In women with Pelvic organ prolapse (POP)is doing pelvic floor muscle exercises alone better than no treatment for relief of POP symptoms and quality of life?
Date First Published:
August 30, 2011
Last Updated:
July 20, 2012
Report by:
Queen Charlottes and Chelsea Hospital -Women's Health Physiotherapy team , Lead- Jo Dafforn (Imperial College Healthcare Trust )
Three-Part Question:
In [women with pelvic organ prolapse] are [Pelvic floor muscle exercises better than no treatment] for [relief of POP symptoms and quality of life?]
Clinical Scenario:
A 40 year old female arrives to the physiotherapy department with a diagnosed pelvic organ prolapse (POP) from the Gynaecology clinic. She wants to know if pelvic floor muscle exercises alone will help improve her POP symptoms.
Search Strategy:
Medline 1966-09 using the PubMed Clinical queries database was searched using the following terms (Therapy/Narrow[filter]) AND (Therapy/Broad[filter]) AND (exercis* AND pelvic organ prolapse) and (Therapy/Broad[filter]) AND[women with pelvic organ prolapse] AND [pelvic floor muscles exercises] AND [advice]. (Therapy/Broad[filter]) AND ((Therapy/Narrow[filter]) AND (Therapy/Broad[filter]) AND (Pelvic organ prolapse AND pelvic floor muscle training))
In addition the BestBETS database was searched using similar terms. Finally, the PEDrO (Physiotherapy best evidence) database was searched, Pedro Simple search: pelvic organ prolapse, Pedro advanced search: therapy strength training, women’s health, incontinence: perineum and gentio tract, with only papers already rated as 7/10 on the quality score being selected for inclusion. The Athens database was also searched: the databases were AMED, CINAHL and PUBMED with the terms Pelvic organ prolapse AND pelvic floor muscle training
PEDrO (Physiotherapy best evidence database): http://www.pedro.org.au/
Pub Med: http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml
Best BETS http://www.bestbets.org
https://auth.athensams.net/
In addition the BestBETS database was searched using similar terms. Finally, the PEDrO (Physiotherapy best evidence) database was searched, Pedro Simple search: pelvic organ prolapse, Pedro advanced search: therapy strength training, women’s health, incontinence: perineum and gentio tract, with only papers already rated as 7/10 on the quality score being selected for inclusion. The Athens database was also searched: the databases were AMED, CINAHL and PUBMED with the terms Pelvic organ prolapse AND pelvic floor muscle training
PEDrO (Physiotherapy best evidence database): http://www.pedro.org.au/
Pub Med: http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml
Best BETS http://www.bestbets.org
https://auth.athensams.net/
Outcome:
Altogether 64 abstracts were identified from the combined searches, after duplicates had been removed. Abstracts were screened. Full papers were obtained for those papers that answered, or potentially answered the three part search question. This resulted in 14 papers being obtained. These papers were rated for quality and risk of bias using a standard proforma with papers scoring over 6/10 being summarised in Table 1. This process resulted in 3 papers being rated as good quality and directly answering the PICO question
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| A Randomised controlled trial of pelvic floor muscle training for stages I and II pelvic organ prolapse Hagen, S, Stark, D, Glazener, C 2009 Scotland | Women Stage I/II POP confirmed with POP-Q |
RCT | POP symptom score | Significant improvement in symptoms in intervention group. Between baseline and 26weeks. ( 3.5 change compared to 0.1 ) | No blinding , gynaecologist aware of previous score on POP-Q at each assessment |
| POP-Q score | significant improvement from baseline to 20 weeks in intervention group (45% improvement) 0% in control group | ||||
| A Mulitcentre Randomised controlled trial of a pelvic floor muscle training intervention for women with pelvic organ prolapse Hagan, S, Glazener, C, Sinclair, L, Wilson, D, Dickson, S, McPherson, G, Logan, J, Frawley, H, Moore, K, Walker A 2011 Scotland | Women with Pelvic organ prolapse stages I-III | Multicentred RCT | POP-Q | POP-Q: marginal difference at 6/12 (p=0.052). | Slightly underpowered (needed 253 each group) |
| Postal questionnaire (POP-SS) | 6/12 mean dif 2.84 (p=0.001) 12/12 1.52 (p=0.005) | ||||
| Womens perceived change in POP | 52% v 17% at 6/12 (p<0.001) | ||||
| Cost effectiveness | £127/woman | ||||
| Can pelvic floor muscle training reverse pelvic organ prolapse Ingeborg Hoff Brækken, PhD, PT; Memona Majida, MD; Marie Ellström Engh 2010 Norway | Women 1 year post partum with pelvic organ prolpase stages I, II or III | RCT | •tStage POP-Q | •t19% of women in PFMT vs 8% in control group showed improvement or 1 grade on POP-Q | Significantly more patients with stage 1 POP in control vs PFMT group (22% vs 13.8%) . |
| •tPosition of bladder and bowel with standing ultrasound, height measured by locating urethrovesical junction and rectal ampulla | •tCranial elevation of the bladder improved by 3mm in the PFMT group compared with the control group ,•tCranial elevation of the rectum improved by 5.5mm in the PFMT group vs control | ||||
| •tFrequency and bother of prolapse symptoms as measured by a validated questionnaire (Int Urogynecol J Pelvic floor dysfunction 2003; 14; 122-7, Mouritsen et al) | •tSignificantly reduced frequency (p=.015) and bother (p.04) of prolapse symptoms in PFMT group vs control | ||||
| •tPFM function determined by vaginal balloon catheter and manometer | •tSignificantly greater improvement in PFM strength vs control (13.1 cmH20 vs 1.1 cmH20 (P<..001)) | ||||
| Effect of conservative treatment in the management of low degree urogenital prolapse Ghroubi, S, Kharrat, O, Chaari, M, Ben Ayed, B, Guermazi, M and Elleuch, M 2008 France | 47 women with grade grade 1 or 2 cystocele or rectocele | RCT group 1: pelvic floor muscle training and advice on healthy living versus the control of no treatment for the treatment of genital prolapse a 2 year follow up. |
Measurement of Urinary Handicap (MUP) | significant improvement in group 1 | |
| Urodynamics | increase in urethral closure pressure ranges from 54.4 to 57.81 versus 54.05 to 52.18 in control group | ||||
| Uroflowmetry | Significant improvement in flow rate in treatment group | ||||
| Vaginal heaviness | signifcant improvment, Only 18% in treatment group had heaviness ocmpared to 70% in control group. | ||||
| Ditrovie Score | improvements in treatment group |
Bottom Line:
There is now evidence to conclude that doing pelvic floor muscle training (PFMT) alone is effective in reducing pelvic organ prolpase symptoms. PFMT should be the first line of treatment for these patients.
References:
- Hagen, S, Stark, D, Glazener, C. A Randomised controlled trial of pelvic floor muscle training for stages I and II pelvic organ prolapse
- Hagan, S, Glazener, C, Sinclair, L, Wilson, D, Dickson, S, McPherson, G, Logan, J, Frawley, H, Moore, K, Walker A. A Mulitcentre Randomised controlled trial of a pelvic floor muscle training intervention for women with pelvic organ prolapse
- Ingeborg Hoff Brækken, PhD, PT; Memona Majida, MD; Marie Ellström Engh. Can pelvic floor muscle training reverse pelvic organ prolapse
- Ghroubi, S, Kharrat, O, Chaari, M, Ben Ayed, B, Guermazi, M and Elleuch, M. Effect of conservative treatment in the management of low degree urogenital prolapse