Women’s Health – Pelvic Organ Prolapse (6) – Anna Wallin Women’s Health Physio

5. Discussion

5.1 Result discussion

Five out of six studies that were included in this review had a moderate to high level of quality (≥6/10) according to the PEDro quality assessment scale (17). The review concluded that a conservative method like PFMT was effective when treating POP. It showed that PFMT could decrease symptoms, perceived bother and reduce severity of POP. Additionally, it could improve morphological factors such as muscle thickness and tightness.

5.1.1 Effectiveness of PFMT

Through daily PFMT the cross-sectional area (CSA) of levator ani increased. It brought the training group from an average of 1.6 at baseline to 2.1 mm at the end of the study, versus controls where CSA decreased by 0.1 during the same period (18). The groups that received the intervention decreased PFM length from 121.2 to 117.2 mm (i.e. increased tightness), when controls did not (19). Women that received PFMT programs reported fewer symptoms and less bother at finish, compared to controls (10). At the end of the intervention period, the studies by Braekken and Hagen reported that 19 (10) and 27 (6) % of women in the intervention groups had improved POP-Q score, compared to controls where corresponding figures were 8 (10) and 20 (6) %. The study by Frawley was the only study that did not find any significant change between training and control group with the given dosage of PFMT when used as an adjunct to prolapse surgery. The study did however find a statistically significant difference in quality of PFM contraction at the final checkup, where the intervention group was more likely to perform a “correct contraction” than controls (16).

It is worth mentioning that POP symptom and bother is based on subjective measurements, making it difficult to separate the actual and anticipated effect of treatment. All but one study was assessor blinded, decreasing the risk of assessor bias. The participants on the other hand could not be blinded. This means there is a sample bias. However, as mentioned earlier symptoms are the main cause for POP patients to seek medical attention. We believe that symptom reduction is the biggest gain of PFMT, but it can also improve function of PFM. The study groups were not homogenous with regards to age, severity of POP and menopausal status etc.

PFMT is a non-invasive treatment (4) (20). There is no convalescence period, risk of infection or other peri- or postoperative complications. The benefit of PFMT programs seems to be that it does not necessarily need to be supervised. The study by Kashyap shows that even self-instructive PFMT programs were effective for managing POP (21). However, clinical supervision may be more effective and needed in difficult cases.

5.1.2 Prevention

The included studies did not look at the potential of PFMT to prevent POP, no conclusions could therefore be drawn regarding POP prevention. However, as mentioned above included research showed that PFMT could reverse POP development in some patients and improve symptoms and morphological factors. In short, PFMT change and improve the structures that cause POP to occur (16) (18). Based on these findings it could be speculated that PFMT could have a preventative effect in healthy individuals. POP prevention through PFMT is of yet not scientifically proven and needs to be further investigated in future studies.

5.1.3 PFMT programs

There is still no evidence based POP PFMT program with guidelines for duration, number of repetitions and frequency. Where specified the included studies used between eight and 50 repetitions, in one to three sets daily with long and/or short held muscle contractions. None of the studies compared different types of PFMT interventions (such as yoga, Pilates, Kegel exercises etc.) and we could therefore not draw any conclusions comparing various types of PFMT programs. However, it seems that some PFMT is better than no PFMT.

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