Pelvic Floor Muscle Training for Mild Pelvic Organ Prolapse
Pelvic Floor Muscle Training for Mild Pelvic Organ Prolapse
Objective. To compare the effects of pelvic floor muscle training and watchful waiting on pelvic floor symptoms in a primary care population of women aged 55 years and over with symptomatic mild pelvic organ prolapse.
Design. Randomised controlled trial.
Setting. Dutch primary care.
Participants. Women aged 55 years or over with symptomatic mild prolapse (leading edge above the hymen) were identified by screening. Exclusion criteria were current prolapse treatment or treatment in the previous year, malignancy of pelvic organs, current treatment for another gynaecological disorder, severe/terminal illness, impaired mobility, cognitive impairment, and insufficient command of the Dutch language.
Interventions. Pelvic floor muscle training versus watchful waiting.
Main Outcome Measures. The primary outcome was change in bladder, bowel, and pelvic floor symptoms measured with the Pelvic Floor Distress Inventory-20 (PFDI-20), three months after the start of treatment. Secondary outcomes were changes in condition specific and general quality of life, sexual function, degree of prolapse, pelvic floor muscle function, and patients' perceived change in symptoms.
Results. Of the 287 women who were randomised to pelvic floor muscle training (n=145) or watchful waiting (n=142), 250 (87%) completed follow-up. Participants in the intervention group improved by (on average) 9.1 (95% confidence interval 2.8 to 15.4) points more on the PFDI-20 than did participants in the watchful waiting group (P=0.005). Of women in the pelvic floor muscle training group, 57% (82/145) reported an improvement in overall symptoms from the start of the study compared with 13% (18/142) in the watchful waiting group (P<0.001). Other secondary outcomes showed no significant difference between the groups.
Conclusions. Although pelvic floor muscle training led to a significantly greater improvement in PFDI-20 score, the difference between the groups was below the presumed level of clinical relevance (15 points). Nevertheless, 57% of the participants in the intervention group reported an improvement of overall symptoms. More studies are needed to identify factors related to success of pelvic floor muscle training and to investigate long term effects.
Trial Registration. Dutch Trial Register (www.trialregister.nl) identifier: NTR2047.
Pelvic organ prolapse is a common condition characterised by descent of the anterior or posterior vaginal wall, the uterus, or the vaginal vault (after hysterectomy). In a Dutch community survey, 75% of women aged 45-85 years had some degree of prolapse. The prevalence of typical symptoms of prolapse (seeing or feeling a vaginal bulge) is reported to be about 3-12%. Typical prolapse symptoms are thought to emerge when the leading edge of the prolapse is at or below the hymen. Women with milder forms of prolapse more often experience other common prolapse related symptoms such as pelvic pressure/heaviness or pelvic pain and urinary or bowel symptoms. Treatment options include conservative management (pelvic floor muscle training or pessary treatment) and surgical correction. However, surgery is associated with several problems. Comorbidity and frailty can make surgery undesirable, and risks of complications and recurrence are considerable. Finally, costs for prolapse related surgery are high and are expected to substantially increase owing to the ageing population and the higher prevalence of prolapse in older women.
As women with mild prolapse often experience mild symptoms, surgery is generally not an option. However, evidence suggests that women with symptomatic mild prolapse might benefit from pelvic floor muscle training. There are two main hypotheses on how pelvic floor muscle training may be effective in the treatment of prolapse: descent of the pelvic floor is prevented by teaching women to consciously contract their pelvic floor muscles before and during any increase in abdominal pressure; and structural support of the pelvic floor is improved by the performance of pelvic floor muscle exercises, and, as a result, the pelvic organs are held in place better. Beneficial effects of pelvic floor muscle training in symptomatic stage 1 and/or 2 prolapse were shown in three small studies, of which two were pilot studies and the other was of moderate methodological quality. Other studies investigating the effect of pelvic floor muscle training on prolapse also included women without symptoms, women with more severe stage prolapse (at or below the hymen), or both.
Pelvic floor muscle training could typically be applied in primary care. However, high quality studies on the effectiveness of pelvic floor muscle training in women with symptomatic (mild) prolapse in this setting are lacking. The aim of this study was to compare the effects of pelvic floor muscle training and watchful waiting on pelvic floor symptoms in a primary care population of women aged 55 years or over with symptomatic mild prolapse.
Abstract and Introduction
Abstract
Objective. To compare the effects of pelvic floor muscle training and watchful waiting on pelvic floor symptoms in a primary care population of women aged 55 years and over with symptomatic mild pelvic organ prolapse.
Design. Randomised controlled trial.
Setting. Dutch primary care.
Participants. Women aged 55 years or over with symptomatic mild prolapse (leading edge above the hymen) were identified by screening. Exclusion criteria were current prolapse treatment or treatment in the previous year, malignancy of pelvic organs, current treatment for another gynaecological disorder, severe/terminal illness, impaired mobility, cognitive impairment, and insufficient command of the Dutch language.
Interventions. Pelvic floor muscle training versus watchful waiting.
Main Outcome Measures. The primary outcome was change in bladder, bowel, and pelvic floor symptoms measured with the Pelvic Floor Distress Inventory-20 (PFDI-20), three months after the start of treatment. Secondary outcomes were changes in condition specific and general quality of life, sexual function, degree of prolapse, pelvic floor muscle function, and patients' perceived change in symptoms.
Results. Of the 287 women who were randomised to pelvic floor muscle training (n=145) or watchful waiting (n=142), 250 (87%) completed follow-up. Participants in the intervention group improved by (on average) 9.1 (95% confidence interval 2.8 to 15.4) points more on the PFDI-20 than did participants in the watchful waiting group (P=0.005). Of women in the pelvic floor muscle training group, 57% (82/145) reported an improvement in overall symptoms from the start of the study compared with 13% (18/142) in the watchful waiting group (P<0.001). Other secondary outcomes showed no significant difference between the groups.
Conclusions. Although pelvic floor muscle training led to a significantly greater improvement in PFDI-20 score, the difference between the groups was below the presumed level of clinical relevance (15 points). Nevertheless, 57% of the participants in the intervention group reported an improvement of overall symptoms. More studies are needed to identify factors related to success of pelvic floor muscle training and to investigate long term effects.
Trial Registration. Dutch Trial Register (www.trialregister.nl) identifier: NTR2047.
Introduction
Pelvic organ prolapse is a common condition characterised by descent of the anterior or posterior vaginal wall, the uterus, or the vaginal vault (after hysterectomy). In a Dutch community survey, 75% of women aged 45-85 years had some degree of prolapse. The prevalence of typical symptoms of prolapse (seeing or feeling a vaginal bulge) is reported to be about 3-12%. Typical prolapse symptoms are thought to emerge when the leading edge of the prolapse is at or below the hymen. Women with milder forms of prolapse more often experience other common prolapse related symptoms such as pelvic pressure/heaviness or pelvic pain and urinary or bowel symptoms. Treatment options include conservative management (pelvic floor muscle training or pessary treatment) and surgical correction. However, surgery is associated with several problems. Comorbidity and frailty can make surgery undesirable, and risks of complications and recurrence are considerable. Finally, costs for prolapse related surgery are high and are expected to substantially increase owing to the ageing population and the higher prevalence of prolapse in older women.
As women with mild prolapse often experience mild symptoms, surgery is generally not an option. However, evidence suggests that women with symptomatic mild prolapse might benefit from pelvic floor muscle training. There are two main hypotheses on how pelvic floor muscle training may be effective in the treatment of prolapse: descent of the pelvic floor is prevented by teaching women to consciously contract their pelvic floor muscles before and during any increase in abdominal pressure; and structural support of the pelvic floor is improved by the performance of pelvic floor muscle exercises, and, as a result, the pelvic organs are held in place better. Beneficial effects of pelvic floor muscle training in symptomatic stage 1 and/or 2 prolapse were shown in three small studies, of which two were pilot studies and the other was of moderate methodological quality. Other studies investigating the effect of pelvic floor muscle training on prolapse also included women without symptoms, women with more severe stage prolapse (at or below the hymen), or both.
Pelvic floor muscle training could typically be applied in primary care. However, high quality studies on the effectiveness of pelvic floor muscle training in women with symptomatic (mild) prolapse in this setting are lacking. The aim of this study was to compare the effects of pelvic floor muscle training and watchful waiting on pelvic floor symptoms in a primary care population of women aged 55 years or over with symptomatic mild prolapse.
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