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Overview

  • In June 2019, NICE withdrew recommendations 1.8.21 and 1.8.22 on the use of synthetic polypropylene or biological mesh insertion for women with recurrent anterior vaginal wall prolapse. These have been replaced with a link to the NICE interventional procedures guidance on transvaginal mesh repair of anterior or posterior vaginal wall prolapse. For further details see update information.
  • This guideline covers assessing and managing urinary incontinence and pelvic organ prolapse in women aged 18 and over. It also covers complications associated with mesh surgery for these conditions.
  • This guideline replaces CG171 and IPG154.
  • This guideline is the basis of QS77.

Contents included in this summary

Contents not included in this summary

1.8.8–1.8.13 Surgery for uterine prolapse

1.8.14–1.8.17 Surgery for vault prolapse

1.8.18 Colpocleisis for vault or uterine prolapse

1.8.19–1.8.22 Surgery for anterior prolapse

1.8.23 Surgery for posterior prolapse

1.8.24–1.8.25 Follow-up after surgery

1.9.1–1.9.2 Surgery for women with both stress urinary incontinence and pelvic organ prolapse

Table 1 Investigations for assessing suspected mesh-related complications  

 

1.6 Assessing pelvic organ prolapse

1.6.1 For women presenting in primary care with symptoms or an incidental finding of vaginal prolapse:

  • take a history to include symptoms of prolapse, urinary, bowel and sexual function
  • do an examination to rule out a pelvic mass or other pathology and to document the presence of prolapse (see the sections on ovarian cancer and bladder cancer in the NICE guideline on suspected cancer)
  • discuss the woman’s treatment preferences with her, and refer if needed. [2019]

1.6.2 For women referred to secondary care for an unrelated condition who have incidental symptoms or an incidental finding of vaginal prolapse, consider referral to a clinician with expertise in prolapse. [2019]

1.6.3 For women who are referred for specialist evaluation of vaginal prolapse, perform an examination to:

  • assess and record the presence and degree of prolapse of the anterior, central and posterior vaginal compartments of the pelvic floor, using the POP‑Q (Pelvic Organ Prolapse Quantification) system
  • assess the activity of the pelvic floor muscles
  • assess for vaginal atrophy
  • rule out a pelvic mass or other pathology. [2019]

1.6.4 For women with pelvic organ prolapse, consider using a validated pelvic floor symptom questionnaire to aid assessment and decision making. [2019]

1.6.5 Do not routinely perform imaging to document the presence of vaginal prolapse if a prolapse is detected by physical examination. [2019]

1.6.6 If the woman has symptoms of prolapse that are not explained by findings from a physical examination, consider repeating the examination with the woman standing or squatting, or at a different time. [2019]

1.6.7 Consider investigating the following symptoms in women with pelvic organ prolapse:

  • urinary symptoms that are bothersome and for which surgical intervention is an option
  • symptoms of obstructed defaecation or faecal incontinence (the NICE guideline on faecal incontinence in adults has recommendations on baseline assessment of faecal incontinence)
  • pain
  • symptoms that are not explained by examination findings. [2019]

To find out why the committee made the 2019 recommendations on assessing pelvic organ prolapse and how they might affect practice, see rationale and impact.

1.7 Non-surgical management of pelvic organ prolapse

1.7.1 Discuss management options with women who have pelvic organ prolapse, including no treatment, non-surgical treatment and surgical options, taking into account:

  • the woman’s preferences
  • site of prolapse
  • lifestyle factors
  • comorbidities, including cognitive or physical impairments
  • age
  • desire for childbearing
  • previous abdominal or pelvic floor surgery
  • benefits and risks of individual procedures. [2019]

Lifestyle modification

1.7.2 Consider giving advice on lifestyle to women with pelvic organ prolapse, including information on:

  • losing weight, if the woman has a BMI greater than 30 kg/m2
  • minimising heavy lifting
  • preventing or treating constipation. [2019]

Topical oestrogen

1.7.3 Consider vaginal oestrogen for women with pelvic organ prolapse and signs of vaginal atrophy. For recommendations on managing urogenital atrophy, see managing short-term menopausal symptoms in the NICE guideline on menopause. [2019]

1.7.4 Consider an oestrogen-releasing ring for women with pelvic organ prolapse and signs of vaginal atrophy who have cognitive or physical impairments that might make vaginal oestrogen pessaries or creams difficult to use. [2019]

Pelvic floor muscle training

1.7.5 Consider a programme of supervised pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic POP‑Q (Pelvic Organ Prolapse Quantification) stage 1 or stage 2 pelvic organ prolapse. If the programme is beneficial, advise women to continue pelvic floor muscle training afterwards. [2019]

Pessaries

1.7.6 Consider a vaginal pessary for women with symptomatic pelvic organ prolapse, alone or in conjunction with supervised pelvic floor muscle training. [2019]

1.7.7 Refer women who have chosen a pessary to a urogynaecology service if pessary care is not available locally. [2019]

1.7.8 Before starting pessary treatment:

  • consider treating vaginal atrophy with topical oestrogen
  • explain that more than 1 pessary fitting may be needed to find a suitable pessary
  • discuss the effect of different types of pessary on sexual intercourse
  • describe complications including vaginal discharge, bleeding, difficulty removing pessary and pessary expulsion
  • explain that the pessary should be removed at least once every 6 months to prevent serious pessary complications. [2019]

1.7.9 Offer women using pessaries an appointment in a pessary clinic every 6 months if they are at risk of complications, for example because of a physical or cognitive impairment that might make it difficult for them to manage their ongoing pessary care. [2019]

To find out why the committee made the 2019 recommendations on non-surgical management of pelvic organ prolapse and how they might affect practice, see rationale and impact.

1.8 Surgical management of pelvic organ prolapse

There is public concern about the use of mesh procedures. For all of the procedures recommended in this section, including mesh procedures, there is some evidence of benefit, but limited evidence on long-term effectiveness and adverse effects. In particular, the true prevalence of long-term complications is unknown.

1.8.1 Offer surgery for pelvic organ prolapse to women whose symptoms have not improved with or who have declined non-surgical treatment. [2019]

1.8.2 If a woman is thinking about a surgical procedure for pelvic organ prolapse, use a decision aid (use the NICE patient decision aids on surgery for uterine prolapse and surgery for vaginal vault prolapse where they apply) to promote informed preference and shared decision making. Discussion with the woman should include:

  • the different treatment options for pelvic organ prolapse, including no treatment or continued non-surgical management
  • the benefits and risks of each surgical procedure, including changes in urinary, bowel and sexual function
  • the risk of recurrent prolapse
  • the uncertainties about the long-term adverse effects for all procedures, particularly those involving the implantation of mesh materials
  • differences between procedures in the type of anaesthesia, expected length of hospital stay, surgical incisions and expected recovery period
  • the role of intraoperative prolapse assessment in deciding the most appropriate surgical procedure. [2019]

1.8.3 Do not offer surgery to prevent incontinence in women having surgery for prolapse who do not have incontinence. [2019]

1.8.4 Explain to women considering surgery for anterior or apical prolapse who do not have incontinence that there is a risk of developing postoperative urinary incontinence and further treatment may be needed. [2019]

1.8.5 If the woman’s chosen procedure for pelvic organ prolapse is not available from the consulting surgeon, refer her to an alternative surgeon. [2019]

1.8.6 If mesh is to be used in prolapse surgery:

  • explain to the woman about the type of mesh that will be used and whether or not it is permanent
  • ensure that details of the procedure and its subsequent short- and long-term outcomes are recorded in a national registry (see collecting data on surgery and surgical complications in this guideline)
  • give the woman written information about the implant, including its name, manufacturer, date of insertion, and the implanting surgeon’s name and contact details. [2019]

1.8.7 Providers must ensure that data on surgical procedures for pelvic organ prolapse are recorded in a national registry, as outlined in the section on collecting data on surgery and surgical complications in this guideline. [2019]

To find out why the committee made the 2019 recommendations on surgical management of pelvic organ prolapse and how they might affect practice, see rationale and impact.

1.10 Assessing complications associated with mesh surgery

1.10.1 For women who report new-onset symptoms after having mesh surgery for urinary incontinence or pelvic organ prolapse, evaluate whether the symptoms might be caused by a mesh-related complication. These symptoms could include:

  • pain or sensory change in the back, abdomen, vagina, pelvis, leg, groin or perineum that is:
    • either unprovoked, or provoked by movement or sexual activity and
    • either generalised, or in the distribution of a specific nerve, such as the obturator nerve
  • vaginal problems including discharge, bleeding, painful sexual intercourse, or penile trauma or pain in sexual partners
  • urinary problems including recurrent infection, incontinence, retention, or difficulty or pain during voiding
  • bowel problems including difficulty or pain on defaecation, faecal incontinence, rectal bleeding or passage of mucus
  • symptoms of infection, either alone or in combination with any of the symptoms outlined above. [2019]

1.10.2 Refer women with a suspected mesh-related complication to a urogynaecologist, urologist or colorectal surgeon for specialist assessment. [2019]

1.10.3 For women who are referred for specialist evaluation of a suspected mesh complication:

  • take a history of all past surgical procedures for prolapse or incontinence using mesh, including the dates, type of mesh and site of mesh placement and the relationship of the symptoms to the surgical procedure(s)
  • consider using a validated pelvic floor symptom questionnaire and a pain questionnaire to aid assessment and decision making
  • perform a vaginal examination to:
    • assess whether mesh is palpable, exposed or extruded
    • localise pain and its anatomical relationship to mesh
  • consider performing a rectal examination, if indicated, to assess for the presence of mesh perforation or fistula
  • consider performing a neurological assessment to assess the distribution of pain, if present, sensory alteration or muscle weakness. [2019]

1.10.4 For women with a confirmed mesh-related complication or unexplained symptoms after a mesh procedure:

  • refer to a consultant at a regional centre specialising in the diagnosis and management of mesh-related complications or
  • if the woman has a vaginal exposure of mesh that is smaller than 1 cm2 and no other symptoms, follow recommendations 1.11.3 and 1.11.4 in this guideline. [2019]

1.10.5 The responsible consultant should develop an individualised investigation plan for each woman with suspected or confirmed mesh-related complications, involving other members of the regional MDT if needed, and use table 1 in this guideline to inform decisions on possible investigations. [2019]

1.10.6 The responsible consultant must ensure that details of any confirmed mesh-related complications are:

To find out why the committee made the 2019 recommendations on assessing complications associated with mesh surgery and how they might affect practice, see rationale and impact.

1.11 Managing complications associated with mesh surgery

General considerations before removing mesh

1.11.1 If a woman who has had a mesh procedure to treat urinary incontinence or pelvic organ prolapse is thinking about having the mesh removed, discuss the decision with her and with a regional MDT. [2019]

1.11.2 When discussing surgery to remove mesh, explain to the woman that:

  • there is limited evidence on the benefits of partial or complete removal compared with no mesh removal
  • surgery to remove mesh can have significant complications including organ injury, worsening pain, and urinary, bowel and sexual dysfunction
  • it is not certain that removing the mesh will relieve symptoms
  • it might not be possible to remove all of the mesh
  • removing only part of the mesh might be just as effective at improving symptoms as removing all of it
  • urinary incontinence or prolapse can recur after the mesh has been removed. [2019]

Managing vaginal complications

1.11.3 Discuss non-surgical treatment with topical oestrogen cream with women who have a single area of vaginal mesh exposure that is smaller than 1 cm2[2019]

1.11.4 Offer a follow‑up appointment within 3 months to women with vaginal mesh exposure who choose treatment with topical oestrogen cream. [2019]

1.11.5 Consider partial or complete surgical removal of the vaginal portion of mesh for women:

  • who do not wish to have treatment with topical oestrogen or
  • if the area of vaginal mesh sling exposure is 1 cm2 or larger or
  • if there is vaginal mesh extrusion or
  • if there has been no response to non-surgical treatment after a period of 3 months. [2019]

1.11.6 Offer imaging and further treatment to women who have signs of infection in addition to vaginal mesh exposure or extrusion. [2019]

1.11.7 Discuss with women who have vaginal complications after mesh sling surgery for stress urinary incontinence that:

  • complete removal of the vaginal portion of mesh sling is associated with a greater risk of recurrence of stress urinary incontinence than partial removal
  • partial removal is associated with a higher rate of further mesh sling extrusion
  • complete removal might not be possible. [2019]

1.11.8 Explain to women who have vaginal complications after vaginally placed mesh for pelvic organ prolapse that:

  • complete removal might not be possible
  • complete removal has a higher risk of urinary tract or bowel injury than partial removal
  • there may be a risk of recurrent prolapse. [2019]

1.11.9 Explain to women who have vaginal complications after abdominally placed mesh for pelvic organ prolapse that:

  • removal is associated with a risk of urinary tract and bowel injury
  • there is a risk of recurrent prolapse
  • they might need abdominal surgery to remove the mesh
  • complete removal might not be possible. [2019]

1.11.10 For women who have pain or painful sexual intercourse suspected to be related to previous mesh surgery:

  • if specialist assessment indicates a mesh-related complication, seek advice from a regional MDT
  • if assessment and investigation do not show a mesh abnormality such as vaginal extrusion or exposure, or an infection, consider non-surgical treatments such as pain management, vaginal oestrogen, dilators, counselling (including psychosexual counselling) and physiotherapy
  • if pain does not respond to initial management, seek advice from a regional MDT. [2019]

Managing urinary complications

1.11.11 Refer women who have mesh perforating the lower urinary tract to a centre for mesh complications for further assessment or management. [2019]

1.11.12 For women with urinary symptoms after mesh surgery for stress urinary incontinence or pelvic organ prolapse who are considering mesh removal surgery, explain that:

  • urinary symptoms might not improve and new symptoms might occur after complete or partial removal of the mesh
  • stress urinary incontinence might recur after mesh removal, and the risk of this happening is higher with complete than with partial mesh removal
  • complete removal of the mesh might not be possible
  • further treatment might be needed for mesh complications, or recurrent or persistent urinary symptoms
  • there is a risk of adverse events such as urinary tract fistula. [2019]

1.11.13 Discuss division of mesh sling with women who have voiding difficulty after mesh sling surgery. [2019]

1.11.14 Refer women considering excision of mesh sling for persistent voiding dysfunction to a centre specialising in the diagnosis and management of mesh-related complications for assessment and management. [2019]

1.11.15 For women considering surgery to alleviate voiding symptoms caused by mesh surgery, explain that:

  • the risk of recurrent stress urinary incontinence is higher after mesh excision than mesh division
  • further surgery might be needed. [2019]

Managing bowel symptoms

1.11.16 For women who present with functional bowel disorders after mesh surgery for pelvic organ prolapse, follow the recommendations in the NICE guideline on faecal incontinence in adults for women with faecal incontinence or locally agreed protocols for women with obstructed defecation. [2019]

1.11.17 For women with bowel complications that are directly related to mesh placement, such as erosion, stricture or fistula, discuss treatment with a regional MDT that has expertise in complex pelvic floor dysfunction and mesh-related problems. Use this discussion to formulate an individualised treatment plan with the woman. [2019]

1.11.18 Explain to women with bowel complications directly related to mesh placement that:

  • complete removal might not be possible
  • bowel symptoms might persist or recur after mesh removal
  • they might need a temporary or permanent stoma after mesh removal. [2019]

To find out why the committee made the 2019 recommendations on managing complications associated with mesh surgery and how they might affect practice, see rationale and impact.

Terms used in this guideline

Please refer to the full guideline for a full list of terms.

Mesh procedure

An operation to insert plastic mesh to support tissues. Mesh procedures are used to treat stress urinary incontinence and pelvic organ prolapse in women.

© NICE 2019. Urinary incontinence and pelvic organ prolapse in women: management.  Available from: www.nice.org.uk/guidance/NG123. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

First included: April 2019.