Which treatments for pelvic floor disorders are backed by evidence?

OBG Management. 2017 April;29(4):20-21

March 29, 2017|ObGyn

Q. Which treatments for pelvic floor disorders are backed by evidence?

A. Recent studies support stepwise treatment of pelvic floor disorders. Pelvic floor muscle training (PFMT) produced a small but important reduction in pelvic organ prolapse (POP) symptoms in a randomized controlled trial of women with stage 1 to 3 prolapse. Surgical repairs with native tissue or mesh expand treatment choices for POP as well as urinary incontinence, but reoperation for these disorders often is necessary, and mesh should be used with caution, according to data from 2 randomized trials and a cohort study.

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.

Glazener CM, Breeman S, Elders A, et al; PROSPECT study group. Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: two parallel-group, multicentre, randomised, controlled trials (PROSPECT). Lancet. 2017;389(10067):381–392.

Morling JR, McAllister DA, Agur W, et al. Adverse events after first, single, mesh and non-mesh surgical procedures for stress urinary incontinence and pelvic organ prolapse in Scotland, 1997–2016: a population-based cohort study. Lancet. 2017;389(10069):629–640.

Adverse events after surgical procedures for pelvic floor disorders. In Scotland, Morling and colleagues performed a retrospective observational cohort study of first-time surgeries for SUI (mesh or colposuspension; 16,660 procedures) and prolapse (mesh or native tissue; 18,986 procedures).

After 5 years of follow-up, women who underwent midurethral mesh sling placement or colposuspension had similar rates of repeat surgery for recurrent SUI (adjusted incidence rate ratio, 0.90; 95% CI, 0.73–1.11). Use of mesh slings was associated with fewer immediate complications (adjusted relative risk, 0.44; 95% CI, 0.36–0.55) compared with nonmesh surgery.

Among women who underwent surgery for prolapse, those who had anterior and posterior repair with mesh experienced higher late complication rates than those who underwent native tissue repair. Risk for subsequent prolapse repair was similar with mesh and native-tissue procedures.

Authors’ commentary. The researchers noted that their data support the use of mesh procedures for incontinence but additional research on longer-term outcomes would be useful. However, for prolapse repair, the study results do not decidedly favor any one vault repair procedure.

WHAT THIS EVIDENCE MEANS FOR PRACTICEThese studies highlight the prevalence of pelvic floor disorders and underscore the need for evidence-based treatment strategies. Women with symptomatic pelvic floor disorders initially should be offered conservative options and education. Although mesh grafts certainly have expanded the surgical options for managing pelvic floor disorders, they should be used with caution transvaginally for primary prolapse repairs. Because of the complexity of POP and its treatment, it is reasonable to refer patients with the condition to a specialist experienced in female pelvic medicine and reconstructive surgery.
--Meadow M. Good, DO

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