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    The future of treating pelvic organ prolapse

     

    Nonsurgical management of POP

    Conservative measures are appropriate in patients who do not want surgery, those who are poor surgical candidates due to medical comorbidities, or patients who are pregnant or have not completed childbearing.7

    Expectant management

    If prolapse is asymptomatic, patient education, reassurance, and expectant management can be offered. In patients with advanced prolapse, experts recommend renal ultrasound and creatinine measurement annually to evaluate for urinary retention, hydronephrosis, or compromise of the upper tracts.8 Many women interested in expectant management are often concerned about the risk of POP worsening. Data are limited with which to guide patients; in a small percentage of cases, POP may spontaneously regress, although that is infrequent when the condition is bothersome and extends to or beyond the hymen.9,10

    Vaginal pessaries

    Vaginal pessaries are silicone devices available in a variety of shapes and sizes. Patients may be taught to perform self-care but if they are unable to do so, a pessary should be removed and cleaned every 2 to 3 months. Pessaries can be used in women of any age and can be successful for multiple stages of prolapse.11,12 Commonly thought of as a temporizing measure, pessaries can be successfully used long term in the right patients,13 but independent predictors for pessary discontinuation include age <65, stage >3 posterior wall prolapse, and desire for surgery.

    Sexual activity status has not been found to be associated with pessary discontinuation.14 In a study of pessary users, approximately half of the women reported sexual activity and pessary use did not change sexual function.15

    Pelvic floor muscle training

    Burgeoning evidence favors pelvic floor muscle training (PFMT) in conservative management of POP. PFMT has demonstrated subjective improvement in women’s prolapse symptoms and bother. Those who received PFMT had reduced frequency and bother of prolapse symptoms, with anatomic improvement by one POPQ stage compared to controls. Adherence with home exercises and PT sessions was >80%.16,17 A systematic review concluded that women who received PFMT had subjective and objective improvement in Stage 1-2 POP symptoms and severity.18 Although its use for stage 3 prolapse remains questionable,19 greater standardization of PFMT intervention could potentially improve clinical outcomes.

     

    Cara Ninivaggio, MD, FACOG
    Dr Ninivaggio is a fellow in the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, ...
    Gena Dunivan, MD, FACOG
    Dr Dunivan is an Associate Professor and Fellowship Program Director in the Division of Female Pelvic Medicine & Reconstructive Surgery, ...

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