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

Impact of postpartum exercise on pelvic floor disorders and diastasis recti abdominis: a systematic review and meta-analysis

OBJECTIVE

To examine the effect of exercise during the first year postpartum on pelvic floor disorders and diastasis recti abdominis.

DESIGN

Systematic review with random effects meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, SPORTDiscuss, Evidence-Based Medicine Reviews (Ovid), Scopus, Web of Science and ClinicalTrials.gov were searched until 12 January 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies of all designs (except case studies) and languages were included if they contained information on the Population (individuals in the first year postpartum), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise alone ('exercise-only') or in combination with other intervention (eg, biofeedback; 'exercise+co-intervention')), Comparator (no exercise or different exercise measures) and Outcome (symptom severity and risk of urinary incontinence, anal incontinence, pelvic organ prolapse, diastasis recti abdominis and sexual function).

RESULTS

65 studies (n=21 334 participants) from 24 countries were included. 'Moderate' certainty of evidence revealed that pelvic floor muscle training reduced the odds of urinary incontinence by 37% (seven randomised controlled trials (RCTs), n=1930; OR 0.63, 95% CI 0.41 to 0.97, I2 72%) and pelvic organ prolapse by 56% (one RCT, n=123; OR 0.44, 95% CI 0.21 to 0.91) compared with control groups. 'Low' certainty of evidence showed a greater reduction in inter-rectus distance measured at rest and during a head lift following abdominal muscle training compared with no exercise. Evidence on the effect of exercise on the risk of anal incontinence and diastasis recti abdominis, as well as the severity of anal incontinence, urinary incontinence, pelvic organ prolapse and sexual function, is limited.

CONCLUSION

Evidence supports the effectiveness of postpartum pelvic floor muscle training in reducing the odds of urinary incontinence and pelvic organ prolapse and postpartum abdominal exercise training in reducing inter-rectus distance.

PROSPERO REGISTRATION NUMBER

CRD42022359282.

Effectiveness of breathing exercises on urinary symptoms, muscle activity, and strength in women with multiple sclerosis and urinary incontinence-a study protocol for a randomized controlled trial study

BACKGROUND

Urinary incontinence (UI) is a common and debilitating condition among people with multiple sclerosis (MS) and is more prevalent among women. Over the past decade, numerous studies have investigated the effects of pelvic floor muscle training (PFMT) as a treatment for UI in people with MS. MS negatively impacts pulmonary function even in the early stages of the disease and people with MS may experience respiratory muscle weakness. Considering the synergy between the pelvic floor muscle (PFM) and respiratory muscles, this trial will evaluate the effects of PFMT and breathing exercises on PFM activity and strength, diaphragm activity, and urinary symptoms in women with MS who experience UI.

METHODS

Fifty women with MS and UI will participate in this parallel randomized controlled trial, comprising 32 treatment sessions. The intervention group consists of PFMT and breathing exercises, and the control group includes PFMT. The severity of UI symptoms, PFM activity, diaphragm activity, and PFM strength will be evaluated using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, ultrasound imaging, and modified Oxford grading scale, respectively before and after the intervention.

DISCUSSION

The current trial is designed to examine the effects of a combined exercise program for UI in women with MS. It is hypothesized that using breathing exercises in conjunction with PFM exercises will improve patient symptoms compared to PFMT alone.

TRIAL REGISTRATION

The trial was registered in the Iranian Registry of Clinical Trials with code IRCT20180916041051N3 and was approved on 23 May 2024.

Patient-Reported Outcome Measures for Pelvic Organ Prolapse: A Systematic Review Using the COnsensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) Checklist

BACKGROUND

Patient-reported outcome measures (PROMs) are recommended to measure the impact of a health condition or intervention effectiveness as they aim to capture what is most meaningful to patients. Several PROMs are used to evaluate pelvic organ prolapse (POP)-related domains, yet the measurement properties of these instruments have not been fully explored with a rigorous analysis of the methodological quality and quality of evidence.

OBJECTIVE

To conduct a systematic review reporting on the measurement properties of PROMs used for the assessment of POP-related domains in accordance with the COSMIN guidelines.

SEARCH STRATEGY

Five databases were searched from inception to December 2023.

SELECTION CRITERIA

Studies were eligible if they involved (1) at least one group of female adults diagnosed with or presenting with symptoms of POP; (2) a self-reported outcome measure (PROMs, questionnaires) to evaluate POP-related domains; and (3) at least one measurement property.

DATA COLLECTION AND ANALYSIS

Methodological quality and measurement quality were assessed using the COSMIN risk of bias (ROB) checklist and the COSMIN criteria for good measurement properties.

MAIN RESULTS

A total of 13 PROMs were included. The BIPOP had the lowest ROB for Content Validity. The POP-SS was the only PROM with sufficient evidence of adequate construct validity and responsiveness to be used in both surgical and conservative management settings.

CONCLUSION

This original work identified a gap in evidence regarding the measurement qualities of identified PROMs used in the POP population.

Is there evidence for pelvic floor muscle relaxation training in nonneurogenic female bladder outlet obstruction?-A narrative review

INTRODUCTION

Functional bladder outlet obstruction (BOO) in women is postulated to be caused by pelvic floor muscle (PFM) dyssynergia or increased tone. The aim of the present review was to investigate the effect of PFM relaxation training on PFM tone and female BOO symptoms.

MATERIALS AND METHODS

This was a narrative review using an open search strategy on PubMed with the search terms "Bladder outlet obstruction" AND "female" AND ("pelvic floor muscles" OR "Kegel"). The risk of bias of the randomized controlled trials (RCTs) was scored with the Physiotherapy Evidence Database (PEDro) scale (0-10).

RESULTS

Only three RCTs were found. All three RCTs compared different types of exercise, and no trial compared relaxation training with no or sham treatment. None of the trials reported the effect between groups on the reduction of PFM tone. There was a tendency toward positive effect of PFM relaxation training to improve BOO symptoms in women. PEDro score varied between 4 and 7. Few studies yielded information on the immediate effect of any type of PFM relaxation technique on PFM tone.

CONCLUSION

Few RCTs have been conducted on the effect of PFM relaxation training on PFM tone and functional female BOO symptoms. There is an urgent need for RCTs with high methodological and interventional quality in addition to basic research on mechanisms of different relaxation techniques on PFM activity.

Impact of Lifestyle Modifications on the Prevention and Treatment of Pelvic Organ Prolapse

INTRODUCTION AND HYPOTHESIS

This manuscript is a part of the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) chapter three, committee three, on the impact of lifestyle modifications (i.e., weight loss, treatment of constipation, activity restriction, etc.) on the prevention and treatment of POP.

MATERIALS AND METHODS

An international group containing ten female pelvic medicine specialists and one university-based medical librarian performed a systematic search of the literature in Medline using the MeSH terms: pelvic organ prolapse (ID: D056887), cystocele (ID: D052858), uterine prolapse (ID: D014596), rectocele (ID: D020047), and women (ID: D014930) to identify studies addressing lifestyle modifications as prevention or treatment for POP on 10/18/21. Relevant studies were included in this review.

RESULTS

A total of 18,483 studies were identified in the initial literature search; 187 full-text articles were deemed pertinent and independently reviewed and double-screened by ten reviewers. After full-text review, information from 86 articles was included in this review.

CONCLUSION

Women may consider various lifestyle modifications to help prevent and treat POP, even if it is challenging to quantify the efficacy of these interventions.

Do Women with Urinary Incontinence and Pelvic Organ Prolapse Receive Optimal First-Line Treatment?

INTRODUCTION AND HYPOTHESIS

There is scant knowledge on previous pelvic floor muscle training (PFMT) in women with urinary incontinence (UI) and pelvic organ prolapse (POP) referred to hospitals. We hypothesized that women with predominately UI and POP had not received optimal primary care conservative management.

METHODS

This was a descriptive, cross-sectional survey among women attending a gynecological outpatient's clinic. The questionnaire included questions about demographics, PFMT dosage, whether ability to contract had been assessed and whether the patients had used precontraction before increase in intra-abdominal pressure ("the knack").

RESULTS

One hundred two women, mean age 52.5 (SD 13.4) years, responded; 37.3% had never been treated previously. There was no statistically significant difference in age, BMI, level of education, parity, time since last birth, SUI, or POP between the women who had been treated conservatively or not before the hospital visit. Thirty-three percent had trained with a physiotherapist and > 35% reported that their ability to contract had not been assessed or were unsure whether it had been assessed; 37% were not able to stop their urine stream; 52% reported that they performed "the knack," with 15.7% reporting it to be effective. Reasons for not having trained the PFM before visiting the hospital included not being motivated, not knowing how to do PFMT, not being told/advised to do PFMT and not believing PFMT would help.

CONCLUSION

The results of this study indicated that there is a need for improvement within first-line health care service for women with predominately UI and POP.

Vaginal erbium laser versus pelvic floor exercises for the treatment of pelvic organ prolapse: A randomised controlled trial

OBJECTIVES

To compare the efficacy of Er:YAG laser for mild to moderate pelvic organ prolapse (POP) to that of pelvic floor exercises (PFE).

DESIGN

Single center randomised controlled trial.

SETTING

Tertiary center, Belgium.

PARTICIPANTS

Forty-six women with mild to moderate prolapse were enrolled (23 in each group). There were no missing data for the primary outcome; three patients were lost to follow-up at 24-months.

INTERVENTIONS

Comparison of vaginal laser treatment (3-6 applications) to PFE (9-18 sessions).

MAIN OUTCOME MEASURES

Subjective change in prolapse symptoms at four months from baseline measured by the Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6) (primary), adverse events, other subjective outcomes and independent anatomical assessment up to 24 months.

RESULTS

The mean difference in POPDI-6 scores at 4 months was 1.09 (95 %CI = -6.02;8.12), showing non-inferiority of laser to PFE (p = 0.004). Within groups, the difference in mean POPDI-6 four months following the start of therapy tended to be lower for laser-treatment (65.2 % (15/23) of laser-participants were 'better' or 'much better') than for PFE (60.9 % (14/23) in the PFE group), yet without difference between groups (OR = 1.21; 95 %CI = 0.39-3.23). There were no obvious between group differences in any other subjective nor objective outcomes. At 24 months, 50 % (11/22) of laser-patients and 43 % (9/21) of PFE-patients requested additional, yet alternative treatment. There were no serious adverse events at any time-point.

CONCLUSIONS

Vaginal laser application and PFE improve symptoms of mild and moderate prolapse to a similar extent. Both treatments had a measurable yet not durable effect. There were no adverse events in either arm.

TRIAL REGISTRATION

ClinicalTrials.gov(NCT04523298).

FUNDING

The laser device was provided by Fotona, Slovenia for the duration of this trial.

Mechanisms for pelvic floor muscle training: Morphological changes and associations between changes in pelvic floor muscle variables and symptoms of female stress urinary incontinence and pelvic organ prolapse-A narrative review

INTRODUCTION

Today there is Level 1, recommendation A for pelvic floor muscle training (PFMT) to be effective in treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP). However, the mechanisms of action are discussed. The aim of the present overview was to give an update of studies evaluating the effect of PFMT on pelvic floor morphology and associations between changes in PFM strength and symptoms of female SUI and POP. MATERIALS AND METHODS: This was a narrative review retrieving studies from systematic reviews of PFMT for SUI and POP. In addition, an open search on PubMed with the search terms PFMT and morphology was conducted. Both randomized controlled trials (RCTs) and pre-posttest design studies were included. PEDro rating scale (0-10) was used to assess risk of bias.

RESULTS

Ten studies were found reporting on morphological changes after PFMT. The four RCTs had PEDro score between 5 and 8/10. The studies found significant higher bladder neck position and narrower levator hiatus dimensions, thicker external urethral sphincter, increased cross-sectional area of PFM, improvement in PFM tears and blood flow. Twenty studies analyzed associations between changes in different PFMT variables and SUI and POP. Eleven studies found a positive weak to moderate association and six studies reported no association. Studies comparing responders and nonresponders to PFMT found statistically significant better PFM variables in responders.

CONCLUSION

PFMT can change pelvic floor muscle and external urethral sphincter anatomy. This contributes to the understanding on how PFMT can be effective in prevention and treatment of SUI and POP.

POP-Q Versus Upright MRI Distance Measurements: A Prospective Study in Patients with POP

INTRODUCTION AND HYPOTHESIS

The gold standard for quantifying pelvic organ prolapse is the pelvic organ prolapse quantification (POP-Q) system; however, upright magnetic resonance imaging (MRI) is a promising new method. The objective of this study was to determine the correlation between POP-Q and MRI measurements of the bladder and cervix.

METHODS

This prospective study included patients with prolapse in whom POP-Q points Aa or Ba and C were measured as standard care. MRI scans were performed in an upright position, and the distances of the lowest points of the bladder and cervix to the Pelvic Inclination Correction System (PICS) were calculated. Correlations between POP-Q and MRI-PICS measurements were determined using the Pearson correlation coefficient for normally distributed data and the Spearman's rank correlation coefficient for non-normally distributed data.

RESULTS

A total of 63 patients were suitable for analysis. There was a moderate positive correlation between the POP-Q and MRI-PICS measurements for bladder (r(61) = 0.480, r < 0.001) and uterus (r(61) = 0.527, p < 0.001). Measurement differences between POP-Q and MRI-PICS of the bladder and uterus vary from -3.2 cm to 7.1 cm, and from -2.1 cm to 8.5 cm respectively. In 71.4% of patients more descent was seen on upright MRI than with POP-Q measurement for both bladder and uterus. For patients with similar POP-Q measurements, a high variation in MRI measurements of the bladder and uterus was found.

CONCLUSION

Despite a moderate positive correlation, upright MRI shows a larger POP extent in 71.4% of the patients than POP-Q. A high variation in MRI measurements for patients with the same POP-Q measurement was seen.

Randomised controlled pilot trial to assess effect of electrical stimulation of weak pelvic floor muscles

INTRODUCTION AND HYPOTHESIS

Pelvic floor muscle training (PFMT) has level 1A scientific evidence for the treatment of urinary incontinence and pelvic organ prolapse. Past studies, however, have often excluded women with very weak pelvic floor muscles (PFM). The aim was to investigate the hypothesis that intravaginal electrical stimulation (iES) improves PFM strength more than PFMT in women with weak PFM, and to use these results to calculate sample size required for a future large randomised controlled trial (RCT).

METHODS

This assessor-blinded pilot RCT had a two arm, parallel design with computer-generated Randomisation. Both groups were offered 12 one-to-one physiotherapy sessions over a 6-month period. The iES group received individual tailored electrical pulse parameters. The PFMT group received PFM exercises, with the addition of facilitation techniques at therapy sessions. A power calculator was used to calculate sample size.

RESULTS

Fifteen women were recruited. Eight were randomised to iES and 7 to PFMT. Two subjects dropped out of the iES group. Median age was 49 years (range 36-77) and parity 2.1 (range 1-3). Both groups showed increases in PFM strength measured by manometery (iES 12.3, SD 12.0 vs PFMT 10.0, SD 8.1) cmH2O. There was no significant difference between groups. With a power of 0.80 we need a sample size of 95 women in each group to detect a difference between groups.

CONCLUSION

There was no significant difference between the groups in improvements in PFM strength. To detect a difference, we would have required 95 women in each group.

Pelvic floor muscle training in female functional fitness exercisers: an assessor-blinded randomised controlled trial

OBJECTIVE

Stress urinary incontinence (SUI) is common among females during functional fitness training, such as CrossFit. The aim of this study was to assess the effect of pelvic floor muscle training (PFMT) on SUI in female functional fitness exercisers.

METHODS

This was an assessor-blinded randomised controlled trial with a PFMT group (n=22) and a control group (n=25). The PFMT group followed a 16-week home-training programme with 3 sets of 8-12 maximum pelvic floor muscle (PFM) contractions daily and weekly follow-up/reminders by phone. The primary outcome was change in a total score of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF). The secondary outcomes were perceived change of symptoms of SUI, change of PFM strength measured by vaginal manometry and symptoms of anal incontinence (AI) and pelvic organ prolapse (POP).

RESULTS

47 women, mean age of 33.5 years (SD: 8.1), participated. At 16 weeks, there was a mean difference between groups of -1.4 (95% CI: -2.6 to -0.2) in the change of the ICIQ-UI-SF score in favour of the PFMT group. The PFMT group completed a mean of 70% (SD: 23) of the prescribed protocol. 64% in the PFMT group versus 8% in the control group reported improved symptoms of SUI (p<0.001, relative risk: 7.96, 95% CI, 2.03 to 31.19). There were no group differences in the change of PFM strength or AI/POP symptoms.

CONCLUSION

A 16-week home-training programme of the PFM led to improvements in SUI in female functional fitness exercisers. However, PFM strength and AI and POP symptoms did not improve significantly in the PFMT group compared with the control group.

Pelvic Floor Therapy and Initial Interventions for Pelvic Floor Dysfunction in Gynecologic Malignancies

PURPOSE OF REVIEW

This review provides evidence-based updates for the first-line management approaches for pelvic floor disorders in patients with gynecologic malignancies, as well as important provider considerations when referring for pelvic floor physical therapy.

RECENT FINDINGS

Currently, there is strong evidence to recommend pelvic floor muscle training as initial treatment for urinary incontinence and for pelvic organ prolapse; some evidence to recommend a more targeted pelvic floor muscle training program for fecal incontinence; and mostly expertise-based evidence to recommend vaginal gels or estrogen to aid with dyspareunia causing sexual dysfunction. More research is greatly needed to understand the role of overactive pelvic floor muscles in survivors with chronic pelvic pain and the treatment of post-radiation pelvic complications such as vaginal stenosis and cystitis. While pelvic floor disorders are common concerns in gynecologic cancer survivors, there are evidence-based initial noninvasive treatment approaches that can provide relief for many individuals.

Effect of Pelvic Floor Muscle Training With Smartphone Reminders on Women in the Postpartum Period: A Randomized Controlled Trial

IMPORTANCE

Standard postpartum pelvic floor muscle training (PFMT) can effectively reduce the incidence of pelvic floor dysfunction diseases.

OBJECTIVE

This study aimed to evaluate the adherence of PFMT with smartphone application reminders on women in the postpartum period.

STUDY DESIGN

We conducted a randomized controlled trial. This single-center randomized (1:1) controlled study included primiparous women admitted to Tongji Hospital between March 2022 and June 2022 (ChiCTR2200059157). Every puerpera was given pelvic floor muscle (PFM) assessment and PFMT guidance at 6 weeks after delivery. After randomization, women in the intervention group received daily training reminders from the smartphone application WeChat. Adherence to PFMT, a symptom of stress urinary incontinence, and PFM characteristics were measured 3 months later.

RESULTS

A total of 148 participants were included in the final analysis (76 in the intervention group and 72 in the control group). The adherence rate of daily PFMT was higher in the intervention group than in the control group (53.9% vs 20.8%, P = 0.00) at 3-month follow-up. In addition, participants in the intervention group showed higher peak surface electromyography of PFMs (39.8 ± 6.2 vs 37.5 ± 5.9 μV, P = 0.03) and longer PFM endurance (8.1 ± 2.0 vs 7.3 ± 2.0 seconds, P = 0.01) than in the control group, whereas there was no difference between the 2 groups in International Consultation on Incontinence Questionnaire-Short Form ( P = 0.60) and the Patient Global Impression of Improvement scores ( P = 1.00).

CONCLUSIONS

Smartphone application-based PFMT could increase adherence and improves electromyography of PFMs in the short term but did not affect stress urinary incontinence symptoms in women in the postpartum period.

Sexual dysfunction in patients after cystocele surgery. Is the g-spot a myth or reality?

The anterior wall of the vagina is very rich in nerves, blood vessels, and exocrine glands. This anatomical region is related to female sexual desire. During the anterior colporrhaphy operation, dissection of the anterior vaginal wall causes damage to this area, which may lead to decreased sexual satisfaction. In the present study, we aimed to investigate sexual function after anterior vaginal wall surgery.

METHODS

Totally 89 patients who had undergone the anterior colporrhaphy operation between May 2021 and December 2021 were included in the study. The patients' sexual function was investigated before surgery and six months after surgery. The effects on sexual function were determined according to the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire.

RESULTS

According to our study results, orgasm and orgasm intensities decreased after anterior colporrhaphy surgery (p = 0.000; p = 0.000), while sexual desire or arousal did not change (p = 0.405; p = 0.052). In addition, an increase in pain was observed during sexual intercourse after surgery (p = 0.000). No statistically significant difference was observed in the PISQ-12 score before or after anterior colporrhaphy surgery (p = 0.675).

CONCLUSION

Based on the results of our study, we found a remarkable decrease in orgasm in these patients. Furthermore, we think that it is appropriate to recommend conservative or alternative treatments for the early stages of cystocele. Nevertheless, larger-scale studies may be designed to reveal the importance of this region in sexual function.

International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction.

METHODS

An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed.

RESULTS

The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP.

CONCLUSIONS

The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

Validation of the short forms of the Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire in Estonian

INTRODUCTION AND HYPOTHESIS

Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) are reliable instruments for evaluating the quality of life in women with pelvic organ prolapse (POP). They have been translated and validated in many languages. The study was aimed at validating the Estonian translations of the PFDI-20 and PFIQ-7 tools.

METHODS

The questionnaires were translated into Estonian using a multistep translation method. A total of 132 women were enrolled: patients with diagnosed POP (n=57) were allocated to test-retest reliability analyses, and those with no POP signs (n=88) completed the questionnaire only once. The total scores of questionnaires and their subscales of both patient and reference groups were compared. Item response rate, floor and ceiling effects, corrected item-total correlations, internal consistency, and convergent and discriminant validity were analyzed. The study was approved by the Ethics Committee of Human Research of the University Clinic of Tartu, Estonia, and informed consent was obtained from each participant.

RESULTS

The translated questionnaires demonstrated good internal consistency (Cronbach's α values 0.77-0.93). The item response rate was 99%. Intra-class correlations (ICC) were strong for PFDI-20 and PFIQ-7 and their subscales ranged from 0.86 to 0.96. Construct validity of the tools demonstrated by manyfold higher scores among patients with POP compared with women without POP (p<0.0001).

CONCLUSIONS

The Estonian versions of the PFDI-20 and PFIQ-7 tools are reliable and valid instruments for assessing the quality of life in women with POP.

Association between vaginal or cesarean delivery and later development of stress urinary incontinence or pelvic organ prolapse: A retrospective population-based cohort study

INTRODUCTION AND HYPOTHESIS

Child delivery mode may be associated with pelvic floor disorders. We explored the association between different delivery modes and later development of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in Taiwanese women.

METHODS

This was a retrospective population-based cohort study. Women who delivered babies between January 1, 2000, and December 31, 2018, were selected for this study. The study used Taiwan's National Health Insurance (NHI) Research Database. After propensity score matching, 51,587 women who underwent cesarean section (C/S) and 51,587 women who underwent vaginal delivery (VD) were recruited. Primary outcomes were the presence of SUI and POP after delivery.

RESULTS

The incidence of SUI (1.6/1000 person-years) and POP (1.5/1000 person-years) was higher in the VD group than in the C/S group (0.8 and 0.6 in 1000 person-years). VD was associated with an increased risk of SUI [hazard ratio (HR): 2.79, 95% confidence interval (CI): 2.45-3.17] and POP (HR: 1.96, 95% CI: 1.75-2.19) compared to C/S. We also found that age (HR: 1.06, 95% CI: 1.05-1.08 in SUI, HR: 1.08, 95% CI: 1.07-1.09 in POP) and Charlson Comorbidity Index (CCI) (HR: 1.28, 95% CI: 1.12-1.46 in SUI, HR: 1.27, 95% CI: 1.13-1.43 in POP) were associated with an increased risk of SUI and POP. The cumulative incidence of SUI and POP was higher in the VD group than in the C/S group (log-rank test, P < 0.05).

CONCLUSIONS

The current study was the largest retrospective cohort study regarding the influence of delivery mode on SUI and POP so far. VD was found to be associated with an increased risk of SUI and POP compared with C/S. Postpartum care for pelvic physical therapy should be provided particularly to women undergoing VD.

Evaluating compliance and applicability of postpartum pessary use for preventing and treating pelvic floor dysfunction: a prospective multicenter study

PURPOSE

Pelvic floor disorders are common and associated with pregnancy and childbirth. For restitution of pelvic floor connective tissue and thereby therapy of postpartum pelvic organ prolapse and stress urinary incontinence, the Restifem® pessary is approved. It supports the anterior vaginal wall behind the symphysis, the lateral sulci and the sacro-uterine ligaments and stabilises the connective tissue. We evaluated the compliance and applicability of Restifem® use in women postpartum in a preventive and therapeutic approach.

METHODS

Restifem® pessary was handed out to 857 women. Six weeks after birth, they started the pessary use. After 8 weeks, 3 and 6 months postpartum, women received a questionnaire via online survey for evaluation of pessary applicability and efficacy.

RESULTS

After 8 weeks, 209 women answered the questionnaire. 119 women used the pessary. Common problems were discomfort, pain and the pessary use was to circuitous. Vaginal infections were rare. After 3 months, 85 women and after 6 months, 38 women still used the pessary. 3 months postpartum, 94% of women with POP, 72% of women with UI and 66% of women with OAB stated to have an improvement of their symptoms using the pessary. 88% women without any disorder felt an improvement of stability.

CONCLUSIONS

Use of the Restifem® pessary in the postpartum period is feasible and accompanied with less complications. It reduces POP and UI and leads to an increased sense of stability. So, Restifem® pessary can be offered to women postpartum to improve pelvic floor dysfunction.

Strenuous physical activity, exercise, and pelvic organ prolapse: a narrative scoping review

INTRODUCTION AND HYPOTHESIS

High-intensity physical activity and exercise have been listed as possible risk factors for pelvic organ prolapse (POP). The aim of the present study is to conduct a literature review on the prevalence and incidence of POP in women who engage in regular physical activity. In addition, we review the effects of a single exercise or a single session of exercise on pelvic floor support. Finally, the effect of exercises on POP in the early postpartum period is reviewed.

METHODS

This is a narrative scoping review. We searched PubMed and Ovid Medline, the Physiotherapy Evidence Database (PEDro), and the Cochrane Database of Systematic Reviews up to May 2022 with the following MeSH terms: "physical activity" AND "exercise" AND "pelvic floor" AND "pelvic organ prolapse".

RESULTS

Eight prevalence studies were retrieved. Prevalence rates of symptomatic POP varied between 0 (small study within different sports) and 23% (Olympic weightlifters and power lifters). Parity was the only factor associated with POP in most studies. Three studies evaluated the pelvic floor after a single exercise or one session of exercise and found increased vaginal descent or increased POP symptoms. One prospective cohort study reported the development of POP after 6 weeks of military parashot training, and one randomized trial reported increased POP symptoms after transverse abdominal training. There is scant knowledge on exercise and POP in the postpartum period.

CONCLUSIONS

Prevalence of POP in sports varies widely. Experimental and prospective studies indicate that strenuous exercise increased POP symptoms and reduced pelvic floor support.

Postpartum pelvic organ prolapse and pelvic floor muscle training: secondary analysis of a randomized controlled trial of primiparous women

INTRODUCTION AND HYPOTHESIS

Pelvic floor dysfunction is common after childbirth. We hypothesize that physiotherapist-guided pelvic floor muscle training (PFMT) is effective regarding pelvic organ prolapse (POP) symptoms during the first postpartum year.

METHODS

This was a secondary analysis from a randomized controlled trial (RCT), carried out at a physiotherapy clinic, Reykjavik. Participants were eighty-four primiparous women with a singleton delivery. They were screened for eligibility 6-13 weeks postpartum. Women in a training group conducted 12 weekly individual sessions with a physiotherapist within an RCT, starting on average 9 weeks postpartum. Outcomes were assessed after the last session (short term) and at approximately 12 months postpartum (long term). The control group received no instructions after the initial assessment. Main outcome measures were self-evaluated POP symptoms by the Australian Pelvic Floor Questionnaire.

RESULTS

Forty-one and 43 women were in the training and control groups, respectively. At recruitment, 17 (42.5%) of the training group and 15 (37%) of the control group reported prolapse symptoms (p = 0.6). Five (13%) from the training group and nine (21%) controls were bothered by the symptoms (p = 0.3). There was a gradual decrease in the number of women with symptoms and no significant short-term (p = 0.08) or long-term (p = 0.6) differences between the groups regarding rates of women with POP symptoms. The difference between groups regarding bother in the short (p = 0.3) or longer term (p = 0.4) was not significant. Repeated-measures analyses using Proc Genmod in SAS did not indicate a significant effect of the intervention over time (p > 0.05).

CONCLUSIONS

There was an overall decrease in postpartum symptoms of POP and bother during the first year. Physiotherapist-led PFMT did not change the outcomes.

CLINICAL TRIAL REGISTRATION

The trial was registered 30 March 2015 at https://register.

CLINICALTRIALS

gov (NCT02682212). Initial participant enrollment was on 16 March 2016 and reported following CONSORT guidelines for randomized controlled trials.

Pelvic floor muscle training as a method of prevention and treatment of pelvic floor dysfunction and genital prolapse

Relevance. Pelvic floor dysfunction and pelvic organ prolapse are a significant problem today - even the initial manifestations of pelvic floor dysfunction can lead to reduced quality of sexual life, decreased activity, and then to social isolation and decreased self-esteem of women. Due to the growth of general life expectancy, the incidence rate is also increasing. One of the most popular conservative treatments for pelvic floor dysfunction is pelvic floor muscle training. The aim of this literature review is to consolidate the scattered information about the effectiveness of pelvic floor muscle training as a prevention and treatment of pelvic floor dysfunction. Materials and Methods. In writing the review, publications from the PubMed and Google Scholar databases from January 2019 were analyzed and systematized. Results and Discussion. Pelvic floor muscle training is one of the most prospective methods of non-invasive treatment for pelvic organ prolapse. It can take many forms and is represented by a range of different techniques: from the simple short-term muscle contraction and Kegel exercises to more complex and high-tech methods using electromyostimulation and biofeedback. However, timing of introduction and method for pelvic floor muscle training must be carefully considered in order to gain the maximum result. Conclusion. Based on the study, it can be concluded that the introduction of pelvic floor muscle training as part of prenatal care and in the antenatal period is the most appropriate way to prevent pelvic floor failure and genital prolapse. Further research is required to confirm the hypothesis.

Are hypopressive and other exercise programs effective for the treatment of pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS

Pelvic floor muscle training (PFMT) is effective for the treatment of pelvic organ prolapse (POP), but other exercise programs have also been promoted and used. The aim of this review was to evaluate the effect of hypopressive and other exercise programs besides PFMT for POP.

METHODS

A literature search was conducted on Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro, and Scopus databases from January 1996 to 30 December 2021. Only randomized controlled trials (RCTs) were included. The keywords were combinations of "pelvic organ prolapse" or "urogenital prolapse," and "exercise therapy," "hypopressive exercise," "Kegel," "pelvic floor muscle training," "pelvic floor muscle exercises," "Pilates," "treatment," "yoga," "Tai Chi." Methodological quality was assessed using the PEDro rating scale (0-10).

RESULTS

Seven RCTs containing hypopressive exercise, yoga or breathing and hip muscle exercises in an inverted position were retrieved and analyzed. PEDro score ranged from 4 to 7. There was no additional effect of adding hypopressive exercise to PFMT, and PFMT was more effective than hypopressive exercise alone. The studies that included the term "yoga" included regular PFMT and thus can be classified as PFMT. Hip exercises in an inverted position added to PFMT vs PFMT alone showed better improvement in some secondary outcomes but not in the primary outcome, POP stage.

CONCLUSIONS

There are few RCTs assessing the effects of other exercise programs besides PFMT in the treatment of POP. To date, there is no evidence that other exercise programs are more effective than PFMT for POP.

Effect of Pelvic Floor Workout on Pelvic Floor Muscle Function Recovery of Postpartum Women: Protocol for a Randomized Controlled Trial

BACKGROUND

There is a risk of pelvic floor dysfunction (PFD) from baby delivery. Many clinical guidelines recommend pelvic floor muscle training (PFMT) as the conservative treatment for PFD because pelvic floor muscles (PFMs) play a crucial role in development of PFD. However, there is disagreement about the method and intensity of PFM training and the relevant measurements. To pilot the study in PFM training, we designed a Pelvic Floor Workout (PEFLOW) for women to train their pelvic through entire body exercises, and we planned a trial to evaluate its effectiveness through comparing the outcomes from a group of postpartum women who perform PELFLOW at home under professional guidance online with the control group.

METHODS/DESIGN

The randomized controlled trial was projected to be conducted from November 2021 to March 2023. A total of 260 postpartum women would be recruited from the obstetrics departments of the study hospital and women would be eligible for participation randomized into experimental or control groups (EG/CG) if their PFM strength are scaled by less than Modified Oxford grading Scale (MOS) to be less than grade 3. Women in EG would perform a 12-week PEFLOW online under the supervision and guidance of a physiotherapist, while women in CG would have no interventions. Assessments would be conducted at enrollment, post intervention (for EG) or 18th to 24th week postpartum (for CG), and 1 year postpartum. Assessment would be performed in terms of pelvic floor symptoms, including MOS, cough stress test, urinary leakage symptoms, pelvic organ prolapse quantitation (POP-Q), and vaginal relaxation, clinic examinations including Pelvic floor electrophysiological test, Pelvic floor ultrasound and Spine X-ray, overall body test including trunk endurance test, handgrip test, body composition test, and questionnaires including International Physical Activity Questionnaire Score-Short Form(IPAQ-SF), Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20), Pelvic Floor Impact Questionnaire-7 (PFIQ-7), the 6-item Female Sexual Function Index (FSFI-6), and the Pittsburgh Sleep Quality Index (PSQI). Primary analysis will be performed to test our main hypothesis that PEFLOW is effective with respect to strengthen PFM strength.

DISCUSSION

This trial will demonstrate that pelvic floor-care is accessible to most women and clinical practice on PFD may change relevantly should this study find that Online PEFLOW approach is effective to improve PFMs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05218239.