In order to clarify the outcome, the patients were divided into groups: the 118 respondents at 48 hours are referred to as Group 1, and the 110 at 7 days and the 46 at 3 months are referred to as Groups 2 and 3, respectively.
Frequency of discomfort in Groups 1 (48 hours), 2 (7 days) and 3 (3 months)
The respective frequencies of discomfort in all three groups are presented in Table . While there were major variations in the types of discomfort over time, the most common type described was pain at all three time-points. Discomfort from the surgical wound was reported both at 48 hours and at seven days but the frequency decreased quite sharply over time. Bleeding or residual blood in the wound was reported at all three time-points, with a slight increase at seven days. Pneumonia was also mentioned at 48 hours. Patients who experienced discomfort at three months had also done so earlier in the recovery period, as a rule.
Frequency of discomfort type at 48 hours, 7 days and 3 months, respectively, following day surgery.
Discomfort over time in Group 3 (3 months)
When the 46 patients with persisting discomfort after 3 months were compared with the 252 not reporting any persisting discomfort, the former were significantly older than the latter (mean 58 vs 53 years, p = 0.0175, t-test) but there was no significant difference in gender (p = 0.1282, Fisher's exact test). The majority (n = 34) of those with persisting discomfort had undergone their procedures at a general surgery clinic while six were orthopedic surgery patients and six were urology patients. The groups with and without persisting discomfort did not differ in terms of surgical specialty (p = 0.7756, Chi square test with two degrees of freedom).
The experiences and perceived causes of persisting discomfort following day surgery varied in Group 3 see Table . A majority in this group had experienced discomfort at 48 hours (n = 31) and at seven days (n = 37) after surgery as well. The categories that emerged in Group 3 are presented in Table . The subcategories indicate variability in patients' understanding of what caused their persisting discomfort.
Categories emerging over time for the 46 patients who experienced persisting discomforts three months after day surgery.
Table presents the types of discomfort and certain factors leading to discomfort, according to the patients' perceptions. Varying types of discomfort were reported over time: each time-point in Group 3 will thus be illustrated with quotes below. Categories and subcategories are written in bold italics.
Types of discomfort in group 1 (48 hours)
Discomfort was described as a sign indicating a complication, e.g. bleeding: Bleeding after the first surgery which necessitated two further surgical procedures. It was also reported from the urethra and anus after surgery in those areas in other cases. Side effects such as dizziness and headache were described at this time-point: I got a packet of pain medication to take home... I was supposed to take two Citodon (paracetamol-codeine) every 6th hour... I took it three times but I felt terrible......nausea, dizziness and headache. Nausea was explained as due to the surgery itself or, for example, anxiety: After the surgery I felt nauseous...nausea because of the tension and anxiety.
Pain was connected to the surgical wound that was sore and swollen in some cases, and impacted on daily function such as the ability to sleep. I couldn't sleep the first night because of the pain, but the second night I did manage to sleep a couple of hours at a time. Patients also experienced tiredness and described exhaustion interfering with daily function: have also been very tired, have no energy whatsoever. Get dizzy easily. Patients also described thoughts and feelings such as sadness: ...have been sad and depressed since the surgery. I don't know why. Some experienced postoperative stiffness in various locations, such as the wound or the body part in which the surgery was performed: A little stiff and sore after surgery in my groin and thigh. Spasms in the anal sphincter was another type of discomfort, one patient who had his hemorrhoids removed described this as: Spasms for about ten minutes after voiding and then I felt OK...Swelling was described as a consequence of the healing process or of bleeding in the surgery area: The day after surgery, I was really swollen... turned out to be a major hemorrhage. Patients described tiredness as being caused by the fact that they could not always sleep in their accustomed position or because of tension due to pain. Wound problems at 48 hours tended to be regarded as a natural process, apparently deriving from the understanding that time heals wounds: discomfort was interpreted as being due to the fact that the healing process was still ongoing: I guess the pain is natural and that it will get better when the wound is healed.
Types of discomfort in group 2 (7 days)
Some patients expressed anxiety at having been too active: It might be because you get so much pain medication...since you don't feel so much you might move around too much. Varying types of discomfort, such as blood accumulation in the surgical wound and big bruises on the leg after radical inguinal hernia, occurred at seven days: Since the wound bled after the surgery and it kept on bleeding that night, I think blood might have accumulated inside it, because I've got burning and smarting pain and my belly and down toward my groin are numb.. Patients also described pain in different situations. It hurts when I stand still and after having sat with my legs up, and it hurts when I start to walk again. Pain types reported were soreness, smarting and burning pain: It's sore after surgery.... burning and smarting pain. Like at 48 hours, discomfort in the sphincter was described as: spasms for about ten minutes after voiding. Swelling in the surgical scar was also mentioned: bleeding inside the wound was a perceived cause. Wound problems, such as swelling, were experienced as worse when the individual was moving. Inflammation of the wound also occurred. At seven days patients also stated that the healing process was ongoing: The healing process isn't finished and ...tender and swollen wound. It hasn't healed. At both 48 hours and seven days following surgery, swelling and tenderness were considered to be normal reactions after surgery.
Types of discomfort in group 3 (3 months)
Bleeding was considered to be due to old accumulated blood: ...it began to bleed profusely from a surgical incision. Was old blood that remained... or to be surface bleeding after hemorrhoidectomy when blood was seen on toilet paper. Nausea was explained as caused by special kinds of drink or food, connected with abdominal pain, or else the cause was unclear: That nausea sometimes comes in the evenings, not really sure why but it's probably nothing to worry about. In addition to the surgery and to being in motion, patients also connected pain with the surgical wound, urinating or defecating: The wound does not heal. I have still pain and bleeding. Types of pain experienced were pressure and soreness. Patients also experienced discomfort from the urinary tract. For example, some described a frequent need to urinate when sitting in certain positions, which disturbed their activities. ... that I have frequent urges to pee and have to pee often and when I lean back, for example in a sofa, I get the urge and it's really difficult because the more often I go the worse it gets. Itching and blood on toilet paper were described by patients as being due to hemorroidectomy: ...itching and cracking after a bowel movement. The experiences of discomfort proved to differ to a great extent. After hand surgery one patient had still had numbness in the thumb: The pain is gone but I have not got back all the feeling in my thumb yet. A cosmetically unappealing scar was experienced as discomfort by another. Patients also described abnormalities indicating disease. One had problems with urinary incontinence that had been cured but returned and another thought that the signs were likely due to inflammation after varicose vein surgery: It's probably an inflammation - it comes from the groin where they pulled the blood vessel out. The swelling and stiffness started about 4 1/2 weeks after the surgery.
Patients with remaining wound problems at three months referred to the long time it was taking for the wound to heal and did not always perceive a reason for it: The wound isn't healing......it still hurts and is bleeding......cause??? There were also descriptions of swollen, red and pus-filled wounds.
Factors leading to discomfort in Group 3 (3 months)
In the following, the patients' perceived causes of persisting discomfort will be presented. The descriptions seem to be linear, but they contain an intermingling of different symptoms and perceived causes. At seven days and three months insufficient access to health care and information were experienced and perceived as factors leading to discomfort. This discomfort was described as physiological as well as in psychological/psychosocial terms.
The patients believed that something had gone wrong with the surgery, i.e. incorrect or suboptimal treatment. Some also believed that it was the very nature of the surgery, i.e. the type of surgery, they had undergone, that caused the discomfort. Furthermore, some patients expressed frustration with encounters with health care professionals, the results of the surgery, or insufficient access to care or information, and some expressed a need for treatment e.g. wound treatment.
Type of surgery was a perceived cause of discomfort at all three time-points I will never have haemorrhoid surgery again. It was dreadful. At the first two time-points, some had reported, briefly, that they believed that something was amiss, i.e. incorrect or suboptimal treatment: Something went wrong or else I wasn't reacting normally after surgery. At three months they elaborated, expressing the conviction that carelessness or lack of skill on the part of the surgeon had caused their discomfort: I think my surgery went wrong. The doctor who operated on the patient in the next bed said, ' Stand up so I can make sure I've got the right one.', but my doctor only read his piece of paper and that's why it turned out like it did. Some patients also regarded repeat surgery as a cause of discomfort. Some underwent repeat surgery on account of discovered pathology for example, a renal calculus was found when an x-ray was done during the first operation or not enough tissue being removed the first time. Patients who considered incorrect or suboptimal treatment to be the cause of persisting discomfort expressed feelings of anger, disappointment and sadness. Strong feelings of anger at the surgeon emerged because of his/her bedside manner or because the results were unsatisfactory: Everything sucks, I'm being treated like shit ... my leg looks terrible now, even worse than before. In the subcategory incorrect or suboptimal treatment there were also aspects associated with feeling of distrust in the providers and, indirectly, in the structure of the organization: Poor advice and help. Then received a notice to attend which I thought was a return visit. It was a referral which I would have had to come along for before the operation. I just had to get on with it and go home. On top of that was the 3-month waiting period. Maybe you should review these procedures.
Patients reported insufficient access, both to contact with health care professionals and to information, at 48 hours and seven days: I contacted the nurse at the surgery department and she said she would talk to the physician who operated on me. He's off duty this week so they'll let me know later on when my follow-up appointment will be scheduled.
Patients experienced that complications occurred while they were waiting to get in touch with the health care system. For example, a wound ruptured, releasing pus and serum, the day after a patient had tried to come into contact with the surgeon for advice. Patients also reported unsatisfactory information when they had problems related to the surgery and encounters with healthcare professionals were inadequate: I was disappointed when I called the day surgery ward after just over a week; the nurse said everything was normal even though I told her about the swelling in my groin, belly and private parts. The whole area is pulsating. I suspect an infection. The nurse said that it is normal even though it aches really badly, I called the nurse - she thought it looked all right and agreed to ask the doctor to call me up, I called the emergency room according to the instructions I was given. They weren't willing to help me at all. This period was VERY tough. Bad information and help.
Several of the patients with persisting discomfort expressed a need for health care but they were left to rely on their own advice and care: They weren't willing to help me at all. On my own initiative, I started using aluminum acetotartrate dressings which I changed often. I've started to treat it with anti-inflammatory gel and I think it's better already. However, some actually were treated, at the primary care center, at the hospital's surgery clinic, at the emergency room or by admission to hospital for a few days. Others were waiting to be examined or had been given prescriptions for medication.
Impact on daily function in groups 1 (48 hours), 2 (7 days) and 3 (3 months)
All groups reported the discomfort's impact on daily living at all three time-points, e.g. being unable to live normally, problems walking, feeling inhibited at the idea of having sex, restricted mobility or impact on sleep: I can't walk as much as I want to. Tiredness in the leg when walking, standing or exercising was another example of impact on normal function: My leg gets really tired and the varicose vein pulsates when I exert myself and work out.