PELVIC ORGAN PROLAPSE (KL NOBLETT, SECTION EDITOR)

The Past, Present and Future of POP and Physical Therapy

Rhonda K. Kotarinos & Elizabeth Kotarinos

# Springer Science+Business Media New York 2014

Abstract Pelvic organ prolapse (POP) is a very commoncondition of women worldwide. Research is ongoing to de-termine the “perfect” surgery for anatomical correction of thevarious support problems within the pelvic floor. In tandem tothe surgical research, there are ongoing studies investigatingthe role of pelvic floor physical therapy as conservative man-agement to prevent surgery or the need for recurrent repairsafter a surgical procedure. As the research matures, there isstronger evidence that pelvic floor physical therapy may beefficacious in the management of POP. A review of recentresearch supports this finding.

Keywords Pelvic organ prolapse . Pelvic floor physicaltherapy . Diastasis recti . Pelvic floor muscle training

Introduction

Descent of the anterior vaginal wall, the vaginal apex, theposterior vaginal wall, or all of them is the generally accepteddefinition of pelvic organ prolapse (POP) [1]. Subjectivepatient symptoms associated with POP are a sense of pelvicheaviness, vaginal bulging, incomplete bowel or bladder emp-tying, the need to splint the perineum or posterior vaginal wallto facilitate defecation or pain/discomfort with sexual inter-course [1]. The etiology is considered to be multifactorial withestablished and possible risk factors implicated. Theestablished risk factors are vaginal childbirth, old age, andobesity [2]. There are many other potential risk factors asso-ciated with POP that include, but are not limited to the indi-vidual bony pelvis shape or orientation, family history, race orethnic origin, connective tissue disorders, chronic increase in

intra-abdominal pressure (heavy lifting, COPD), and chronicconstipation [2].

In spite of the magnificent advances in medicine, POPremains a very common and bothersome condition in thefemale population worldwide. It is estimated that 50 % of allparous women present with some stage of POP [3]. At thistime, only 10 to 20 % of those will seek evaluation andtreatment for the condition [4]. More than 300,000 surgicalprocedures are performed yearly to manage the symptoms ofPOP [5]. The recurrence rate for POP surgical procedures isreported to be up to 29 % [6]. Outcomes for surgical studieshave historically been focused on anatomical correction ratherthan the resolution of the subjective symptoms. Anatomicalcorrection is the least concern of the patient, whereas vaginalfunction is of the utmost importance [7].

The efficacy of physical therapy for treatment of severalpelvic floor disorders has been well documented with systematicreviews and randomized controlled trials [8]. Research in supportof physical therapy for POP is in its infancy, but is slowlymaturing. The most recent Cochrane review has concluded thatpelvic floor muscle training (PFMT) with short-term follow-uphas a positive effect on POP symptoms as well as POP severity[9]. Compliance has been found to be a limitation in determiningthe long-term benefits of PFMT. There are seven reports in thepast year that have investigated the benefit of PFMT with themanagement of POP [10–13, 14••, 15, 16]. Four of the studieslooked at impact of PFMT in association with surgical manage-ment [10–13]. The other three studies compared PFMT to otherconservative approaches [14••, 15, 16] These studies are brieflyreviewed in this document.

Pelvic Organ Prolapse and Physical Therapy:Coming of Age

Evidence of the benefit of PFMT in the management of POPcontinues to grow. In the second Cochrane update on

R. K. Kotarinos (*)Rhonda Kotarinos Physical Therapy, Ltd, 1 TransAm Plaza Drive,Suite 170, Oakbrook Terrace, IL 60181, USAe-mail: RKotarinos@icloud.com

Curr Obstet Gynecol RepDOI 10.1007/s13669-014-0088-5

conservative prevention and management of POP in women,the reviewers concluded that there were compelling trial find-ings that support the use of PFMT, but that there was a lack ofevidence regarding other interventions or the combination ofinterventions to make a clinically relevant statement [9]. Re-cent studies have investigated PFMT as adjunct to surgery[10–13], PFMT alone in the ability to reduce symptoms andthe need of additional treatment [14••] and PFMT alone ascompared to pessary use or watchful waiting [15] and POPsymptom changes with PFMT self-taught or pelvic floorphysical therapist instructed [16].

As detailed elsewhere in this issue, the gold standard treat-ment for bothersome POP is surgery. Unfortunately, the long-term POP surgical results are not ideal with recurrence ratesranging from 29 % [6] to 40 % [17, 18]. Patient satisfaction isnot always achieved because persistent or de novo symptomsoccur, even when there is perfect anatomical success after aPOP surgical procedure. Lakeman et al did a review of currentliterature with the goal of providing a clinical opinion regard-ing the effects of perioperative PFMTon postoperative pelvicfloor symptoms, the need for repeat POP surgery and thecurrent clinical practice in the Netherlands [13].

Differing from a Cochrane review and in hopes of gather-ing more evidence, the reviewers chose to look at prospectiveobservational studies, retrospective studies as well as RCTsbetween January 1996 and May 2012. All studies that evalu-ated the effects of perioperative PFMTon postoperative pelvicfloor symptoms and the prevention of repeat surgical treat-ment for POP were considered. To meet their goal ofdocumenting current clinical practice in the Netherlands, 26gynecologists weremailed a questionnaire to query about theircurrent clinical practice with respect to the use of postopera-tive pelvic physical therapy.

Two small RCTs reviewed [19, 20] had favorable resultsindicating that perioperative PFMT may decrease the persis-tent or de novo pelvic floor symptoms, increase pelvic floorstrength, and improve the quality of life of the POP surgicalpatient. There was no evidence found that the noted improve-ments decreased the risk of recurrent treatment. Current clin-ical practice in the Netherlands does not include regular refer-ral to a pelvic floor physical therapist before or after POPsurgery. The lack of scientific evidence to support the use ofpelvic floor physical therapy in the primary treatment orperioperative management of POP was the reason given forthe low referral rate to pelvic physical therapy. Their findingsagain highlight the need for rigorous, well-designed, random-ized controlled trials to determine benefits, efficacy, and costeffectiveness of perioperative PFMT in preventing bother-some recurrent POP.

McClurg et al, well aware of the strong evidencesupporting PFMT and lifestyle changes in improving thesymptoms and stage of prolapse in a non-surgical population,recognized that rock solid evidence was needed to establish

the benefit of perioperative PFMT to address postoperativesymptoms and POP recurrence [12]. They did a pilot study toevaluate feasibility and collect pilot data to determine thesample size calculation for a randomized controlled multicen-ter trial on the use of PFMTafter surgical management of POP.A sample size of 30 per group was established. This was thefirst study to use a POP-specific symptom questionnaire astheir primary outcome, Pelvic Organ Prolapse SymptomScore (POP-SS). Women having primary surgery to treat theirPOP symptoms were asked to participate in the trial. Oncethey agreed and were consented they were randomized to atreatment group (TG) or a control group (CG). The TG (n=28)received perioperative PFMT by a pelvic floor physical ther-apist. The CG received usual surgical care.

The standardized intervention for the TG included a peri-operative appointment, post discharge and outpatient appoint-ments. Physical therapy intervention was standardized byinstruction from the study principal investigator at all threesites. During the perioperative appointment a standardizedhistory was taken, education about normal anatomy and thevarious forms of POP was provided, the surgical procedurewas discussed, and information was given regarding recoveryand limitations. A pelvic exam was performed to instruct eachsubject in the correct contraction of their pelvic floor muscles,and subjects were also told to do an active contraction beforeany increase in intra-abdominal pressure. This maneuver ismost commonly referred to as the knack. Exercise instructionswere to do three sets of 10 maximal contractions per day witha work/rest cycle of a maximum 10-s hold to a 4-s restfollowed by a 1-min rest, and then 10 fast contractions.

During the post-discharge week, the TG was mailed alifestyle advice brochure with information about POP types,advice on toileting, activity levels, and incisional bracingtechniques for coughing, sneezing, or lifting. A member ofthe research team also called during this week to answer anyquestions.

The first outpatient physical therapy visit was at 6 weekspost operatively. At this visit a history of their recovery wastaken and a vaginal exam was performed to assess their pelvicfloor contraction. Over the course of 12 weeks, there were atotal of five outpatient visits. An individualized home exerciseprogram was provided. Therapists were allowed to use ad-juncts to treatment such as biofeedback, electrical stimulationand exercise balls. Advancement of the exercise program wasadjusted according to their progress. At each physical therapyvisit symptom changes, pelvic floor muscle strength, andadherence to lifestyle advice was recorded. The CG (n=29)had no contact with hospital personnel until their post-surgicalphysician appointment, and they did not see a physical ther-apist, but were mailed the same lifestyle advice brochure.

As a pilot feasibility study, the investigators achieved theirprimary goal of proving that a multicenter clinical trial wouldbe possible to investigate the role of perioperative PFMT to

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prevent POP recurrence. This was the first study using pro-lapse symptoms as measured by the POP-SS as a primaryoutcome measure. The TG (n=28) experienced fewer pro-lapse symptoms at 12 months than did the CG (n=29). Thecaveat of this report as stated by the investigators is that thereis possible selection bias; therefore, it should be viewed withcaution.

The randomized controlled trial done by Pauls et al had aprimary objective of determining if perioperative pelvic floorphysical therapy (PFPT) in women following vaginal recon-structive surgery for prolapse and incontinence improved theiroverall quality of life [10]. Use of subjective validated mea-sures of pelvic floor dysfunction, sexual function, postopera-tive pain/activity scales, and objective measures of pelvicfloor function by transvaginal surface EMG were their sec-ondary outcomes. There were a total of 49 subjects dividedbetween two groups, a PFPT group (n=24) and a controlgroup (n=25). Both groups had significant improvement inquality of life measures;World Health OrganizationQuality ofLife-BREF (WHOOL-BREF), Pelvic Floor Distress Invento-ry (PFDI), Pelvic Floor Impact Questionnaire (PFIQ), and theShort Form General Health Survey (SF-12). In the short term,this supports the effectiveness of surgical management inimproving the quality of life of patients dealing with thesymptoms of POP. The finding that the PFPT group hadsignificant improvement in pelvic floor function, evidencedby improved coordination and control of the pelvic floor,support the use of perioperative PFPT in patients undergoingvaginal reconstructive surgery for prolapse or incontinence.

The Operations and Pelvic Muscle Training in the Man-agement of Apical Support Loss (OPTIMAL) was a random-ized trial that compared the outcomes of sacrospinous liga-ment fixation (SSLF) and uterosacral ligament suspension(ULS) as one objective, with a second objective to comparebehavioral pelvic floor muscle training (BPMT) and usualcare in women having surgery for vaginal prolapse and stressurinary incontinence [11]. Surgical outcomes at 2 years foundthat neither surgical procedure was better than the other. TheBPMT was very consistent with what was reported in otherstudies [10]: individualized program, limited visits beforesurgery, and 4 – 5 postoperative visits which included pelvicfloor muscle training with individualized progression andeducation on lifestyle changes. Unlike other studies [12, 13],the OPTIMAL study did find that perioperative pelvic floormuscle therapy did not improve urinary symptoms at 6months or prolapse outcomes 2 years post surgery.

Pelvic organ prolapse in primary care: effects of pelvicfloor muscle training and pessary treatment study (POPPS),is a proposed study design with two parallel, open-labelrandomized controlled trials [15]. POPPS trial 1 will be toinvestigate the short- and long-term effects of PFMT as com-pared to watchful waiting in women with mild prolapse. Thesecond POPPS trial will investigate the short- and long-term

effects of PFMTas compared to pessary use in the presence ofadvanced prolapse. The primary outcome in both POPPStrials will be improvement in POP-related symptoms withthe secondary outcomes being quality of life, sexual function,POP-Q stage, pelvic floor muscle function, post void residual(PVR), the perceived improvement by the patient, and costsrelated to the treatment. The purpose of the article is to reportthe design, the various difficulties and methods of resolution,and baseline characteristics of the study participants. The goalof the investigators is that the study results will allowwomen’shealth care providers to make an evidenced-based clinicaldecision regarding treatment choices: watchful waiting,PFMT, or pessary use.

The Pelvic Organ Prolapse Physiotherapy (POPPY) trialconducted by Hagen and colleagues was a randomized con-trolled trial to compare one-to-one individualized pelvic floormuscle training (PFMT) to management by an educationallifestyle brochure in women with stage 1, 2, or 3 prolapsedetermined by Pelvic Organ Prolapse Quantifier (POP-Q)[14••]. Specialized pelvic floor physical therapists providedthe treatment for the study group in five one-to-one visits overthe course of 16 weeks. The specific intervention for the studygroup included education regarding normal anatomy, functionof the pelvic floor muscles, and types of prolapse; trans-vaginal pelvic floor evaluation and instruction in correct con-traction; pre-contraction of the pelvic floor before increases inintra-abdominal pressure (the knack). All study subjects re-ceived an educational lifestyle brochure that provided adviceregarding weight loss, avoidance of constipation, heavylifting, coughing, and high impact exercise. The control grouphad no contact with a physical therapist and only saw thesurgeon at a 6-month visit after the entry into the trial.

Results of the POPPY trial contribute strong data in supportof PFMT in the management of POP. Subjects of the inter-vention group reported fewer prolapse symptoms that weremeasured by the pelvic organ prolapse symptom score ques-tionnaire (POP-SS) than those in the control group at both 6and 12 months. Although the POP-Q scores improved withinthe intervention group they were not statistically significant.Other studies have also reported improvement in prolapseseverity, but lack of conformity in the reporting limits thestrength of their findings [21–23].

Kashyap and colleagues conducted a randomized con-trolled trial with a much longer intervention time than otherstudies [16]. The intervention group received a self-instructionmanual (SIM) of educational material and home exercisesalong with one-to-one PFMT including verification that prop-er technique occurred during the home exercise program(HEP). The control group received only the SIM. Their pri-mary outcomes were symptom relief as measured by the POP-SS and visual analog scale scores, quality life as measured bythe pelvic floor impact questionnaire-7 (PFIQ-7), and POPseverity measured by POP-Q. Therefore, the study compared

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the changes in POP symptoms achieved by one-to-one train-ing of a HEP to a self-instructed HEP. While both groupsdemonstrated improvement in their POP symptoms, severityof POP, and quality of life, the intervention group had greatersignificant results.

Although there is growing evidence of the positive effects ofPFMTon the scope of POP the optimal PFMT protocol includ-ing duration and frequency has not been elucidated. Integral tosuccessful PFMT is appropriate pelvic floor examination, in-struction in correct pelvic floor contraction, and individual orgroup training with professional supervision [16, 24–27]. Amajor concern of the health care provider working with pelvicfloor dysfunction patients is maintenance of a PFMT programbeyond the short term. A by-product of the POPPY trial was astudy to understand the lack of continued adherence in the longterm to a prescribed PFMT program [28]. The study revealedthat the study participants tended to allow family responsibilityto come before their own personal needs relating to their exer-cise patterns and long-term adherence to the PFMT program.

Tibaek and Dehlendorff recognize that many women arereferred to physical therapy for PFMT, but questioned howmany women actually complete the program to which theyhave been referred [29]. A retrospective chart review, at ahospital out-patient clinic, was done on women with pelvicfloor dysfunction referred to a PFMT program. The results ofthe study discovered that less than half of the women referredto a PFMT program finish the program. Women not complet-ing the program were divided between those that dropped out(1/3) and those that cancelled or just stayed away (1/5). Themajor factors between completers and non-completers wereage, year of referral, and nationality. Distance travelled, yearof referral, wait list times, and diagnosis were the differenti-ating elements between the dropouts and non-attendees.

Pelvic Organ Prolapse and Physical Therapy:Transitioning into Adulthood

As evidenced by the previously discussed studies and manythat have come before them, research is consistently indicatingthat pelvic floor physical therapy can have a positive impact onthe symptoms and severity of POP. Could the study results bebetter? Is there something missing? Surgery, of course, willalways be necessary for certain stages of prolapse, but whatabout the recurrence rate? If addressed earlier, can POP beprevented? At the 1909 meeting of the American Associationof Genito-Urinary Surgeons, Dr. Joel Goldthwait presented apaper in which he states that the surgeon “…has a higherfunction than the mere treatment of local conditions…”[30••]. The surgeon’s “…work must be judged upon the basesof the ultimate cure or general efficiency rather than simply theimmediate relief of some local lesion ”, and “…care should notstop until the highest degree of physical efficiency for that

individual is obtained” [30••]. The surgeon attempts an ana-tomic cure, but does not take into consideration all factors thathave an impact upon the organs within their resident container.Dr. Goldthwait’s paper describes the additional factors thathave an impact upon pelvic organ support [30••]. He states thatthe surgical correction addresses the anatomic problem causedby postural dysfunction and the loss of integrity of the abdom-inal wall. To not treat these components of pelvic support willpromote prolapse or increase the risk of recurrence.

To date the current research on physical therapy and POPhas primarily manipulated only the pelvic floor component ofpelvic organ support. References are made to core exercises,but there is no description of the evaluation of the abdominalwall or the specific core exercises administered [10]. There aremany historical references that echo the importance of postureand the abdominal wall in the function of pelvic organ support[31, 32, 33••, 34, 35]. Gillian describes the pelvic organsupport derived from the abdominal wall as the “retentivepower” of the abdominal wall [33••]. To illustrate this concepthe describes a filled barrel. When there is only one opening,the contents within will not flow out. A second hole is re-quired above the level of the fluid within: “…this counterbal-ances the atmospheric pressure at the opening…the contentsescape by their own weight” [33••]. Within the human body,the first opening is the levator hiatus, the second opening thatpromotes descent is the decreased strength of the abdominalwall or the presence of a diastasis recti. In the historicalliterature, a diastasis recti (DR) was directly related to“visceroptosis” or “enteroptosis” [34, 36].

There has been a more recent discussion of diastasis recti inthe urogynecologic literature. Spitznagle et al, in a retrospec-tive chart review, found that more than 50 % of the womenpresenting at their urogynecology clinic were found to have adiastasis recti [37]. Unique to this clinic was that 99 % of thecharts reviewed documented an abdominal examination fordiastasis and assigned a pelvic floor dysfunction diagnosis.Sixty-six percent of the patients with a DR had one or more ofthe support-related diagnoses: stress urinary incontinence,fecal incontinence, or pelvic organ prolapse. An additionalfinding within this study, relative to the relationship of DR andPOP, was that a greater degree of pelvic floor muscle weak-ness was noted in patients with a DR. Ranney observed thatout of 1,738 parous women undergoing abdominal hysterec-tomy, almost 40 % presented with a DR [38]. Within theplastic surgery literature there have been several reports ofurinary incontinence incidentally being cured with a DR repairassociated with an abdominoplasty [39–41]. There certainly isenough anecdotal evidence that assessing the abdominal wallfor strength and a DR is warranted and should be consideredas a component of the pelvic floor physical therapy protocol infuture POP and UI research.

The attitude of the body is a simple definition of posture[42]. Standing posture is usually described as the shoulders,

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pelvis and eyes are level, and the sagittal plane passes betweenthe feet and the line of gravity passes through the center ofgravity at the lumbosacral junction [43]. Goldthwait describedfor the gynecologic surgeons the various postural deviationsthat would predispose women to POP [30••]. The normalspinal curvatures create shelves that support and protect theorgans and pelvic floor from the direct intra-abdominal pres-sure increases. A disruption in the normal spinal curves, as aresult of weak and lax or short and tight abdominal musclesdiminishes this protection. Sir Arthur Keith stated, “In themaintenance of posture, Nature never uses ligaments; it isalways muscle, striped or unstriped… Ligaments only comeinto action when the muscular supports or guards have beenovercome or broken down; ligaments are a second line ofdefense – the first line is always held by muscles. Hence, itis that if the postural tone of the abdominal musculature isdamaged, then the mesenteries and the visceral ligamentscome into action; the dropped organs become supported orsuspended by their attachments” [44]. And, as we know, theseorgan ligaments are not made to withstand the constant stressrequired to hold the organ in place. According to Goldthwait,“It means that in the treatment of disturbances or displace-ments of the pelvic organs, it is only half doing the work if thecondition is simply treated locally, while an imperfect posturewhich may have been largely responsible for the trouble isallowed to go uncorrected” [30••]. The more common namesfor the dysfunctional postures would be flat back or decreasedlordosis and kypho-lordosis. Two recent studies have foundthat the loss of lumbar lordosis is a risk factor for the devel-opment of POP [45, 46]. Lind et al determined that there wasan association between thoracic kyphosis and the prevalenceof advanced uterine prolapse [47].

Culligan [1] asked a thought-provoking question: “So,what kind of pelvic floor exercise program might lead tohigher rates of long-term compliance?” His suggestion was afull-body program that focused on the pelvic floor musclestrength, but also addressed other muscle groups. A study byBrubaker et al provided some support to this idea [48]. Sig-nificant improvement was reported by women who participat-ed in an 11-week class of full-body exercise similar to yoga orPilates. Unfortunately, there was no objective evaluation ofthe pelvic floor within the study design. The ultimate studydesign would include physical therapy to evaluate all compo-nents of pelvic organ support: posture, abdominal wall, andpelvic floor, resulting in the development of an appropriateindividualized therapeutic exercise program.

Conclusion

In the current political arena there is much talk about thefounding fathers and their continued importance in life, aswe know it today. Unfortunately, the founding fathers in the

world of urogynecolgy are not granted the same respect. Eventhough it appears that current and past studies are not ascomprehensive as they should be, they do support a multidis-ciplinary approach to the management of POP. Health careproviders in the world of women’s health are remiss atattacking the POP dilemma in a comprehensive fashion. Mostoften POP of a stage 1 or 2, and sometimes 3, will not besymptomatic. If all components of pelvic organ support wereevaluated and addressed at this point, maybe there would beno progression to a symptomatic POP that requires surgery.When surgery is required to fix the local dysfunction, puttingthe organ back in its correct anatomic home, possiblycorrecting the position of the home will keep the organ in itsrightful place. With the appropriate positioning of the levatorplate the pelvic organs have their normal support and themuscles controlling the levator hiatus functional normally,even in conditions of increased intra-abdominal pressure.What the “founding fathers” of urogyencology knew so manyyears ago still applies to the female body, as we know today.Granted, there is no clinical evidence yet to prove that lookingat the whole body and correcting the functional anatomycomponents of pelvic organ support is warranted. A principalprecept of medical ethics taught in healthcare education isnon-maleficence, or commonly known as “above all, do noharm”. Are we, the health care providers, doing harm byomission? In order to answer this question, rigorous, well-designed, multicenter randomized controlled trials need to beundertaken to determine what is the ideal comprehensivepelvic floor physical therapy intervention.

Compliance with Ethics Guidelines

Conflict of Interest Rhonda K. Kotarinos and Elizabeth Kotarinosdeclare that they have no conflict of interest.

Human and Animal Rights and Informed Consent This article doesnot contain any studies with human or animal subjects performed by anyof the authors.

References

Papers of particular interest, published recently, have beenhighlighted as:•• Of major importance

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