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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/

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
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
Hagan et al 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
Braekken et al 2010 Norway	Women 1 year post partum with pelvic organ prolpase stages I, II or III	RCT	• Stage POP-Q	• 19% 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%) .
			• Position of bladder and bowel with standing ultrasound, height measured by locating urethrovesical junction and rectal ampulla	• Cranial elevation of the bladder improved by 3mm in the PFMT group compared with the control group ,• Cranial elevation of the rectum improved by 5.5mm in the PFMT group vs control
			• Frequency and bother of prolapse symptoms as measured by a validated questionnaire (Int Urogynecol J Pelvic floor dysfunction 2003; 14; 122-7, Mouritsen et al)	• Significantly reduced frequency (p=.015) and bother (p.04) of prolapse symptoms in PFMT group vs control
			• PFM function determined by vaginal balloon catheter and manometer	• Significantly greater improvement in PFM strength vs control (13.1 cmH20 vs 1.1 cmH20 (P<..001))
Ghroubi et al 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

Clinical 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

1. Hagen, S, Stark, D, Glazener, C A Randomised controlled trial of pelvic floor muscle training for stages I and II pelvic organ prolapse 2009; 45-51
2. 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
3. Ingeborg Hoff Brækken, PhD, PT; Memona Majida, MD; Marie Ellström Engh Can pelvic floor muscle training reverse pelvic organ prolapse
4. 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 Annales de Readaption Medecine Physique 2008, 96-102