Pelvic floor muscle training as an adjunct to prolapse surgery: a randomised feasibility study

International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor muscle training

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 3 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) describes the current evidence and suggests future directions for research on the effect of pelvic floor muscle training (PFMT) in prevention and treatment of POP.

METHODS

An international group of four physical therapists, four urogynecologists and one midwife/basic science researcher performed a search of the literature using pre-specified search terms on randomized controlled trials (RCTs) in Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro and Scopus databases for publications between 1996 and 2021. Full publications or expanded abstracts in English or in other languages with abstracts in English were included. The PEDro rating scale (0-10) was used to evaluate study quality. Included RCTs were reviewed to summarize the evidence in six key sections: (1) evidence for PFMT in prevention of POP in the general female population; (2) evidence for early intervention of PFMT in the peripartum period for prevention and treatment of POP; (3) evidence for PFMT in treatment of POP in the general female population; (4) evidence for perioperative PFMT; (5) evidence for PFMT on associated conditions in women with POP; (6) evidence for the long-term effect of PFMT on POP. Full publications in English or in other languages with abstracts in English and expanded abstracts presented at international condition specific societies were included. Internal validity was examined by the PEDro rating scale (0-10).

RESULTS

After exclusion of duplicates and irrelevant trials, we classified and included 2 preventive trials, 4 trials in the post-partum period, 11 treatment trials of PFMT for POP in the general female population in comparison with no treatment or lifestyle interventions, 10 on PFMT as an adjunct treatment to POP surgery and 9 long-term treatment trials. Only three treatment studies compared PFMT with the use of a pessary. The RCTs scored between 4 and 8 on the PEDro scale. No primary prevention studies were found, and there is sparse and inconsistent evidence for early intervention in the postpartum period. There is good evidence/recommendations from 11 RCTs that PFMT is effective in reducing POP symptoms and/or improving POP stage (by one stage) in women with POP-Q stage I, II and III in the general female population, but no evidence from 9/10 RCTs that adding PFMT pre- and post -surgery for POP is effective. There are few long-term follow-up studies, and results are inconsistent. There are no serious adverse effects or complications reported related to PFMT.

CONCLUSIONS

There are few studies on prevention and in the postpartum period, and the effect is inconclusive. There is high-level evidence from 11 RCTs to recommend PFMT as first-line treatment for POP in the general female population. PFMT pre- and post-POP surgery does not seem to have any additional effect on POP. PFMT is effective and safe but needs thorough instruction and supervision to be effective.

Effects of Pelvic-Floor Muscle Training in Patients with Pelvic Organ Prolapse Approached with Surgery vs. Conservative Treatment: A Systematic Review

The aim of this systematic review was to explore the effectiveness of pelvic-floor muscle training (PFMT) in the treatment of women with pelvic organ prolapse (POP) who had undergone either surgery or only conservative treatment, based on a selection of randomized clinical trials (RCT). The search was carried out in PubMed, Cochrane, Scopus, CINAHL, and PEDro databases between April 2021 and October 2021 using the following MeSH terms or keywords: “pelvic organ prolapse”, “POP”, “pelvic floor muscle training”, “pelvic floor muscle exercise”, “kegel exercise”, and “surgery”. The methodological quality of the studies was assessed using the PEDro scale. Eighteen RCTs were included in this review. The findings showed improvements in symptoms associated with POP, in pelvic-floor function, and in quality of life in women who performed a PFMT protocol. However, PFMT did not produce significant changes in sexual function, and the results of the change in POP stage were inconclusive. When viewing PFMT as a complementary treatment to surgery, no significant improvements were observed in any of the analyzed variables. In conclusion, a PFMT program is an effective way to improve the pelvic, urinary, and intestinal symptoms associated with POP; function of the pelvic floor; and quality of life. PFMT as an adjunct to surgery does not seem to provide a greater benefit than surgical treatment alone. RCTs of higher methodological quality, with a larger sample size and a longer follow-up, are needed to confirm the results.

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.

Completeness of exercise reporting among randomized controlled trials on pelvic floor muscle training for women with pelvic organ prolapse: A systematic review

AIMS

This systematic review aimed to assess the completeness of exercise reporting in randomized controlled trials (RCTs) on pelvic floor muscle training (PFMT) for women with pelvic organ prolapse (POP).

METHODS

MEDLINE, Cochrane Central, CINHAL, Embase, SCOPUS, and PEDro databases were searched up to October 2020. Full-text RCTs comparing PFMT to any type of intervention among women with any type and stage of POP were eligible for inclusion. Completeness of intervention was evaluated with t20he template for intervention description and replication (TIDieR) and the consensus on exercise reporting template (CERT). Inter-rater agreement for each item of the tools was calculated.

RESULTS

Twenty-six RCTs were included. None of the studies completely reported all intervention descriptors. On average 57.1% (6.8 ± 2.4; out of 12) of the overall TIDieR items and 35.3% (6.7 ± 2.9; out of 19) of the CERT were well described. In particular, 7 and 5 items were completely reported more than 50% of the time for the TIDieR and CERT, respectively. Frequent shortcomings were the undetailed reporting of information regarding tailoring and modifications of exercises and their adherence. Detailed descriptions of exercise repetitions to enable replication were missing in 53.8%. According to the CERT, only 11.5% of the RCTs sufficiently described the main providers' characteristics.

CONCLUSION

The completeness of PFMT reporting for women with POP is still below desirable standards and it is insufficient to ensure transferability into practice. The present results may add relevant knowledge and contribute to improving adequate reporting of exercise.

Validation of the Sinhala translations of the Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire in a Sri Lankan population

INTRODUCTION AND HYPOTHESIS

This study was to translate and validate self-reported questionnaires, the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) into Sinhala, the language spoken by the majority of Sri Lankans.

METHODS

A total of 270 patients were enrolled in this study. Two groups were selected with pelvic organ prolapse (POP)-cases and without POP-controls in a ratio of 1:2 respectively. Psychometric properties of the questionnaires were assessed using content validity, face validity, convergent validity, construct validity, internal consistency, and reliability. Pelvic Organ Prolapse Quantification (POP-Q) was used as the test to quantify POP.

RESULTS

Excellent content validity was demonstrated by a content validity ratio for all items by experts. Face validity was confirmed by non-experts using a five-point Likert scale and Mann-Whitney U test for all items. Internal consistency was found to be high for both questionnaires (Cronbach's alpha >0.8) in all items. Construct validity was assessed by receiver-operating characteristic curves and the area under the curve is above 0.5 in all items in both questionnaires. Convergent validity was assessed using Pearson coefficient correlation, which was above 0.8 for all subscales. Reliability was low for all subscales in the paired t test.

CONCLUSIONS

The Sinhala versions of PFDI-20 and PFIQ-7 were valid, consistent, responsive, but have low reliability in the Sri Lankan setting.

Pelvic floor muscle training as an adjunct to a midurethral sling: a single-blind randomised controlled trial

INTRODUCTION AND HYPOTHESIS

This single-blind, randomised controlled trial was aimed at determining whether peri-operative physiotherapist-supervised pelvic floor muscle (PFM) training was superior to standard care (handout) in terms of improvements in stress urinary incontinence (SUI) symptoms, cure rate, and/or post-operative filling or voiding symptoms among women undergoing surgical mid-urethral sling (MUS) insertion for SUI.

METHODS

Women with SUI were recruited from surgical wait lists at four participating urogynecology clinics. Participants were assessed at baseline (V1) then randomised (1:1 allocation) to receive supervised PFM training or a handout. Immediately following the 12-week intervention period (V2) and at 12 weeks following surgery (V3) the groups were compared based on the Female Lower Urinary Tract Symptoms (FLUTS) questionnaire total score and urinary incontinence, filling, and voiding subscale scores as well as on a standardised 30-min pad test administered by a blinded assessor. Intention-to-treat analyses were performed.

RESULTS

A total of 52 participants were randomised to physiotherapy and 51 to the control group between December 2012 and August 2016. The groups were not different on any outcomes at V1 and all were improved at V3 compared with V1 (p < 0.001). At V3 the physiotherapy group reported significantly fewer UI symptoms (FLUTS UI subscale score) than the control group; yet, there were no group differences in FLUTS overall score or the pad test (p > 0.05). Based on a FLUTS UI subscale score <4, the cure rate at V3 was higher in the intervention group (73%) than in the control group (47%); (2.36 < OR < 3.47, p = 0.012). There were no group differences in cure rate at V3 based on a pad test (p = 0.27). No group differences were found in the filling or voiding symptoms at V3 (p > 0.05). No adverse events were reported.

CONCLUSION

Physiotherapist-supervised PFM training improves SUI cure rates associated with surgical MUS insertion when considering symptoms of SUI, but does not improve post-operative continence function as measured by a pad test, nor does it lead to fewer post-operative voiding or filling symptoms.

The effect of preoperative pelvic floor muscle training on urinary and colorectal-anal distress in women undergoing pelvic organ prolapse surgery-a randomized controlled trial

Introduction and hypothesis

Pelvic floor muscle training (PFMT) improves urinary incontinence and mild pelvic organ prolapse (POP). We aimed to investigate the effect of preoperative PFMT on urinary and colorectal-anal distress and related quality of life (QoL) in women with severe POP scheduled for surgery.

Methods

Randomized controlled trial of 159 women scheduled for POP surgery (intervention = 81, controls = 78). Intervention consisted of daily PFMT from inclusion to the day of surgery. Symptoms and QoL were assessed at inclusion, day of surgery and 6 months postoperatively using the Urinary Distress Inventory (UDI-6), Colorectal-Anal Distress Inventory (CRADI-8), Urinary Impact Questionnaire (UIQ) and Colorectal-Anal Impact Questionnaire (CRAIQ) (range 0–100). Mixed model statistical analyses were used.

Results

One hundred fifty-one (95%) women completed the study (intervention = 75, controls = 76). Mean waiting times until surgery and follow-up were 22 and 28 weeks. There was no difference in mean postoperative symptom and QoL scores (95% CI) between the intervention and control group: UDI-6 16 (12–21) vs. 17 (13–22), CRADI-8 15 (11–18) vs. 13 (10–16), UIQ 11 (7–15) vs. 10 (6–13) and CRAIQ 5 (2–7) vs. 6 (4–9), all p > 0.05. Overall mean scores were reduced from baseline to postoperative follow-up: UDI-6 37 (33–41) vs. 17 (14–20), CRADI-8 22 (19–25) vs. 14 (11–16); UIQ 28 (24–32) vs. 10 (7–13) and CRAIQ 16 (12–19) vs. 5 (3–7), all p < 0.01.

Conclusions

We found no added effect of preoperative PFMT on symptoms or QoL related to urinary and colorectal-anal distress in women scheduled for POP surgery. They achieved symptomatic improvement postoperatively regardless of PFMT.

Clinical trial registration

The study was registered in clinicaltrials.gov: NCT 03,064,750.

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.

Pelvic floor muscle training in the treatment of pelvic organ prolapse: A meta-analysis of randomized controlled trials

BACKGROUND

We aimed to assess the overall effect of pelvic muscle training (PFMT) on patients with pelvic organ prolapse (POP) based on eligible randomized controlled trials (RCT).

METHODS

We searched the following databases, such as PubMed, Cochrane, and Embase, to identify eligible RCT based on the index words updated to December 2018. We also searched the publications related to the present study. Odds rations (OR), and mean difference (MD) along with 95% confidence interval (95% CI) were used to analyze the main outcomes.

RESULTS

In this meta-analysis, 15 RCTs were included with a total of 1309 patients in the PFMT group and a total of 1275 patients in the control group. The overall results showed no significant difference in the incidence of add 2 POP-Q stages (RR: 0.55, 95%CI: 0.19-1.63), add 1 POP-Q stages (RR: 1.04, 95%CI: 0.69-1.57), no POP-Q stages change (RR: 0.94, 95%CI: 0.81-1.09), reduce 2 POP-Q stages (RR: 1.72, 95%CI: 0.79-3.76), self-reported same symptom change (RR: 0.70, 95%CI: 0.45-1.09), and self-reported worse symptom change (RR: 0.67, 95%CI: 0.22-2.03) between the 2groups. Besides, the incidence of reduce 1 POP-Q stages was significantly higher in the PFMT group than that of the control group (RR: 1.80, 95%CI: 1.20-2.69), and the PFMT significantly changed the self-reported symptoms with better outcomes when compared with the control group (RR: 2.90, 95%CI: 1.72-4.89). However, after the therapy, the PFMT group decreased the POP-SS (SMD: -0.24, 95%CI: -0.71-0.22), POPDI-6 (SMD: -0.14, 95%CI: -0.43-0.15), CRADI-8 (SMD: -0.03, 95%CI: -0.16-0.11), and UDI-6 (SMD: -0.17, 95%CI: -0.43-0.10) versus the control group, but without statistical significance.

CONCLUSION

PMFT showed better effect in reducing 1 POP-Q stages, changing the self-reported symptoms with better outcomes, decreasing the score of POP-SS, POPDI-6, CRADI-8, and UDI-6 in women with POP versus the control group. However, more high-quality multicenter RCTs with a larger sample size are needed to confirm the present conclusions.

Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women

PURPOSE OF REVIEW

To describe the principles of pelvic floor physical therapy (PFPT), review the evidence for PFPT as a treatment for pelvic floor dysfunction, and summarize the current recommendations for PFPT as a first-line conservative treatment option for pelvic floor disorders.

RECENT FINDINGS

Pelvic floor dysfunction can cause voiding and defecation problems, pelvic organ prolapse (POP), sexual dysfunction, and pelvic pain. PFPT is a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction. Based on the available evidence, PFPT with or without supplemental modalities can improve or cure symptoms of urinary incontinence, POP, fecal incontinence, peripartum and postpartum pelvic floor dysfunction, and hypertonic pelvic floor disorders, including pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia. Currently, there is conflicting evidence regarding the effectiveness of perioperative PFPT before or after POP and urinary incontinence surgery.

SUMMARY

PFPT has robust evidence-based support and clear benefit as a first-line treatment for most pelvic floor disorders. Standards of PFPT treatment protocols, however, vary widely and larger well designed trials are recommended to show long-term effectiveness.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

Effect of preoperative pelvic floor muscle training on pelvic floor muscle contraction and symptomatic and anatomical pelvic organ prolapse after surgery: randomized controlled trial

OBJECTIVES

To evaluate the effect of preoperative pelvic floor muscle training (PFMT) on pelvic floor muscle (PFM) contraction, symptoms of pelvic organ prolapse (POP) and anatomical POP, 6 months after prolapse surgery, and to assess the overall changes in PFM contraction, POP symptoms and pelvic organ descent after surgery.

METHODS

This was a randomized controlled trial of 159 women with symptomatic POP, Stage 2 or higher, scheduled for surgery. Participants were randomized to intervention including daily PFMT from inclusion to surgery (n = 81) or no intervention (controls; n = 78). Participants were examined at inclusion, on the day of surgery and 6 months after surgery. PFM contraction was assessed by: vaginal palpation using the Modified Oxford scale (MOS; 0-5); transperineal ultrasound, measuring the percentage change in levator hiatal anteroposterior diameter (APD) from rest to maximum PFM contraction; vaginal manometry; and surface electromyography (EMG). POP distance from the hymen in the compartment with the most dominant prolapse and organ descent in the anterior, central and posterior compartments were measured on maximum Valsalva maneuver. POP symptoms were assessed based on the sensation of vaginal bulge, which was graded using a visual analog scale (VAS; 0-100 mm). Linear mixed models were used to assess the effect of PFMT on outcome variables.

RESULTS

Of the 159 women randomized, 151 completed the study, comprising 75 in the intervention and 76 in the control group. Mean waiting time for surgery was 22 ± 9.7 weeks and follow-up was performed on average 28 ± 7.8 weeks after surgery. Postoperatively, no difference was found between the intervention and control groups with respect to PFM contraction assessed by vaginal palpation (MOS, 2.4 vs 2.2; P = 0.101), manometry (19.4 vs 19.7 cmH₂ O; P = 0.793), surface EMG (33.5 vs 33.1 mV; P = 0.815) and ultrasound (change in hiatal APD, 20.9% vs 19.3%; P = 0.211). Furthermore, no difference between groups was found for sensation of vaginal bulge (VAS, 7.4 vs 6.0 mm; P = 0.598), POP distance from the hymen in the dominant prolapse compartment (-1.8 vs -2.0 cm; P = 0.556) and sonographic descent of the bladder (0.5 vs 0.8 cm; P = 0.058), cervix (-1.3 vs -1.1 cm; P = 0.569) and rectal ampulla (0.3 vs 0.4 cm; P = 0.434). In all patients, compared with findings at initial examination, muscle contraction improved after surgery, as assessed by palpation (MOS, 2.1 vs 2.3; P = 0.007) and ultrasound (change in hiatal APD, 17.5% vs 20.1%; P = 0.001), and sensation of vaginal bulge was reduced (VAS, 57.6 vs 6.7 mm; P < 0.001). In addition, compared with the baseline examination, POP distance from the hymen in the dominant prolapse compartment (1.9 vs -1.9 cm; P < 0.001) and sonographic descent of the bladder (1.3 vs 0.6 cm; P < 0.001), cervix (0.0 vs -1.2 cm; P < 0.001) and rectal ampulla (0.9 vs 0.4 cm; P = 0.001) were reduced.

CONCLUSIONS

We found no effect of preoperative PFMT on PFM contraction, POP symptoms or anatomical prolapse after surgery. In all patients, PFM contraction and POP symptoms were improved at the 6-month follow-up, most likely due to the anatomical correction of POP. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Perioperative pelvic floor muscle training did not improve outcomes in women undergoing pelvic organ prolapse surgery: a randomised trial

QUESTION

In women undergoing surgery for pelvic organ prolapse (POP), what is the average effect of the addition of perioperative pelvic floor muscle training on pelvic organ prolapse symptoms, pelvic floor muscle strength, quality of life, sexual function and perceived improvement after surgery?

DESIGN

Randomised controlled trial with concealed allocation, blinded assessors, and intention-to-treat analysis.

PARTICIPANTS

Ninety-six women with an indication for POP surgery.

INTERVENTION

The experimental group received a 9-week pelvic floor muscle training protocol with four sessions before the surgery and seven sessions after the surgery. The control group received surgery only.

OUTCOME MEASURES

Symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI-20), which is scored from 0 'unaffected' to 300 'worst affected'. Secondary outcomes were assessed using vaginal manometry, validated questionnaires and Patient Global Impression of Improvement, which is scored from 1 'very much better' to 7 'very much worse'. All participants were evaluated 15 days before surgery, and at Days 40 and 90 after surgery.

RESULTS

There was no substantial difference in POP symptoms between the experimental and control groups at Day 40 (31 (SD 24) versus 38 (SD 42), adjusted mean difference -6, 95% CI -25 to 13) or Day 90 (27 (SD 27) versus 33 (SD 33), adjusted mean difference -4, 95% CI -23 to 14). The experimental group perceived marginally greater global improvement than the control group; mean difference -0.4 (95% CI -0.8 to -0.1) at Day 90. However, the estimated effect of additional perioperative pelvic floor muscle training was estimated to be not beneficial enough to be considered worthwhile for any other secondary outcomes.

CONCLUSION

In women undergoing POP surgery, additional perioperative pelvic floor muscle training had negligibly small effects on POP symptoms, pelvic floor muscle strength, quality of life or sexual function.

TRIAL REGISTRATION

ReBEC, RBR-29kgz5.

Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial

Importance

Mixed urinary incontinence, including both stress and urgency incontinence, has adverse effects on a woman's quality of life. Studies evaluating treatments to simultaneously improve both components are lacking.

Objective

To determine whether combining behavioral and pelvic floor muscle therapy with midurethral sling is more effective than sling alone for improving mixed urinary incontinence symptoms.

Design, Setting, and Participants

Randomized clinical trial involving women 21 years or older with moderate or severe stress and urgency urinary incontinence symptoms for at least 3 months, and at least 1 stress and 1 urgency incontinence episode on a 3-day bladder diary. The trial was conducted across 9 sites in the United States, enrollment between October 2013 and April 2016; final follow-up October 2017.

Interventions

Behavioral and pelvic floor muscle therapy (included 1 preoperative and 5 postoperative sessions through 6 months) combined with midurethral sling (n = 209) vs sling alone (n = 207).

Main Outcomes and Measures

The primary outcome was change between baseline and 12 months in mixed incontinence symptoms measured by the Urogenital Distress Inventory (UDI) long form; range, 0 to 300 points; minimal clinically important difference, 35 points, with higher scores indicating worse symptoms.

Results

Among 480 women randomized (mean [SD] age, 54.0 years [10.7]), 464 were eligible and 416 (86.7%) had postbaseline outcome data and were included in primary analyses. The UDI score in the combined group significantly decreased from 178.0 points at baseline to 30.7 points at 12 months, adjusted mean change -128.1 points (95% CI, -146.5 to -109.8). The UDI score in the sling-only group significantly decreased from 176.8 to 34.5 points, adjusted mean change -114.7 points (95% CI, -133.3 to -96.2). The model-estimated between-group difference (-13.4 points; 95% CI, -25.9 to -1.0; P = .04) did not meet the minimal clinically important difference threshold. Related and unrelated serious adverse events occurred in 10.2% of the participants (8.7% combined and 11.8% sling only).

Conclusions and Relevance

Among women with mixed urinary incontinence, behavioral and pelvic floor muscle therapy combined with midurethral sling surgery compared with surgery alone resulted in a small statistically significant difference in urinary incontinence symptoms at 12 months that did not meet the prespecified threshold for clinical importance.

Trial Registration

ClinicalTrials.gov Identifier: NCT01959347.

Perioperative interventions in pelvic organ prolapse surgery

BACKGROUND

Pelvic organ prolapse (POP) affects as many as 50% of parous women, with 14% to 19% of women undergoing a surgical correction. Although surgery for the treatment of POP is common, limited supportive data can be found in the literature regarding the preoperative and postoperative interventions related to these procedures. The main goal of perioperative interventions is to reduce the rate of adverse events while improving women's outcomes following surgical intervention for prolapse. A broad spectrum of perioperative interventions are available, and although the benefits of interventions such as prophylactic antibiotics before abdominal surgery are well established, others are unique to women undergoing POP surgeries and as such need to be investigated separately.

OBJECTIVES

The aim of this review is to compare the safety and effectiveness of a range of perioperative interventions versus other interventions or no intervention (control group) at the time of surgery for pelvic organ prolapse.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In Process, ClinicalTrials.gov, WHO ICTRP, handsearching of journals and conference proceedings (searched 30 November 2017), and reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of women undergoing surgical treatment for symptomatic pelvic organ prolapse that compared a perioperative intervention related to pelvic organ prolapse surgery versus no treatment or another intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Our primary outcomes were objective failure at any site and subjective postoperative prolapse symptoms. We also measured adverse effects, focusing on intraoperative blood loss and blood transfusion, intraoperative ureteral injury, and postoperative urinary tract infection.

MAIN RESULTS

We included 15 RCTs that compared eight different interventions versus no treatment for 1992 women in five countries. Most interventions were assessed by only one RCT with evidence quality ranging from very low to moderate. The main limitation was imprecision, associated with small sample sizes and low event rates.Pelvic floor muscle training (PFMT) compared with no treatment (three RCTs) - peri-operative intervention The simplest of the PFMT programmes required women to attend six perioperative consultations in the three months surrounding prolapse surgery. Trial results provided no clear evidence of a difference between groups in objective failure at any site at 12 to 24 months (odds ratio (OR) 0.93, 95% confidence interval (CI) 0.56 to 1.54; two RCTs, 327 women; moderate-quality evidence). With respect to awareness of prolapse, findings were inconsistent. One RCT found no evidence of a difference between groups at 24 months (OR 1.07, 95% CI 0.61 to 1.87; one RCT, 305 women; low-quality evidence), and a second small RCT reported symptom reduction from the Pelvic Organ Prolapse Symptom Questionnaire completed by the intervention group at 12 months (mean difference (MD) -3.90, 95% CI -6.11 to -1.69; one RCT, 27 women; low-quality evidence). Researchers found no clear differences between groups at 24-month follow-up in rates of repeat surgery (or pessary) for prolapse (OR 1.92, 95% CI 0.74 to 5.02; one RCT, 316 women; low-quality evidence).Other interventionsSingle RCTs evaluated the following interventions: preoperative guided imagery (N = 44); injection of vasoconstrictor agent at commencement of vaginal prolapse surgery (N = 76); ureteral stent placement during uterosacral ligament suspension (N = 91); vaginal pack (N = 116); prophylactic antibiotics for women requiring postoperative urinary catheterisation (N = 159); and postoperative vaginal dilators (N = 60).Two RCTs evaluated bowel preparation (N = 298), and four RCTs assessed the method and timing of postoperative catheterisation (N = 514) - all in different comparisons.None of these studies reported our primary review outcomes. One study reported intraoperative blood loss and suggested that vaginal injection of vasoconstrictors at commencement of surgery may reduce blood loss by a mean of about 30 mL. Another study reported intraoperative ureteral injury and found no clear evidence that ureteral stent placement reduces ureteral injury. Three RCTs reported postoperative urinary tract infection and found no conclusive evidence that rates of urinary tract infection were influenced by use of a vaginal pack, prophylactic antibiotics, or vaginal dilators. Other studies did not report these outcomes.

AUTHORS' CONCLUSIONS

There was a paucity of data about perioperative interventions in pelvic organ prolapse surgery. A structured programme of pelvic floor muscle training before and after prolapse surgery did not consistently demonstrate any benefit for the intervention; however, this finding is based on the results of two small studies. With regard to other interventions (preoperative bowel preparation and injection of vasoconstrictor agent, ureteral stent placement during uterosacral ligament suspension, postoperative vaginal pack insertion, use of vaginal dilators, prophylactic antibiotics for postoperative catheter care), we found no evidence regarding rates of recurrent prolapse and no clear evidence that these interventions were associated with clinically meaningful reductions in adverse effects, such as intraoperative or postoperative blood transfusion, intraoperative ureteral injury, or postoperative urinary tract infection.

The Role of Pelvic Floor Muscle Training in the Conservative and Surgical Management of Female Stress Urinary Incontinence: Does the Strength of the Pelvic Floor Muscles Matter?

The purpose of this review is to provide an in-depth overview of the role of pelvic floor muscle (PFM) training in the management of stress urinary incontinence (SUI). The definition, epidemiology, and pathogenesis of SUI are described. We review the anatomy of the PFM and the importance of PFM strength in maintaining urinary continence and establishing normal voiding function. A brief description of the surgical options currently available for SUI and the existing data regarding the role of perioperative PFM training for SUI are included. Critical research questions to better evaluate and assess PFM training during the perioperative period are proposed. Promising novel approaches in the treatment of SUI are also presented. This review is useful for physiatrists, urogynecologists, female urologists, and nurse practitioners who specialize in the management and treatment of women with SUI. LEVEL OF EVIDENCE: IV.

Factors affecting continuation of clean intermittent catheterisation in people with multiple sclerosis: Results of the COSMOS mixed-methods study

BACKGROUND

Clean intermittent catheterisation (CIC) is often recommended for people with multiple sclerosis (MS).

OBJECTIVE

To determine the variables that affect continuation or discontinuation of the use of CIC.

METHODS

A three-part mixed-method study (prospective longitudinal cohort ( n = 56), longitudinal qualitative interviews ( n = 20) and retrospective survey ( n = 456)) was undertaken, which identified the variables that influenced CIC continuation/discontinuation. The potential explanatory variables investigated in each study were the individual's age, gender, social circumstances, number of urinary tract infections, bladder symptoms, presence of co-morbidity, stage of multiple sclerosis and years since diagnosis, as well as CIC teaching method and intensity.

RESULTS

For some people with MS the prospect of undertaking CIC is difficult and may take a period of time to accept before beginning the process of using CIC. Ongoing support from clinicians, support at home and a perceived improvement in symptoms such as nocturia were positive predictors of continuation. In many cases, the development of a urinary tract infection during the early stages of CIC use had a significant detrimental impact on continuation.

CONCLUSION

Procedures for reducing the incidence of urinary tract infection during the learning period (i.e. when being taught and becoming competent) should be considered, as well as the development of a tool to aid identification of a person's readiness to try CIC.

Pelvic floor muscle weakness: a risk factor for anterior vaginal wall prolapse recurrence

INTRODUCTION AND HYPOTHESIS

Native tissue vaginal repairs are associated with relatively high levels of recurrence. Systematic reviews have noted that preoperative pelvic floor muscle strength was associated with increased risk of recurrence in the short term.

METHODS

This is a retrospective review of patients who underwent a primary reconstructive surgery for anterior compartment vaginal prolapse between 2001 and 2015. Patients were divided into "absent," "weak" and "good" preoperative PFM strength (aPFM, wPFM and gPFM, respectively) based on a modified Oxford scale. Failure rates were determined by a composite of subjective and objective anatomic outcomes. Subjects who underwent re-operations or procedures for recurrent prolapse of the anterior compartment were considered failures. A p value < 0.05 was considered statistically significant.

RESULTS

Two hundred ninety-nine patients were included. The aPFM (n = 36), wPFM (n = 115) and gPFM (n = 148) groups had similar descriptive statistics, except subjects in the aPFM and wPFM groups were significantly older than the gPFM group (p = 0.008). All groups underwent similar reconstructive surgeries. Average length of follow-up of 143.9 weeks (41 to 717 weeks) was similar among the three groups (p = 0.472). For the primary outcome of composite failure, aPFM had significantly more anterior vaginal wall recurrences than both the wPFM and gPFM groups, 13.89% vs. 3.48% and 4.05%, respectively (p = 0.033).

CONCLUSIONS

Patients with preoperative absent pelvic floor muscle strength (nonfunctioning PFM) had a significantly higher anterior vaginal wall recurrence rate than those with weak or good pelvic floor muscle strength.

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.

Movement System Impairment-Guided Approach to the Physical Therapist Treatment of a Patient With Postpartum Pelvic Organ Prolapse and Mixed Urinary Incontinence: Case Report

BACKGROUND AND PURPOSE

Women with postpartum pelvic organ prolapse (POP) and urinary incontinence are often treated by physical therapists specializing in women's health. Movement system impairments often coexist in this patient population. The purpose of this case report is to describe the physical therapist treatment of a woman with postpartum POP complicated by additional pelvic symptoms.

CASE DESCRIPTION

A 31-year-old woman presented with postpartum POP, diastasis recti, urinary incontinence, and constipation. Movement system impairments were consistent with a physical therapist diagnosis of femoral adduction-medial rotation syndrome exacerbated by levator ani muscle weakness and incoordination and impaired intra-abdominal pressure regulation. Interventions, based on a movement system guided approach, included postural correction; pelvic-floor, abdominal, and hip muscle strengthening; functional training to correct identified movement faults; and patient education.

OUTCOMES

Movement system impairment outcomes included: correction of femoral adduction-medial rotation and knee hyperextension during standing at rest, ambulation, and exercise; increased hip muscle strength; and effective regulation of intra-abdominal pressure (resolution of breath holding with the Valsalva maneuver) during all transitional movements and therapeutic exercise. The patient also demonstrated reductions in POP, urinary, and colorectal symptom severity that exceeded the minimal clinically important difference. Additionally, she demonstrated a reduction in diastasis rectus distance.

DISCUSSION

A movement system impairment-guided approach led the physical therapist to consider impairments outside the pelvic floor that could have contributed to the patient's pelvic symptoms. Using this approach, the patient achieved resolution of musculoskeletal and movement impairments and reductions in POP, urinary and colorectal symptoms, and symptom-related distress.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Optimising the validity and completion of adherence diaries: a multiple case study and randomised crossover trial

BACKGROUND

Diaries are the most commonly used adherence measurement method in home-based rehabilitation trials, yet their completion and validity varies widely between trials. We aimed to: (1) generate theory to explain this variation, (2) create an optimised diary and (3) evaluate the optimised diary's validity.

METHODS

Stage 1.

DEVELOPMENT

using a multiple case study approach, we collected trialist interviews (n = 7), trial publications (n = 16) and diaries (n = 7) from seven purposively sampled UK rehabilitation trials. We explored return rates, diary designs and trialists' ideas as to what affected diary completion and validity. Using explanatory case study analysis, we developed a diary optimisation model. Stage 2.

EVALUATION

we compared a diary optimised according to several model components to one nonoptimised according to the same components in a randomised AB/BA crossover trial. Healthy adults aged 60+ years without mobility impairments undertook a home-based 8-week walking programme. They recorded walking duration and frequency for 4 weeks per diary. We hypothesised that the optimised diary would possess greater validity for self-reported adherence to walking duration (criterion: the Activpal accelerometer), assessed during each diary's final week. Participants were blinded to the hypothesis. Secondary outcomes included test-retest reliability and acceptability. Ethical approval was granted from Glasgow Caledonian University.

RESULTS

Thirty-two out of 33 participants completed the study. Diaries did not significantly differ in validity, reliability or acceptability. Both diaries agreed closely with the Activpal when assessing duration adherence at a group level, however, inter and intraindividual variation in validity was high (mean difference (95 % limits of agreement (LOA): limits of agreement plot the difference between measurements collected using two different methods against their mean and thus assess the extent to which the two measures agree with each other)) optimised diary = 3.09 % (-103.3 to 109.5 %), nonoptimised diary = -0.34 % (-131.1 to 130.5 %), p = 0.732). We found similarly wide LOA for percentage of days adhered to and percentage of walks taken, whilst frequency adherence was underestimated. Participants rated both diaries as low-burden and equal numbers favoured each diary or were neutral. Preference appeared to impact minimally upon validity.

CONCLUSION

Group-level adherence diary data are likely to be valid. However, individual diary data lack validity, which raises concerns if using this data in calculations such as predicting functional outcomes. Different diary designs are likely interchangeable, though unanticipated high variation meant that this study was underpowered.

TRIAL REGISTRATION

The trial was not eligible for registration in a clinical trial database as diary measurement property outcomes, not clinical health outcomes of participants, were assessed.

The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Our objective was to assess the effectiveness of pelvic floor muscle training (PFMT) as a treatment for women with pelvic organ prolapse (POP) or as an adjunct to prolapse surgery.

METHODS

Relevant literature sources were searched using databases including PubMed, Ovid, Web of Science, Scopus, ClinicalTrials.gov, EBSCO, CINAHL, the Cochrane Central Register of Controlled Trials, CNKI, VIP, Wanfang, and CBM until 5 July 2015. Eligible studies were restricted to randomized controlled trials (RCT). The available data were pooled using Review Manager version 5.2. For data deemed not appropriate for synthesis, a narrative overview was conducted.

RESULTS

In total, 13 studies with 2,340 patients were included. Our results indicated women receiving PFMT gained a greater improvement than controls in prolapse symptom score [mean difference (MD) -3.07, 95 % confidence interval (CI) -3.91 to -2.23] and POP stages [risk ratio (RR) 1.70, 95 % CI 1.19-2.44]. The number of women who said their prolapse was getting better was higher (RR 5.48, 95 % CI 2.19-13.72) and other discomfort syndromes, such as vaginal, bladder, and rectum, were lower in the PFMT groups than in controls. Meanwhile, women after PFMT had greater improvement in muscle strength and endurance but did not show a significant difference for further treatment needs. In addition, the results evaluating PFMT as an adjunct to prolapse surgery were inconclusive because of the variability in methods of measuring outcome.

CONCLUSIONS

Our meta-analysis demonstrated women who received PFMT showed a greater subjective improvement in prolapse symptoms and an objective improvement in POP severity.

Heterogeneity in post-intervention prolapse and urinary outcome reporting: a one-year review of the International Urogynecology Journal

INTRODUCTION

This review aimed to examine post-intervention prolapse, incontinence, and overactive bladder outcome measures published in the International Urogynecology Journal over the previous year and to report on the heterogeneity in outcome reporting.

METHODS

All original article abstracts published in the print version of the International Urogynecology Journal in 2014 were reviewed for possible inclusion. Those reporting on prolapse and/or incontinence and/or overactive bladder outcomes following a urogynecological intervention were analyzed. Articles were reviewed for all reported outcomes. Outcomes were categorized as primary or secondary and objective or subjective.

RESULTS

Of 117 original articles published, 45 were reviewed. Among primary outcomes, 9 different outcomes were reported for prolapse and 11 for incontinence and overactive bladder. For prolapse, 6 different objective and 13 subjective outcomes were reported. For incontinence, 21 objective and 36 subjective outcomes were reported. Three different definitions were used for the outcome of "prolapse cure," 3 for "prolapse recurrence," and 4 for "stress incontinence cure." Several validated and non-validated questionnaires in addition to single unvalidated questions were used to measure subjective outcomes.

CONCLUSIONS

This research highlights the diversity in outcome reporting for prolapse, incontinence, and overactive bladder after an intervention in the last year of publications alone. This can lead to serious challenges in the generation of higher order evidence, such as systematic reviews and meta-analyses. As a subspecialty, we need to aim for more cohesive reporting so as to allow for robust comparison and evidence dissemination.

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.

Prevention and management of pelvic organ prolapse

Pelvic organ prolapse is a highly prevalent condition in the female population, which impairs the health-related quality of life of affected individuals. Despite the lack of robust evidence, selective modification of obstetric events or other risk factors could play a central role in the prevention of prolapse. While the value of pelvic floor muscle training as a preventive treatment remains uncertain, it has an essential role in the conservative management of prolapse. Surgical trends are currently changing due to the controversial issues surrounding the use of mesh and the increasing demand for uterine preservation. The evolution of laparoscopic and robotic surgery has increased the use of these techniques in pelvic floor surgery.