Chapter 1 14 1.2 Non-surgical treatment Non-surgical treatment for both prolapse and urinary incontinence include life style interventions, pharmacotherapy for UUI, pelvic floor exercises (PFE; which officially should be referred to as Pelvic Floor Muscle Training (PFMT))14 and/or pessaries for prolapse and SUI. Each of these treatment modalities have their specific benefits and possible adverse events (AE). Lifestyle interventions include behavioral training (bladder training, fluid management), weight loss, reducing activities that strain the pelvic floor and treating constipation to avoid further exacerbation of pelvic floor dysfunctions by decreasing intra-abdominal pressure. There are no studies evaluating the long-term effectiveness of life style interventions in the treatment of pelvic floor dysfunction.15 Several studies have demonstrated efficacy of pelvic floor exercises in the treatment of pelvic floor dysfunctions. PFE may reduce the symptoms and severity of prolapse and stress urinary incontinence, and as a result improve quality of life on the short term, typically without any undesirable side effects. However, PFE requires a high level of commitment in order to achieve desired results and long-term follow-up studies are scarce and show inconsistent results.15,16 Pessaries are another non-surgical option for the treatment of both symptomatic prolapse or SUI. Pessaries can be categorized in two types: supporting type (e.g. ring pessaries) and spaceoccupying type (e.g. Gellhorn pessaries), shown in Fig. 4. In general, supporting pessaries are used in patients with mild prolapse (stage I or II), whereas space-occupying pessaries are typically used in advanced prolapse (stage III or IV) and when supporting pessaries fail.17 There is no difference in efficacy between pessary treatment and PFE in reducing pelvic floor symptoms, but specific prolapse-related symptoms seem to improve more with pessary treatment. For women suffering from SUI, vaginal pessaries may improve symptoms equally to little better compared to PFE.17 However, pessaries fit less good in 43% of women. Predictors of unsuccessful pessary fitting are higher BMI, older patients, shorter transvaginal length, previous hysterectomy and underactive pelvic floor muscles.18 Furthermore, pessary use is associated with local side effects (e.g. increased vaginal discharge, bleeding, extrusion) in more than half of women, leading to discontinuation rates up to 24-86% after 5 or more years.19 Fig. 4. Pessary fitting (A) and available pessary types (B). (Drawing by DreamTeam) A B
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