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Urinary Incontinence and Pelvic Organ Prolapse in Women (Part 2) (NICE NG…
Urinary Incontinence and Pelvic Organ Prolapse in Women (Part 2)
(NICE NG 123 - Apr 2019)
Assessment
History taking
: Include symptoms of prolapse (vaginal bulge or sensation of something coming down), urinary or bowel symptoms, pelvic and back pain, sexual symptoms
Examination
Assess and record presence and degree of prolapse of anterior, central, and posterior vaginal components of the pelvic floor using the
POP-Q system
Assess for vaginal atrophy
Assess activity of pelvic floor muscles
Exclude a pelvic mass or other pathology
Consider investigating the following symptoms:
Urinary symptoms that are bothersome and for which surgical intervention is an option
Symptoms of obstructed defaecation or faecal incontinence
Pain
Symptoms not explained by examination findings
Non-Surgical Management
Lifestyle modification
Weight loss if BMI >30
Minimising heavy lifting
Preventing or treating constipation
Topical oestrogen
Consider
vaginal oestrogen
if there are signs of vaginal atrophy
Consider an
oestrogen-releasing ring
for women with signs of vaginal atrophy who have cognitive or physical impairments that might make vaginal oestrogen pessaries or creams difficult to use
Pelvic floor muscle training
Consider supervised pelvic floor muscle training for
at least 16 weeks as a first option
for women with
symptomatic POP-Q stage 1 or stage 2 pelvic organ prolapse
Pessaries
Consider a vaginal pessary alone or in conjunction with supervised pelvic floor muscle training (92% satisfaction rate)
Complications
: Vaginal discharge, bleeding, difficulty removing pessary, pessary expulsion
Offer referral to a
pessary clinic
every 6 months if at risk of complications (physical/cognitive impairment) making it difficult to manage ongoing pessary care
Advise changing pessary at least once
every 6 months
Surgical Management
Anterior/apical prolapse
Women who do not have incontinence should be counselled of the risk of developing post-op urinary incontinence
Anterior repair without mesh
Uterine prolapse
Vaginal sacrospinous hysteropexy with sutures
Manchester repair
Sacro-hysteropexy with mesh (abdominal or laparoscopic)
Vaginal hysterectomy (with or without vaginal sacrospinous fixation with sutures)
Colpoclesis: Consider for women who do not intend to have penetrative vaginal sex and who have a physical condition putting them at increased risk of operative and post-op complications
Vault prolapse
Vaginal sacrospinous fixation with sutures
Sacrocolpopexy (abdominal or laparoscopic) with mesh
Colpoclesis: Consider for women who do not intend to have penetrative vaginal sex and who have a physical condition putting them at increased risk of operative and post-op complications
Posterior prolapse
Posterior repair without mesh
Follow-up
: Offer review 6 months post-surgery, including a vaginal examination to check for mesh exposure if relevant
Both SUI and POP
Consider concurrent surgery
Counsel that SUI might persist despite surgery
Complications with Mesh Surgery
Presentation
Pain or sensory changes in the back, abdomen, vagina, pelvis, leg, groin, or perineum
: This can be unprovoked or provoked by movement or sexual activity, either generalised or in the distribution of a specific nerve (e.g.: obturator)
Vaginal problems
: Discharge, bleeding, painful sex, penile trauma or pain
Urinary problems
: Recurrent infection, incontinence, retention, difficult or pain during voiding
Bowel problems
: Difficulty or pain on defecation, faecal incontinence, rectal bleeding, mucous
Infection
either alone or in combination with other symptoms listed
Examination
Vaginal
: Assess whether mesh is palpable, exposed, or extruded. Localise pain and anatomical relationship to mesh.
Rectal
: Assess for mesh perforation or fistula
Neurological
: Assess distribution of pain, sensory alteration, muscle weakness
Investigations for Mesh Complications
Examination under anaesthesia
Type of mesh: All
Indications: Pain, suspected vaginal or rectal exposure or extrusion, sinus tract, urinary or bowel fistula
Cystourethroscopy
Type of mesh: All
Indications: Suspected urethral or bladder perforation, fistula, calculus on suture or mesh
Sigmoidoscopy
Type of mesh: Abdominally, laparoscopically, or vaginally placed
Indications: Suspected bowel perforation by mesh
Laparoscopy
Type of mesh: Abdominally, laparoscopically, or vaginally placed
Indications: Suspected bowel entrapment around mesh, adhesions secondary to mesh placement, pain
MRI
Type of mesh: All
Indications: Suspected mesh infection, anatomical mapping of suspected fistula, mesh localisation to guide surgery, back pain following abdominal mesh placement with mesh attachment to sacral promontory, identification of osteomyelitis or discitis
Ultrasound
Type of mesh: Vaginally placed mesh to treat incontinence
Indications: Pain, voiding dysfunction, suspected infection, suspected urethral mesh perforation, anatomically mapping to guide excision surgery
CT
Type of mesh: All
Indications: Suspected urinary tract or bowel injury, bowel obstruction
Fluoroscopic studies
Type of mesh: All
Indication: Suspected urinary or bowel fistula
Urinary flow studies and post-void residual volume assessment or cystometry
Type of mesh: All
Indication: Voiding dysfunction, urinary incontinence
Neurophysiology and nerve conduction studies
Type of mesh: All
Indication: Suspected nerve injury
Management of Complications associated with Mesh Surgery
General considerations
Explain surgery to remove the mesh can have significant complications including organ injury, worsening pain, and urinary/bowel/sexual dysfunction
May not be possible to remove all the mesh, but removing part might be just as effective at improving symptoms, equally removal may not guarantee relief of symptoms
Urinary incontinence and prolapse may recur after removal
Managing vaginal complications
Offer topical oestrogen
if there is a single area of vaginal mesh exposure
<1cm
; offer follow-up in
3 months
Consider partial or complete surgical removal of the vaginal portion of mesh
:
If the area of exposure is 1cm or larger
If the woman declines treatment with topical oestrogen
If there is vaginal mesh extrusion
No response to non-surgical treatment after 3 months
Complications after mesh sling surgery for SUI
Complete removal of the vaginal portion of the mesh sling is associated with greater risk of recurrence of SUI than partial removal
Partial removal associated with higher rate of further mesh sling extrusion
Complete removal may not be possible
Complications after vaginally placed mesh for POP
Complete removal has higher risk of urinary tract or bowel injury than partial removal
Risk of recurrent prolapse
Complete removal may not be possible
Complications after abdominally placed mesh for POP
Removal associated with risk of urinary tract and bowel injury
Risk of recurrent prolapse
May need abdominal surgery to remove the mesh
Complete removal may not be possible
Managing urinary complications
Urinary symptoms after mesh surgery for SUI/POP
Urinary symptoms may not improve and new symptoms might occur after complete or partial removal of the mesh
Complete removal may not be possible
SUI might recur after mesh removal and risk is higher with complete than with partial
Risk of adverse events such as urinary tract fistula
Further treatment may be needed for mesh complications, or recurrent/persistent urinary symptoms
Voiding symptoms caused by mesh surgery
Risk of recurrent SUI higher after mesh excision than mesh division
Further surgery may be required
Managing bowel symptoms
Advise that complete removal may not be possible
Bowel symptoms may persist or recur after mesh removal
A temporary or permanent stoma may be required
Epidemiology
Definition
: Pelvic organ prolapse is defined as symptomatic descent of 1 or more of the anterior vaginal wall, posterior vaginal wall, cervix, uterus, or vaginal vault
Prevalence
: 8.4% of women
1 in 10 women
will need at least 1 surgical procedure (10%)
Re-operation rate
: 19%