Pelvic floor muscle training for pelvic organ prolapse

760 www.thelancet.com Vol 383 March 1, 2014 Pelvic organ prolapse aff ects between 5% and 10% of women, and is strongly associated with increasing age, as shown by its prevalence of 40% in women older than 50 years. The disorder is one of the most common indications for gynaecological surgery in older women, and the estimated lifetime cumulative risk of surgery is 7–11%. In addition to the surgical procedures available for prolapse, conservative treatments include intravaginal pessaries, avoidance of activities that increase pressure on the pelvic fl oor, weight loss, and pelvic fl oor muscle training. Pelvic fl oor muscle training is an established treatment for some pelvic fl oor disorders, including urinary and faecal incontinence. Such training is often combined with other behavioural approaches, such as urge suppression strategies, and can improve urinary urgency, frequency, and nocturia. In fact, the International Consultation on Incontinence recommends pelvic fl oor muscle training as the fi rst-line treatment for stress, urge, or mixed incontinence in women of all ages. The 2011 American Urological Association guideline for diagnosis and treatment of overactive bladder in adults recommends that behavioural treatments, including pelvic fl oor muscle training, be the fi rst treatments off ered to all women, and men, with overactive bladder. Although pelvic fl oor muscle training is used clinically to treat prolapse, little empirical evidence is available for its eff ectiveness. In The Lancet, Suzanne Hagen and colleagues report results from their Pelvic Organ Prolapse PhysiotherapY (POPPY) trial, a 25-site, randomised controlled trial comparing one-to-one individualised pelvic fl oor muscle training with a lifestyle advice leafl et (control) in women with symptomatic stage I, II, or III prolapse, as confi rmed by objective assessment. The intervention was delivered to newly diagnosed women by women’s health physiotherapists in fi ve in-person visits over 16 weeks. Notably, the intervention was not limited to daily pelvic fl oor muscle exercise. Women were taught to precontract pelvic fl oor muscles during activities that increase intraabdominal pressure. Thus, in addition to the possible Pelvic fl oor muscle training for pelvic organ prolapse heterogeneity and susceptibility across diff erent risk groups and regions. Despite major improvements in air quality in the past 50 years, the data from Beelen and colleagues’ report draw attention to the continuing eff ects of air pollution on health. These data, along with the fi ndings from other large cohort studies, suggest that further public and environmental health policy interventions are necessary and have the potential to reduce morbidity and mortality across Europe. Movement towards more stringent guidelines, as recommended by WHO, should be an urgent priority.