Diagnosis and Management of Complex Pelvic Floor Disorders in Women

PFPT has also been studied as a treatment option for pelvic organ prolapse. In a randomized controlled trial (RCT) that compared PFPT to controls over time, more women in the PFPT group improved 1 POP-Q stage compared to the control group. They also had significantly improved pelvic floor symptom bother [17]. In the POPPY study examining PFPT versus a control condition, researchers were not able to show statistically significant improvement in prolapse stages but did show improvement in secondary outcomes, including symptom bother and the feeling of “bulge.” Fewer women sought further treatment for prolapse after undergoing PFPT [18]. PFPT can be effective in managing prolapse symptoms and may help improve prolapse stage.

Pessary

Pessaries are commonly used for management of pelvic organ prolapse in patients who choose nonoperative management. In a large study of pessary use in the Medicare population, it was noted that of 34,782 women diagnosed with prolapse between 1999 and 2000, 11.6% were treated with a pessary. Complications noted during the 9 years of follow-up included 3% with vesicovaginal or rectovaginal fistulas and 5% with a device-associated complication [19]. Use increased with age, with 24% of women over 85 being managed with a pessary. In a review examining quality of life, improvement in bulge, irritative symptoms, and sexual satisfaction occurred with pessary use. In the medium-term, prolapse-related bother symptoms, quality of life, and overall perception of body image improved with the use of a pessary [20]. For SUI, rings with a knob or an incontinence dish can provide support to the urethra and help to pinch it closed with coughing, sneezing, and laughing, preventing leakage. In an RCT comparing women who received behavioral therapy, an incontinence pessary, or both, at 3 months 33% of those assigned to pessary reported improved incontinence symptoms compared to 49% with behavioral therapy, and 63% were satisfied with pessary treatment compared to 75% with behavioral therapy [21,22]. Differences did not persist to 12 months with over one third of all women improved and even more satisfied. A pessary can be safely used in the elderly population but does require office management and regular follow-up to prevent complications.

Initital Treatment

The patient was treated with 3 months of PFPT with biofeedback and pelvic floor muscle strengthening. In addition, she was able to decrease her caffeine use from 4 cups of coffee per day to 1 cup in the morning. At her 3-month follow-up visit, she noticed significant improvement in her voiding symptoms, and her voiding diary showed improved voided volumes and decreased frequency and nocturia. However, she was becoming more active in her community, going to aerobics and dance classes. She was more bothered by the “bulge” feeling in her vagina. She was not interested in a pessary but wanted to hear about surgical options for prolapse treatment.

• What is operative management of pelvic organ prolapse?

The goals for surgical pelvic organ prolapse repair are to resolve symptoms, restore normal or near-normal anatomy, preserve sexual, urinary and bowel function, and minimize patient morbidity. The extent of prolapse, patient risk factors for recurrence, patient preference, and overall medical condition all influence the method for surgical repair. Surgeon familiarity and experience is also important when selecting the appropriate repair. Recent concerns regarding the use of synthetic mesh material has become a factor in counseling patients since the 2011 US Food and Drug Administration safety communication on transvaginal mesh [23].