What is the best nonsurgical therapy for pelvic organ prolapse?

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Clinical Inquiries

What is the best nonsurgical therapy for pelvic organ prolapse?

J Fam Pract. 2014 August;63(8):471,479

By

Zachariah Overby, MD

Robert K. Persons, DO

Misty J. Carrillo, MLIS

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References

1. Richter HE, Burgio KL, Brubaker L, et al;Pelvic Floor Disorders Network. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol. 2010;115:609-617.

2. Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2011;12:CD003882.

3. Bugge C, Adams EJ, Gopinath D, et al. Pessaries (mechanical devices) for pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013;2:CD004010. 

4. Handa VL, Garrett E, Hendrix S, et al. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol. 2004;190:27-32. 

5. Ismail SI, Bain C, Hagen S. Oestrogens for treatment or prevention of pelvic organ prolapse in postmenopausal women. Cochrane Database Syst Rev. 2010;9:CD007063.

6.  ACOG Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol. 2007;110:717-729.

EVIDENCE-BASED ANSWER:

Pelvic floor muscle training (PFMT) and pessaries are equally effective in treating symptoms of pelvic organ prolapse (POP). PFMT transiently improves patient satisfaction and reduces urinary incontinence more than pessaries do (strength of recommendation [SOR]: B, a randomized controlled trial [RCT]).

PFMT moderately improves prolapse symptoms and severity, especially following 6 months of supervised intervention (SOR: B, a systematic review of randomized trials with some methodologic flaws).

Two pessaries (ring with support and Gellhorn) reduce symptoms in as many as 60% of patients (SOR: B, a systematic review of randomized trials). 

Untreated postmenopausal women with mild grades of uterine prolapse are unlikely to develop more severe prolapse; 25% to 50% improve spontaneously (SOR: C, a prospective cohort study with methodologic flaws).

EVIDENCE SUMMARY

A 2010 multicenter RCT with 445 women (mean age 49.8 years) compared PFMT, pessary use, and combined treatment.¹ Investigators used the Patient Global Impression of Improvement and the stress incontinence subscale of the Pelvic Floor Distress Inventory to measure patient satisfaction and urinary incontinence symptoms.

At 3 months, equivalent numbers of women using PFMT and a pessary (49% and 40%, respectively; P=.09) reported they were “much better” or “very much better.” More women in the PFMT cohort than women using a pessary reported resolution of incontinence symptoms at 3 months (49% vs 33%; P=.006), and satisfaction with treatment (75% vs 63%; P=.02), but these differences disappeared at 12 months. Combination therapy wasn’t superior to PFMT alone.

Pelvic floor muscle training improves symptoms, especially with perseverance

A 2011 Cochrane review that compared women receiving PFMT with a control group (observed but not treated) found that PFMT moderately improved prolapse symptoms and severity, especially following 6 months of supervised intervention.² Investigators evalu-ated 4 trials, (N=857), including 3 with fewer than 25 women per arm.

Evidence-based answers from the Family Physicians Inquiries Network

What is the best nonsurgical therapy for pelvic organ prolapse?

References

Pelvic floor muscle training improves symptoms, especially with perseverance

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