Key messages
• Women undergoing surgery for pelvic organ prolapse may be offered various treatments meant to reduce surgical complications, improve outcomes, or both.
• In general, there is limited evidence to strongly recommend any treatment.
• However, women’s risk of developing a urinary tract infection may be 3 to 8 times greater if they have an in-dwelling catheter (to drain urine) for more than 24 hours after surgery.
What is pelvic organ prolapse?
Pelvic organ prolapse (POP) occurs when one or more pelvic organs (vagina, uterus, small intestine, bladder, rectum) bulge or protrude into the vagina. The support structures suspending the pelvic organs can weaken, leading to POP. This is usually caused by vaginal childbirth, ageing and obesity. POP can cause a range of issues for women, including leakage of urine or faeces, pressure symptoms and painful sex, seriously reducing quality of life.
When having surgery for POP, what additional treatments are available?
Surgery is one way to manage POP. Surgery aims to restore normal anatomy by suspending organs in their usual position. POP surgery can offer life-changing outcomes for women. But experts are divided about the usefulness and potential harms of various treatments undertaken prior to, during or following prolapse surgery. These treatments aim to reduce the rate of possible complications or improve prolapse repair surgical outcomes.
What did we want to find out?
Complications can occur during surgery (e.g. damage to the bowel) and after (e.g. urinary tract infection (UTI)). We wanted to determine which treatments prior to, during or following POP surgery can reduce these complications.
POP surgery ideally repairs the prolapse and improves the symptoms. We also wanted to determine which treatments best help achieve this goal.
What did we do?
We searched for studies that compared prolapse surgery with and without treatments undertaken prior to, during or following surgery, for women 18 years of age and older. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 49 studies involving 5657 women, with studies undertaken in 16 countries. They evaluated 19 different types of treatment, which we grouped into 12 main comparisons for analysis. The studies did not measure many of the outcomes we were interested in. Overall, there was limited evidence to strongly recommend any treatment.
Pelvic floor muscle training (PFMT)
PFMT aims to strengthen the pelvic floor muscles and increase the support provided for any descending organs. There may be little to no difference between women who did PMFT prior to surgery and those who did not in their awareness of their prolapse: if 20% of women are aware of their prolapse after surgery without PFMT, 13% to 31% may be aware of it after surgery with PFMT. Similarly, there may be little or no difference in the need for repeat surgery, the likelihood of the prolapse recurring, and women’s self-reported quality of life with or without PFMT.
In-dwelling catheter
Following surgery for POP, women are temporarily fitted with an in-dwelling catheter: a soft, flexible tube placed into the bladder to drain urine. Two studies compared the effects of removing the catheter at 24 hours versus later (1 study at 48 hours after surgery; 1 study at 4 days after). Women with a catheter in place for longer than 24 hours may have a large increase in the risk of having a UTI: if 4% of women get a UTI with catheter removal at 24 hours after surgery, 12% to 47% may get a UTI when catheter removal occurs more than 24 hours after surgery. Similarly, having a catheter for longer than 24 hours probably increases the length of hospital stay and may result in a large increase in the total number of days with a catheter. Neither study measured our primary outcomes.
Other treatment comparisons
The remaining 35 studies compared the effects of having prolapse surgery with or without a wide range of treatments, including:
• bowel preparation (emptying patients’ bowels before surgery);
• short- versus long-acting pain relief medicine;
• vasoconstrictors (medicine that narrows blood vessels at the operating site);
• vaginal antiseptic treatments;
• cranberry supplements (for UTI prevention);
• vaginal oestrogen (used to optimise vaginal health before surgery).
In general, the studies found little to no difference in outcomes between the two groups for all these treatments.
Limitations of the evidence
There is limited strong evidence for POP treatments before, during or after surgery because most of the women, as well as the researchers and doctors, knew which treatment was being given. This might have affected how the results were reported or measured. Additionally, many studies did not measure outcomes we were interested in.
How current is this evidence?
This review updates our previous review. The evidence is current to April 2024.