Pelvic floor exercises are effective at successfully managing pelvic organ prolapse, but do they have long-term benefits? New evidence on this topic is presented here with an expert commentary
Citation: Jaques H (2015) Muscle training for pelvic organ prolapse. Nursing Times; 111: 5, 20.
Author: Helen Jaques is medical writer, Evidence Information Services, National Institute for Health and Care Excellence.
Pelvic organ prolapse is the bulging of one or more pelvic organs into the vagina. It is most common in women who have had children and those who are overweight, and its prevalence increases with age. Symptoms may include discomfort during sex or the sensation of a bulge or something coming down, or out of, the vagina. Pelvic floor prolapse can also cause problems with urinating such as slow stream, incomplete voiding, frequency and stress incontinence. Treatments may be conservative, such as weight loss, use of a vaginal pessary, and exercises for the pelvic floor muscles (Fig 1). For more severe symptoms, surgical options should be considered.
Hagen et al (2014) reported a randomised controlled trial (n = 447) comparing individualised pelvic floor muscle exercise (n = 225) and lifestyle advice (n = 222) in women with pelvic organ prolapse. The primary outcome was self-reported symptoms of prolapse at 12 months using the pelvic organ prolapse symptom score (range 0-28; higher scores indicated worse symptoms).
Pelvic floor muscle training was delivered by a physiotherapist in five one-to-one sessions over 16 weeks. All women received a leaflet with lifestyle advice on weight loss and avoiding heavy lifting, constipation, coughing and high-impact exercise. Members of the exercise group were given the leaflet at their first appointment; the control group received it by post. Women had an appointment with their gynaecologist at six months, at which point they could be referred for further treatment.
At baseline, participating women had a mean age of 56.8 years and a mean body mass index of 27, and most had had at least one vaginal birth. Mean pelvic organ prolapse symptom score was 10.04 in the exercise group and 9.51 in the controls. Analyses were adjusted for baseline prolapse symptom score, stage of prolapse, centre and whether surgery was wanted.
The mean reduction in self-reported symptoms from baseline was 3.77 in the exercise group and 2.09 in controls. The reduction was significantly greater in the exercise group compared with controls.
Significantly more people in the control group had further prolapse treatment by 12 months - mainly due to the large proportion of people referred for physiotherapy compared with the intervention group. However, there was no significant difference between groups in the number of women who received surgery, vaginal pessary or other treatments.
Box 1. Commentary
Pelvic organ prolapse affects a great number of women, and the associated health costs to the NHS are large, so the authors should be applauded for gathering high-quality evidence on conservative, low-risk measures that may improve patient care and use of NHS resources.
The trial raises a useful question: can physiotherapy achieve similar results if delivered in an alternative form, for example by an information leaflet, group sessions or less frequent sessions? After 12 months, only 80% of women in this study were still doing pelvic floor exercises. Further follow-up of this group may provide answers on the feasibility and benefit to patients of performing this activity in the long term.
Some questions about this trial are difficult to explain:
- Why, at the end of the study, were the same number of people in both groups having surgical treatment, despite greater symptom improvement in the intervention arm?
- Why do symptoms improve despite no changes in the anatomical appearance of the prolapse? This issue is especially important as surgical correction tries to restore normal anatomy of the pelvic floor.
The positive results in the study are in an intervention group that had intensive physiotherapy from specialised experts; however the applicability of this approach in the modern NHS is questionable because of resource issues.
Nikesh Thiruchelvam, consultant urological surgeon, Addenbrookes Hospital, Cambridge
- This study was sponsored by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates, New Zealand Lottery Grants Board, and Australian National Health and Medical Research Council.
Hagen S et al (2014) Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. The Lancet; 383: 796-806.