As pelvic health physiotherapists, we are often involved in the conservative management of women with postpartum pelvic organ prolapse (POP). One of the most important — and sometimes difficult — conversations we have with patients is whether conservative treatment can genuinely reverse their anatomy, or whether surgery is the inevitable next step.
A published case report by Nemeth and Ott (2011) offers a striking example of how layered conservative care can produce significant anatomical and symptomatic change even in severe prolapse.
■ The patient
The case involved a healthy 35-year-old woman who gave birth vaginally to a 3.6 kg baby boy in September 2008. Her delivery was complicated by a long second stage and a vacuum-assisted birth. From day one postpartum she reported significant pelvic pain, discomfort and stress urinary incontinence.
At her six-week check-up, her gynaecologist diagnosed:
- Stage III cystocele
- Stage III rectocele
- Stage II uterine prolapse
She was referred for physiotherapy and commenced pelvic floor muscle training (PFMT) with lifestyle advice. By her four-month review, however, there had been no improvement and surgery was recommended.
At one year postpartum, she sought a second opinion from Dr Nemeth, the author of the case report.
■ Baseline findings at 12 months postpartum
On examination:
- POP-Q: Stage III uterine prolapse (+2 cm), Stage II anterior wall (+1 cm), Stage II posterior wall (0 cm)
- Levator ani: weak (Modified Oxford Scale grade 2)
- Genital hiatus (GH): widened at 6 cm
This is a clinically challenging presentation. A GH of 6 cm alone is strongly associated with prolapse progression and poorer outcomes from conservative care — so the question was: what more could be done before resorting to surgery?
■ The treatment plan
Rather than repeating standard PFMT in isolation, a multi-modal protocol was introduced:
- Cube pessary (37 mm) worn during the day and removed each night
- PFMT with graduated vaginal weights (cones) each night after removal of the pessary
- Vaginal neuromuscular electrical stimulation at 50 Hz for 20 minutes, once per week, with 6-second contractions
In essence — passive support during the day, active strengthening in the evening, and neuromuscular re-education once a week.
■ The outcome
One month in
Her pelvic discomfort had resolved and she reported that it had ceased almost immediately on commencing the cube pessary. Vaginal weights, initially difficult, could now be retained in standing. The pessary was downsized from 37 mm to 32 mm.
Two months in
With the pessary removed, the uterus was now staying above the −1 cm mark. The cube was further reduced to 29 mm.
Seven months in
The patient was functioning entirely without the pessary and reported that her sex life had normalised completely. On examination:
- No signs of anterior or posterior wall prolapse
- Cervix sitting 6 cm above the hymenal remnants
- Genital hiatus reduced from 6 cm to 4 cm
This is a remarkable shift — particularly the reduction in genital hiatus, which is one of the most difficult anatomical parameters to change conservatively.
■ How might this have worked?
The authors propose two plausible mechanisms for the pessary’s role:
- Holding the supportive connective tissues (uterosacral ligaments, pubocervical fascia, rectovaginal fascia) in a shortened position so they can remodel over time.
- Keeping the pelvic organs and vaginal walls above the levator hiatus, offloading the hiatus itself and allowing it to narrow — which in turn helps maintain prolapse reduction even after the pessary is no longer worn.
The clinical implication is that once the hiatus has narrowed, the system becomes more self-supporting. The pessary is doing more than just holding organs up — it is altering the mechanical environment in which the pelvic floor muscles and connective tissues operate.
■ What this means for clinical practice
A few reflections I take from this case:
- PFMT alone is not always enough. This patient had already completed months of PFMT and lifestyle advice with no change. Adding a pessary and neuromuscular stimulation was the step-change.
- Genital hiatus is a genuine treatment target. The research literature suggests pessary use is one of the few effective conservative options for reducing GH and levator hiatus — and this case illustrates exactly that.
- Pessary choice matters. With a GH of 6 cm, most support pessaries would not have stayed in place. The cube pessary is one of the few options that can retain position in this setting — although it works differently, as a space-occupying device with suction, rather than a support pessary.
- Conservative care can change anatomy, not just symptoms. A reduction from GH 6 cm to 4 cm, and from Stage III uterine prolapse to no demonstrable prolapse, is an anatomical outcome — not simply symptom management.
| AN IMPORTANT CAVEAT This is a single case report published precisely because the outcome was unusual. We cannot know whether the same result would have been achieved with the pessary alone, or whether the cones and electrical stimulation added a meaningful contribution. We can say, however, that her previous PFMT course without a pessary produced no change — so the addition of the pessary does appear to have been pivotal. Case studies don’t prove efficacy but they do show what is possible, and they should prompt us to think more broadly about the tools we combine in conservative care. |
■ The takeaway
If you are living with postpartum prolapse — or you are a clinician managing someone who is — this case is a reminder that conservative treatment can still have a lot more to offer after standard PFMT has been tried. Pessary management, particularly with devices like the cube pessary that can hold in a widened hiatus, deserves a place in the conversation before surgery is the only option left on the table.
| If you would like to discuss pessary options or a tailored postpartum rehabilitation plan, please get in touch with the clinic to book an assessment. |