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PubMed2006

Conservative management of pelvic organ prolapse in women.

BACKGROUND: Pelvic organ prolapse is common, and some degree of prolapse is seen in 50% of parous women. Women with prolapse can experience a variety of pelvic floor symptoms. Treatments include surgery, mechanical devices and conservative management. Conservative management approaches, such as giving lifestyle advice and delivering pelvic floor muscle training, are often used in cases of mild to moderate prolapse. OBJECTIVES: To determine the effects of conservative management (physical interventions and lifestyle interventions) for women with pelvic organ prolapse in comparison with no treatment or other treatment options (such as mechanical devices or surgery). SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Trials Register (searched on 19 September 2005), MEDLINE (January 1966 to August 2005), MEDLINE In Process & Other Citations (15 September 2005), EMBASE (January 1996 to Week 43 2005), CINAHL (January 1982 to October 2005), PEDro (September 2005), the UK National Research Register (Issue 3, 2005), the US National Institute of Health clinical trial register (5 October 2005), Current Controlled Trials register (5 October 2005), Controlled Clinical Trials (September 2005) and ZETOC (September 2005). We searched the reference lists of relevant articles. SELECTION CRITERIA: Randomised and quasi-randomised trials in women with pelvic organ prolapse that included a physical or lifestyle intervention in at least one arm of the trial. DATA COLLECTION AND ANALYSIS: Two reviewers assessed all trials for inclusion/exclusion and methodological quality. Data were extracted by the lead reviewer onto a standard form and cross checked by another. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS: Three trials of relevance to this review were identified. The largest of these, of pelvic floor muscle training in preventing anterior prolapse from worsening, had significant limitations which affect the generalisability and rigor of the findings. A small feasibility study (which is to be followed up with a larger trial) randomised 47 women to pelvic floor muscle training or control and found suggestions of better outcomes (better self-reported improvement, decreased severity) in the intervention group. The third trial evaluated peri-operative physiotherapy for women undergoing surgery for prolapse and/or incontinence. The authors report that urinary symptoms, pelvic floor muscle function and quality of life were improved more in the treatment group than the control group, but data were not provided to allow this to be assessed. The trial was small and no prolapse-specific outcome measures were used. It was not possible to combine data from the three trials. AUTHORS' CONCLUSIONS: Despite there now being reports of three eligible trials in this update, the evidence available is not significant to guide practice. There is some encouragement from a feasibility study that pelvic floor muscle training, delivered by a physiotherapist to symptomatic women in an outpatient setting, may reduce severity of prolapse. Further evidence from larger, better quality randomised control trials is however still necessary.

Adult↗
PubMed2004

Surgical management of pelvic organ prolapse in women.

BACKGROUND: Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse. OBJECTIVES: To determine the effects of surgery in the management of pelvic organ prolapse. SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register (8 June 2004) and reference lists of relevant articles. We also contacted researchers in the field. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse. DATA COLLECTION AND ANALYSIS: Trials were assessed and data extracted independently by at least two reviewers. Four investigators were contacted for additional information with two responding. MAIN RESULTS: Fourteen randomised controlled trials were identified evaluating 1004 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were to evaluate other clinical outcomes and adverse events. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by Vicryl mesh overlay (RR 1.39, 95% CI 1.02 to 1.90) but data on morbidity and other clinical outcomes were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh overlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new symptoms after surgery. However, more women with occult stress urinary incontinence developed postoperative stress urinary incontinence after endopelvic fascia plication alone than after endopelvic fascia plication and tension-free vaginal tape (RR 5.5, 95% CI 1.36 to 22.32). REVIEWERS' CONCLUSIONS: Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of a polyglactin mesh overlay at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. Adequately powered randomised controlled clinical trials are urgently needed.

Female↗
PubMed2001

[Dynamic MR defecography for diagnosis of combined functional disorders of the pelvic floor in proctology].

PURPOSE: Evaluation of magnetic resonance defecography in the diagnosis of pelvic floor disorders were examined prospectively. MRI was performed on a 1.5 T scanner. The rectum was opacified with 200 ml of ultrasound transmission gel. A sagittal single section T2-weighted gradient echo sequence with a temporal resolution of 1.1 second was performed. Changes of the anorectal angle and the position of the pelvic organs in relation to the pubococcygeal line were registered at rest, during straining, and during evacuation of the rectum. RESULTS: Patients with obstructed defecation (n = 15) showed prolapse of the rectal mucosa (n = 5), anterior rectocele (n = 8), pelvic floor descent (n = 5), enterocele (n = 2), and anorectal dyscoordination (n = 3). Individuals with stool incontinence (n = 15) had an anterior rectocele (n = 10), pelvic floor descent (n = 11), enterocele (n = 2), prolapse of rectal mucosa (n = 1), and a puborectal insufficiency (n = 1). Urine incontinence was associated with cystocele (n = 10) or normal findings (n = 4). In patients with unspecific symptoms (n = 6), anorectal dyscoordination (n = 4) and prolapse of the rectal mucosa (n = 2) were found. MRI was superior for the detection of enteroceles, cystoceles and pelvic floor descent compared with clinical investigation. CONCLUSION: Dynamic MR imaging supplies complex information in anorectal disease and thus improves proctoscopy.

Adolescent↗
PubMed1995

Haemorrhoidectomy and disordered rectal and anal physiology in patients with prolapsed haemorrhoids.

The effect of haemorrhoidectomy on rectal and anal physiological abnormalities was studied in 24 consecutive patients (12 men and 12 women of mean (s.e.m.) age 39.1 (2.4) years) and compared with results in 13 sex- and age-matched controls. Before operation those with haemorrhoids had significantly higher resting anal pressures (P < 0.005), lower rectal compliance (P < 0.05) and more perineal descent (P < 0.05). Following haemorrhoidectomy there were significant decreases in the maximum resting (P < 0.05) and maximum squeeze anal (P < 0.001) pressures to within normal values 3 months after operation. Rectal compliance also increased significantly (P < 0.05), to that of normal controls. The abnormalities found in patients with prolapsed piles reverted to the normal range within 3 months of haemorrhoidectomy. These physiological changes are therefore more likely to be an effect, rather than the cause, of enlarged anal cushions.

Adult↗