Pain Catastrophizing and Impact on Pelvic Floor Surgery Experience
Authors: Powell T. Clark , Meyer Isuzu , Redden David T. , Maier Julia , Nguyen Christine , Richter Holly E. 
Published: March 2024

Duration, intensity, and management of pain and discomfort may all be affected by experience, personality, and medical and psychosocial comorbidities. A negative cognitive-affective response to actual or anticipated pain, which impacts the pain experience, is called pain catastrophizing. The scale utilized for identifying individuals who magnify, feel helpless to manage, anticipate, or ruminate on pain is known as the Pain Catastrophizing Scale (PCS) and is composed of a 13-question validated measure and 3 subscales. The scale's score ranges from 0 to 52, where scores of 30 and greater indicate pain catastrophizing (30 points is the 75th percentile for PCS score distribution in patients with chronic pain). Pain catastrophizing is associated with increased pain severity, pain persistence, and opioid consumption following surgery, as well as poorer response to endometriosis treatments. Approximately 300,000 prolapse surgical procedures are performed in the United States annually, and because little is known about pain catastrophizing on perioperative pain, pelvic floor symptom distress/impact, and voiding trial (VT) performance following urogynecologic surgery, the authors' primary aim was to assess baseline pain catastrophizing on preoperative pelvic floor symptom impact and distress. The secondary aims included assessing the impact of pain catastrophizing on voiding function and postoperative pain following pelvic floor surgery.

The patients for this prospective cohort study included self-identifying female patients undergoing surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse from March 2020 to December 2021. Inclusion came following completion of appropriate surveys and subsequent surgery. Exclusion was merited through surgery for reasons besides SUI or prolapse. At the baseline patient visit, a PCS score of 30 or greater was defined as pain catastrophizing. The initial visit also included recording data such as body mass index, age, benzodiazepine use, chronic opioid use, anxiety and depression diagnoses, postoperative prolapse stage, bothersome urgency urinary incontinence, and preoperative postvoid residual volume. Charts were used for abstracting surgical data, such as operative time, estimated blood loss, type of pelvic reconstructive surgery performed, and midurethral sling placement. Surgeries were all performed by fellowship-trained reconstructive pelvic surgery providers. Postanesthesia care unit (PACU) nurses and clinic staff were masked to preoperative PCS scores obtained in the PACU and postoperative clinic visits. A standardized void trial was performed.

Of 320 participants in this cohort, 46 had a pain catastrophizing score of ≥30. Mean age was 60.0 ± 12.8 years. Bivariate analysis indicated that the pain catastrophizing group had higher average body mass index and greater preoperative use of benzodiazepines. Variants such as SUI rates, urgency urinary incontinence, or prolapse stage had no significant differences between groups, yet preoperative pelvic floor symptom distress and impact scores were clinically and statistically significantly higher in the catastrophizing group. Higher PACU pain scores were associated with pain catastrophizing, but not first postoperative VT failure. A significant association between pain catastrophizing and symptom distress remained following multivariable analysis, as well as a relationship between high PCS scores and symptom impact. All quality-of-life subscales maintained the significant associations.

This study, although unique in describing pain catastrophizing in this setting, includes various limitations such as its single-institutional nature, which may limit external generalizability. Furthermore, generalizability may also be limited for those electing nonsurgical management, as the study selected for women choosing surgery. Study strengths include its large number of patients cared for by fellowship-trained providers in a similar manner with uniform surgical practice and timing of measures for assessing pelvic pain and pelvic floor symptoms. Also, a relatively standard VT method was utilized.

Although further investigation is warranted for describing pain catastrophizing and its role with pelvic floor symptoms and pain postoperatively, the results of this study support other investigative findings, which indicate the importance of understanding pain catastrophizing and its potential effect on patients undergoing pelvic floor surgery. Future studies around this relationship can potentially enable health care providers to tailor perioperative care for individuals with pain catastrophizing.