Cover of Psychological therapy for women with pelvic floor dysfunction

Psychological therapy for women with pelvic floor dysfunction

Pelvic floor dysfunction: prevention and non-surgical management

Evidence review O

NICE Guideline, No. 210

Authors

.

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-4364-7
Copyright © NICE 2021.

Psychological therapy for pelvic floor dysfunction

Review question

What is the effectiveness of psychological interventions for women with symptoms associated with pelvic floor dysfunction?

Introduction

Women who have pelvic floor dysfunction can also have high levels of depression and anxiety, and experience low mood, and emotional distress, impacting on their quality of life. There is evidence that the presence of these psychological conditions reduces the likelihood that women will attend for PFMT, and, if they do attend, the presence of these disorders will reduce the outcomes of that intervention. Given this, it seemed to the committee important to explore the extent to which psychological interventions would improve pelvic floor symptoms.

Summary of the protocol

See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.

Table 1. Summary of the protocol (PICO table).

Table 1

Summary of the protocol (PICO table).

For further details, see the review protocol in appendix A.

Declarations of interest were recorded according to NICE’s 2019 conflicts of interest policy.

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document (supplementary document 1).

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

Clinical evidence

Included studies

Seven publications were included for this review, (Carty 2018, Felsted 2019, Komesu 2011, Osborne 2016, Ter kuile 2013, van Lankveld 2006 and Zarski 2017), all were randomised controlled trials (RCTs).

The included studies are summarised in Table 3 (studies specifically referring to pelvic floor dysfunction) and Table 2 (studies specifically addressing vaginismus)

One study compared a life stress emotional awareness and expression interview to control in women with chronic urogenital pain (Carty 2018).

One feasibility study compared a mindfulness based stress reduction program to a health enhancement program in women with urge urinary incontinence (UUI) (Felsted 2019).

One study compared hypnotherapy to standard care (behavioural therapy) in women with OAB (Komesu 2011)

One study compared having a motivational interview prior to pelvic floor muscle training (PFMT) to standard care in women with PFD (Osborne 2016)

Three of the studies investigated the effects of psychological therapy on vaginismus (Ter Kuile 2103, van Lankveld 2006, Zarski 2017).

No evidence was found for other symptoms associated with PFD (faecal incontinence, emptying disorders of the bowel or pelvic organ prolapse)

See the literature search strategy in appendix B and study selection flow chart in appendix C.

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K.

Summary of studies included in the evidence review

Summaries of the studies that were included in this review are presented in Table 3 and Table 2

Table 2. Summary of included studies: Psychological therapies for women with PFD or symptoms associated with PFD.

Table 2

Summary of included studies: Psychological therapies for women with PFD or symptoms associated with PFD.

Table 3. Summary of included studies: Psychological therapy for vaginismus.

Table 3

Summary of included studies: Psychological therapy for vaginismus.

See the full evidence tables in appendix D. No meta-analysis was conducted (and so there are no forest plots in appendix E).

Quality assessment of studies included in the evidence review

See the evidence profiles in appendix F.

Economic evidence

Included studies

A single economic search was undertaken for all topics included in the scope of this guideline but no economic studies were identified which were applicable to this review question. See the literature search strategy in appendix B and economic study selection flow chart in appendix G.

Excluded studies

Economic studies not included in this review are listed, and reasons for their exclusion are provided in appendix K.

Economic model

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation because it was unlikely that recommendations would have a significant resource impact.

Brief summary of the evidence

Psychological therapy for vaginismus
  • Very low to low quality evidence showed that exposure therapy as compared to wait list control showed improved outcomes for vaginismus, vaginal penetration, pain, fear of coitus and overall sexual functioning.
  • Very low to low quality evidence showed group CBT and bibliotherapy both improved penetration as compared to waitlist control; however, the bibliotherapy appeared more effective than group CBT.
  • Very low quality evidence showed a benefit of an internet based self-help program in terms of overall sexual functioning but showed no differences compared to control for penetration or fear of coitus.
Emotional expression and awareness interview versus treatment as usual of women with chronic urogenital pain
  • Very low quality evidence showed a benefit for an emotional expression and awareness interview for pain severity and pelvic floor distress scores, but showed no effect on anxiety or depression.
Mindful based stress reduction versus embedded health programme for women with urge urinary incontinence
  • Low quality evidence from a feasibility study showed more women no difference in retention in the intervention when receiving mindfulness based stress reduction as compared to an embedded health program.
Hypnotherapy versus behavioural therapy for women with overactive bladder
  • Very low quality evidence showed no difference in outcomes between hypnotherapy and behavioural therapy.
Motivational interview versus pelvic floor muscle training alone for PFD
  • Low quality evidence suggested a motivational interview before PFMT sessions improves the number of classes attended.

The committee’s discussion of the evidence

Interpreting the evidence
The outcomes that matter most

The committee agreed that improvement in symptoms associated with pelvic floor dysfunction were the most critical outcomes as this is a review on management of symptoms, and therefore the intervention should improve these. The committee agreed that important outcomes were health related quality of life and change in psychological factors (anxiety/depression) as these should be improved by a successful psychological intervention; additionally, and these are important outcomes as PFD often has a large impact on a woman’s psychological state. Other important outcomes included adherence and satisfaction of the intervention, these outcomes likely influence the effect size of the outcome and should therefore be considered.

The quality of the evidence

The quality of the evidence for this review was assessed using GRADE and ranged from very low to low quality. All studies were downgraded due to risk of bias in the measurement of outcomes, as these were generally self-reported and as such open to influence from bias relating to assumptions about the effect of treatment. Additionally, the participants could not be blinded to the interventions due to the nature of treatment. Some outcomes were also downgraded due to imprecision in the data, which may be related to small study size.

No evidence was found for acceptance and commitment therapy, dialectical behaviour therapy, guided self-help therapy, pure self-help or combined pharmacological and psychological treatment.

Benefits and harms

Overall, the evidence presented was limited and varied in quality. Due to the uncertainty in the evidence the committee could not use it to support their recommendations. The committee noted based on their experience that the symptoms of pelvic floor dysfunction can cause embarrassment and that women can feel stigmatised. They therefore decided that it is important to ask the woman about their psychological wellbeing and whether this is affected negatively by their symptoms. The committee discussed that this would allow women to talk about their feelings and help explore whether further psychological help may be need.

Evidence suggested that psychological interventions improved attendance and adherence to therapies such as pelvic floor muscle training. The committee agreed that in their clinical experience, adherence is important in the management of the symptoms associated with pelvic floor dysfunction. However, as the evidence did not address whether psychological interventions directly improve symptoms of pelvic floor dysfunction, the committee discussed whether a research recommendation is needed. They were conscious that the studies identified did not evaluate if psychological interventions improved the psychological distress experienced by the women. Due to this gap in research, the committee made a research recommendation to investigate this further.

Cost effectiveness and resource use

Although the clinical evidence was generally limited the committee noted that some evidence suggested that psychological therapies might improve adherence to treatment and therefore could potentially be cost-effective depending on the size of the effect. However, as there was no direct evidence that these psychological interventions improved the symptoms of pelvic floor dysfunction the committee limited themselves to a research recommendation. They also cross referenced the NICE guidelines on antenatal and postnatal mental health and depression in adults with a chronic physical health problem for cost-effective recommendations that could be related to women’s pelvic floor dysfunction symptoms.

Other factors the committee took into account

They also agreed to refer to the NICE guideline on antenatal and postnatal mental health as this provides relevant advice on psychological wellbeing before and after giving birth and the NICE Depression in adults with a chronic physical health problem: recognition and management (2009) guideline because pelvic floor dysfunction can become a chronic condition which can lead to depression.

Recommendations supported by this evidence review

This evidence review supports recommendations 1.6.28, 1.6.29 and a research recommendation on psychological interventions in the NICE guideline.

References

  • Carty 2018

    Carty, J. N., Ziadni, M. S., Holmes, H. J., Tomakowsky, J., Peters, K., Schubiner, H., Lumley, M. A., The Effects of a Life Stress Emotional Awareness and Expression Interview for Women with Chronic Urogenital Pain: A Randomized Controlled Trial, Pain medicine, 24, 2018 [PMC free article: PMC6611525] [PubMed: 30252113]

  • Felsted 2019

    Felsted, Katarina Friberg, Supiano, Katherine P., Mindfulness-Based Stress Reduction Versus a Health Enhancement Program in the Treatment of Urge Urinary Incontinence in Older Adult Women: A Randomized Controlled Feasibility Study, Research in Gerontological Nursing, 12, 285–297, 2019 [PubMed: 31283830]

  • Komesu 2011

    Komesu, Y. M.; Sapien R. E.; Rogers, r. G.; Ketai, L.H.; Hypnotherapy for treatment of overactive bladder: a randomised controlled trial pilot study. Female Pelvic Medicine & Reconstructive Surgery 17, 308–313 [PMC free article: PMC4575591] [PubMed: 22453228]

  • Osborne 2016

    Osborne, L. A., Whittall, C. M., Edwards, D. J., Emanuel, R., Emery, S., Reed, P., Randomized control trial of a values-based motivational interview support to promote attendance at pelvic floor muscle training physiotherapy treatment, Journal of Pelvic, Obstetric & Gynaecological Physiotherapy, 38–46, 2016

  • TerKuile 2013

    Ter Kuile, M. M., Melles, R., de Groot, H. E., Tuijnman-Raasveld, C. C., van Lankveld, Jjdm, Therapist-aided exposure for women with lifelong vaginismus: a randomized waiting-list control trial of efficacy, Journal of Consulting & Clinical PsychologyJ Consult Clin Psychol, 81, 1127–1136, 2013 [PubMed: 24060195]

  • Van Lankveld 2006

    van Lankveld, J. J., ter Kuile, M. M., de Groot, H. E., Melles, R., Nefs, J., Zandbergen, M., Cognitive-behavioral therapy for women with lifelong vaginismus: a randomized waiting-list controlled trial of efficacy, Journal of Consulting & Clinical PsychologyJ Consult Clin Psychol, 74, 168–78, 2006 [PubMed: 16551154]

  • Zarski 2017

    Zarski, A. C., Berking, M., Fackiner, C., Rosenau, C., Ebert, D. D., Internet-Based Guided Self-Help for Vaginal Penetration Difficulties: Results of a Randomized Controlled Pilot Trial, Journal of sexual medicine, 14, 238–254, 2017 [PubMed: 28161080]

Appendices

Appendix E. Forest plots

Forest plots for review question: What is the effectiveness of psychological interventions for women with symptoms associated with pelvic floor dysfunction?

No meta-analysis was conducted for this review question and so there are no forest plots.

Appendix H. Economic evidence tables

Economic evidence tables for review question: What is the effectiveness of psychological interventions for women with symptoms associated with pelvic floor dysfunction?

No evidence was identified which was applicable to this review question.

Appendix I. Economic evidence profiles

Economic evidence profiles for review question: What is the effectiveness of psychological interventions for women with symptoms associated with pelvic floor dysfunction?

No economic evidence was identified which was applicable to this review question.

Appendix J. Economic analysis

Economic evidence analysis for review question: What is the effectiveness of psychological interventions for women with symptoms associated with pelvic floor dysfunction?

No economic analysis was conducted for this review question.

Appendix K. Excluded studies

Excluded studies for review question: What is the effectiveness of psychological interventions for women with symptoms associated with pelvic floor dysfunction?

Economic studies

No economic evidence was identified for this review.