NICE 123: Pelvic Organ Prolapse — Management

This is the part 2 of summary of the NICE guideline “Urinary Incontinence & Pelvic Organ Prolapse in Women: Management” published in April 2019. As this is a long guideline, so it was decided to cover it in two posts. To access the part 1 of summary please Click Here

• This post #2 mainly focuses on the management of pelvic organ prolapse. It covers assessing pelvic organ prolapse (POP), non-surgical/surgical management of POP, surgery for women with both SUI & POP, assessing & managing complications associated with mesh surgery
• The post #1 of summary covered organization of specialist services, data collection on surgery, assessing urinary incontinence (UI), non-surgical management of UI and surgical management of stress urinary incontinence (SUI). Summary Part 1
• It is advised to read the original guideline to grasp the topic and to make sure no important point is missed
• The full guideline can be downloaded by clicking here: NG 123 Urinary Incontinence & POP in women: Management
• Some other relevant links of this topic are also provided at the end of this post

Kindly let me know if this post was helpful and suggestions to improve future posts are welcome.

Thanks

NICE 123 Pelvic Organ Prolapse in women: Management

Assessing Pelvic Organ Prolapse

• In Primary Care: women with symptoms or incidental findings of vaginal prolapse
• Take history → including prolapse symptoms, urinary, bowel & sexual function
• Examination → to rule out pelvic mass or other pathology / document presence of prolapse
• Discuss → woman’s treatment preferences & refer if needed 
• In secondary Care: If referred due to unrelated condition with incidental symptoms /findings → Consider referral to prolapse expert clinician
• Women referred for specialist evaluation of vaginal prolapse → perform an examination to:
• Assess/ record presence & degree of prolapse of anterior, central & posterior vaginal compartments of pelvic floor, using POP-Q system
• Assess pelvic floor muscle activity
• Assess for vaginal atrophy
• Rule out pelvic mass or other pathology
• Consider using validated pelvic floor symptom questionnaire to aid assessment & decision making
• If prolapse detected by clinical examination → Do Not routinely perform imaging to document the presence of prolapse
• If symptoms of prolapse present → but Not explained by physical examination findings → Consider repeat examination in squatting or standing or at a different time
• Consider investigating
• Urinary symptoms that are bothersome & for which an option is surgical intervention
• Symptoms of obstructed demarcation or faecal continence 
• Pain
• Symptoms unexplained by examination findings

Non-surgical management of pelvic organ prolapse

• Discuss management options with women including no treatment, non-surgical treatment and surgical options. 
• Take into account woman’s preferences, prolapse site, lifestyle factors, comorbidities, including cognitive or physical impairments, age, childbearing desire, previous abdominal or pelvic floor surgery, benefits/ risk of individual procedures

Lifestyle Modification

• Consider giving advice on lifestyle including → losing weight (if BMI >30), minimizing weight lifting and preventing/ treating constipation

Topical Estrogen

• If POP plus signs of vaginal atrophy → Consider vaginal estrogen
• If POP plus signs of vaginal atrophy plus cognitive/ physical impairment → Consider estrogen-releasing ring

Pelvic Floor Muscle Training

• Consider → supervised PFMT for at least 16 weeks as first option of symptomatic POP stage 1 or stage 2
• If beneficial → advice to continue afterwards

Pessaries

• Consider → vaginal pessary in symptomatic POP, alone or in conjunction with supervised PFMT
• If woman chosen pessary & not available locally → refer to urogynecology service
• Before starting pessary treatment
• Consider → topical estrogen to treat vaginal atrophy
• Explain → more than 1 pessary fitting may be needed (to find suitable pessary)
• Discuss → effect of different pessary types on sexual intercourse
• Describe → complications including vaginal discharge, bleeding, removal difficulty & expulsion
• Explain→ pessary should be removed at least once every 6 months (to prevent serious complications)
• Offer → appointment in pessary clinic every 6 months if risk of complications (e.g if physical / cognitive impairment present)

Surgical management of pelvic organ prolapse

• Public concern about use of mesh procedure
• For all recommended procedures → some evidence of benefit, but limited evidence on long-term effectiveness/ adverse effects
• Prevalence of long-term complications → unknown
• Offer surgery for POP → if symptoms not improved or who decline non-surgical options
• If woman considering for surgery, discussion must include
• Different options including no treatment or continued non-surgical treatment
• Benefits/ risks of each procedure
• Risk of prolapse recurrence
• Uncertainties about long-term adverse effects for all procedures (especially involving mesh)
• Differences in type of anaesthesia, incisions, expected hospital stay & recovery period
• Role of intra-operative prolapse assessment to decide most appropriate surgical procedure
• Women having prolapse but no incontinence
• Do not offer surgery to prevent incontinence in women having surgery for prolapse
• Explain to women considering surgery for anterior or apical prolapse → risk of developing postoperative incontinence & need of further treatment
• If woman’s chosen procedure for POP not available → refer to an alternative surgeon
• If mesh is to be used in prolapse surgery 
• Explain→ type of mesh & whether permanent or not
• Ensure details of procedure & subsequent short/long term outcomes→ recorded in national registry
• Written information about implant→ including name, manufacturer, date of insertion and implanting surgeon’s name/ contact details 
• Providers must ensure→ data on surgical procedure for POP recorded in national registry

Surgery for uterine prolapse

• Discuss treatment options → including non-surgical options, hysterectomy & uterus preserving surgery
• Women considering surgery for prolapse
• Discuss possible complications & lack of long-term evidence on procedure effectiveness
• If woman does not wish to preserve uterus → offer a choice of 
• Vaginal hysterectomy +/- vaginal sacrospinous fixation with sutures or
• Vaginal sacrospinous hysteropexy with sutures or 
• Manchester repair
• Also include sacro-hysteropexy with mesh (abdominal/laparoscopic) in this choice
• Woman wishing to preserve uterus → offer a choice of
• Vaginal sacropinous hysteropexy with sutures or
• Manchester repair (unless she wishes to have children in future)
• Also include sacro-hysteropexy with mesh (abdominal/laparoscopic) in this choice
• If synthetic polypropylene mesh inserted → details of procedure, short/long-term outcome must be collected in national registry
• If woman wishes to have children in future → ensure proposed treatment reviewed by regional MDT

Surgery for Vault Prolapse

• Discuss options including non-surgical/surgical
• If woman considering surgery
• Discuss possible complications & lack of long-term evidence of procedure effectiveness
• Offer woman a choice of 
• Vaginal sacroapinous fixation with sutures or
• Sacrocolpopexy (abdominal or laparoscopic) with mesh
• If synthetic polypropylene mesh inserted→ procedure details, short/long- term outcome must be collected in national registry

Colpocleisis for vault or uterine prolapse

• Consider in women who do not intend to have penetrative vaginal sex and with a medical condition which poses them at increased risk of operative & postoperative complications

Surgery for anterior prolapse

• Discuss treatment options including non-surgical/surgical options
• Offer anterior repair without mesh

Surgery for posterior prolapse

• Offer posterior repair without mesh

Follow-up after Surgery

• Offer review→ after 6 months of surgery
• Ensure review include vaginal examination → if mesh used & check for mesh exposure
• Ensure→ women has access to further referral if recurrent symptoms or suspected complications

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

• Consider → concurrent surgery for SUI & POP (in anterior or apical prolapse)
• When considering concurrent surgery → discuss treatment options and explain to woman
• Uncertainty of combined procedure effectiveness (for SUI) beyond one year and SUI may persist despite surgery
• Risk of complications of concurrent vs sequential surgery

Assessing complications associated with mesh surgery

• New-onset symptoms reported → evaluate whether symptoms might be due to mesh-related complication
• Symptoms could include
• Pain/sensory change in back, abdomen, vagina, pelvis, leg, groin or perineum that is 
• Either unprovoked, or provoked (movement/sex) and
• Either generalized, or in distribution of a specific nerve (like obturator)
• Vaginal problems like discharge, bleeding, painful intercourse, or penile trauma or pain in sexual partners
• Urinary problems like recurrent infections, incontinence, retention, difficulty/pain during voiding
• Bowel problems including difficulty/pain on desecration, faecal incontinence, rectal bleeding or passage of mucus
• Infection symptoms either alone or in combination with any of the above mentioned symptoms
• Suspected mesh-related complication → Refer to urogynaecologist, urologist or colorectal surgeon for specialist assessment
• Women referred for specialist evaluation
• Take history of ALL past surgical procedures for prolapse or incontincence using mesh, including dates, type/site of mesh and symptoms relationship with procedure
• Consider → validated pelvic floor symptom questionnaire & pain questionnaire to ai assessment/decision making
• Perform vaginal examination to 
• Assess whether mesh palpable, exposed or extruded
• Localised pain & its anatomical relationship to mesh
• Consider performing 
• rectal examination (if indicated) to assess for mesh perforation or fistula
• neurological assessment to assess distribution of pain, if present, sensory alteration or muscle weakness
• Woman with confirmed mesh-related complications or unexplained symptoms
• Refer to consultant at regional centre specializing in diagnosis/managment of mesh-related complications 
• Responsible consultant 
• Should develop individualized investigation plan involving other regional MDT members (if needed)
• Must ensure that details of any confirmed mesh-related complications are recorded in national registry and  reported to MHRA

Table 1 Investigations for assessing suspected mesh-related complications

Managing Complications Associated with Mesh Surgery

General considerations before removing mesh

• If a woman is thinking about removing mesh → discuss with her & with a regional MDT
• When discussion, explain to woman
• Limited evidence of benefits of partial/complete removal vs no mesh removal
• Surgery to remove mesh→ may have significant complications including organ injury, worsening pain and urinary, bowel/sexual dysfunction
• Not certain→ mesh removal will relieve symptoms
• Might not be possible to remove all mesh
• Partial removal might just be as effective at improving symptoms as removing all of it
• Urinary incontinence or prolapse→ can recur after mesh removal

Managing vaginal complications

• Discuss non-surgical treatment with topical estrogen cream→ if single area vaginal mesh exposure <1cm3
• If chosen topical estrogen cream→ offer follow-up within 3 months
• Consider partial/complete surgical removal of vaginal portion of mesh
• Who do not opt for topical estrogen or
• Area of vaginal mesh exposure ≥1cm3
• Vaginal mesh extrusion
• No response to non-surgical treatment after 3 months
• Signs of infection plus vaginal mesh exposure or extrusion → offer imaging & further treatment
• Vaginal complications after mesh sling surgery for SUI→ discuss
• Complete removal of vaginal portion of mesh skin → associated with greater risk of recurrence of SUI than partial removal
• Partial removal → associated with higher rate of further mesh sling extrusion
• Complete removal→ might not be possible
• Vaginal complication after vaginally placed mesh for POP → explain
• Complete removal→ might not be possible
• Complete removal has higher risk of urinary tract/bowel injury than partial removal
• Risk of recurrent prolapse
• Vaginal complications after abdominally placed mesh for POP → explain
• Removal associated with risk of urinary tract/bowel injury
• Risk of recurrent prolapse
• Might need abdominal surgery for removal
• Complete removal → might not be possible
• Pain or painful intercourse suspected to be related to previous mesh surgery
• Specialist assessment shows mesh-related complication → seek advice from regional MDT
• If NO mesh abnormality seen → consider non-surgical treatments like pain management, vaginal estrogen, dilators, counselling (psychosexual) and physiotherapy
• Seek advice from regional MDT→ if pain does not respond to initial management

Managing urinary complications

• Mesh perforation lower urinary tract → Refer to mesh complication center for further assessment/management
• Mesh surgery for SUI or POP plus urinary symptoms and considering mesh removal surgery→ explain
• Urinary symptoms might not improve & new symptoms might occur after complet/partial mesh removal
• After mesh removal → SUI might recur. Higher risk with complete than with partial
• Complete removal→ might not be possible
• Further treatment→ might be needed
• Risk of adverse events like urinary tract fistula
• Voiding difficulty after mesh sling surgery → discuss division of mesh sling
• If considering excision of mesh sling → refer to a center specializing in diagnosis/ management of mesh related complications for assessment/management
• If considering surgery for voiding symptoms due to mesh surgery → explain
• Risk of recurrent SUI → higher after mesh excision than division
• May need further surgery

Managing bowel symptoms

• Bowel complications directly related to mesh placement
• Discuss treatment with regional MDT with expertise in complex pelvic floor dysfunction and mesh-related problems
• Formulate an individualized treatment plan
• Explain → complete removal → might not be possible
• Bowel symptoms might persist or recur after mesh removal
• Might need temporary or permanent stoma after mesh removal

You may also like:

NICE 123: Management of Urinary Incontinence Summary Part 1

Module 18: Urogynaecology & Pelvic Floor Problems

Continence surgery at POP repair

GTG 46 Post-Hysterectomy Vaginal Vault Prolapse

NICE 133: Hypertension in Pregnancy Part 1 Part 2

NICE 121: Intrapartum Care of women with Medical Disorders 

NICE 140: Abortion Care