Peri-operative physiotherapy to prevent recurrent symptoms and treatment following prolapse surgery: supported by evidence or not?

Postoperative Physiotherapy in Women Undergoing Pelvic Floor Reconstructive Surgery: A Randomized Controlled Clinical Trial

Purpose: Postoperative physiotherapy in conjunction with pelvic organ prolapse (POP) surgery is still under-investigated and controversial. In this randomized controlled trial, pelvic floor muscle training (PFMT) and abdominal training were compared with a control condition (standard in-hospital treatment). Method: Eighty-one women were randomized to one of three groups. The Prolapse Quality of Life questionnaire, two-dimensional ultrasound, Pelvic Organ Prolapse Quantification System scale, the PERFECT (power, endurance, repetitions, fast contractions, every contraction timed) scheme, electromyography, Sahrmann scale, and pressure biofeedback unit (PBU) were used to measure quality of life (QOL), POP, and pelvic floor and abdominal muscle function. A mixed-model analysis of variance and the Kruskal-Wallis test was used for analysis. Results: Beneficial effects (p < 0.05) were found for the PFMT group - increased power, number of fast contractions, amount of movement, endurance, and Sahrmann and PBU measures - compared with the control group. Abdominal training led to a significant (p < 0.05) increase in bulging and discomfort, number of pelvic floor muscle contractions, and Sahrmann and PBU measures compared with the control condition; both groups showed significantly increased urinary frequency (p < 0.05). Conclusions: Postoperative physiotherapy did not have a beneficial effect on QOL or POP symptoms. PFMT and abdominal training had beneficial effects on pelvic floor muscle function and abdominal muscle measures. Additional abdominal training led to increased symptoms.

Impact of pelvic floor muscle training in pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This review article was aimed at evaluating the effectiveness of pelvic floor muscle training (PFMT) during conservative management and as an adjunct to prolapse surgery based on recently published articles.

METHODS

The PubMed and PEdro databases were searched from 2005 to 2020 for all types of studies reporting on PFMT as the primary treatment for conservative management of prolapse as well as an adjunct for prolapse surgery.

RESULT

The result of this review demonstrated that PFMT is effective in conservative management, especially in women with mild to moderate prolapse(stages I-III), for those who wish to have more children, who are not willing to undergo surgery, who are frail because of co-morbidities, and for those who need to delay surgery. However, results evaluating the effectiveness of PFMT as an adjunct to surgery demonstrated insufficient evidence to support the benefit of PFMT in addition to prolapse surgery over the use of surgery alone.

CONCLUSION

Through this review, we have concluded that PFMT shows a more prominent effect when applied as conservative management. Currently available evidence demonstrated no additional clinically significant augmentation of PFMT as an adjunct to surgery compared with prolapse surgery alone.

Perioperative Behavioral Therapy and Pelvic Muscle Strengthening Do Not Enhance Quality of Life After Pelvic Surgery: Secondary Report of a Randomized Controlled Trial

BACKGROUND

There is significant need for trials evaluating the long-term effectiveness of a rigorous program of perioperative behavioral therapy with pelvic floor muscle training (BPMT) in women undergoing transvaginal reconstructive surgery for prolapse.

OBJECTIVE

The purpose of this study was to evaluate the effect of perioperative BPMT on health-related quality of life (HRQOL) and sexual function following vaginal surgery for pelvic organ prolapse (POP) and stress urinary incontinence (SUI).

DESIGN

This study is a secondary report of a 2 × 2 factorial randomized controlled trial.

SETTING

This study was a multicenter trial.

PARTICIPANTS

Participants were adult women with stage 2-4 POP and SUI.

INTERVENTION

Perioperative BPMT versus usual care and sacrospinous ligament fixation (SSLF) versus uterosacral ligament suspension (ULS) were provided.

MEASUREMENTS

Participants undergoing transvaginal surgery (SSLF or ULS for POP and a midurethral sling for SUI) received usual care or five perioperative BPMT visits. The primary outcome was change in body image and in Pelvic Floor Impact Questionnaire (PFIQ) short-form subscale, 36-item Short-Form Health Survey (SF-36), Pelvic Organ Prolapse-Urinary Incontinence Sexual Questionnaire short form (PISQ-12), Patient Global Impression of Improvement (PGII), and Brink scores.

RESULTS

The 374 participants were randomized to BPMT (n = 186) and usual care (n = 188). Outcomes were available for 137 (74%) of BPMT participants and 146 (78%) of the usual care participants at 24 months. There were no statistically significant differences between groups in PFIQ, SF-36, PGII, PISQ-12, or body image scale measures.

LIMITATIONS

The clinicians providing BPMT had variable expertise. Findings might not apply to vaginal prolapse procedures without slings or abdominal apical prolapse procedures.

CONCLUSIONS

Perioperative BPMT performed as an adjunct to vaginal surgery for POP and SUI provided no additional improvement in QOL or sexual function compared with usual care.

Does pelvic floor muscle training augment the effect of surgery in women with pelvic organ prolapse? A systematic review of randomized controlled trials

BACKGROUND

Pelvic floor muscle training (PFMT) is often used as a treatment for pelvic organ prolapse (POP) and can improve function. However, the effectiveness of this modality as an adjunct to prolapse surgery for women with POP is unknown.

AIMS

To evaluate whether the use of pelvic floor muscle training as an adjunct to prolapse surgery is superior to surgery alone for women with pelvic organ prolapse.

METHODS

We searched PubMed, Embase, the Cochrane Library, and the Web of Science from their inception dates to June 30, 2014 for data describing randomized controlled trials (RCTs) that compare the efficacy of PFMT with or without lifestyle modification plus surgery versus surgery alone for women with POP. Additional relevant studies were identified by searching the references of retrieved articles and using Google Scholar. Two investigators independently reviewed and selected relevant studies that met the pre-specified inclusion criteria, extracted the data, and assessed the risk of bias in the included studies according to the Cochrane Handbook, version 5.1.0. Due to great heterogeneity in the choice and reporting of outcome measures and the different durations of follow-up among the studies, this analysis is confined to a qualitative systematic review.

RESULTS

Five RCTs involving 591 women were reviewed (treatment group [TG], 292 cases; control group [CG], 299 cases). Generally, the five RCTs exhibited low risk of bias. This study indicated no significant improvement in prolapse symptoms, in quality of life, or in the degree of prolapse for women with POP in the TG compared to those in the CG.

CONCLUSIONS

Insufficient evidence was found to support adding perioperative PFMT to surgery over the use of surgery alone in women undergoing surgery for POP. Adequately, powered RCTs with longer follow-up periods are required to evaluate the long-term effect of perioperative PFMT. Neurourol. Urodynam. 35:666-674, 2016. © 2015 Wiley Periodicals, Inc.

Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial

IMPORTANCE

More than 300,000 surgeries are performed annually in the United States for pelvic organ prolapse. Sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (ULS) are commonly performed transvaginal surgeries to correct apical prolapse. Little is known about their comparative efficacy and safety, and it is unknown whether perioperative behavioral therapy with pelvic floor muscle training (BPMT) improves outcomes of prolapse surgery.

OBJECTIVE

To compare outcomes between (1) SSLF and ULS and (2) perioperative BPMT and usual care in women undergoing surgery for vaginal prolapse and stress urinary incontinence.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, 2 × 2 factorial, randomized trial of 374 women undergoing surgery to treat both apical vaginal prolapse and stress urinary incontinence was conducted between 2008 and 2013 at 9 US medical centers. Two-year follow-up rate was 84.5%.

INTERVENTIONS

The surgical intervention was transvaginal surgery including midurethral sling with randomization to SSLF (n = 186) or ULS (n = 188); the behavioral intervention was randomization to receive perioperative BPMT (n = 186) or usual care (n = 188).

MAIN OUTCOMES AND MEASURES

The primary outcome for the surgical intervention (surgical success) was defined as (1) no apical descent greater than one-third into vaginal canal or anterior or posterior vaginal wall beyond the hymen (anatomic success), (2) no bothersome vaginal bulge symptoms, and (3) no re-treatment for prolapse at 2 years. For the behavioral intervention, primary outcome at 6 months was urinary symptom scores (Urinary Distress Inventory; range 0-300, higher scores worse), and primary outcomes at 2 years were prolapse symptom scores (Pelvic Organ Prolapse Distress Inventory; range 0-300, higher scores worse) and anatomic success.

RESULTS

At 2 years, surgical group was not significantly associated with surgical success rates (ULS, 59.2% [93/157] vs SSLF, 60.5% [92/152]; unadjusted difference, -1.3%; 95% CI, -12.2% to 9.6%; adjusted odds ratio [OR], 0.9; 95% CI, 0.6 to 1.5) or serious adverse event rates (ULS, 16.5% [31/188] vs SSLF, 16.7% [31/186]; unadjusted difference, -0.2%; 95% CI, -7.7% to 7.4%; adjusted OR, 0.9; 95% CI, 0.5 to 1.6). Perioperative BPMT was not associated with greater improvements in urinary scores at 6 months (adjusted treatment difference, -6.7; 95% CI, -19.7 to 6.2), prolapse scores at 24 months (adjusted treatment difference, -8.0; 95% CI, -22.1 to 6.1), or anatomic success at 24 months.

CONCLUSIONS AND RELEVANCE

Two years after vaginal surgery for prolapse and stress urinary incontinence, neither ULS nor SSLF was significantly superior to the other for anatomic, functional, or adverse event outcomes. Perioperative BPMT did not improve urinary symptoms at 6 months or prolapse outcomes at 2 years.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00597935.

Análise dos recursos para reabilitação da musculatura do assoalho pélvico em mulheres com prolapso e incontinência urinária

Esta revisão teve como objetivo analisar os recursos e sua eficácia na reabilitação do assoalho pélvico no tratamento dos prolapsos genitais e incontinência urinária. As buscas foram realizadas nas bases de dados MEDLINE/PubMed, LILACS/SciELO e Biblioteca Cochrane. Foram encontrados 886 artigos, dos quais foram utilizados 34 estudos clínicos relevantes que respondiam às perguntas construídas pelos autores. Os estudos analisados mostraram que o treinamento do assoalho pélvico pode ser usado no tratamento dos prolapsos, porém são necessários mais estudos randomizados para sustentar essa evidência. Para a incontinência urinária a reabilitação do assoalho pélvico é eficiente e deve ser o tratamento de primeira escolha.