Nonsurgical Options for Treatment of Uterine Prolapse

By Julie Hartman, DC, DICCP

Author: Julie Hartman, DC, DICCP/Thursday, January 07, 2016/Categories: November 2015, Test Category

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A PROLAPSED UTERUS IS commonly categorized as pelvic organ prolapse, which occurs when the uterus descends below its normal anatomical position.(1,2) Some women report vaginal symptoms such as feeling a bulge or protrusion in the vaginal canal, while others may report low-back pain.(3)

Currently about 40 percent of women over age 50 have some degree of pelvic organ prolapse, (4) and an estimated 3.7 million women are expected to suffer with the condition by 2020.(5) Given the high prevalence of the condition, it is possible that you may encounter patients with pelvic organ prolapse in your daily practice.

Clinical Scenario

A female in her mid-50s was recently diagnosed as having a prolapsed uterus by her primary care provider. Surgery was the only treatment option discussed with her. However, she prefers to avoid surgery and asks you if there are any nonsurgical options. While a prolapsed uterus is not a condition you actively treat, you can perform a literature search to find resources regarding treatment alternatives so the patient has information she can use to make a more informed decision.

Literature Search

If you perform a search in PubMed using the terms “pelvic organ prolapse” and “treatment,” you will encounter search results that include more than 7,000 articles. To narrow your search, you can select the “Clinical Trial” option under Article types, as well as the “Free full text” option under Text availability. That narrows the results to about 70 articles. Among the articles on this list is one from March 2014 that describes a clinical trial involving nonsurgical treatment in The Lancet titled “Individualized pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomized controlled trial” by Hagen, et al.(6) Other nonsurgical treatment options that appeared in the search included additional pelvic floor muscle training and the use of a device called a pessary, which provides intervaginal support of the pelvic organs.

Study Description

Hagen’s study was a randomized trial conducted at 25 different outpatient gynecology clinics (a mixture of university teaching hospitals and general hospitals) in the United Kingdom, New Zealand and Australia. Each hospital offered specialized pelvic floor physiotherapy services. Women of any age were eligible to participate if they had a primary complaint of prolapse as determined by their gynecologists on vaginal examination using the pelvic organ prolapse quantification (POP-Q) system. The POP-Q is a grading system that ranges from Stage 0 (no prolapse) to Stage IV (complete prolapse), as well as a quantitative description of the pelvic organ position (anterior, posterior, etc.).(1) Women were eligible if they were diagnosed with Stage I-III prolapse in any position. Women were excluded if they had received previous treatment for prolapse (including surgery), were unable to comply with study treatments or were pregnant or less than six months postnatal.

Participants were randomly assigned to an active treatment (n=225) or control group (n=222). Those in the active group received a specific type of physiotherapy called individualized pelvic floor muscle training. The treatment consisted of five one-hour appointments over a 16-week time period and a pamphlet with advice on prolapse care given at the first appointment. Those in the control group were mailed the prolapse advice pamphlet.

The researchers’ primary outcome of interest was each participant’s pelvic organ prolapse symptom score (POP-SS), which is a seven-item questionnaire asking women about their prolapse symptoms.(2) Participants were asked to complete the POP-SS at the beginning of the study, at six months and then at the end of the study (12 months). Other information gathered about the participants included use of additional treatments and perceived change in prolapse. POP-Q assessment was also performed at the six-month assessment by the same gynecologist who performed the initial assessment and was blinded to the participant’s treatment group throughout the study.

Study Findings

Often authors will report the findings of their study are “significant.” Significance, however, can have different meanings. Statistical significance indicates that patterns in the data are not likely to be the result of random chance. Clinical significance, by contrast, indicates the magnitude of the effect being studied is large enough to have therapeutic implications. Simply because results are statistically significant does not automatically imply that they are clinically meaningful.

At both six- and 12-month assessments, more participants in the pelvic floor muscle training group reported statistically and clinically significant reductions in POP-SS scores compared with those in the control group. More participants in the pelvic floor muscle training group also reported they felt their prolapse had improved since the start of the study than those in the control group at both six and 12 months. At 12 months, 24 percent of those in the active treatment group received further treatment (most commonly surgery), and 50 percent in the control group received further treatment (most commonly physiotherapy referral for individualized pelvic floor muscle training). However, gynecological examinations performed at six months found no significant differences between the groups to indicate improvement of prolapse.

Limitations

This study was a single large clinical trial and lacks the impact of a systematic review or metaanalysis, which combines the results of several studies. Also, no information is provided about the natural progression of pelvic organ prolapse, differences in response to treatment based on stage of prolapse, age of participant or outcomes after 12 months of care. Finally, the control group was only mailed the prolapse advice pamphlet and did not have the experience of coming into the office for visits with providers as did those in the active treatment group.

Conclusions

This study seems to support a significant improvement in reported symptoms for participants in the active treatment group, while showing no measurable differences in prolapse upon physical examination.

How to Help

The type of treatment described in this study involves care from providers who specialize in pelvic floor muscle training. This is something your patient may discuss as an option with her primary medical doctor. As a resource you can provide for your patient, the Women’s Health section of the American Physical Therapy Association (www.womenshealthapta.org) has a “PT Locator” tab to find physical therapists who specialize in pelvic treatments.

Giving a patient evidence-based care not only factors in what the literature shows and clinical expertise but also considers patients’ wishes. (7) In this case, even though our scope of practice and training may not grant us the necessary skills or expertise to diagnose or manage pelvic organ prolapse, our ability to utilize the scientific literature can potentially be of great benefit to patients as we help provide them with resources to make informed healthcare decisions.

References

1) Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996 Jul;175(1):10–7.

2) Hagen S, Glazener C, Sinclair L, Stark D, Bugge C. Psychometric properties of the pelvic organ prolapse symptom score. BJOG. 2009 Jan;116(1):25–31.

3) Lau T, Weinstein M, Wakamatsu M, Macklin EA, Pulliam S. Low-back pain does not improve with surgical treatment of pelvic organ prolapse. Int Urogynecol J. 2013 Jan;24(1):147–53.

4) Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol. 2002 Jun;186(6):1160–6.

5) Ilie CP, Chancellor MB. Female urology-future and present. Rev Urol. 2010;12(2-

6) Hagen S, Stark D, Glazener C, Dickson S, Barry S, Elders A, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet.2014 Mar 1;383(9919):796–806.

7) Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. British Medical J. 1996 Jan 13;312(7023):71–2.

Dr. Julie Hartman is a research study coordinator and research fellow at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa.
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