The use of mesh in treating urinary incontinence and pelvic organ prolapse—conditions that are common after childbirth—has come under intense scrutiny with much public concern. Many women may have the mesh implanted without a problem; however, for others, it can lead to unacceptable complications that include the mesh cutting into organs or through tissues, intense pain and recurring infection.
Recommendations produced by the National Institute for Health and Care Excellence (NICE) (2019) suggest that the full range of non-surgical options should be offered to those women with urinary incontinence and pelvic floor prolapse prior to any surgical procedures being undertaken. The non-surgical options include lifestyle interventions, physical therapies, behavioural therapies and medications that are used for urinary incontinence. Non-surgical options for pelvic organ prolapse include lifestyle modification, the use of topical oestrogen, pelvic floor muscle training and pessary management.
The 2019 NICE recommendation take into account the previous 2016 and 2013 recommendations and guidance. These 2019 recommendations replace the 2013 clinical guideline (NICE, 2013) and the 2016 interventional procedures guidance (NICE 2016). They are based on the NICE (2015) Quality Standard, Urinary Incontinence in Women.
Pelvic floor muscle training
Pelvic floor muscle training is a physical therapy that NICE (2019) has recommended. Decisions about treatment choice will depend on the woman's symptoms and her general health. Lifestyle interventions are a feature of conservative management, usually used by women with a mild prolapse or who do not wish to have more invasive treatment. The aim of these interventions is to improve the woman's general health in order or to avoid exacerbation of the condition by decreasing intra-abdominal pressure.
‘What is absolutely essential is that women are provided with information and offered advice that meets their unique requirements … by practitioners who are competent and confident’
A supervised period of pelvic floor muscle training for at least 3 months is seen as first-line treatment for those women with stress or mixed urinary incontinence. Pelvic floor muscle training programmes should include at least eight contractions that are performed three times a day. There is no requirement for perineometry or pelvic floor electromyography as part of routine pelvic floor muscle training.
The NHS website provides advice for women on pelvic floor exercises (Box 1).
Treatment options
The decision (undertaken with the woman) to embark on a treatment option must be preceded by clinical assessment that categorises the woman's urinary incontinence as stress urinary incontinence, urgency urinary incontinence/overactive bladder or mixed urinary incontinence.
When this is determined, initial treatment should be started based on the outcome of the assessment, with treatment being directed towards the predominant symptom in mixed urinary incontinence. Where stress incontinence is the predominant symptom in mixed urinary incontinence, then a discussion with the woman should be undertaken, outlining the benefit of non-surgical management and the use of medications for overactive bladder prior to offering her surgery. The physical examination incorporates an assessment of the pelvic floor muscles using a digital assessment to confirm pelvic floor contraction prior to the implementation of supervised pelvic floor muscle training.
The 2019 recommendations note there is some evidence demonstrating that surgery is more effective than pelvic floor muscle training to manage stress urinary incontinence. However, the evidence regarding long-term efficacy and adverse effects is limited. Pelvic floor muscle training, however, is just as effective as surgery for some women with stress urinary incontinence and, as such, pelvic floor muscle training is seen as first-line treatment for stress urinary incontinence.
Currently, pelvic floor muscle training is not routinely offered to all women. The NICE recommendations are aiming to address this so as to effect a change in practice to make this option available.
What is absolutely essential is that women are provided with information and offered advice that meets their unique requirements. This must be offered by practitioners who are competent and confident in supporting the often complex needs that women with urinary incontinence and pelvic organ prolapse may experience and present with, from a biopsychosocial perspective. Women should never be denied effective surgical options.
The urogynaecological, urology or continence specialist nurse, part of a local multidisciplinary team, are ideal practitioners to offer women information and support to help them make the right decision about their treatment.
Pelvic health pathway
Women, nurses and others, working together, should be advocating for the introduction of a national pelvic health and wellbeing innovative pathway. The pathway should include the principles of increased promotion of specialist services for continence, physiotherapy and chronic pain. This would be a preventive, out-of-hospital care approach for those women with incontinence and prolapse and surgery should be seen as a last resort.
Focusing on women, community-based initiatives offering preventive interventions and avoiding high-risk surgery, would allow women to receive high-quality, person-centred, safe and effective care. This would put women at the centre of all that is done, while listening to and acknowledging their voices.