Pelvic floor muscle training may improve prolapse stage, muscle function and urinary symptoms compared to no training
- Correspondence to: Dr Cynthia M Sublett
School of Nursing, Xavier University, 3800 Victory Parkway, Cincinnati, OH 45207, USA;
Commentary on: Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2011;12.
Implications for practice and research
Less invasive but effective methods of prevention and treatment by nurses, nurse practitioners and physicians for pelvic organ prolapse (POP) are needed.
Subsequent longitudinal research is needed to support the contention that pelvic floor muscle training (PFMT) can be used as a prevention and treatment for POP.
Two decades ago, POP was estimated to be present in over 50% of parous women.1 Shalom et al2 found that parity had less to do with POP than previously thought, stating it is a multifactorial problem. The development of the POP-Q in 19963 has assisted in standardising the language of POP. Randomised controlled trials (RCTs) have been conducted to address both conservative treatment and prevention of POP as well as surgical intervention for POP.4 Conservative treatment has been found to be effective in some of those trials.5 Women could benefit from less invasive interventions such as PFMT, perhaps in combination with lifestyle treatments such as weight loss, to address POP.
Hagen and colleagues examined a total of six RCTs using 17 comparisons of conservative and non-conservative interventions for POP. All trials fit within two comparisons: PFMT and no treatment, and PFMT and surgery versus surgery alone. The primary outcomes identified were the presence of prolapse symptoms or failure to reduce symptoms of prolapse. Secondary outcomes included severity of prolapse symptoms, such as associated bowel and bladder symptoms, and other quality-of-life measures. Other outcomes included treatment adherence and adverse or other events as a response to conservative interventions. Studies involved women who were either at risk for or diagnosed with POP. With one exception, the trials had small sample sizes; however, risk of bias was assessed as low in four of the six trials.
Findings of the comparison of PFMT to no treatment indicated that PFMT reduced symptom frequency (74% vs 31%) (relative risk (RR) 0.37, 95% CI 0.21 to 0.65), reduced bother of symptoms (67% vs 42%) (RR 0.56, CI 0.33 to 0.97), reduced pelvic heaviness immediately after treatment (19% vs 70%) (RR 0.26, 95% CI 0.11 to 0.61) and improved prolapse symptom score up to the week 26 follow-up (mean difference −3.37, 95% CI −6.23 to −0.51). On follow-up, the women in the treatment group (37% to 76%) (RR 0.48, 95% CI 0.26 to 0.91) felt an improvement in their prolapse although no significant difference was found. Quality of life in the intervention group also improved (standardized mean difference −0.51, 95% CI −0.94 to −0.07). Secondary outcomes included improved prolapse (pooled RR 0.83, 95% CI 0.71 to 0.9), positive change in supporting muscle structure with PFMT (mean difference −1.12, 95% CI −1.58 to −0.66), and improved urinary and bowel symptoms although no pooling of results was reported. With PFMT and surgery versus surgery alone, the PFMT group tended to improve, without significant difference reported in the manometry scores. There was, however, a decrease in urine leakage measured by pad volume test.
With the inclusion of three new studies supporting pelvic floor muscle training (PFMT) as a treatment or adjunct to surgical treatment, this review is encouraging. Data were not pooled across all studies. It is notable that prolapse symptoms improved in three trials as a result of PFMT, along with an improvement in symptom frequency and presence. Data pooled from two studies used the pelvic organ prolapse (POP)-Q and indicated less prolapse potential by 17% compared to no PFMT. Two of three trials showed improved urinary and bowel symptom prevalence and bother.
Although not all of the trials in this review found strong evidence for the use of PFMT as a treatment for POP, there are indications that it does reduce symptoms, and perhaps the degree of prolapse. It is encouraging that conservative treatment with PFMT can be successful in reducing the symptomatology of POP, although practitioners must also consider the degree of prolapse when choosing treatment methods.