Management of Pelvic Organ Prolapse

Female genital prolapse, or Pelvic organ prolapse (POP) ^[1] is a common condition ^{[2] [3]} in which pelvic organs drop into the vaginal canal (prolapse) and can protrude from the opening of the vagina. The condition often occurs when the pelvic diaphragm (defined here as a set of muscles which hold the pelvic organs in place) ^[4] collapses as a result of childbirth, or hysterectomy, but can also occur in the absence of both.

There are different forms of pelvic organ prolapse. They are most commonly classified as: uterine prolapse, rectocele, enterocele, urethrocele and cystocele. There are three types of management offered for Female genital prolapse: surgery, pessaries, and physical therapy.

Vaginal prolapses are often treated by hysterectomy ^[5] and other types of reconstructive surgery ^[6] , including the use of surgical mesh, in the form of a patch or sling ^[7] , but the efficacy and long-term benefit of surgery has been questioned. Urinary incontinence and vaginal prolapse are possible long term adverse effects of Hysterectomy ^[8] , and there is also an increased risk of subsequent corrective surgery ^[9] .^[10] The correction of weakness of the pelvic diaphragm with surgery is not always successful ^[11] , and the use of mesh slings can lead to serious complications.^[12]

The use of a pessary to provide structural support is a common (and ancient) ^[13] treatment for female genital prolapse. However, criticism has been voiced that the use of this medical device is at best palliative rather than curative ^[14] , and it has been known for over a century that they can actually worsen prolapse .^[15] There can be difficulties in the self maintenance; insertion and removal of pessaries and in some cases a distressing discharge and odour results from their use.^[16]

As an alternative to surgery and pessaries, Vaginal prolapses may also be treated with conservative physical therapies, such as exercises to strengthen the pelvic floor muscles, as in Kegel exercise ^[17] , or breathing techniques, as in Hypopressive exercise ,^[18] or lumbosacral postural techniques.^[19]

Kegel exercise has been demonstrated to improve pelvic diaphragm function including incontinence, but its benefit for prolapse has not been demonstrated,and there has been little research on it effectiveness for prolapse.^[20]

The breathing techniques use diaphragmatic aspiration to reduce intra-abdominal pressure, and this may have some benefit for prolapse although the evidence is weak.^[21]

A lumbosacral postural therapy^[22] is offered as an alternative physical therapy for the conservative treatment of Female genital prolapse. Other postural therapies (for example, Alexander technique, Feldenkrais Method and the Mitzvah Technique) do not claim to be treatments for prolapse.

The lumbosacral posture is based on an anatomical realignment which defines the pelvic floor as the pubic bone, rather than the pelvic diaphragm .^[23] It argues that the maintenance of the Lumbosacral.^[24] spine is essential for the prevention and reversal of prolapse. Its effectiveness still needs to be clinically tested.

Acupuncture together with traditional Chinese medicinal herbs is used in the management of prolapse, and is considered to be more successful if the prolapse has not reached the stage where surgery is recommended. Deficiencies in the Spleen and Kidney systems are considered common features to all forms of prolapse. However, as each prolapse presents with other symptoms, all symptoms must be treated after the specific causes pertinent to the position of the prolapse have been investigated. There appears to be an absence of clinical trials as to its effectiveness ^[25]

Many women also turn to Chiropractic for relief from pelvic organ prolapse. Since the findings in a study published in 2000,^[26] Chiropractors have felt confident their treatments would be of benefit. There has been no clinic testing of its effectiveness for pelvic organ prolapse.