Individualized Pelvic Floor Muscle Training Appears to Improve Symptoms in Women with Mild Pelvic Organ Prolapse

EBM Focus - Volume 10, Issue 1

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Reference: BMJ 2014 Dec 22;349:g7378 (level 2 [mid-level] evidence)

Pelvic organ prolapse is a common problem, especially for postmenopausal women. Some loss of vaginal or uterine support has been reported in 43%-76% of women presenting for routine gynecological care and at least stage I pelvic organ prolapse on the Pelvic Organ Prolapse Quantification system has been reported in greater than 70% of women in the United States (Lancet 2007 Mar 24;369(9566):1027, Am J Obstet Gynecol 2005 Mar;192(3):795). While pelvic floor muscle training, pessary use, and surgery are available to women with more advanced prolapse, women with asymptomatic or mildly symptomatic prolapse without descent beyond the hymen are usually relegated to watchful waiting until symptoms worsen (Obstet Gynecol 2007 Sep;110(3):717, Am Fam Physician 2010 May 1;81(9):1111). A recent randomized trial compared individualized pelvic floor muscle training vs. watchful waiting in 287 women ≥ 55 years old with mild symptomatic pelvic organ prolapse.

In this trial, mild pelvic organ prolapse was defined as the leading edge of prolapse remaining above the hymen and corresponded to Pelvic Organ Prolapse Quantification stage 1 and mild stage 2. Women in the pelvic floor muscle training group initially met weekly with a pelvic physiotherapist for assessment and training, and the interval between appointments was extended as women became able to correctly contract and relax their pelvic floor muscles. Exercise programs were individualized to each patient and women were encouraged to practice at home 2-3 times a day for 3-5 days each week. Women were reassessed 3 months after the initiation of treatment or 3 months after randomization for women in the watchful waiting group. After 3 months, pelvic floor muscle training was associated with greater increase in self-reported improvement compared to watchful waiting (57% vs. 13%, p < 0.001). Pelvic floor muscle training was also associated with a 9 point greater improvement on the Pelvic Floor Distress Inventory-20 questionnaire (p = 0.005) and a 5 point greater improvement on the Urinary Distress Inventory-6 questionnaire (p = 0.007) in adjusted analyses. There were no significant differences in the number of patients experiencing an improvement of 1 or more stages on the Pelvic Organ Prolapse Quantification scale or the mean improvement on other questionnaires including the Pelvic Organ Prolapse Distress Inventory-6, ColoRectal Anal Distress Inventory-8, or the Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire-12.

This trial suggests that pelvic floor muscle training may be beneficial for women with mild symptomatic pelvic organ prolapse. While pelvic floor muscle training had a statistically significant effect on the Pelvic Floor Distress Inventory-20 questionnaire, the authors questioned whether the difference of 9 points was clinically meaningful, suggesting instead a difference of 15 points or more as clinically relevant based on previous trials. However, the women included in this trial had milder symptoms at baseline (mean score of 62.1 out of 300 points) than women in previous trials and a minimum clinically meaningful difference may not be the same in this population. In addition, pelvic floor muscle training was perceived as beneficial by a significantly greater percentage of women compared to those who received watchful waiting. Also, though pelvic floor muscle training did not improve prolapse stage, the short duration of this trial does not allow it to determine if pelvic floor muscle training may prevent worsening of the prolapse. In summary, while pelvic floor muscle training may not have achieved pre-defined clinical significance, more than half of women reported improvement in symptoms, suggesting that training may provide some benefit to women with mild pelvic organ prolapse.

For more information, see the Pelvic organ prolapse topic in DynaMed.