Nonsurgical Therapy Nonsurgical therapy of pelvic organ prolapse includes conservative behavioral management and the use of mechanical devices. A nonsurgical treatment approach usually is considered in women with mild to moderate prolapse, those who desire preservation of future childbearing, those in whom surgery may not be an option, or those who do not desire surgical intervention.
Conservative Management Conservative management approaches include alteration of lifestyle or physical intervention such as pelvic ﬂoor muscle training (PFMT). These approaches are used mainly in cases of mild to moderate prolapse; however, their true role in managing prolapse and associated symptoms is unclear (29,30). The goals of a conservative therapy approach to the treatment of prolapse are as follows (31):
Decrease the severity of symptoms
Increase the strength, endurance, and support of the pelvic ﬂoor musculature
Lifestyle intervention includes such activities as weight loss and reduction of those activities that increase intra-abdominal pressure. This interaction is typically anecdotal in practice. No case series, prospective studies, or randomized control trials exist that have examined the effectiveness of this approach to the treatment of prolapse.
Pelvic ﬂoor muscle exercises may limit the progression of mild prolapse and related symptoms (32,33); however, a lower response rate has been noted when prolapse extends beyond the vaginal introitus (34).
The efficacy of biofeedback therapy in the treatment of impaired defecation associated with a rectocele has been determined (35). Thirty-two female patients, median age 52 years (range, 34–77 years), experiencing impaired rectal evacuation with a rectocele greater than 2 cm at proctography underwent a structured behavioral retraining. Immediate and medium-term follow-up results were reported (median 10 months; range 2–30 months). Fifty-six percent of patients (n = 14) felt a little and 16% (n = 4) felt major improvement in symptoms, including 3 (12%) with complete symptom relief. Immediately after biofeedback there was a modest reduction in need to strain (67; 50%), feeling of incomplete evacuation (73; 59%), and need to assist defecation digitally (79; 63%) that was maintained at follow-up. Bowel movement frequency was significantly normalized at follow-up (p = .02). These investigators concluded that behavioral retraining, including biofeedback therapy, may be an effective primary therapy for some patients with a rectocele associated with impaired defecation.
Mechanical Devices The use of mechanical devices such as pessaries is usually considered for women who cannot undergo surgery for medical reasons, desire to avoid surgery, or have a significant degree of prolapse that makes other nonsurgical approaches unfeasible. Some practitioners extend indications to include pregnancy-related prolapse as well as prolapse and incontinence in elderly women. Reports have shown that age older than 65 years, the presence of severe medical comorbidity, and sexual activity were associated with successful pessary user (36,37). Unsuccessful use or a preference for surgery has been associated with a shortened vaginal length (≤6 cm), a wide vaginal introitus, sexual activity, stress incontinence, stage III or IV posterior compartment prolapse, and desire for surgery at a first office visit (38). Few literature-based reviews and reports recommend pessaries as first-line treatment for women with POP, and there is little consensus regarding choice of pessary and management of pessary usage (39). Most of the information on pessary use is derived primarily from descriptive and retrospective studies, relatively small prospective series, manufacturer’s recommendations, and anecdotal experience.