The role of pelvic floor muscle training in patients with a prolapse is mainly the treatment of micturition, defecation and sexual complaints if the prolapse is not yet sufficiently pronounced for pessary therapy or surgery. Pessaries offer a safe, non-surgical option for the treatment of POP with a wide range of continued use.
Studies about the effect and results of pelvic floor muscle training in Nepali women with POP are rare despite the fact that pelvic floor muscle training is almost routinely advised. A qualitative study on a group of 10 pregnant women in Dhulikhel Hospital showed that they were interested in self-care and made an effort to fit the exercises in daily life after following a PFMT-program training.9
Recently, in a randomised controlled trial, a one-time intervention of an informational flipchart on pelvic floor muscle training and lifestyle advice showed to be effective in improving QOL and symptoms for Nepali women with a POPstage I-III.6But the same researches highlighted in a small study thelow knowledge of the pelvic floor muscle, and the bad results of a brief verbal instruction with an illustrative leaflet in teaching Nepali women how to correctly contract their pelvic floor muscle.8 Moreover, in a small study in a gynaecological population in Kathmandu it was shown that pelvic floor muscle strength and thickness were not related to POP I-IV.7
There are a few studies on the effect of pessary treatment.
A study among 74 women in Baglung district with POPsymptoms, identified 47 women who got pessary treatment. In 9 women complications were reported: pessary extrusion (n=4), discharge (n=2), pain leading to removal of the pessary (n=4).1
Recently, a 1-year prospective cohort study was conducted in Ramecchap district.2In total 142 women with symptomatic POP were seen; of them 134 got a pessary. At the 1-year follow-up 130 women were evaluated. From them, 72 were still using the pessary (55.4%). The primary reason for discontinuation was the pessary falling out (n=35), uncomfortable (n=14), vaginal discharge (n=4). Among the women retaining the pessary, 18 had vaginal erosions. The authors conclude that pessaries were found to be an acceptable and feasible option with minimal complications for treating POP in rural Nepal.
Over a period of 3 years (2011-2014) WfWF organized in collaboration with RHEST, Cosan, stichting Veldwerk and Maternity Paropakar Hospital, 66 gyno-camps in 15 VDCs in Dhading, ranging from 2 to 5 gyno-camp per VDC.3 A total of 4087 women were seen, of whom 3350 (82%) once, and 737 (18%) multiple times. 861 women (40%) of the total group of women with POP 1-4 (n=2392) received pessaries. Of these 861 women 363 (42%) were seen again, and 507 (58%) were not seen again. Among the group of women who were seen again (n=363), 50% were using a pessary. The majority of these women (75%) tend to handle the pessary themselves; the remainder visit the healthcare post for a check up. In 40% of those cases where the pessary is no longer used, the reason given is that the pessary has become dislodged. In 28% of the women who got a pessary at first visit, the pessary has been prematurely removed due to pain symptoms.
In 2009, a follow-up study of a WfWF gynocamp in 2007 was completed.4 All women who visited the gynocamp in 2007 completed also a questionnaire. In 2008 during a gynocamp in the same VDC, all women treated for POP with a pessary (n=120) were invited for follow-up. From these women, 47 did come (39%) and 24 women still used the pessary. Within the pessary users, 20 women were satisfied and felt improvement of their earlier complaints. Most of the women, who did not used the pessary after one year, told that they had lost the pessary.
A small follow up study on the results of pessary treatment was conducted in 2008.5 Researchers adapted the Pelvic Floor Distress Inventory short, as the original version was too long and complicated for both interviewers and women. In total 40 pessary-treated women were included, of which 23 still used the pessary and 20 of them were satisfied with its effect. From them, 17 stopped pessary due to fell out, pain, or discharge. Mostly women stopped either during the first month of treatment or in the month before the follow up. Within this population, a qualitative research with interviews among 12 women with POP and before treatment was done. Sudden pain, shame and fear through ignorance were the most discussed items.
1. Non-surgical intervention for pelvic organ prolapse in rural Nepal: a prospective monitoring and evaluation study. Fitchett JR, Bhatta S, Sherpa TY, Malla BS, Fitchett EJA, Samen A, Kristensen S. journal of the Royal Society of Medicine Open, 2015
2. Feasability of using pessaries for treatment of pelvic organ prolapse in rural Nepal. Robert M, Govan AJ, Lohani U, Uprety A. Int J Gynaecol Obstet 2017:136:325-330
3. POP in Dhading district. WfWF report 2015
4. Evaluation of pessary use. Mellema M. Scientific traineeship report 2009
5. Follow up of conservative POP treatment and surgical treatment of POP (in Dutch, summary in English) Sebille EA van. Scientific traineeship report 2009
6. Impact of an informational flipchart on lifestyle advice for nepali women with a pelvic organ prolapse: a randomised controlled trial. Caagbay D, Reynes-Greenow C, Dangal G, Mc Geechan K, Black KI. International Urogynecology Journal (2020) 31:1223-1230.
7. Is pelvic floor muscle strength and thickness associated with pelvic organ prolapse in Nepali women? - A cross sectional study. Caagbay D, Turel F, Dietz HP, Raynes-Greenow C, Martinho N, Black KI. Braz J of Phys Ther 2020, https://doi.org/10.1016/j.bjpt.2020.05.011
8. Can a Leaflet with Brief Verbal Instruction TeachNepali Women How to Correctly Contract Their Pelvic Floor Muscles?Caagbay DM,Black K,Dangal G,Raynes-GreenowC.J Nepal Health Res Counc 2017 May - Aug;15(36): 105-9
9. Pregnant women’s experiences with a pelvic floor muscle training program in Nepal.Stensdotter AK, Håland A, Ytterhus B, Shrestha S, Stuge B. Global Health Action, 14:1, 1940762, DOI: 10.1080/16549716.2021.1940762