IMPACT: A Standardized Tool for Assessment of Pelvic Floor Disorders

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In the management of pelvic floor disorders, most outcomes cannot be quantified by objective tests or imaging, so health care providers rely heavily on patient-reported symptoms. To date, however, no standardized instrument has been used universally across subspecialties and even within same subspecialty to capture how patients view the severity of their condition and to allow sharing of data, pulling of data and having the same initial baselines to compare outcomes. This deficit hinders scientific research as well as communication between clinicians about specific patients.

To address this problem, experts from 12 countries recently participated in the Pelvic Floor Disorders Consortium Consensus Meeting on Patient-Reported Outcomes. They agreed on an initial patient assessment measure that's designed to be useful regardless of which type of specialist (colorectal surgeon, urogynecologist, urologist, gastroenterologist or physical therapist) a patient consults first.

Liliana G. Bordeianou, MD, MPH, FACS, FASCRS, chief of the Colorectal Surgery Center at Massachusetts General Hospital, co-chair of the Partners HealthCare Colorectal Surgery Collaborative, co-chair of the Mass General Pelvic Floor Disorders Center and associate professor of Surgery at Harvard Medical School, and Tracy Hull, MD, professor of Colorectal Surgery at the Cleveland Clinic Hospitals and president of the American Society of the Colon and Rectal Surgeons, report on the meeting together with colleagues from each of the other subspecialty on this effort in three journals simultaneously: Diseases of the Colon and Rectum, Female Pelvic Medicine and Reconstruction Surgery and Techniques of Coloproctology.

The IMPACT Short Form

The battery of recommended questionnaires is named IMPACT (Initial Measurement of Patient-reported pelvic floor Complaints Tool). The consensus panel created two versions, one long form (85 to 94 questions) and one short form (45 questions for women, 34 for men); clinicians can decide which version they prefer to use for both research and clinical practice. The report details which instruments were considered for inclusion in IMPACT and why particular instruments were selected.

The questionnaires suggested for use in both the long and short IMPACT forms are the same, but the IMPACT short form ensures that questions that may overlap between questionnaires are only asked once, while allowing complete ultimate scoring of each of the included questionnaires for ultimate standardized reporting:

• To assess fecal incontinence severity: Both the Cleveland Clinic Florida Incontinence Score and the St. Mark's Incontinence Score
• To assess urinary incontinence severity: The Urogenital Distress Inventory, short form
• To assess lower urinary tract symptoms in women: The International Consultation on Incontinence Questionnaire–Female Lower Urinary Tract Symptoms, short form
• To assess lower urinary tract symptoms in men: The International Prostate Symptoms Screening
• To assess sexual function in women: The Female Sexual Function Index, short version
• To assess sexual function in men: Eight questions from the International Index of Erectile Function (IIEF) questionnaire: questions 1, 2, 3, 4 and 5 about erectile dysfunction, questions 9 and 10 about orgasmic/ejaculatory function and question 15 about quality of life
• To assess constipation: Both the Patient Assessment of Constipation Symptoms (PAC-SYM) and the Constipation Severity Instrument (CSI)
• To assess pelvic organ prolapse: Pelvic Organ Prolapse Distress Inventory (POPDI)
• To assess additional common associated anorectal complaints: Bristol Stool Scale (BSS) and Colorectal Anal Distress Inventory (CRADI)

The IMPACT Long Form

The IMPACT long form comprises the same instruments in their initial formats, with some repetition and redundancy, for those clinicians who prefer to use the questionnaires in their original versions.

Acceptance by Professional Societies

The consensus meeting was supported by the American Society of Colon and Rectal Surgeons and the American Urogynecologic Society, each of them endorsing the document. The report was also reviewed, endorsed and approved for publication by the International Continence Society and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. The report was also endorsed for female patients by the Society of Gynecological Surgeons.

Future Directions

Following this collaborative effort, experts from these societies held further consensus panels to discuss standardization of imaging for pelvic floor disorders. Efforts are also underway to convene a discussion on how to approach patients with various forms of pelvic organ prolapse. These efforts include multiple subspecialists and are led by several Mass General surgeons from the Pelvic Floor Disorders Center, including: Milena M. Weinstein, MD, and May M. Wakamatsu, MD, from the Department of Obstetrics and Gynecology, Elise De, MD, and Ajay Singla, MD, from the Department of Urology; David A. Rosman, MD, MBA, from the Department of Radiology, and Kyle D. Staller, MD, MPH, from the Division of Gastroenterology.

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