Rationale and impact
- Raising awareness of pelvic floor dysfunction for all women
- Risk factors for pelvic floor dysfunction
- Physical activity and diet and other modifiable risk factors
- Pelvic floor muscle training for preventing pelvic floor dysfunction
- Communicating with and providing information to women with pelvic floor dysfunction
- Assessment in primary care
- Community-based multidisciplinary teams
- Lifestyle changes
- Pelvic floor muscle training for managing pelvic floor dysfunction
- Intravaginal devices and pessaries
- Psychological interventions
- Behavioural approaches
These sections briefly explain why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee's discussion.
The evidence was limited to 1 study, so most of the recommendations were based on the committee's knowledge and experience. However, this study did show that teaching pelvic floor health in school improved young women's understanding of their pelvic floor anatomy.
Improving women's knowledge of pelvic floor health is important because this increases the chance they will take action to prevent pelvic floor dysfunction (for example, through lifestyle changes and pelvic floor muscle training). The range of communication formats and strategies recommended is broad, because pelvic floor dysfunction can happen to any woman, so different strategies will be more effective for different groups of women. The committee discussed what the content of this information should be and decided that this would need to be tailored to the individual and the situation in which it is provided (for example, they noted that information provided during school lessons would likely have a different focus to information provided at a local community group). However, to ensure information is accurate and useful, it should include the topics highlighted in recommendation 1.1.1. The committee acknowledged that there can be groups of women that experience inequalities (for example, in access to services). When there is evidence of this, the committee noted that local authorities should consider designing information programmes that increase awareness of the condition with the aim of advancing equality in healthcare provision and fostering good relations with communities.
Healthcare professionals themselves need to understand enough about pelvic floor dysfunction to discuss it with women. In the committee's experience, this is not consistently taught during training, so they made a recommendation that this should be added to the syllabus for relevant professionals.
The committee believed it was particularly important to raise awareness in maternity services; this is when symptoms can first occur, when risk factors can be identified and when prevention strategies can be started. The recommendations could lead to midwives providing information about pelvic floor dysfunction many times during a woman's pregnancy. However, the committee believe this is reasonable, because it gives the midwife an opportunity to normalise the topic and time to discuss it in detail. Normalisation is important, because embarrassment often gets in the way of discussions about pelvic floor dysfunction. The committee also noted that frequent discussions would reinforce the message and improve adherence to prevention or management, which is key to their effectiveness.
Because of the sparsity of evidence, and the potential benefits of raising awareness of pelvic floor dysfunction, the committee made a recommendation for research on raising awareness about pelvic floor dysfunction.
Pelvic floor dysfunction is not currently covered in the school curriculum. However, sex and relationship education is already a compulsory part of the curriculum, and pelvic floor dysfunction could be covered as part of these classes.
School nurses and nurses in other education settings could also be involved in raising awareness of pelvic floor dysfunction. There are already resources available on this topic (for example, this video on pelvic floor by NHS Highland).
Interpreting the evidence was difficult, because there was a lot of variation in how the studies were done, the way risk factors were defined, and which symptom each risk factor affected. However, the evidence did consistently reflect the committee's experience.
The evidence suggested a number of modifiable and non-modifiable risk factors. The committee recommended advising women of these, so that they are aware of their risks, and (for modifiable factors) they can take steps to reduce them. For example, the evidence showed that constipation is a risk factor for pelvic floor dysfunction (the committee believe that this is because of the straining involved). For women with constipation, there are recommendations on diet to help with constipation and reduce their risk of pelvic floor dysfunction (see recommendation 1.3.3 and recommendation 1.6.9).
Although some risk factors are non-modifiable (such as age or familial history), the committee agreed that it is still useful for women to be told about these. This is because if women know about their risks, they may be encouraged to reduce any modifiable risk factors and use preventative interventions (such as pelvic floor muscle training). Women with some of these risk factors will also be offered supervised pelvic floor muscle training (see the recommendations on pelvic floor muscle training).
For the risk factors related to vaginal birth, the committee discussed whether more information was needed in the recommendations, because these risk factors affect the decision to have a vaginal or caesarean birth. However, women consider many other factors beyond pelvic floor dysfunction when deciding on mode of birth. The committee decided not to make further recommendations on this, because the NICE guideline on caesarean section goes into much more detail on the benefits and risks of caesarean and vaginal birth.
Due to the evidence being unclear, the committee made a recommendation for research on whether multiple pregnancy is an independent risk factor for pelvic floor dysfunction.
There was evidence for a variety of physical coexisting conditions associated with pelvic floor dysfunction. There was variation in the quality of the evidence because in some studies, the inclusion criteria were not clearly described. In addition, although some conditions were shown to increase the risk of pelvic floor dysfunction, there was uncertainty around how large this increase is. Because of this, the committee did not list every condition identified in the studies. Instead, they highlighted the conditions that have a direct impact on the pelvic floor muscles, when the risk of pelvic floor dysfunction in the evidence aligns with their own experience.
For some conditions that may increase the risk of pelvic floor dysfunction (such as hypermobility, neurological disease and mental health problems), there was little evidence on their effect. In addition, there was only limited evidence on the effect of respiratory disease and chronic cough on the full range of symptoms, and this is particularly important because of the COVID‑19 pandemic. A recommendation for research on coexisting long-term conditions was made to address these evidence gaps.
There are groups of women who have an increased risk of developing pelvic floor dysfunction. There are also interventions that can help prevent pelvic floor dysfunction (see the section on physical activity and diet and the section on pelvic floor muscle training). Because of this, it would be useful to have an effective tool for predicting pelvic floor dysfunction so that women at higher risk can be prioritised for pelvic floor muscle training programmes. However, there was no evidence on the effectiveness of existing tools. The committee agreed this was an important area for further study, and made a recommendation for research on prediction tools.
The recommendations will standardise the information and advice that is provided to women, to enable better shared decision making. There are no significant costs associated with this, because providing information is already standard practice. The costs of the time taken to give this information would be outweighed by better satisfaction with services and the potential for avoiding future pelvic floor dysfunction.
The evidence suggested that physical activity, healthy diet and appropriate fluid intake help to prevent pelvic floor dysfunction. The quality of the evidence was low because some studies did not account for other factors that could potentially explain the findings. However, it reflected the committee's experience in clinical practice and was in line with standard UK diet and physical activity guidance.
One of the risk factors for pelvic floor dysfunction is constipation, and in the committee's experience, 1 way this can be addressed is by adjusting fluid intake. Public health guidance does not clearly define ideal levels of fluid intake, and there are differences in the fluid needs of individuals (for example, people need more fluid if they are very physically active). The committee therefore decided not to give their own definition of appropriate fluid intake.
The committee recognised that there were other modifiable risk factors: body mass index (BMI) over 25 kg/m2, smoking and diabetes, and they referenced relevant NICE guidance for management strategies for these, which would help prevent pelvic floor dysfunction.
There was only limited evidence on specific dietary factors, such as caffeine and carbonated drinks. To address this, the committee made a recommendation for research on lifestyle factors to reduce the risk of pelvic floor dysfunction.
No evidence was found on the impact of other lifestyle factors that can prevent symptoms associated with pelvic floor dysfunction (such as pelvic organ prolapse, emptying disorders of the bladder or bowel, sexual dysfunction or chronic pelvic pain syndromes). However, in the committee's experience, physical activity that involves repetitive pelvic floor loading (such as weight training) can improve pelvic floor muscle strength and so prevent symptoms. The committee agreed that more research is needed to support this, particularly in relation to the intensity of physical activity needed, so they made a recommendation for research on long-term effects of different types, intensities and frequencies of physical activity for preventing symptoms associated with pelvic floor dysfunction.
Currently, lifestyle advice is given to women to help with the management of symptoms of pelvic floor dysfunction. However, lifestyle advice is rarely considered as part of pelvic floor dysfunction prevention, because these women are symptom free. Therefore, these recommendations will help standardise the advice women receive on preventing pelvic floor dysfunction.
The available evidence covered women in 3 settings: community, antenatal and postnatal. It specifically addressed pelvic floor dysfunction and associated symptoms (including urinary incontinence, pelvic organ prolapse and sexual dysfunction).
In addition to the research evidence, the committee also took account of the Independent Medicines and Medical Devices Safety Review and the NHS Long Term Plan, which made recommendations on pelvic floor muscle training.
Pelvic floor muscle training was shown to prevent symptoms of pelvic floor dysfunction in all 3 settings. Evidence was not available for some symptoms (such as faecal incontinence and pelvic pain). The training was most effective in the short term. The committee noted that most studies looked at pregnant women (antenatal and postnatal). However, all healthcare professionals can provide encouragement to all women doing pelvic floor muscle training in all settings (there are already resources available on this, such as the video on pelvic floor by NHS Highland). Because there are particular obstetric risk factors associated with pelvic floor dysfunction (see the section on risk factors), pelvic floor muscle training could be particularly beneficial for pregnant women. The evidence supported this, because pelvic floor muscle training was shown to be effective in preventing pelvic floor symptoms when started during or after pregnancy.
Most of the evidence was for a narrow age range of women in their twenties or thirties. However, there was a consistent pattern of risk reduction across this group. The committee believed that this supported them in making recommendations for women of all ages.
An economic analysis showed that antenatal supervised pelvic floor muscle training is likely to be cost effective for some pregnant women:
the evidence suggested that women who have a first-degree relative with pelvic floor dysfunction are at higher risk
the committee identified 3 risk factors related to labour that they thought would increase risk.
However, there was some uncertainty about the conclusion generated from the economic analysis, which was based on evidence from only 1 study. Because of these limitations, and the costs of providing supervised pelvic floor muscle training to such a large group, the committee did not recommend routinely offering training to all of these women. The committee still recommended the training as an option, because it is likely to be cost effective for some women in these groups.
The committee did not include 'an active second stage labour taking more than 1 hour' in the recommendation on supervised pelvic floor muscle training. This is because it is quite common (so would have a high potential cost), and the evidence on this was inconsistent (some studies showed an increased risk when labour was longer than 1 hour, but others did not show increased risk when it was longer than 20 minutes).
In all the studies, pelvic floor muscle training was supervised by a trained healthcare professional. The committee agreed that this is important for ensuring that pelvic floor muscle contraction and relaxation is done correctly. In their experience, it is also important to tailor the training for each woman, to ensure that it is manageable and will meet their training goals.
There was limited evidence on long-term effectiveness, because only 2 studies had a longer follow-up period (12 months in 1 study, and 8 years in the other). However, all the studies showed that adherence decreased over time. In the committee's experience, continuing with the training is key for continued prevention of symptoms, and they agreed that low long-term adherence is likely to explain the limited evidence for long-term effectiveness. To address adherence problems, the committee made the recommendation on encouraging women to continue pelvic floor muscle training.
The committee made recommendations for research to investigate several gaps in the evidence:
Most effective ways to provide training: the studies did not give much detail on how training should be done.
Younger women: there was no evidence on training for young women (between 12 and 17).
Older women: there was only 1 study supporting training for women over 60.
Women who are pregnant and at particular risk of pelvic floor dysfunction: there was little evidence specific to women who are pregnant and have particular risk factors.
Faecal incontinence and emptying disorders of the bowel: there was no evidence on whether pelvic floor muscle training improves these symptoms (which can be particularly distressing).
The Independent Medicines and Medical Devices Safety Review recommended 'that the NHS adopts the French model for universal postnatal pelvic floor rehabilitation', to help prevent pelvic floor dysfunction. This model includes 10 sessions of routinely prescribed perineal rehabilitation sessions (pelvic floor muscle training with manual internal techniques, biofeedback and electrical stimulation) starting at least 8 weeks after birth, regardless of symptoms. The committee did not think the evidence (in particular the cost-effectiveness evidence) was strong enough to support this for all women during or after pregnancy. Instead, they identified the risk factors that put women at the greatest risk, for which pelvic floor training was most likely to be cost effective. They also made a recommendation for research on universal postnatal pelvic floor muscle training to investigate further.
Currently, pelvic floor muscle training is rarely used for prevention, and is usually only considered and taught to women when they develop symptoms (such as urinary incontinence). There would likely be a significant resource impact if training was provided to all women with the risk factors specified in the recommendation (particularly given the size of the population who would be eligible). Some of this cost is likely to be offset by savings from preventing or delaying pelvic floor dysfunction.
Pregnant women receive information on pelvic floor muscle training. However, this is usually general advice rather than specific instructions or supervised sessions. Women are not routinely told about how pelvic floor muscle training can help prevent sexual dysfunction during and after pregnancy. The recommendations ensure that all women are getting information on the benefits of pelvic floor muscle training to prevent pelvic floor dysfunction. This will standardise practice.
Qualitative evidence showed that women with pelvic floor dysfunction perceived some communication styles as unhelpful. It also indicated that some women are not given enough information to understand their symptoms, diagnosis, investigations or treatment. The quality of the evidence was mixed, because of concerns about methodological limitations in the design of the studies. The committee also made recommendations based on their own experience, in areas where there was no evidence (such as video and telephone consultations).
The recommendation on asking women if they want their family, carers or other people involved is particularly important for addressing potential barriers to support for women with cognitive impairments.
Pelvic floor dysfunction is a complex condition, with particular communication issues (such as embarrassment). Based on the evidence and on their experience, the committee highlighted key issues to take into account when discussing pelvic floor dysfunction with women.
Because of the COVID‑19 pandemic, many services are being provided remotely. In the committee's experience, this has been well received by some women. A particular benefit of remote services can be reduced embarrassment (both for women and for healthcare professionals), which makes women more willing to discuss problems. However, even though this may be the case for some women, the committee acknowledged that it may be harder for the healthcare professional to identify whether symptoms may not be reported because of embarrassment during a remote consultation.
The committee made recommendations for research in areas where there was no evidence:
Healthcare professionals already discuss pelvic floor dysfunction with women and provide information on this. However, the information given and how it is communicated can vary, and these recommendations will standardise the process. Because the symptoms of pelvic floor dysfunction are often distressing and embarrassing, communication and sensitivity are very important for all healthcare professionals to ensure good care is provided.
Services already use translation services as needed to overcome communication barriers. However, there may be an impact in areas where video consultation or digital information aids are not currently available.
There are a number of signs and symptoms associated with pelvic floor dysfunction. However, there was no evidence on which assessments are needed in non-specialist care to identify these signs and symptoms. Because of this, the committee made recommendations based on their clinical expertise, highlighting the investigations they use in their practice and the most important signs and symptoms to look out for.
There was evidence that healthcare professionals may overlook symptoms of pelvic floor dysfunction in women who have recently given birth. The evidence also highlighted that there are common misconceptions about pelvic floor dysfunction during and after pregnancy, which can prevent women from seeking care early. To address this, the committee emphasised that women who have recently given birth should be asked about symptoms.
In the committee's experience, many medications can impact on symptoms of pelvic floor dysfunction. In addition, this impact is often larger for people who are taking multiple medicines. Because of this, a medication review is important.
A focused history is important for identifying the likely cause of any symptoms, because many of the symptoms of pelvic floor dysfunction can be caused by other conditions as well.
The committee highlighted some of the examinations that would be needed to clarify whether symptoms are likely to be associated with pelvic floor dysfunction or not. Because some of these are intimate examinations, they highlighted the importance of checking the woman's preferences and ensuring a private space is available.
Further assessments are described in the NICE guideline on urinary incontinence and pelvic organ prolapse in women and the section on baseline assessment in the NICE guideline on faecal incontinence. These guidelines only cover adults, but many of the initial assessments recommended are non-specialist and the committee agreed that they could be relevant for younger women (aged 12 to 17) in primary care.
Pelvic floor dysfunction is a complex condition, and there is currently variation in how it is assessed. These recommendations will ensure consistency in the initial assessments that are done in primary care.
There was limited evidence on team-based approaches for managing pelvic floor dysfunction. However, the available evidence reflected the committee's experience in practice. They decided that the range of competencies needed could not be covered by 1 healthcare professional alone, and so a multidisciplinary team approach should be considered. Because pelvic floor dysfunction can happen to any woman, multidisciplinary teams will need a wide range of skills to be able to care for all women who need support. The committee agreed that several teams could be needed (for example, a team for pregnant women and another for older women). These teams would need to be community based, to ensure that care is accessible to all women.
Adherence and satisfaction with care are important factors in effective management of pelvic floor dysfunction, and the committee agreed that these would also be improved by community-based multidisciplinary teams.
The experience and training of multidisciplinary team members is likely to vary widely in different areas. Because of this, the committee made a recommendation on competencies, based on their own experience of the key knowledge and experience that is needed in the team to implement the other recommendations in this guideline.
The committee did not recommend including specific roles (such as specialist continence advisors) in the team, because community healthcare professionals can be trained to carry out non-specialist assessment, and because including specific specialists in every team could have substantial costs. The committee made a recommendation for research on the roles needed in community-based multidisciplinary pelvic floor dysfunction teams.
When agreeing a management plan, it is important to involve the woman with pelvic floor dysfunction, to ensure the plan takes account of her needs, preferences and goals.
Community-based multidisciplinary teams may represent a change to current practice, because there is variation in their availability. Pelvic floor dysfunction is a common condition, and other services (such as community-based continence services) could form the basis of these teams. The committee decided that the benefits of good pelvic floor dysfunction management would outweigh potential costs associated with setting up community-based multidisciplinary teams.
There is currently variation in the competencies that community-based multidisciplinary teams have on assessing and managing pelvic floor dysfunction. There would be upfront costs for training healthcare professionals in the competencies recommended in this guideline, but these costs would be outweighed by better long-term outcomes (improved identification of symptoms and better management as a result).
The evidence showed that positive communication improves patient motivation and adherence to lifestyle changes. This was also consistent with the committee's experience. It can take time for women to see a benefit from lifestyle changes, so the committee believed it was important to emphasise encouraging and motivating women in the recommendation.
All healthcare professionals communicate with women and this recommendation will raise awareness that this communication should not be framed only in a negative way but provide positive messages when appropriate.
The evidence showed that in women with a BMI over 30 kg/m2, weight loss helped with urinary incontinence and overactive bladder. In the committee's experience, excess body weight exacerbates these symptoms by putting pressure on the pelvic floor muscles and organs, so weight loss will be particularly beneficial. The evidence did not show any effect from weight loss on symptoms of pelvic organ prolapse. However, the committee still believe that weight loss may be beneficial in the early stages of pelvic organ prolapse, because less weight would press on the pelvic organs and this could improve symptoms.
The committee recommended against delaying other management options until women have lost weight because:
there was no evidence on the impact of weight loss for many symptoms of pelvic floor dysfunction and
there are other interventions that could benefit women with pelvic floor dysfunction.
Because other NICE guidelines cover helping people to lose weight, the committee referred to these guidelines rather than making new recommendations on weight loss interventions.
Weight loss referral related to pelvic floor dysfunction differs across the country. The recommendations would reduce variation and promote consistency in care.
There was some evidence suggesting that reducing caffeine intake helps with urinary incontinence and overactive bladder, and this was supported by the committee's experience in practice.
No evidence was found on other symptoms associated with pelvic floor dysfunction. However, the committee agreed that in their experience, addressing fluid intake can help with symptoms by promoting an ideal stool consistency. Public health guidance does not clearly define ideal levels of fluid intake, and there are differences in the fluid needs of individuals (for example, people need more fluid if they are very physically active). The committee therefore decided not to give their own definition of appropriate fluid intake.
A balanced diet also reduces the risk of constipation and so would indirectly reduce the risk of pelvic floor dysfunction. This is particularly important for women with pelvic organ prolapse, faecal incontinence, emptying disorders of the bowel and chronic pelvic pain syndromes.
The committee believed that more research specific to pelvic floor dysfunction related to food rather than fluid intake is needed, and therefore made a recommendation for research on diet to address this.
These recommendations are in line with current clinical practice. Clinicians will already be familiar with the practical details of lifestyle changes that can be made to promote pelvic floor health, and lifestyle changes are a common aspect of management for symptoms of pelvic floor dysfunction.
There was some evidence on urinary incontinence, overactive bladder and pelvic organ prolapse. The evidence showed that physical activity could improve these symptoms, but the physical activity programmes in these studies were supervised and included pelvic floor muscle training as part of the interventions.
The physical activity interventions covered were yoga, pilates, weight training and aerobic exercises. However, it was not clear from the studies what type of exercises were beneficial, because they were usually combined with some form of pelvic floor muscle training. Because of this, the committee did not recommend specific activities. The committee know from their own experience that women often ask whether physical activity could improve or worsen their symptoms. Because of the evidence that showed some improvement, they made a recommendation in favour of supervised exercise. 'Supervised' exercise is specified because certain exercises, if done incorrectly, can weaken the pelvic floor by increasing intra-abdominal pressure. This could worsen symptoms of pelvic floor dysfunction.
There is no evidence that unsupervised physical activity improved or worsened symptoms of pelvic floor dysfunction. The committee acknowledged that there are general health benefits associated with having an active lifestyle. Therefore, they also made a recommendation for research on unsupervised activities (in particular, common activities such as walking and swimming).
Heavy lifting has been considered a risk factor for damaging the pelvic floor by increasing intra-abdominal pressure. The NICE guideline on urinary incontinence and pelvic organ prolapse in women recommends minimising heavy lifting. However, a more recent study showed that weight training combined with pelvic floor muscle training could improve symptoms of urinary incontinence. Because there was uncertainty around the evidence and it was not entirely consistent with the committee's experience, they made a recommendation for research on weight training to investigate this further.
The recommendations cover providing information, which is part of current practice, so there should be no cost to services. These recommendations will ensure women are educated on exercises they can do to improve their symptoms and exercises that are not harmful. In addition, they will help standardise the information being provided.
The evidence showed that pelvic floor muscle training improves several symptoms of pelvic floor dysfunction (pelvic organ prolapse, stress and mixed urinary incontinence, and faecal incontinence with coexisting pelvic organ prolapse). There was greater uncertainty around the findings on faecal incontinence with coexisting pelvic organ prolapse, because there was much less evidence in this area.
For pelvic organ prolapse, the evidence showed a benefit from pelvic floor muscle training for prolapse that does not extend more than 1 cm beyond the hymen. This matched the committee's experience, because they agreed that more extensive pelvic organ prolapse would be managed in specialist care.
The recommended lengths of time for the training programmes are based on the most common time points used in the studies for assessing the benefit of training. This was 16 weeks for pelvic organ prolapse and faecal incontinence, and 3 months for urinary incontinence. The committee noted that this would give enough time to assess whether the training improved symptoms. This is also consistent with the recommendations on pelvic floor muscle training in the NICE guideline on urinary incontinence and pelvic organ prolapse in women.
In addition to the research evidence, the committee also took account of the Independent Medicines and Medical Devices Safety Review and the NHS Long Term Plan, which made recommendations on pelvic floor muscle training.
See the rationale section on pelvic floor muscle training for preventing pelvic floor dysfunction, for an explanation of the recommendations on supervising pelvic floor muscle training.
For additional therapies, such as weighted vaginal cones, biofeedback and electrical stimulation, the evidence was inconsistent. Some studies showed benefits, and others showed no effect. Some of the evidence suggested that these interventions could help women with pelvic floor muscle training by improving their ability to contract their pelvic floor muscles. In the committee's experience, effective pelvic floor contractions and relaxations are important for improving pelvic floor dysfunction symptoms and most women are able to do this as part of a supervised pelvic floor muscle training programme. However, the committee believed that supplementing a pelvic floor muscle training programme with biofeedback, electrical stimulation or vaginal cones could be cost effective in the subgroup who make little progress during supervised pelvic floor muscle training. These additional therapies are particularly likely to be cost effective if using them allows women to avoid the need for surgical intervention.
Based on their experience, the committee thought it would be important that women are advised to continue doing pelvic floor muscle training and that they have the opportunity to discuss progress in regular reviews during the initial training programme. The committee believed that reviews with a healthcare professional improve adherence, which is important for the long-term effectiveness of pelvic floor muscle training.
There was some evidence suggesting that training in a group improved adherence and symptoms, but it was not consistently found to be more effective than individual training. This was supported by the committee's experience, because some women benefit from peer support whereas others feel more motivated with one-to-one supervision. To take account of this, the committee recommended giving women a choice of group or individual training. One-to-one supervision is more expensive than group training, but the difference in cost is relatively small and so the approach favoured by each woman is likely to be cost effective.
It was unclear whether using a pessary or intravaginal device would be effective when combined with pelvic floor muscle training, so the committee made a recommendation for research on intravaginal devices and pessaries. The development of remote clinical practice during the COVID‑19 pandemic also made the committee curious about the effectiveness of virtual pelvic floor muscle training, so they recommended research into the effectiveness of virtual and in-person contact time for pelvic floor muscle training.
The recommendations will standardise practice. Pelvic floor muscle training is a key intervention for managing the symptoms of pelvic floor dysfunction and is already widely used in the NHS. However, access to group pelvic floor muscle training classes differs across the country. Although some healthcare services may need to change practice, group pelvic floor muscle training classes are less expensive, so the committee did not anticipate a significant resource impact.
The evidence on intravaginal devices was unclear, with variance across outcomes. For example, there was no measurable reduction in urinary leakage, but women reported that their symptoms improved. However, the committee noted that a subjective improvement in symptoms was still important, because it is an indication of the woman's perception of the device's success. The committee were also aware from their experience that these devices can help to prevent urinary leakage in certain circumstances (for example, during exercise). Based on the limitations of the evidence and the potential complications, the committee recommended trialling intravaginal devices if other non-surgical options have been tried and have been unsuccessful, so that women could decide whether they were beneficial before using them long term.
This differs from recommendation 1.4.23 in the NICE guideline on urinary incontinence and pelvic organ prolapse, which recommends against the use of intravaginal devices. However, the committee noted that recommendation 1.4.23 had not been updated since 2006. Most of the evidence they reviewed for this guideline has been published since 2006. Even though the findings from the evidence were not entirely certain, they decided that these devices should not be ruled out if other non-surgical options were unsuccessful. This would provide another option that may prevent the need for more invasive treatment.
The evidence on pessaries indicated that they help with symptoms of pelvic organ prolapse while they are in position, and this is in keeping with the committee's clinical experience. However, there was a lack of long-term evidence on the effectiveness and potential complications of pessary use. Because of the uncertainty around pessaries, the committee specified particular benefits and harms to discuss with women, based on the evidence that was available and their clinical experience. This will help women to make an informed decision on whether a pessary is right for them.
In the committee's experience, women with physical or cognitive impairments may have difficulty in managing an intravaginal device or pessary and are at higher risk of complications. Because of this, these women should have regular appointments to check for complications. The committee also recommended telling women how to self-refer if they are managing the device themselves, so that they know how to get help if they are having problems or if their intravaginal device or pessary does not help.
There was a lack of evidence on the physical devices available for managing faecal incontinence (which is a particularly distressing symptom). The existing evidence consists of studies in mixed populations of men and women, so it could not be used to make recommendations for the population of this guideline. To address this, the committee made a recommendation for research on anal plug devices and rectal irrigation for managing bowel symptoms in women with pelvic floor dysfunction.
These recommendations are in line with current practice on pessaries. There is variation in the use of intravaginal devices, but the recommendations would not involve major changes to practice because it would be an option only if other options had not been successful. Even though this may increase the general use of intravaginal devices, they are already used in some areas. They may also prevent more invasive options (such as surgery) which are more costly.
The evidence showed a psychological impact from the symptoms of pelvic floor dysfunction. However, the committee noted that there was a lot of uncertainty about this evidence and made recommendations based on their experience and expertise. They made a recommendation emphasising this because women with pelvic floor dysfunction often do not seek help with the psychological impact of their symptoms, and healthcare professionals do not always ask them about it.
Some therapies were shown to improve distress associated with pelvic floor dysfunction, but the studies were very small. There was also evidence that psychological therapy could help with vaginismus, but it was not clear from the studies whether the participants' symptoms were related to pelvic floor dysfunction. The committee decided that they could not recommend therapies based on this evidence.
Because other NICE guidelines cover identifying and managing mental health problems for people with a chronic health condition, the committee referenced these guidelines instead of making new recommendations on specific psychological interventions.
There was some evidence showing that psychological interventions improved attendance and adherence to pelvic floor muscle training. However, there were several limitations to this evidence:
it did not show whether the improvement in attendance and adherence was sustained in the long term
although some of the interventions improved the mental health of participants, it was not clear whether the interventions also had an impact on symptoms (which could mean that the improvement in mental health may not be sustained in the long term)
the studies were small.
These limitations meant that the committee could not make a practice recommendation. However, they do believe that better attendance and adherence to training improves the benefit of pelvic floor muscle training. Because of this, they made a recommendation for research on ways to improve adherence for women who are having this training.
The committee agreed that there is variation in practice in how well psychological factors related to pelvic floor dysfunction are considered when planning treatment. The recommendations would not involve major changes to practice, but would standardise current good practice.
There was evidence about behavioural techniques including bladder retraining and lifestyle education, provided under direct supervision by a trained healthcare professional. The studies usually included pelvic floor muscle training as part of the interventions. The symptoms covered in the studies included urinary incontinence, urinary urgency and frequency, and faecal incontinence. Evidence was not available for some symptoms (such as emptying disorders of the bladder and bowel).
The evidence was difficult to interpret because there was variation in the quality of the research and a mixture of different interventions and comparators, which made it difficult to combine results. This meant that it was not clear which aspects of interventions were directly improving the symptoms of pelvic floor dysfunction.
The evidence showed that behavioural techniques in combination with pelvic floor muscle training improved these symptoms, which was in keeping with the committee's experience in clinical practice. The committee noted that bladder retraining consists of advice about when or how frequently to go to the toilet to encourage a routine that can help prevent incontinence episodes.
There was some limited evidence suggesting that a combination of behavioural techniques and pelvic floor muscle training was associated with improved adherence and satisfaction. The committee agreed that motivation and adherence were key to long-term benefit. The committee were conscious that behavioural techniques should be tailored to the individual, because ability may differ based on other coexisting conditions (such as cognitive impairment).
Behavioural techniques involve a wide range of techniques that can be used to change behaviour and teach women skills to reduce symptoms of pelvic floor dysfunction. These techniques are already used by most services, so the recommendations will reinforce current practice.
Bladder training can easily be provided in conjunction with a pelvic floor muscle training programme and would not add significant costs.
There was limited evidence on medicines for general pelvic floor dysfunction. However, the evidence available did show that intravaginal diazepam was not effective at improving symptoms. Although this evidence was based on a small population, the committee were also concerned about the risk of dependency from diazepam use. Because of this risk and the lack of evidence for any benefit, the committee recommended against intravaginal diazepam.
Women with high muscle tone are specifically mentioned in this recommendation because this is the only group diazepam would be considered for in current practice (because diazepam relaxes muscles and relieves muscle spasms). Because the evidence showed that diazepam was not effective, the committee wanted to make sure it was not used even in this group.
The NICE guidelines on urinary incontinence and pelvic organ prolapse in women, and faecal incontinence in adults, make recommendations on medicines for symptoms that can be associated with pelvic floor dysfunction. The committee recommended following these recommendations for women with pelvic floor dysfunction, because the medicines recommended are likely to be effective even if the underlying cause of symptoms is different in the other guidelines. They also thought that some of the recommendations in this guideline may also be relevant for women under 18.
Topical intravaginal oestrogen is currently used in clinical practice for managing pelvic floor dysfunction. However, no evidence was identified for this, so the committee made a recommendation for research on vaginal oestrogen.
The recommendation on intravaginal diazepam will not change current practice, because this is not currently used in the NHS. Because the other recommendation cross refers to other NICE guidance, it will reinforce current guidance and will not have any significant resource impact.