Pelvic floor muscle training reduced symptoms at two years slightly more than the improvement seen in women who just received a leaflet with lifestyle advice. In addition to this 1 point change on a 28 point scale, 8% fewer women who had training needed further treatment for prolapse.
This randomised controlled trial included 412 women with relatively minor prolapse but who had not had any previous treatment. The basic training was provided by physiotherapists in five treatment sessions with added pilates classes and a DVD.
Pelvic floor exercises are safe and can be carried out easily by most women with this common condition. They may be helpful even before women have any troublesome symptoms of prolapse. The researchers are planning longer-term follow-up, which will help to determine whether it is a cost-effective option.
Why was this study needed?
Pelvic organ prolapse is common, occurring in 40 to 60% of women who have given birth. Eight in every 100 UK women in the community report symptoms. Surgery to treat a prolapse is relatively common – about one in ten women will have this treatment by the time they reach 80 years.
Non-surgical options include pelvic floor muscle exercises and there is evidence that these can help reduce prolapse severity and symptoms. However, there has been little research about whether pelvic floor muscle training can help to prevent prolapse symptoms and reduce the need for other, more costly, treatment such as surgery.
What did this study do?
This randomised controlled trial, PREVPROL, recruited 412 women from three centres in the UK and New Zealand who had given birth in 1993 to 1994. The women could be any age, with evidence of prolapse, who had not already undergone treatment.
Researchers randomly allocated 206 women to pelvic floor muscle training and 206 women to the control group. The training group were offered five appointments with a physiotherapist, given an individualised training programme and advice, and given a lifestyle advice leaflet. They also had pilates classes and physiotherapy review appointments after one and two years. At two years 77% of women in the treatment group were still doing their pelvic floor exercises. The control group received the lifestyle advice leaflet in the post. The results were measured after two years, comparing symptoms and cost effectiveness.
The results of this large multicentre trial are likely to be reliable, although the participants and physiotherapists knew which group they were in. This could have introduced some bias when reporting symptoms.
What did it find?
- The main outcome was severity of prolapse symptoms at two years, measured using the Pelvic Organ Prolapse Symptom Score (POP-SS). This has a scale of 0 to 28, with 0 meaning no symptoms in the previous four weeks, and 28 meaning all symptoms were present all the time. Average POP-SS reduced from a baseline of 4.4 to 3.2 at two years in those who had pelvic floor muscle training compared to increasing from 3.9 to 4.2 in the control group (mean difference [MD] ‑1.01, 95% confidence interval [CI] ‑1.70 to ‑0.33).
- Using the ICIQ-Urinary Incontinence form (a scale of 0 to 21 which combines frequency of urine leakage, amount and associated bother, with a higher score indicating more problems), the training group average score decreased from 4.8 to 3.3 after two years while it remained the same for the control group, 4.2 to 4.1(MD ‑0.83, 95% CI ‑1.44 to ‑0.22).
- Fewer women in the training group had any further treatment for prolapse symptoms during the two-year follow-up (6%) than those in the control group (14.4%). Odds Ratio 0.29 (95% CI 0.12 to 0.71). In particular, women in the training group were less likely to see their GP: 3% versus 12%.
What does current guidance say on this issue?
NICE is developing a guideline on the management of urinary incontinence and pelvic organ prolapse (due in February 2019). NICE has produced a number of pieces of guidance on surgical techniques to treat different types of prolapse – these all list pelvic floor muscle training as an option for treatment.
What are the implications?
This high quality study suggests that pelvic floor muscle training could be a useful option for managing minor pelvic organ prolapse. It may also reduce the need for further treatment such as surgery. It is a safe option that could be done easily learned by most women and started once prolapse is first recognised and before they symptoms become more troublesome.
The effects seen in this study are small, and as a research study involved a lot of input from specialist physiotherapists. The researcher’s planned long-term follow-up would allow us to see if there would be real cost-savings or if there are simpler ways of delivering the intervention.
Citation and Funding
Hagen S, Glazener C, McClurg D, et al. Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial. Lancet. 2017;389(10067):393-402.
This study was funded by the Wellbeing of Women charity, the New Zealand Continence Association, and the Dean’s Bequest Fund of Dunedin School of Medicine. One of the authors was part-funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West Midlands.
Cooper J, Annappa M, Dracocardos D, et al. Prevalence of genital prolapse symptoms in primary care: a cross-sectional survey. Int Urogynecol J. 2015;26(4):505-10.
NHS Choices. Pelvic organ prolapse. London: Department of Health; 2015.
NICE. Urinary incontinence (update) and pelvic organ prolapse in women: management. GID-NG10035. London: National Institute for Health and Care Excellence; in development.
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