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Meta-Analysis
. 2011 Dec 7;2011(12):CD003882.
doi: 10.1002/14651858.CD003882.pub4.

Conservative prevention and management of pelvic organ prolapse in women

Suzanne Hagen  1 , Diane Stark
Affiliations
Meta-Analysis

Conservative prevention and management of pelvic organ prolapse in women

Suzanne Hagen et al. Cochrane Database Syst Rev. .

Abstract

Background: Pelvic organ prolapse is common, and some degree of prolapse is seen in 50% of parous women. Women with prolapse can experience a variety of pelvic floor symptoms. Treatments include surgery, mechanical devices and conservative management. Conservative management approaches, such as giving lifestyle advice and delivering pelvic floor muscle training (PFMT), are often used in cases of mild to moderate prolapse. This is an update of a Cochrane review first published in 2004, and previously updated in 2006.

Objectives: To determine the effects of conservative management (physical and lifestyle interventions) for the prevention or treatment of pelvic organ prolapse in comparison with no treatment or other treatment options (such as mechanical devices or surgery).

Search methods: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 6 May 2010), EMBASE (1 January 1996 to 6 May 2010), CINAHL (1 January 1982 to 10 May 2010), PEDro (January 2009), the UK National Research Register (January 2009), ClinicalTrials.gov (April 2009), Current Controlled Trials register (April 2009), CENTRAL (Issue 1, 2009) and ZETOC (January 2009) and the reference lists of relevant articles.

Selection criteria: Randomised and quasi-randomised trials in women with pelvic organ prolapse that included a physical or lifestyle intervention in at least one arm of the trial.

Data collection and analysis: Two reviewers assessed all trials for inclusion/exclusion and methodological quality. Data were extracted by the lead reviewer onto a standard form and cross checked by another. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions.

Main results: Six trials were included; three of these trials are new to this update. Four trials were small (less than 25 women per arm) and two had moderate to high risk of bias. Four trials compared PFMT as a treatment for prolapse against a control group (n = 857 women); two trials included women having surgery for prolapse and compared PFMT as an adjunct to surgery versus surgery alone (n = 118 women).PFMT versus controlThere was a significant risk of bias in two out four trials in this comparison. Prolapse symptoms and women's reports of treatment outcomes (primary outcomes) were measured differently in the three trials where this was reported: all three indicated greater improvement in symptoms in the PFMT group compared to the control group. Pooling data on severity of prolapse from two trials indicated that PFMT increases the chance of an improvement in prolapse stage by 17% compared to no PFMT. The two trials which measured pelvic floor muscle function found better function (or improvement in function) in the PFMT group compared to the control group; measurements were not known to be blinded. Two out of three trials which measured urinary outcomes (urodynamics, frequency and bother of symptoms, or symptom score) reported differences between groups in favour of the PFMT group. One trial reported bowel outcomes, showing less frequency and bother with symptoms in the PFMT group compared to the control group.PFMT supplementing surgery versus surgery aloneBoth trials were small and neither measured prolapse-specific outcomes. Pelvic floor muscle function findings differed between the trials: one found no difference between trial groups in muscle strength, whilst the other found a benefit for the PFMT group in terms of stronger muscles. Similarly findings relating to urinary outcomes were contradictory: one trial found no difference in symptom score change between groups, whilst the other found more improvement in urinary symptoms and a reduction in diurnal frequency in the PFMT group compared to the control group.

Authors' conclusions: There is now some evidence available indicating a positive effect of PFMT for prolapse symptoms and severity. The largest most rigorous trial to date suggests that six months of supervised PFMT has benefits in terms of anatomical and symptom improvement (if symptomatic) immediately post-intervention. Further evidence relating to effectiveness and cost-effectiveness of PFMT, of different intensities, for symptomatic prolapse in the medium and long term is needed. A large trial of PFMT supplementing surgery is needed to give clear evidence about the usefulness of combining these treatments. Other comparisons which have not been addressed in trials to date and warrant consideration include those involving lifestyle change interventions, and trials aimed at prolapse prevention.

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Conflict of interest statement

Suzanne Hagen was the Chief Investigator of one of the included studies (Hagen 2009), and was one of the reviewers who carried out the study quality assessment and data extraction.

Figures

1
1
PRISMA study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 PFMT versus no treatment, Outcome 1 number with increased frequency of prolapse symptoms.
1.2
1.2. Analysis
Comparison 1 PFMT versus no treatment, Outcome 2 number with increased bother of prolapse symptoms.
1.3
1.3. Analysis
Comparison 1 PFMT versus no treatment, Outcome 3 number with pelvic heaviness.
1.4
1.4. Analysis
Comparison 1 PFMT versus no treatment, Outcome 4 prolapse symptom score: mean change from baseline.
1.5
1.5. Analysis
Comparison 1 PFMT versus no treatment, Outcome 5 self‐report of no improvement in prolapse.
1.6
1.6. Analysis
Comparison 1 PFMT versus no treatment, Outcome 6 prolapse QoL score.
1.7
1.7. Analysis
Comparison 1 PFMT versus no treatment, Outcome 7 Satisfaction with treatment (visual analogue scale 0‐10).
1.8
1.8. Analysis
Comparison 1 PFMT versus no treatment, Outcome 8 number with POP‐Q stage not improved.
1.9
1.9. Analysis
Comparison 1 PFMT versus no treatment, Outcome 9 POP‐Q measurements.
1.10
1.10. Analysis
Comparison 1 PFMT versus no treatment, Outcome 10 mean pelvic floor muscle measures.
1.11
1.11. Analysis
Comparison 1 PFMT versus no treatment, Outcome 11 number with worse bladder symptoms.
1.12
1.12. Analysis
Comparison 1 PFMT versus no treatment, Outcome 12 change in ICIQ UI‐SF.
1.13
1.13. Analysis
Comparison 1 PFMT versus no treatment, Outcome 13 mean bladder symptom score.
1.14
1.14. Analysis
Comparison 1 PFMT versus no treatment, Outcome 14 urodynamics: post void residual (mL).
1.15
1.15. Analysis
Comparison 1 PFMT versus no treatment, Outcome 15 urodynamics: flow rate (mL/s).
1.16
1.16. Analysis
Comparison 1 PFMT versus no treatment, Outcome 16 urodynamics: closure pressure (cm H2O).
1.17
1.17. Analysis
Comparison 1 PFMT versus no treatment, Outcome 17 number with dysuria.
1.18
1.18. Analysis
Comparison 1 PFMT versus no treatment, Outcome 18 number with stress incontinence.
1.19
1.19. Analysis
Comparison 1 PFMT versus no treatment, Outcome 19 number with urgency.
1.20
1.20. Analysis
Comparison 1 PFMT versus no treatment, Outcome 20 number with frequency.
1.21
1.21. Analysis
Comparison 1 PFMT versus no treatment, Outcome 21 number with worse bowel symptoms.
14.1
14.1. Analysis
Comparison 14 PFMT and/or lifestyle plus surgery versus surgery, Outcome 1 Change in manometry measures (cm H2O).
14.2
14.2. Analysis
Comparison 14 PFMT and/or lifestyle plus surgery versus surgery, Outcome 2 Digital muscle test (modified Oxford).
14.3
14.3. Analysis
Comparison 14 PFMT and/or lifestyle plus surgery versus surgery, Outcome 3 Change in UDI total score (12 months post‐op ‐ baseline).
14.4
14.4. Analysis
Comparison 14 PFMT and/or lifestyle plus surgery versus surgery, Outcome 4 Change in UDI irritative score (12 months post‐op ‐ baseline).
14.5
14.5. Analysis
Comparison 14 PFMT and/or lifestyle plus surgery versus surgery, Outcome 5 Change in UDI stress score (12 months post‐op ‐ baseline).
14.6
14.6. Analysis
Comparison 14 PFMT and/or lifestyle plus surgery versus surgery, Outcome 6 Change in UDI obstructive score (12 months post‐op ‐ baseline).
14.7
14.7. Analysis
Comparison 14 PFMT and/or lifestyle plus surgery versus surgery, Outcome 7 Number with irritative bladder symptoms at 12 months (UDI‐19).
14.8
14.8. Analysis
Comparison 14 PFMT and/or lifestyle plus surgery versus surgery, Outcome 8 Number with stress bladder symptoms at 12 months (UDI‐19).
14.9
14.9. Analysis
Comparison 14 PFMT and/or lifestyle plus surgery versus surgery, Outcome 9 Number with obstructive bladder symptoms at 12 months (UDI‐19).
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

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