09 October 2018

NICE says non-surgical options should be offered first for stress urinary incontinence or pelvic organ prolapse

Women should be offered the treatment option of their choice, in discussion with their clinician

A full range of non-surgical options should be offered to women for stress urinary incontinence or pelvic organ prolapse before any operations, NICE has said.

There are a number of non-surgical options for both urinary incontinence and pelvic organ prolapse, which should be considered before surgery. The non-surgical options for urinary incontinence include:

  • Lifestyle interventions
  • Physical therapies
  • Behavioural therapies
  • Medicines

Non-surgical options for pelvic organ prolapse include:

  • Lifestyle modification
  • Topical oestrogen
  • Pelvic floor muscle training
  • Pessary management

Where surgery is offered, if a woman’s chosen intervention is not available from the consulting surgeon, she should be referred to an alternative surgeon, the draft guideline recommends.

Surgical interventions using surgical mesh/tape should only be considered when other non-surgical options have failed or are not possible.

A national database should be set up to record all procedures involving the use of surgical mesh/tape in operations for stress urinary incontinence or pelvic organ prolapse to help with future decision making.

In the cases where it is agreed to use surgical mesh/tape, women must be fully informed of the risks, the independent NICE committee said in the draft guideline.

Sir Andrew Dillon, chief executive of NICE, said: “Our independent advisory committee looked at a range of evidence for interventions for urinary incontinence and pelvic organ prolapse in women and made a series of detailed recommendations, using the best evidence currently available.

“It is important that every woman is supported to make decisions that are right for her, consents to a procedure, and fully understands the benefits and risks of the procedure being offered before consenting to it.

“Where surgical mesh/tape could be an option, there is almost always another intervention recommended in our guideline, which does not involve surgical mesh/tape. If a surgeon cannot provide a full range of choices to the patient, then she should be referred to one who can.

“Surgeons must also record any intervention using surgical mesh/tape in a national database.

“The guideline committee was asked to look at a range of interventions and examine the evidence for them. Importantly, our recommendations offer women a range of options for treatment that don’t involve the use of surgical mesh/tape.”

In July a national pausewas announced by the government on the use by the NHS of surgical mesh/tape to treat stress urinary incontinence and for urogynaecological prolapse where the mesh is inserted through the vaginal wall. This pausetakes the form of a high vigilance restriction period during which certain conditions apply.

This will remain in place until a number of conditions are met including:

  • Registering all operations and any complications on a national database
  • Surgery being performed by specialist surgeons based at specialist centres

A follow up appointment should be offered within six months to all women who have had urinary incontinence or prolapse surgery.

The draft guideline also recommends how complications associated with surgical mesh/tape surgery should be assessed and managed.

Consultants at centres specialising in the diagnosis and management of surgical mesh/tape-related complications should develop an individualised investigation plan for each woman with suspected or confirmed mesh-related complications.

Complications related to the device should be reported to the Medicines and Healthcare products Regulatory Agency (MHRA) and details of the complications should be collected in a national registry.

There are a number of recommendations included in the guideline for surgical mesh/tape-related complications. These include:

  • Referring women who suffer a suspected surgical mesh/tape-related complication to a urogynaecologist, urologist or colorectal surgeon for specialist assessment.
  • Referring women with a confirmed surgical mesh/tape-related complication, or unexplained symptoms after a surgical mesh/tape procedure, to a consultant at a regional centre specialising in the diagnosis and management of surgical mesh/tape-related complications.
  • The development of an individualised investigation plan for each woman with suspected or confirmed surgical mesh/tape-related complications.

Registered stakeholder organisations can now submit comments on these proposed recommendations until 19 November 2018.

Importantly, our recommendations offer women a range of options for treatment that don’t involve the use of surgical mesh/tape.

Sir Andrew Dillon, chief executive of NICE