Expectant management

Many women with POP, especially those with minor degrees of prolapse not extending the hymenal remnants, complain of little or no discomfort. In such cases a policy of expectant management is appropriate. Weight reduction and lifestyle adjustment can be useful if relevant.²

Pelvic floor muscle training

Although studies have been published on the effectiveness of pelvic floor muscle training in the treatment of genital prolapse, established scientific evidence on the value of physiotherapy is lacking. The conclusions of published studies suggest a short-term positive effect on the experience of the severity of the complaints without a positive effect on the anatomical abnormality itself. A recent study shows a statistical significant improvement in symptoms, but the difference between the studied groups was not clinically relevant.¹⁵ For the time being, the role of pelvic floor muscle training in patients with a prolapse is mainly beneficial for the treatment of micturition, defecation and sexual complaints.

Pessary treatment

From ancient times mechanical devices have been used to reposition prolapsed organs. Pessaries offer a safe, non-surgical option for the treatment of POP.²⁹  Especially in lower grade POP cases the use of a pessary may result in decreasing the frequency and severity of prolapse symptoms and may avert or delay the need for surgery.^16,17 Pessary use can prevent worsening of the prolapse.¹⁸ A recent study in patients with symptomatic POP has shown that nearly two-thirds of women choose a pessary rather than surgery as initial management.¹⁹ The preference for pessary treatment over surgery appears not to be influenced by differences in POP symptoms like bowel or sexual function.

Complications associated with pessary insertion and use include vaginal discharge, ulcerations, excoriations, bleeding, pain, urinary and/or faecal impaction and pessary expulsion.^20,38 Rarely, pessaries cause major urinary, rectal or genital complications such as fistula, hydronephrosis and urosepsis.² These complications are almost exclusively related to a long period of use or neglected use.²⁶

Although traditionally thought of a treatment only for women deemed unfit for surgery or infirm, pessaries are a viable treatment option for the majority of women in the initial management of POP.

Pessary fitting is achieved through trial and error. Correct fitting relieves patient symptoms, allows the patient to void and defecate, stays in place with activity and causes no discomfort to the patient.²⁷ Not in all women/cases a pessary can be inserted or continued for a longer period. In a prospective study 74% of women with symptomatic POP had a pessary fitted successfully.²¹ Success rates, defined as continued pessary use in women who have a pessary fitted, range from 56 to 89% at 2–3 months^21,22, and 28% at 5 years months after insertion.²³ Risk factors for pessary failure are: previous hysterectomy, increased parity, a short vaginal length and wide vaginal introitus, which can occur after prolapse surgery and hysterectomy.

Pessary treatment can be offered to woman by health care workers with very limited resources, important for remote areas of low-income countries.

Followup visits involve removal and cleaning of the pessary, inspection of the vaginal wall and afterwards replacing the pessary. Intervals between these follow up visits vary widely and studies about the ideal length of such intervals are lacking.^32,33 Pessary self-management is also possible. There is evidence that self-managemant is cost-effective, and does not worsen quality of life.⁴²  

Vaginal pessaries can be broadly divided into two types: support and space-filling pessaries. As there is no evidence to support the use of a specific type of pessary, choice can be based on experience and costs. It is generally accepted that the ring pessary should be the first choice because of ease of insertion and removal. Folding the pessary reduces its size and allows for easy introduction through the vaginal introitus. Its shape prevents collection of vaginal discharge and women can continue to engage in vaginal intercourse with the pessary in situ. The ring pessary with supportmembrane, is useful in cases of procidentia as the uterus cannot prolapse through the closed ring. If the ring pessary fails, other pessaries can be used. Currently, the pessaries are made of silicone or polyvinyl.