Two-year effects and cost-effectiveness of pelvic floor muscle training in mild pelvic organ prolapse: a randomised controlled trial in primary care

Pelvic floor muscle training as treatment for female sexual dysfunction: a systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the efficacy of pelvic floor muscle training in treating female sexual dysfunction.

DATA SOURCES

A systematic review of databases, including PubMed, Ovid Medline, CINAHL, Embase, BVSalud, Scopus, and Cochrane Library, was performed in July 2021 and updated in May 2023.

STUDY ELIGIBILITY CRITERIA

Full-text articles of randomized controlled trials comparing pelvic floor muscle training with no intervention or another conservative treatment were included. At least 1 arm of these trials aimed to improve women's sexual function or treat sexual dysfunction.

METHODS

The data for this review were extracted and analyzed by 2 independent reviewers. Data on the characteristics of each intervention were extracted using the Consensus on Exercise Reporting Template. The risk of bias and certainty of evidence were assessed using the Physiotherapy Evidence Database (PEDro) scale and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria, respectively. A meta-analysis was conducted considering the posttreatment mean score difference in the Female Sexual Function Index between the control and treatment groups.

RESULTS

A total of 21 randomized controlled trials were included in this review. The Consensus on Exercise Reporting Template revealed varying quality of the pelvic floor muscle training protocols. Four studies were included in the meta-analysis showing that pelvic floor muscle training improved arousal (1.49; 95% confidence interval, 0.13-2.85), orgasm (1.55; 95% confidence interval, 0.13-2.96), satisfaction (1.46; 95% confidence interval, 0.14-2.77), pain (0.74; 95% confidence interval, 0.11-1.37), and the Female Sexual Function Index overall score (7.67; 95% confidence interval, 0.77-14.57). Very low certainty of evidence due to the data's high clinical and statistical heterogeneity was found according to the GRADE criteria. No side effects of the interventions were reported.

CONCLUSION

This systematic review and meta-analysis showed that pelvic floor muscle training improved female Female Sexual Function Index total score and several subscales; however, the certainty of the evidence is low.

Pelvic Floor Disorders and Sexual Function: A Review

Pelvic floor disorders can result in laxity, hypertonicity or spasm, all of which can impact sexual function. It is important for clinicians to understand this impact in order to appropriately counsel and treat their patients.

Cost-effectiveness of pessary therapy versus surgery for symptomatic pelvic organ prolapse: an economic evaluation alongside a randomised non-inferiority controlled trial

OBJECTIVE

To evaluate the cost-effectiveness of pessary therapy as an initial treatment option compared with surgery for moderate to severe pelvic organ prolapse (POP) symptoms in secondary care from a healthcare and a societal perspective.

DESIGN

Economic evaluation alongside a multicentre randomised controlled non-inferiority trial with a 24-month follow-up.

SETTING

21 hospitals in the Netherlands, recruitment conducted between 2015 and 2022.

PARTICIPANTS

1605 women referred to secondary care with symptomatic prolapse stage ≥2 were requested to participate. Of them, 440 women gave informed consent and were randomised to pessary therapy (n=218) or to surgery (n=222) in a 1:1 ratio stratified by hospital.

INTERVENTIONS

Pessary therapy and surgery.

PRIMARY AND SECONDARY OUTCOME MEASURES

The Patient Global Impression of Improvement (PGI-I), a 7-point scale dichotomised into successful versus unsuccessful, with a non-inferiority margin of -10%; quality-adjusted life-years (QALYs) measured by the EQ-5D-3L; healthcare and societal costs were based on medical records and the institute for Medical Technology Assessment questionnaires.

RESULTS

For the PGI-I, the mean difference between pessary therapy and surgery was -0.05 (95% CI -0.14; 0.03) and -0.03 (95% CI -0.07; 0.002) for QALYs. In total, 54.1% women randomised to pessary therapy crossed over to surgery, and 3.6% underwent recurrent surgery. Healthcare and societal costs were significantly lower in the pessary therapy (mean difference=-€1807, 95% CI -€2172; -€1446 and mean difference=-€1850, 95% CI -€2349; -€1341, respectively). The probability that pessary therapy is cost-effective compared with surgery was 1 at willingness-to-pay thresholds between €0 and €20 000/QALY gained from both perspectives.

CONCLUSIONS

Non-inferiority of pessary therapy regarding the PGI-I could not be shown and no statistically significant differences in QALYs between interventions were found. Due to significantly lower costs, pessary therapy is likely to be cost-effective compared with surgery as an initial treatment option for women with symptomatic POP treated in secondary care.

TRIAL REGISTRATION NUMBER

NTR4883.

A Qualitative Exploration of the Perceptions of Women Living with Pelvic Floor Disorders and Factors Related to Quality of Life

Background: Pelvic floor dysfunction encompasses conditions like urinary and fecal incontinence, pelvic organ prolapse, and pelvic pain, significantly affecting women's quality of life. Despite its prevalence, few studies have adopted a qualitative approach to understanding women's perceptions and emotions regarding these issues. This study aims to delve into how women with pelvic floor disorders perceive their condition and its impact on their daily lives. Methods: We analyzed qualitative data from interviews with 160 women suffering from pelvic floor dysfunctions. Using inductive qualitative content analysis, we systematically examined the data to identify variations, differences, and similarities. Results: The analysis revealed four primary themes in the women's narratives: "Physical Impacts", "Emotional and Psychological Impacts", "Social and Relational Impacts", and "Sexual Health Impacts", along with 12 subthemes. The findings predominantly highlight how pelvic floor dysfunctions detrimentally affect women's quality of life and emotional well-being, instilling fear and insecurity in daily activities, compounded by sleep disturbances and sexual dysfunction. Conclusions: Women living with pelvic floor dysfunction face multifaceted challenges that adversely affect various aspects of their lives, diminishing their overall quality of life. This includes notable impacts on sleep, physical, and sexual activities. However, not all affected women report these issues, often due to fear of stigma, choosing instead to conceal their struggles in an effort to maintain an appearance of normalcy.

Pelvic organ prolapse: Women's experiences of Accessing Care & Recommendations for improvement

Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life.Many women with POP symptoms present initially to primary care settings. Research has shown these interactions are often unsatisfactory, with women reporting their health care professional (HCP) trivialized their symptoms or appeared to have poor knowledge about pelvic floor dysfunction (PFD).Aim The aim of this qualitative study was to explore experiences of younger women seeking treatment for POP and their recommendations for improvements.Methods Ethics approval was obtained (LS-21-01-Carroll-Ful). Women with POP were recruited from an online support group (n = 930 members). Inclusion criteria: adult women, diagnosed with POP and aware of their POP stage. Following informed consent, a demographic questionnaire, interview questions and the Central Sensitization Inventory (CSI) were forwarded. Semi-structured zoom audio-recorded interviews were conducted. Thematic analysis was undertaken; transcripts coded, and themes identified.Results Fourteen women aged 32-41, parity 1-3, with POP Grade 1-3 participated. Many women reported HCPs as dismissive or not appreciative of the impact of their condition. Others described interactions with HCPs who they felt listened, understood the impact of their POP, gave simple explanations, a positive prognosis and outlined a realistic treatment plan.Current antenatal education, post-partum care and primary HCP screening for PFD were identified by women as deficient. Many highlighted delays in accessing specialist care for POP. Women made several recommendations for improvements to the current model of care.Conclusions Increased focus on person-centred care, particularly emotional support, information and education may improve younger women's experiences when seeking care for POP.

Stress Urinary Incontinence: An Unsolved Clinical Challenge

Stress urinary incontinence is still a frequent problem for women and men, which leads to pronounced impairment of the quality of life and withdrawal from the social environment. Modern diagnostics and therapy improved the situation for individuals affected. But there are still limits, including the correct diagnosis of incontinence and its pathophysiology, as well as the therapeutic algorithms. In most cases, patients are treated with a first-line regimen of drugs, possibly in combination with specific exercises and electrophysiological stimulation. When conservative options are exhausted, minimally invasive surgical therapies are indicated. However, standard surgeries, especially the application of implants, do not pursue any causal therapy. Non-absorbable meshes and ligaments have fallen into disrepute due to complications. In numerous countries, classic techniques such as colposuspension have been revived to avoid implants. Except for tapes in the treatment of stress urinary incontinence in women, the literature on randomized controlled studies is insufficient. This review provides an update on pharmacological and surgical treatment options for stress urinary incontinence; it highlights limitations and formulates wishes for the future from a clinical perspective.

Management of vaginal laxity through bilateral wall tightening without mucosal excision

BACKGROUND

Vaginal tightening or vaginoplasty has been gaining popularity, while validated methods of evaluation and treatment are still lacking. Herein, we describe a bilateral wall tightening technique for vaginal laxity and evaluate the feasibility of this method.

METHODS

From April 2020 to September 2021, 25 women with vaginal laxity underwent vaginal tightening, and 22 women were included in this retrospective observational study. The inclusion criteria were as follows: participants with at least one delivery and reported vaginal laxity, but without a history of underlying diseases. Vaginal pressure tests and questionnaires were used to evaluate vaginal laxity and sexual quality before and 6 months after the surgery.

RESULTS

The study included 22 women (aged 29-46 years), and the follow-up period was 14.1 ± 3.3 months. The score based on the vaginal laxity questionnaire was improved as a result of surgery (preoperative median: 2.00, interquartile range [IQR]: 1.00-2.00; postoperative median: 5.00, IQR: 5.00-6.25, p < 0.001). The vaginal pressure increased from 2.3 ± 1.8 mm/Hg to 21.4 ± 3.7 mm/Hg. Sexual distress changed from 24.2 ± 8.9-16.1 ± 4.8 after surgery (p < 0.001), and sexual dysfunction with an average score of 20.1 ± 10.6 before surgery improved after the procedure (26.0 ± 10.8, p < 0.001). Women also reported improved scores in desire, arousal, orgasm, and satisfaction. In addition, there were no intraoperative complications or significant events during the follow-up period.

CONCLUSIONS

Bilateral vaginal tightening without mucosal excision is a feasible and effective surgical approach for the management of vaginal laxity.

Long-term effects and costs of pelvic floor muscle training for prolapse: trial follow-up record-linkage study

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse affects around 40% of women aged over 50 years. A multicentre parallel group randomised trial (the Pelvic Organ Prolapse PhysiotherapY (POPPY) trial) demonstrated that pelvic floor muscle training (PFMT) was effective in reducing prolapse symptoms compared with no treatment. However, insight into the long-term impact of PFMT on health outcomes and health-service utilisation is scarce.

METHODS

This study utilised linkage of Scottish administrative health records to follow-up POPPY trial participants resident in Scotland over 11 years. Mixed effects logistic regression determined the likelihood of receiving further prolapse treatment for those in the PFMT and control groups. Analyses were adjusted for age group, prolapse stage, baseline symptom severity and attitude towards surgery. A cost assessment estimated longitudinal costs to the UK National Health Service (in Scotland) of accessing further prolapse treatment for each trial group.

RESULTS

Two hundred and ninety-three women, aged 25 to 79 years, were followed up. One hundred and forty-one women (48.1%) had received further prolapse treatment: 65 (of 149; 43.6%) in the PFMT group compared with 76 (of 144; 52.8%) in the control group. PFMT was associated with a reduction in the odds of any prolapse treatment during follow-up (AOR 0.61; 95% CI 0.37 to 0.99). Total cost of secondary care was £154,544 (GBP) in the PFMT group and £172,549 (GBP) in the control group.

CONCLUSIONS

Although PFMT did not lead to significant differences in total costs for further prolapse treatment over a post-intervention period of more than 10 years, it reduced the overall long-term risk of requiring hospital-based treatment for pelvic floor disorders.

Opportunities and Capabilities to Perform Pelvic Floor Muscle Training Are Critical for Participation: A Systematic Review and Qualitative Meta-Synthesis

OBJECTIVE

Pelvic floor muscle training (PFMT) is considered a behavioral task that requires the interaction of physical, social, and cognitive processes. Enablers and barriers to participation in PFMT have been explored primarily in women. This review aimed to identify the barriers and enablers that influence participation in PFMT in all adult populations.

METHODS

A systematic review and meta-synthesis of qualitative literature was conducted. The inclusion criteria comprised qualitative studies with populations of people aged 18 years and older who have been recommended for PFMT. Line-by-line coding and an inductive thematic analysis identified themes that were applied to the Theoretical Domains Framework and Capabilities, Opportunities, and Motivation Behavioral Model to determine behavioral influences on PFMT.

RESULTS

Twenty full-text articles met inclusion criteria. PFMT was mostly influenced by individual opportunities impacted by social determinants and competing demands. Capability of carrying out PFMT was impacted by knowledge, understanding, and appropriate skill acquisition linked to self-efficacy.

CONCLUSION

Increasing opportunities and capabilities for engagement in PFMT are the most important factors in optimizing positive behavior changes. Ways to address these factors include clear patient communication to boost confidence in skill acquisition and using technology to encourage autonomy and improve convenience. Future research should address the impact of health professionals' beliefs about patient participation, assess the role of social values and gender roles, and explore the timing of the implementation of behavioral change strategies to improve PFMT.

IMPACT

This is believed to be the first systematic review and qualitative meta-synthesis to consider the enablers and barriers to participation in PFMT for all adult populations, purposes, and symptom complexes. Patient opportunities and capabilities are the greatest influencers on participation and self-efficacy. Individualized treatment approaches that acknowledge and address social influencers and competing demands will optimize self-efficacy and participation.

LAY SUMMARY

If you have pelvic floor muscle dysfunction, your opportunities and capabilities are the greatest influencers on participation and self-efficacy in PFMT. Your physical therapist can design individualized treatment approaches that acknowledge and address social influencers and competing demands to help you optimize participation.

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.

Patient and economic benefits of psychological support for noncompliant patients

The current paper provides an overview of treatment noncompliance at various points in the treatment pathway, especially with respect to treatment for Pelvic-floor Dysfunction (PFD). The effects of noncompliance on healthcare are considered, and examples of supporting patients psychologically to increase compliance are discussed. An outline of a method to identify costs of non-compliance, and where such costs most intensely impact the healthcare system, is provided. It is suggested that psychological support is effective in terms of increased compliance and improved healthcare economics. The model is presented for PFD, but the principles developed can be generalised to many aspects of healthcare.

Effect of electroacupuncture on symptoms of female pelvic organ prolapse (stage II-III) (EAPOP study): protocol of a randomised controlled trial

INTRODUCTION

Pelvic organ prolapse (POP) is downward descent of pelvic organs, which causes symptoms of the lower genital, urinary and gastrointestinal tracts, and undermines women's daily activities and quality of life. Although studies indicated that electroacupuncture (EA) may be effective in improving the POP symptoms, evidences were not robust. Therefore, this study aims to conduct a randomised controlled trial (RCT) to evaluate the efficacy and safety of electroacupuncture on relieving symptoms of a POP stage II and III among women.

METHODS AND ANALYSIS

A two-arm, multicentre, patient-blind RCT will be conducted to compare EA with sham electroacupuncture (SEA) for treating symptoms of POP stage II and III among women in six tertiary hospitals in China. One hundred and sixty eligible women will be assigned with a 1:1 ratio to have received either EA or SEA for 24 times in 12 weeks and followed-up for 24 weeks. The primary outcome will be the change on the total score of the Pelvic Floor Distress Inventory-short form 20 at week 12 from baseline, and will be analysed by t-test or multiple regression model. Intention-to-treat analysis will be performed for all outcomes, and a p value of less than 0.05 (two-sided testing) will be considered as statistical significance.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Medical Ethical Committee of Guang'ammen Hospital (No. 2019-249-KY-01). Patients will be informed about the details of the study and asked to sign consent form before enrolment. The results of this study are expected to be written and published on peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04589715.

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.

Clinical Efficacy of LSC and TVT-O for Stress Urinary Incontinence Complicated with Pelvic Organ Prolapse and Factors Influencing Postoperative Urinary Function Recovery

Pelvic organ prolapse is caused by various causes, which leads to the weakness of the tissue supporting the pelvic floor and then causes the downward displacement of female reproductive organs and adjacent organs. Clinical studies have shown that pop is often associated with stress urinary incontinence. This research project aimed to clarify the clinical effect of laparoscopic sacrocolpopexy (LSC) and tension-free vaginal tape obturator (TVT-O) for stress urinary incontinence (SUI) complicated with pelvic organ prolapse (POP) and the influencing factors of postoperative urinary function (UF) recovery. The clinical data of 125 patients with SUI complicated with POP treated in Wenzhou Central Hospital and Beidahuang Industry Group General Hospital between March 2018 and December 2019 were retrospectively analyzed. Patients were assigned to the following two arms based on different treatment methods: the combination group (n = 65, treated with LSC plus TVT-O) and the control group (n = 60, treated with LSC). The alterations of perioperative clinical and urodynamic indexes were analyzed. The objective and subjective response rates were observed and compared. The degree of POP before and after surgery was evaluated. According to the urinary function recovery time, the patients were divided into the fast and non-fast recovery groups, and then, the factors influencing postoperative UF recovery were analyzed between groups. The combination group showed statistically longer operation time (OT) and postoperative indwelling catheter and higher intraoperative blood loss (IBL) than the control group (all P < 0.05), but the anal exhaust time and postoperative length of stay (LOS) differed insignificantly between the two arms. The combination group outperformed the control group in the objective response rate, as well as the scores of illness, quality of life (QOL), and sexual life (all P < 0.05). Menopause, maximum flow rate (MFR), and preoperative residual urine volume were identified as the influencing factors for normal urination. For patients with SUI complicated with POP, the efficacy of laparoscopic sacrocolpopexy was limited, while combining with TVT-O would obtain more significant short-term and long-term efficacy, which can significantly improve patients' urination and long-term quality of life, with higher safety and clinical promotion value.

The effect of pelvic floor muscle training for women with pelvic organ prolapse: a meta-analysis

INTRODUCTION AND HYPOTHESIS

This study was aimed at evaluating the effect of pelvic floor muscle training (PFMT) as a conservative treatment for patients with pelvic organ prolapse (POP).

METHODS

A comprehensive search to identify eligible randomized controlled trial (RCT) studies was conducted using electronic databases including PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase up to 10 June 2021. Results were presented as risk ratio (RR), the weighted mean difference (WMD), with 95% confidence interval (95% CI) using the random effects model. Outcome variables were pooled using Review Manager version 5.3.

RESULTS

Thirteen studies were included. Our results demonstrated that women who received PFMT intervention had a greater improvement than controls in prolapse symptom score (POP-SS; mean difference [MD] -1.66, 95% CI -2.36 to -0.97, p < 0.00001] and POP stages (risk ration [RR] 1.51, 95% CI 1.14-2.01, p = 0.004). The number of participants who felt better after PFMT was higher (RR 1.98, 95% CI 1.21-3.24, p = 0.006). Subgroup analysis showed that the symptoms of prolapse and the degree of prolapse were improved significantly in the short term, but there was no significant difference in the long-term effect. In addition, there was no significant difference in the impact of PFMT on the elderly and the quality of life. More RCTs are needed to evaluate the effect of PFMT on the elderly and whether the quality of life can be improved.

CONCLUSIONS

We found that PFMT can improve subjective symptoms and objective POP severity. More research is needed on the long-term effect.

International Urogynaecology Consultation chapter 1 committee 4: patients' perception of disease burden of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reports on the patients' perception of disease burden associated with pelvic organ prolapse.

MATERIALS AND METHODS

An international group containing a team of eight urogynaecologists, a physiotherapist and a statistician performed a search of the literature using pre-specified search terms in PubMed and Embase (January 2000 to August 2020). The division of sections within this report includes: (1) perception of POP and the relationship with body image and poor health; (2) a vaginal bulge as it impacts health and wellbeing in women; (3) the impact of POP on sexual life; (4) body image and pelvic floor disorders; (5) POP and mood; (6) appropriate use of treatment goals to better meet patients' expected benefits; (7) using health-related quality of life questionnaires to quantify patients' perception of POP; (8) The financial burden of POP to patients and society. Abstracts were reviewed and publications were eliminated if not relevant or did not include populations with POP or were not relevant to the subject areas as noted by the authors. The manuscripts were next reviewed for suitability using the Specialist Unit for Review Evidence (SURE) checklists for cohort, cross-sectional and case-control epidemiologic studies.

RESULTS

The original individual literature searches yielded 2312 references of which 190 were used in the final manuscript. The following perceptions were identified: (1) women were found to have varying perceptions of POP including shame and embarrassment. Some regard POP as consequence of aging and consider there is no effective therapy. (2) POP is perceived as a vaginal bulge and affects lifestyle and emotional wellbeing. The main driver for treatment is absence of bulge sensation. (3) POP is known to affect frequency of sexual intercourse but has less impact on satisfaction. (4) Prolapse-specific body image and genital self-image are important components of a women's emotional, physical and sexual wellbeing. (5) POP is commonly associated with depression and anxiety symptoms which impact HRQoL although are not correlated with objective anatomical findings. (6) Patient-centered treatment goals are useful in facilitating communication, shared decision-making and expectations before and after reconstructive surgery. (7) Disease-specific HRQoL questionnaires are important tools to assess bother and outcome following surgery, and there are now several tools with Level 1 evidence and a Grade A recommendation. (8) The cost of POP to the individual and to society is considerable in terms of productivity. In general, conservative measures tend to be more cost-effective than surgical intervention.

CONCLUSIONS

Patients' perception of POP varies in different patients and has a far-reaching impact on their overall state of health and wellbeing. However, recognizing that it is a combination of body image and overall health (which affects mental health) allows clinicians to better tailor expectations for treatment to individual patients. There are HRQoL tools that can be used to quantify these impacts in clinical care and research. The costs to the individual patient (which affects their perception of POP) is an area that is poorly understood and needs more research.

Role of Preoperative and Postoperative Pelvic Floor Distress Inventory-20 in Evaluation of Posthysterectomy Vault Prolapse

Background:

Posthysterectomy vault prolapse is a common problem after vaginal or abdominal hysterectomy. The objective was to assess the role of Pelvic Floor Distress Inventory 20 (PFDI-20) in evaluation of vault prolapse.

Materials and Methods:

Prospective study in 20 women with posthysterectomy vault prolapse of Stage 2 and above. The outcome measure was to calculate PFDI-20 score in all cases before surgical intervention and to recalculate it again in 6 months after different surgical procedures for vault prolapse and to statistically compare the PFDI-20 score in different types of surgery over 4 years period at a tertiary referral hospital for surgical treatment. Prolapse was classified using Pelvic Organ Prolapse Quantification and intraoperative findings. All women were operated for vault prolapse as per hospital protocol and stage of prolapse by either vaginal sacrospinous fixation or abdominal sacrocolpopexy.

Results:

Mean age, parity, and body mass index were 54.8 years, 3.5, and 22.71 kg/m² respectively. Preceding surgery was vaginal hysterectomy in 75% women and abdominal hysterectomy in 25% women. Complaints were bulge or mass feeling at perineum (100%), pressure in lower abdomen and perineum (55%), and constipation (60%). The type of prolapse was vault prolapse (100%), cystocele (100%), rectocele (100%), and enterocele (45%). The range of PFDI-20 was 88–152 with mean being 123.50 ± 22.71 before surgery while its range decreased significantly to 80–126 with mean being 106.40 ± 16.45 after surgery (P < 0.01). Mean postoperative PFDI-20 score was 107.40 in vaginal sacrospinous fixation group and was 105.30 in abdominal sacrocolpopexy group and was not statistically different (P = 0.18).

Conclusion:

PFDI-20 score can be used to see the adverse impact of vault prolapse on pelvic floor and to assess the beneficial effect of different types of surgeries on the score.

Surgery for pelvic organ prolapse and stress urinary incontinence and female sexual functions: A quasi-experimental study

Objectives:

To assess the effect of pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI) on various domains of female sexual functions in patients before and after reconstructive surgery for these pelvic floor disorders.

Methods:

We conducted a quasi-experimental study of 126 women aged 25-65 years, presenting with POP / SUI, from January 1^st 2019 to December 31^st 2019 at Aga Khan University Hospital. POP surgery was performed only in patients with symptomatic POP ≥ stage 2 according to POP-Q (quantification). Sexual functions were assessed using Female Sexual Function Index (FSFI) questionnaire, among sexually active women at baseline and 18 months after surgery.

Results:

Mean age of the participants was 51.6, with a mean parity of four. Out of 126 patients, 31 patients underwent vaginal hysterectomy, pelvic floor repair and mid-urethral sling (MUS), 55 had vaginal hysterectomy with pelvic floor repair, 12 women had only pelvic floor repair and 10 patients had uterine suspension surgery for prolapse, while 18 patients underwent MUS operation alone for SUI. There was a statistically significant difference in female sexual functions after surgery for POP and/or SUI (p<0.01). This improvement was observed in both total and individual scores of each domain of FSFI with an overall improvement in sexual function from a mean of 18.5 pre-surgery to 20.8 post-surgery.

Conclusions:

This study reveals that women sexual functions are affected by POP and SUI and improve remarkably after reconstructive surgeries for these pelvic floor disorders.

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.

Evaluation of Awareness, Adherence, and Barriers of Pelvic Floor Muscle Training in Pregnant Women: A Cross-sectional Study

INTRODUCTION

Adherence to pelvic floor muscle training (PFMT) may be enhanced when the women become aware of its preventive/therapeutic role in pelvic floor disorders.

OBJECTIVE

This study is conducted to evaluate the PFMT awareness, adherence, and barriers in pregnant women.

METHOD

We studied the awareness, adherence, and barriers of PFMT in 200 pregnant women attended in prenatal care clinic in their third trimester of pregnancy using semistructured interviews with open and closed questions derived from recent literature review on PFMT.

RESULT

Fifty-four (27%) of studied women were familiar with PFMT, 175 (87.5%) of patients thought that the UI is normal during pregnancy, and 25 (32.05%) had experienced UI episodes and had consulted with their obstetrician. Twenty-one (10.5%) of patients did the PFMT exercises before their pregnancy, 14 (66.6%) of them continued their PFMT exercises during their pregnancy, and 7 (33.4%) stopped it. Concerns about miscarriage were the main reason of discontinuing the exercises during pregnancy. Routes of knowledge acquisition were the Internet in 24 cases (44.4%), health system in 13 cases (24.07%), family and friends in 11 cases (20.3%), and books/magazines in 6 cases (11.1%). Main means of mass communication (including TV, radio, and newspapers) had no role in knowledge distribution in this filed.

CONCLUSIONS

Pregnant women require more health education regarding PFMT. Health care professionals should be more involved in patient education process. Internet resources are used widely by women and need more academic/scientific supervision.

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.

MAIN MANOMETRIC FINDINGS AND POTENTIAL FOR ANORECTAL PHYSICAL THERAPY IN THE TREATMENT OF PATIENTS WITH EVACUATION DISORDERS

BACKGROUND

Evacuation disorders are prevalent in the adult population, and a significant portion of cases may originate from pelvic floor muscle dysfunctions. Anorectal manometry (ARM) is an important diagnostic tool and can guide conservative treatment.

OBJECTIVE

To evaluate the prevalence of pelvic dysfunction in patients with evacuation disorders through clinical and manometric findings and to evaluate, using the same findings, whether there are published protocols that could be guided by anorectal manometry.

METHODS

A retrospective analysis of a prospective database of 278 anorectal manometries performed for the investigation of evacuation disorders in patients seen at the anorectal physiology outpatient clinic of Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto between January 2015 to June 2019 was conducted. The following parameters were calculated: resting pressure (RP), squeeze pressure (SP), high-pressure zone (HPZ), rectal sensitivity (RS) and rectal capacity (RC). The pressure measurements and manometric plots were reviewed to determine the diagnosis and to propose potential pelvic physical therapy procedures. Analysis of variance (ANOVA) and Fisher's exact test were used to compare the continuous variables and to evaluate the equality of variances between groups of patients with fecal incontinence (FI) and chronic constipation (CC). Results with a significance level lower than 0.05 (P-value <0.05) were considered statistically significant. Statistical analysis was performed using IBM® SPSS® Statistics version 20.

RESULTS

The mean age of the sample was 45±22 years, with a predominance of females (64.4%) and economically inactive (72.7%) patients. The indications for exam performance were FI (65.8%) and CC (34.2%). Patients with FI had lower RP (41.9 mmHg x 67.6 mmHg; P<0.001), SP (85.4 mmHg x 116.0 mmHg; P<0.001), HPZ (1.49 cm x 2.42 cm; P<0.001), RS (57.9 mL x 71.5 mL; P=0.044) and RC (146.2 mL x 195.5 mL; P<0.001) compared to those of patients with CC. For patients with FI, the main diagnosis was the absence of a functional anal canal (49.7%). For patients with CC, the main diagnosis was outflow tract obstruction (54.7%). For patients with FI, the main protocol involved a combination of anorectal biofeedback (aBF) with tibial nerve stimulation (TNS) (57.9%). For patients with CC, the most indicated protocol was aBF combined with TNS and rectal balloon training (RBT) (54.7%).

CONCLUSION

There was a high prevalence of pelvic floor changes in patients with evacuation disorders. There was a high potential for performing pelvic floor physical therapy based on the clinical and manometric findings.

Effect of different electrical stimulation protocols for pelvic floor rehabilitation of postpartum women with extremely weak muscle strength: Randomized control trial

BACKGROUND

Pregnancy is one of the main risk factor of pelvic floor muscle dysfunction. Postpartum women with extremely weak muscle strength have difficulty to do voluntary pelvic floor muscle training. This study aims to evaluate the effects of different protocols of electrical stimulation in the treatment of postpartum women with extremely weak muscle strength.

METHODS

A total of 67 women were randomized into 2 groups: group A received transvaginal electrical stimulation (TVES) for 5 times, and group B received TVES for 3 times with electromyogram (EMG)-triggered neuromuscular stimulation twice. Subjects were evaluated before and after treatment. Pelvic muscle strength was measured by both digital vaginal palpation and EMG variables, and quality of life was investigated by 4 kinds of pelvic floor disease-related questionnaires.

RESULTS

According to the intention-to-treat principle, compared with baseline, in group A, EMG of contractile amplitude of endurance phase was significantly elevated (P = .03), variation of contractile amplitude in tonic phase was more stable after treatment (P = .004), and EMG of mean value of final rest was significantly elevated after treatment (P = .047). After 5 times treatments, the incidence of correct pelvic floor muscle contraction in group A was significantly elevated (P = .045). No significant difference of muscle strength test by digital vaginal palpation was detected between the 2 groups, so did questionnaires.

CONCLUSION

For postpartum women with extremely weak muscle strength, TVES for 5 times might be more benefit for control ability of pelvic muscle contractions and elevating muscle strength even in short-time treatment.

Effect of pelvic floor dysfunction on sexual function and quality of life in Chinese women of different ages: An observational study

AIM

The aim of the present study was to investigate the effect of female pelvic floor dysfunction on sexual function and quality of life among different age groups.

METHODS

An observational study was carried out on 648 patients with pelvic organ prolapse (POP) or/and stress urinary incontinence. We assessed female sexual function and quality of life through the Prolapse/Urinary Incontinence Sexual Questionnaire Short Form and Incontinence Quality of Life Scale before surgeries, respectively. Patients were assigned into different age groups.

RESULTS

The mean age of all patients was 62.04 ± 9.39 years. A total of 436 patients had POP, 120 patients had stress urinary incontinence and the remaining patients had both. Although sexual frequency decreased with increasing age, 517 patients still remained sexually active. A total of 10.83% of the patients aged ≥70 years were still sexually active, and 8.51% of them had sex less than one time per month. The Prolapse/Urinary Incontinence Sexual Questionnaire Short Form score and sexual frequency decreased with increasing age. However, the Incontinence Quality of Life Scale score increased with increasing age. Patients with only POP and aged ≥70 years showed a higher Incontinence Quality of Life Scale score (P < 0.001).

CONCLUSIONS

The present study showed that POP and stress urinary incontinence are common among older Chinese women, and re associated with decreased sexual satisfaction and quality of life in China. It suggests that the existing sexual requirement of these patients should also be reconsidered before surgical assessment. Doctors should take sexual satisfaction into consideration when choosing a personalized type of surgery to improve the patients' quality of life physiologically and psychologically. Geriatr Gerontol Int 2019; 19: 299-304.

Predictors of Success for Pelvic Floor Muscle Training in Pelvic Organ Prolapse

BACKGROUND

Although the effectiveness of pelvic floor muscle training in women with prolapse has been demonstrated in several studies, there seem to be subgroups of responders and nonresponders.

OBJECTIVE

The objective of this study was to identify factors that predict treatment success in women receiving pelvic floor muscle training for prolapse.

DESIGN

The design was a secondary analysis of data from 2 randomized controlled trials comparing conservative prolapse treatments.

METHODS

After 12 months, 172 women subjectively assessed treatment success ("better") or failure ("the same" or "worse"). Potential predictors were identified by a literature search and by consultation with experts in the field of urogynecology and pelvic floor muscle training. The relationship between potential predictors and treatment success was explored using logistic regression analysis.

RESULTS

Treatment was successful in 94 women (55%) and unsuccessful in 78 women (45%). The presence of ≥1 indicators of obstetric trauma (eg, high birth weight, episiotomy, perineal laceration during vaginal delivery, forceps delivery, or vacuum extraction) (odds ratio = 4.4; 95% CI = 1.6-12.0) and younger age (odds ratio = 0.94 per year; 95% CI = 0.9-1.0) independently predicted treatment success. The area under the receiver operating characteristic curve for the final model was 0.65 (95% CI = 0.57-0.74), and the model explained 11.7% of the variance.

LIMITATIONS

Although attempts were made to include all relevant predictors, the selection or operationalization of variables could have been incomplete or insufficient.

CONCLUSIONS

Identifying women who have prolapse and are likely to benefit most from pelvic floor muscle training is of great importance to clinical practice. In this study, 2 factors that independently predicted favorable outcomes were identified with this management approach. However, further research is needed to identify other predictive factors and to validate a new model in another population.

COST-EFFECTIVENESS OF INTERVENTIONS BASED ON PHYSICAL ACTIVITY IN THE TREATMENT OF CHRONIC CONDITIONS: A SYSTEMATIC LITERATURE REVIEW

Objectives:

The aim of this study is to review evidence on the cost-effectiveness of exercise-based interventions in the treatment of chronic conditions a decade after the publication of Roine et al. in 2009 (Roine E, Roine RP, Räsänen P, et al. Int J Technol Assess Health Care. 2009;25:427–454).

Methods:

We carried out a review of published articles in PUBMED and JSTOR between January 1, 2008, and December 31, 2016. Full economic evaluations of exercise programs targeting patients with a chronic condition were eligible for inclusion. Data on program, design, and economic characteristics were extracted using a predefined extraction form. The quality of the economic evaluations was appraised using the adjusted Consensus Health Economic Criteria List.

Results:

A total of 426 articles were identified and thirty-seven studies were selected. Eleven studies dealt with musculoskeletal and rheumatologic disorders, ten with cardiovascular diseases, six with neurological disorders, three with mental illnesses, three with cancers, and four with diabetes, respiratory diseases, or pelvic organ prolapse. In total, 60 percent of exercise programs were dominant or cost-effective. For musculoskeletal and rheumatologic disorders, 72 percent of programs were dominant or cost-effective while this was the case for 57 percent of programs for cardiovascular diseases using a nonsurgical comparator.

Conclusions:

There is clear evidence in favor of exercise-based programs for the treatment of musculoskeletal and rheumatologic disorders and, to a lesser extent, for the treatment of cardiovascular diseases. More research is needed to evaluate the cost-effectiveness of physical activity in the treatment of neurological disorders, mental illnesses, cancers, respiratory diseases, and diabetes/obesity.

Women's experiences of managing digitation: do we ask enough in primary care?

The aim of this paper was to consider the available evidence for the current management of pelvic organ prolapse, which is a common presentation in primary care. However, not all women will present, only presenting when symptoms become bothersome. Particular attention was paid to understanding the problem of rectocele and its influence on obstructive defaecation symptoms. The burden of rectocele and its consequences are not truly known. Furthermore, healthcare professionals may not always enquire about bowel symptoms and patients may not disclose them. Complex emotions around coping and managing stress add to the challenges with seeking healthcare. Therefore, the impact on the lived experience of women who have difficulty with rectal emptying can be significant. The review identified a dearth of knowledge about women living with the problem of obstructive defaecation resulting in the use of digitation. Improving the management of digitation, an under-reported problem, is necessary to improve the quality of life for women. Primary care needs to increase access to conservative measures for women struggling with bothersome symptoms, such as constipation, the need to digitate or anxiety.

Comparison of transperineal ultrasound with POP-Q for assessing symptoms of prolapse

INTRODUCTION

Our aim was to study any correlation between pelvic organ prolapse quantification (POP-Q) and ultrasound measurement of prolapse in women from a normal population and to identify the method with a stronger association with prolapse symptoms.

METHODS

A cross-sectional study of 590 parous women responding to the Pelvic Floor Distress Inventory was carried out. They were examined using POP-Q and transperineal ultrasound, and correlation was tested using Spearman's rank test. Numerical measurements and significant prolapse (POP-Q ≥ 2 in any compartment or bladder ≥10 mm, cervix ≥0 mm or rectal ampulla ≥15 mm below the symphysis on ultrasound) were compared in symptomatic and asymptomatic women (Mann-Whitney U and Chi-squared tests).

RESULTS

A total of 256 women had POP-Q ≥ 2 and 209 had significant prolapse on ultrasound. The correlation (r_s) between POP-Q and ultrasound was 0.69 (anterior compartment), 0.53 (middle), and 0.39 (posterior), p < 0.01. Women with a "vaginal bulge" (n = 68) had greater descent on POP-Q and ultrasound in the anterior and middle compartments than asymptomatic women, p < 0.01. For women with a symptomatic bulge, the odds ratio was 3.8 (95% CI 2.2-6.7) for POP-Q ≥ grade 2 and 2.4 (95% CI 1.4-3.9) for prolapse on ultrasound. A sensation of heaviness (n = 90) and incomplete bladder emptying (n = 4) were more weakly associated with ultrasound (p = 0.03 and 0.04), and splinting (n = 137) was associated with POP-Q Bp, p = 0.02.

CONCLUSION

POP-Q and ultrasound measurement of prolapse had moderate to strong correlation in the anterior and middle compartments and weak correlation in the posterior compartment. Both methods were strongly associated with the symptom "vaginal bulge," but POP-Q had a stronger association than ultrasound.

Pelvic Floor Physical Therapy and Women's Health Promotion

Pelvic floor dysfunction is defined as abnormal function of the pelvic floor and includes conditions that can have significant adverse impacts on a woman's quality of life, including urinary incontinence (stress, urge, and mixed), fecal incontinence, pelvic organ prolapse, sexual dysfunction, diastasis recti abdominis, pelvic girdle pain, and chronic pain syndromes. Women's health care providers can screen for, identify, and treat pelvic floor dysfunction. This article examines the case of a woman with multiple pelvic-floor-related problems and presents the evidence for the use of pelvic floor physical therapy (PFPT) for pregnancy-related pelvic floor dysfunction. PFPT is an evidence-based, low-risk, and minimally invasive intervention, and women's health care providers can counsel women about the role that PFPT may play in the prevention, treatment, and/or management of pelvic floor dysfunction.

The effect of pelvic organ prolapse type on sexual function, muscle strength, and pelvic floor symptoms in women: A retrospective study

Objective:

This retrospective research was planned to investigate the effect of pelvic organ prolapse (POP) type on sexual function, muscle strength, and pelvic floor symptoms in symptomatic women.

Materials and Methods:

Data on POP type and stages as assessed using the Pelvic Organ Prolapse-Quantification system of 721 women who presented to the women’s health unit between 2009 and 2016 were collected retrospectively. POP types were recorded as asymptomatic, anterior, apical, and posterior compartment prolapses. Sexual function was assessed using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short-form (PISQ-12), pelvic floor muscle strength was assessed through vaginal pressure measurement, and pelvic floor symptoms and quality of life were assessed using the Pelvic Floor Distress Inventory-20 (PFDI-20).

Results:

Among 168 women who met the inclusion criteria, 96 had anterior compartment prolapses, 20 had apical compartment prolapses, 16 had posterior compartment prolapses, and 36 women were asymptomatic. There was no difference between the groups in their PISQ-12 total and subscales scores, PFDI-20 total and two subscale (colorectal/anal, urinary) scores, and muscle strength (p>0.05). In the Pelvic Organ Prolapse Distress Inventory-6, another subscale of PFDI-20, it was determined that there was a difference between asymptomatic women and those with anterior compartment prolapses (p=0.044) and apical compartment prolapses (p=0.011).

Conclusion:

This research found that POP type did not affect sexual function, muscle strength, and colorectal and urinary symptoms in our cohort. There were more prolapse symptoms and complaints in women with anterior and apical compartment prolapses.