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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: January 7, 2015
Expiration Date: January 7, 2016

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. Program ID: 1405237I2

Last week 80 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 28 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Individualized Pelvic Floor Muscle Training Appears to Improve Symptoms in Women with Mild Pelvic Organ Prolapse

Reference: BMJ 2014 Dec 22;349:g7378 (level 2 [mid-level] evidence)

Pelvic organ prolapse is a common problem, especially for postmenopausal women. Some loss of vaginal or uterine support has been reported in 43%-76% of women presenting for routine gynecological care and at least stage I pelvic organ prolapse on the Pelvic Organ Prolapse Quantification system has been reported in greater than 70% of women in the United States (Lancet 2007 Mar 24;369(9566):1027, Am J Obstet Gynecol 2005 Mar;192(3):795). While pelvic floor muscle training, pessary use, and surgery are available to women with more advanced prolapse, women with asymptomatic or mildly symptomatic prolapse without descent beyond the hymen are usually relegated to watchful waiting until symptoms worsen (Obstet Gynecol 2007 Sep;110(3):717, Am Fam Physician 2010 May 1;81(9):1111). A recent randomized trial compared individualized pelvic floor muscle training vs. watchful waiting in 287 women ≥ 55 years old with mild symptomatic pelvic organ prolapse.

In this trial, mild pelvic organ prolapse was defined as the leading edge of prolapse remaining above the hymen and corresponded to Pelvic Organ Prolapse Quantification stage 1 and mild stage 2. Women in the pelvic floor muscle training group initially met weekly with a pelvic physiotherapist for assessment and training, and the interval between appointments was extended as women became able to correctly contract and relax their pelvic floor muscles. Exercise programs were individualized to each patient and women were encouraged to practice at home 2-3 times a day for 3-5 days each week. Women were reassessed 3 months after the initiation of treatment or 3 months after randomization for women in the watchful waiting group. After 3 months, pelvic floor muscle training was associated with greater increase in self-reported improvement compared to watchful waiting (57% vs. 13%, p < 0.001). Pelvic floor muscle training was also associated with a 9 point greater improvement on the Pelvic Floor Distress Inventory-20 questionnaire (p = 0.005) and a 5 point greater improvement on the Urinary Distress Inventory-6 questionnaire (p = 0.007) in adjusted analyses. There were no significant differences in the number of patients experiencing an improvement of 1 or more stages on the Pelvic Organ Prolapse Quantification scale or the mean improvement on other questionnaires including the Pelvic Organ Prolapse Distress Inventory-6, ColoRectal Anal Distress Inventory-8, or the Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire-12.

This trial suggests that pelvic floor muscle training may be beneficial for women with mild symptomatic pelvic organ prolapse. While pelvic floor muscle training had a statistically significant effect on the Pelvic Floor Distress Inventory-20 questionnaire, the authors questioned whether the difference of 9 points was clinically meaningful, suggesting instead a difference of 15 points or more as clinically relevant based on previous trials. However, the women included in this trial had milder symptoms at baseline (mean score of 62.1 out of 300 points) than women in previous trials and a minimum clinically meaningful difference may not be the same in this population. In addition, pelvic floor muscle training was perceived as beneficial by a significantly greater percentage of women compared to those who received watchful waiting. Also, though pelvic floor muscle training did not improve prolapse stage, the short duration of this trial does not allow it to determine if pelvic floor muscle training may prevent worsening of the prolapse. In summary, while pelvic floor muscle training may not have achieved pre-defined clinical significance, more than half of women reported improvement in symptoms, suggesting that training may provide some benefit to women with mild pelvic organ prolapse.

For more information, see the Pelvic organ prolapse topic in DynaMed.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: ENT, Gastroenterology, Hematology, Oncology (especially Breast cancer, Head and neck cancer, Pancreatic cancer), Ophthalmology, Orthopedics, Pediatric Neurology, and Vascular.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

PEMSoft Mobile

Free Trial of PEMSoft Mobile Available For iPhone, iPad, and Android Devices

The PEMSoft Mobile app, a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools, is now available from EBSCO Health. Designed by pediatricians, emergency physicians and other medical specialists, the vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

Content in the PEMSoft Mobile app covers more than 3,000 conditions and includes a similar number of medical illustrations, clinical images and videos. PEMSoft Mobile also includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms, and topics covering pediatric injuries and management approaches.

Visit the PEMSoft Mobile App Trial page to access a free trial for both Apple and Android devices.

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