Change from Baseline, Adjusted Means, Mesh vs. Comparison
Supplemental Table 2: Body Image Pelvic Organ Prolapse (BIPOP) Score Estimated Baseline or Change from Baseline, Adjusted Means, Vaginal vs. Comparison
Supplemental Table 3: Body Image Pelvic Organ Prolapse (BIPOP) Score Change of at least 0.6 points decrease (improvement) from Baseline, Adjusted Proportions of Participants, Mesh vs. Comparison
Supplemental Table 4: Body Image Pelvic Organ Prolapse (BIPOP) Score Change of at least 0.6 points decrease (improvement) from Baseline, Adjusted Proportions of Participants, Vaginal vs. Comparison
Supplemental Table 5: Body Image Pelvic Organ Prolapse (BIPOP) Item Response Indication of Poor Body Image at Baseline, 12-, 24-, and 36-Months, Mesh vs. Comparison
Supplemental Table 6: Body Image Pelvic Organ Prolapse (BIPOP) Item Response Indication of Poor Body Image at Baseline, 12-, 24-, and 36-Months, Vaginal vs. Comparison
Supplemental Table 7: Summary of Sexually Active Status by Treatment, 3 arms
Supplemental Table 8: PISQ-IR Average Score Estimated Baseline or Change from Baseline, Adjusted Means, Mesh vs. Comparison)
Supplemental Table 9: PISQ-IR Average Score Estimated Baseline or Change from Baseline, Adjusted Means, Vaginal vs. Comparison)
Supplemental Table 10 Model to predict decreased body image based on surgical failure.
AJOG at a Glance:
- Why was this study conducted?
- To describe changes in body image after surgical repair of vaginal vault prolapse and to evaluate whether changes in sexual function are correlated with changes in body image.
- What are the key findings?
- Body image improved following vaginal vault prolapse repair regardless of the surgical approach and improvement in body image and sexual function were positively correlated.
- What does this study add to what is already known?
- Body image improves and is correlated with improved sexual function regardless of route of surgery (abdominal versus vaginal) or mesh augmentation following vaginal vault prolapse repair.
ACKNOWLEDGEMENTS
Alpert Medical School of Brown University, Providence, RI
Cassandra Carberry, Star Hampton, Jazmeen Hernandez, Nicole Korbly, Leah McKay, Ann Meers, Deborah Myers, Aileen Rajaei, Charles Rardin, Vivian Sung, Sarashwathy Veera, Kyle Wohlrab
Cleveland Clinic
Cecile Ferrando, Annette Graham
Duke University Medical Center, Durham, NC
Cindy Amundsen, Matthew Barber (formerly Cleveland Clinic), Paige Green, Amie Kawasaki, Michele O’Shea, Stephanie Yu
Kaiser Permanente - San Diego
Keisha Dyer, Kimberly Ferrante, Linda Mackinnon, Gisselle Zazueta-Damian
RTI International
Lindsey Barden, Katrina Burson, Marie Gantz, Kimberly McMillian, Amaanti Sridhar, Sonia Thomas, Dennis Wallace
University of Alabama at Birmingham, Alabama
Kathy Carter, David Ellington, Ryanne Johnson, Isuzu Meyer, Sunita Patel, Holly Richter
UC San Diego Health, San Diego, CA
Marianna Alperin, Laura Aughinbaugh, Lindsey Burnett, Gouri Diwadkar, Charles Nager
University of New Mexico, Albuquerque
Gena Dunivan, Yuko Komesu, Peter Jeppson, Rebecca Rogers, Kate Meriwether
University of Pennsylvania
Heidi Harvie, Lily Arya, Yelizaveta Borodyanskaya, Zandra Kennedy
Magee-Women’s Hospital, Pittsburgh, PA
Megan Bradley Judy Gruss, Pam Moalli, Halina Zyczynski
University of Texas Southwestern, Dallas, TX
Juanita Bonilla, Agnes Burris, Christina Hegan, Rachael Medrano, David D Rahn, Joseph Schaffer
Source of Funding:
The study was supported with the following grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and National Institutes of Health Office of Research on Women’s Health:
University of Alabama Birmingham (UG1 HD041261)
Brown University/Womens & Infants Hospital (UG1 HD069013)
University of California at San Diego (UG1 HD054214)
Duke University (UG1 HD041267)
University of Texas Southwestern (UG1 HD054241)
University of Pennsylvania (UG1 HD069010)
University of Pittsburgh/Magee Womens Hospital (UG1 HD069006)
University of New Mexico (FP1810/3RG40)
RTI International (U24 HD069031)
Cleveland Clinic (RTII 1606MB)
Footnotes
Disclosures: None
Clinical Trial Information: Identification Number NCT04201821
Presentation Information: This research was presented at the annual American Urogynecology Society Pelvic Floor Disorders’ Week October 22–25, 2024. Washington, DC.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Table 1: Body Image Pelvic Organ Prolapse (BIPOP) Score Estimated Baseline or Change from Baseline, Adjusted Means, Mesh vs. Comparison
Supplemental Table 2: Body Image Pelvic Organ Prolapse (BIPOP) Score Estimated Baseline or Change from Baseline, Adjusted Means, Vaginal vs. Comparison
Supplemental Table 3: Body Image Pelvic Organ Prolapse (BIPOP) Score Change of at least 0.6 points decrease (improvement) from Baseline, Adjusted Proportions of Participants, Mesh vs. Comparison
Supplemental Table 4: Body Image Pelvic Organ Prolapse (BIPOP) Score Change of at least 0.6 points decrease (improvement) from Baseline, Adjusted Proportions of Participants, Vaginal vs. Comparison
Supplemental Table 5: Body Image Pelvic Organ Prolapse (BIPOP) Item Response Indication of Poor Body Image at Baseline, 12-, 24-, and 36-Months, Mesh vs. Comparison
Supplemental Table 6: Body Image Pelvic Organ Prolapse (BIPOP) Item Response Indication of Poor Body Image at Baseline, 12-, 24-, and 36-Months, Vaginal vs. Comparison
Supplemental Table 7: Summary of Sexually Active Status by Treatment, 3 arms
Supplemental Table 8: PISQ-IR Average Score Estimated Baseline or Change from Baseline, Adjusted Means, Mesh vs. Comparison)
Supplemental Table 9: PISQ-IR Average Score Estimated Baseline or Change from Baseline, Adjusted Means, Vaginal vs. Comparison)
Supplemental Table 10 Model to predict decreased body image based on surgical failure.