Non-Surgical Treatments

Treatments for Pelvic Organ Prolapse

Urogynecologists describe the severity of pelvic organ prolapse using the POP-Q system. This system assigns a series of points to areas of the vagina. Surgeons than measure how far these specific points have prolapsed with reference to the opening of the vagina. When a referenced point has not moved beyond the opening of the vagina and is more than 1 cm from doing so, the prolapse is consider Stage One. When it is within 1 cm of the vaginal opening (inside or outside the vagina), the prolapse is considered Stage 2. Any prolapse that is more than one cm outside the vagina is either Stage 3 or Stage 4 prolapse. Some treatments for pelvic organ prolapse are not suitable to Stage 3 or 4 disorders.

Pelvic Floor Physiotherapy:
National Average Success Rates (50-80%)
Zipper Urogynecology Success Rates (60-80%)

The support of the pelvic organs is created by both collagen based and muscular structures. Loss of support is typically caused by a combination of damage and or weakness to all of these structures. Damage to the collagen based structures, fascia and ligaments, will not respond to Pelvic Floor Physiotherapy. However, damage and weakness to the muscular structures, Levator Muscle Group, are responsive to physiotherapy. Stage 3 and Stage 4 prolapse are typically associated with severe damage to the fascia and ligaments. Improvement in the muscular support will not be enough to compensate for this damage. Significant improvement in prolapse is unlikely. The lower the grade of prolapse, the more likely it is that increased Levator muscle tone can help. Stage 1 prolapse is very treatable with pelvic floor physiotherapy. Milder cases of Stage 2 prolapse may respond as well. However, as Stage 1 Prolapse is rarely symptomatic, treatment of such is of questionable importance. Therefore, symptomatic mild Stage 2 prolapse is perhaps the only prolapse disorder that should be treated with physiotherapy.

Kegel Exercises:
Dr. Arnold Kegel first described these exercises in the early 1950s. These exercises were intended for the treatment of stress urinary incontinence, not for prolapse. The Kegel excersises involved placing a small device in the vagina that the patient could squeeze. This device was attached to a gauge that would show the patient how hard she squeezed the pubococcygeous muscle (part of the Levator Muscle Group). Dr. Kegel described three 20 minute sessions per day. Many patients with stress incontinence demonstrated symptomatic improvement. To date, there is very limited data to suggest that Kegel Exercises are beneficial in the treatment of prolapse. It is important to remember that the success of Dr. Kegel's protocol was predicated on the use of a device that let the patient know how well she was contracting the Levator Muscle. When done without such a device, even in the treatment of mild stress incontinence, Kegel exercises are of limited value. Although we do recommend Kegel exercises with a perineometer (the device used by Dr. Kegel to measure the muscle contraction) for our patients with mild stress incontinence, we do not recommend it to our patients with symptomatic prolapse.

Biofeedback Therapy:
The mainstay of pelvic floor physiotherapy is call Biofeedback Therapy. Small pad electrodes (EKG type pads) are placed on the skin of the abdomen and anus. These pads are typically connected to a computer screen that displays easy-to-see messages when the patient contracts the correct or incorrect muscles. Hence, the patient learns to exercise and control the pelvic muscles without contracting the abdominal muscles. This is a very effective method of strengthening the Levator Muscle Group and improving the success of Kegel Exercises. However, once again, this has only been shown to be effective in the treatment of urinary incontinence. There is not substantial data to demonstrate the effectiveness of biofeedback therapy in the treatment of pelvic organ prolapse. Although we do recommend Biofeedback Therapy for our patients with some forms of urinary incontinence and fecal incontinence associated with muscle weakness, we do not recommend it to our patients with symptomatic prolapse.

Ring PessaryPessaries:
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Pessaries are rubber or silicon rings, squares, or unique shapes which may be worn inside the vagina. By taking up space inside the vagina, they prevent the pelvic organs from prolapsing through the herniated area. The pessary is held in place by the pubic bone and the Levator Muscle Group. Hence, when severe weakness to the muscle is present, a pessary will not stay in place. It will fall out. There are many different shapes and sizes of pessaries. Some seem to work better for specific types of prolapse. However the shape of the bony pelvis will often dictate which pessary can be used. Each woman must undergo a pessary fitting. The Urogynecologist will perfom an office examination and then try to place the pessary that suits your type of pelvis and prolapse. If the pessary stays in and is comfortable with your normal activities and exercise routine, no further fittings will be necessary.

It is important to remember that pessaries do not cure prolapse, they treat the symptoms. As soon as a pessary is removed, the prolapse returns. A pessary may be worn for up to three months, but then should be removed, washed with soap and water, and replaced. Pessary use is associated with increased vaginal discharge, an increase in urinary tract infections, and can cause constipation. Some pessaries may be left in during intercourse. However, most women choose to remove them. Some pessaries are difficult to remove and therefore must be removed and cleaned by your doctor every three months.

Donut Pessary:
Use: All types of prolapse
Ease of insertion and removal: Moderate
Discharge: Moderate
Intercourse: Must Remove

Ring with Support:
Use: All types of prolapse
Ease of insertion and removal: Simple
Discharge: Moderate
Intercourse: May Remain Inserted

Ring:
Use: Not suited for Uterine Prolapse or Apical Failure.
Best suited for mild prolapse
Ease of insertion and removal: Simple
Discharge: Minimal
Intercourse: May Remain Inserted

Gelhorn:
Use: Best choice for Uterine Prolapse. Suitable for all types of prolapse.
Ease of insertion and removal: Difficult
Discharge: Moderate
Intercourse: Must Remove

Cube:
Use: All types of prolapse. Typically reserved for patients who fail other pessaries.
Ease of insertion and removal: Moderate
Discharge: Severe
Intercourse: Must Remove
Special Consideration: Secondary to severe discharge, this pessary is typically reserved for the treatment of severe symptoms in patients who fail other pessaries.

Inflatable:
Use: All types of prolapse. Typically reserved for patients who fail other pessaries.
Ease of insertion and removal: Simple
Discharge: Severe
Intercourse: May Remain Inserted
Special Consideration: Secondary to severe discharge, this pessary is typically reserved for the treatment of severe symptoms in patients who fail other pessaries.

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