Pelvic Organ Prolapse Training Better than Watchful Waiting

1 Pregnancy ranks as the primary, but not the only, risk factor. However, not all cases are symptomatic. For instance, using the Australian Pelvic Floor Questionnaire, three of ten Icelandic mothers report pelvic organ prolapse, with less than half of those finding it bothersome.2 The International Continence Society defines pelvic organ prolapse as a loss of support for the vaginal walls, the uterus, bladder, colon and rectum, resulting in partial or complete prolapse of the affected organs coming down or through the vagina.3

Women sometimes experience it as a bulging sensation. Experts universally recommend exercise therapy for pelvic organ prolapse from stage 1 to stage 3.4 That includes stage 1, which is the most distal part of the prolapse more than 1 cm above the level of the hymen, to stage 3, which is the most distal portion of the prolapse more than 1 cm beyond the plane of the hymen but everted at least 2 cm less than the total vaginal length.5 Nevertheless, healthcare lacks a good number of randomised controlled trials defining the most effective therapeutic exercise, supervision and dose recommendations, timing recommendations, etc.

In December, JBI Evidence Implementation (a peer-review publication of the Joanna Briggs Institute) published the latest systematic review regarding therapeutic exercise for pelvic organ prolapse.5 The current review considers the results of 89 original studies. Regarding pelvic organ prolapse, Ryhtä et al. conclude:

• Women with symptoms of pelvic floor dysfunction should receive individualised guidance.

• Proper training techniques should be verified through palpation or biofeedback.

• Pelvic floor muscle training (PFMT) can be recommended for prevention and treatment.

The recommendations stemmed in part from an earlier meta-analysis comparing structured PFMT to watchful waiting.6 Women receiving PFMT experienced symptomatic pelvic organ prolapse, less than half as often. Likewise, women referred to PFMT were burdened with urinary incontinence (UI) or sexual dysfunction less than half as often. While guidelines recommend supervised therapeutic exercise, what do we know about when to refer, the role of supervision, and the optimal dosage? There are no direct studies on these subjects to date. On the other hand, we can look to the more robust body of evidence for urinary incontinence. The physiological rationale for PFMT in UI is largely the same as for pelvic organ prolapse. Therefore, it can be instructive that Mishra et al. found that, at six months, women who received supervised PFMT accomplished more than twice the improvement on an incontinence scale as women trained in unsupervised PFMT.7 What’s more, readers of this bulletin are well aware of the common themes in rehabilitation of degenerative conditions. Across a range of conditions, researchers repeatedly find that increasing the number of supervised sessions beyond what is usually authorised improves outcomes. 

On average, pelvic organ prolapse progresses at a rate of 0.2 to 0.8 cm every five years. For women with one or more vaginal births, the rate is 250% faster. Women’s health physiotherapists design exercise programs to empower women to mitigate this progression, potentially avoiding symptoms and surgery. One of the challenges in PFMT is the difficulty of coordinating/controlling the contractions of these muscles. Waiting until the muscles are even more deconditioned may complicate rehabilitation. We believe that women are best served by early referrals that call for multiple supervised sessions. 

References

1. Brown HW, Hegde A, Huebner M, Neels H, Barnes HC, Marquini GV, Mukhtarova N, Mbwele B, Tailor V, Kocjancic E, Trowbridge E. International urogynecology consultation chapter 1 committee

2: Epidemiology of pelvic organ prolapse: prevalence, incidence, natural history, and service needs. International Urogynecology Journal. 2022 Feb 1:1-5. 2. Sigurdardottir T, Bø K, Steingrimsdottir T, Halldorsson TI, Aspelund T, Geirsson RT. Cross-sectional study of early postpartum pelvic floor dysfunction and related bother in primiparous women 6–10 weeks postpartum. International Urogynecology Journal. 2021 Jul;32(7):1847-55.

3. Haylen BT, De Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, Monga A, Petri E, Rizk DE, Sand PK, Schaer GN. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourology and Urodynamics: Official Journal of the International Continence Society. 2010 Jan;29(1):4-20.

4. Bø K, Anglès-Acedo S, Batra A, Brækken IH, Chan YL, Jorge CH, Kruger J, Yadav M, Dumoulin C. International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: pelvic floor muscle training. International Urogynecology Journal. 2022 Oct;33(10):2633 -67.

5. Haylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, Goldman HB, Huser M, Milani AL, Moran PA, Schaer GN. Erratum to: An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). International Urogynecology Journal. 2016 Apr;27:655-84.

6. Ryhtä I, Axelin A, Parisod H, Holopainen A, Hamari L. Effectiveness of exercise interventions on urinary incontinence and pelvic organ prolapse in pregnant and postpartum women: umbrella review and clinical guideline development. JBI Evidence Implementation. 2023 Dec 1;21(4):394-408.

7. Wu YM, McInnes N, Leong Y. Pelvic floor muscle training versus watchful waiting and pelvic floor disorders in postpartum women: a systematic review and meta-analysis. Urogynecology. 2018 Mar 1;24 (2):142-9.

8. Mishra DG, Vaishnav SB, Phatak AG. Comparison of effectiveness of home-based verses supervised pelvic floor muscle exercise in women with urinary incontinence. Journal of Mid-life Health. 2022 Jan;13 (1):74.

9. Handa VL, Blomquist JL, Roem J, Muňoz A. Longitudinal study of quantitative changes in pelvic organ support among parous women. American Journal of Obstetrics and Gynecology. 2018 Mar 1;218(3):320-e1.