To assess the effectiveness and adverse events of non-surgical interventions for treating pelvic organ prolapse (POP) in women.

A systematic review with a unique component network meta-analysis (CNMA); the review was preregistered on PROSPERO (CRD42024595871). The Cochrane Incontinence Specialised Register, including randomised controlled trials (RCTs) and quasi-RCTs from MEDLINE, CINAHL, Embase and CENTRAL, and clinical trial registries, was searched from inception to 31 March 2023. The search strategies used to maintain the Cochrane Incontinence Specialised Register were applied to search each database and registry independently, up to 24 April 2025. Iterative reference list and citation checking were undertaken. Ten women with lived experience of POP were involved in defining the scope and eligibility criteria, as well as interpreting the results. The eligibility criteria included RCTs and quasi-RCTs of women with POP assessing the effects of non-surgical interventions compared with no treatment, usual care, another non-surgical intervention, or surgery. Women with lived experience of POP and clinical experts defined the outcomes of interest to the review: quality of life; subjective cure or improvement of POP; activities of daily living (ADLs); objective cure or improvement in POP; and adverse events.

Study selection, data extraction and critical appraisal were undertaken using gold standard methods outlined by the Cochrane Handbook. Pairs of reviewers independently screened abstracts and full-texts for potentially relevant records. Two independent reviewers undertook data extraction using a pre-piloted form and critically appraised each study using Cochrane’s Risk of Bias 2.0 tool. Frequentist CNMAs were conducted to assess the effectiveness of individual intervention components. Where CNMA was considered unsuitable due to heterogeneity, narrative syntheses were undertaken using Synthesis Without Meta-analysis (SWiM) guidance. Two independent reviewers used the Confidence in Network Meta-Analysis (CINeMA) tool and an adapted version of the grading of recommendations assessment, development, and evaluation (GRADE) approach for narrative syntheses to assess the certainty of evidence for each outcome.

Fifty-three studies (with 9442 participants) were eligible. Pelvic floor muscle training (PFMT) alone was the component most often assessed (n = 18 studies). Most studies were at high risk of bias for each outcome assessed. Conducting a CNMA was feasible for three of the five outcomes of interest: quality of life; subjective cure or improvement in POP; and objective cure or improvement in POP. The CNMAs suggested that PFMT may improve patient-reported POP between 0-6 months (n = 14 studies; Table 1) and objectively assessed POP (n = 14 studies), while PFMT and pessaries may improve patient-reported POP symptoms between 6-12 months (n = 14 studies; Table 2). PFMT, lifestyle advice, pessaries, hypopressive exercises, surgery and watchful waiting may improve quality of life. Results for ADLs and adverse events were narratively synthesised. It was unclear whether non-surgical interventions improved women’s ability to undertake ADLs (n = 4 studies). In general, across 24 studies the number of women experiencing adverse events from undertaking a non-surgical intervention for POP was low, but was higher for women who used pessaries.

Most of the evidence was rated as very low-certainty on both CINeMA and GRADE. Therefore, there is currently substantial uncertainty in the evidence base surrounding non-surgical interventions for POP.

PFMT may improve patient-reported symptoms of POP in the short-term, while pessaries may improve patient-reported and objectively-assessed POP in the short-term. However, there is a lack of longer-term data and the evidence supporting the results were highly uncertain. Future research should standardise outcome measures and focus on interventions and outcomes considered most important to women with lived experience of POP to facilitate future evidence syntheses.

Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.5 (updated August 2024). Cochrane, 2024. Available from www.cochrane.org/handbook.