Female Genital / Pelvic Organ Prolapse – Surgical Treatment of (Weakness of pelvic muscles causing organs to drop)

Threshold

Patients with Pelvic Organ Prolapse should usually initially be assessed in primary care and conservative management tried in the first instance.

Conservative Management

• Watchful Waiting – in cases of asymptomatic/mild prolapse it is appropriate to observe for the development of new symptoms or complications.
• Lifestyle Modification – including losing weight and reducing causes of increased intra-abdominal pressure: management of chronic cough, avoiding constipation, avoiding heavy lifting, and avoiding physical activity such as trampolining or high-impact exercise.
• Pelvic Floor Exercises – to strengthen the pelvic floor muscles.
• Vaginal Oestrogen Creams – these are often offered in cases of all types of prolapse.

Vaginal Pessaries

Vaginal pessaries are a good way of supporting prolapse and are more likely to support a uterine prolapse than other types of prolapse.

Pessaries are a good option for women who wish to have children/more children in the future, in cases where a woman does not want surgery, or surgery is not recommended, and for relief prior to having surgery.

Surgery

If conservative management has not been successful there are some surgical procedures that can be used to treat prolapse.

However, it is important for a woman to be fully informed before she consents to surgery, and that she knows that for surgical treatments to be effective a combination of procedures may be required, and re-operation may also be required.

The following clinical scenarios where Norfolk and Waveney ICB will fund referral for specialist assessment:

• Patients with Stage 3 or Stage 4 pelvic organ prolapse (clinically severe prolapse).

OR

• Prolapse combined with urethral sphincter incompetence/ urinary incontinence or faecal incontinence*

OR

• Failure of pessary and conservative treatments

OR

• Women with moderate to severe prolapse who want definitive treatment.

Clinical scenarios where Norfolk and Waveney ICB will NOT routinely fund surgery:

• Asymptomatic pelvic organ prolapse.

OR

• Mild pelvic organ prolapse (unless combined with urinary/faecal incontinence) *

*Note: If a patient, especially if 50 years or older reports increased urinary urgency and/or frequency on a frequent or persistent basis, they should be investigated in Primary Care in with line with NG123 ‘Suspected Cancer Recognition and Referral’ in case a 2 week wait referral is needed – Overview | Urinary incontinence and pelvic organ prolapse in women: management | Guidance | NICE

Please find link below regarding help and support to patients to keep healthy whilst waiting for a hospital appointment or surgery:

• While You Wait – Norfolk & Waveney Integrated Care System (ICS

Norfolk and Waveney Integrated Care Board do not support the use of synthetic polypropylene transvaginal mesh in the surgical repair of anterior or posterior vaginal wall prolapse in line with current NICE guidance.

• Current evidence on the safety of transvaginal mesh repair of anterior or posterior vaginal wall prolapse shows there are serious but well-recognised safety concerns.
• Evidence of long-term efficacy and safety is inadequate in quality and quantity. Therefore, this procedure should only be used in the context of ethically approved research studies.

For other cases of prolapse if a synthetic polypropylene mesh is inserted, the details of the procedure and its subsequent short- and long-term outcomes must be collected in a national registry.

Cases for Individual Funding Consideration

On a case to case basis, patients might be eligible for funding, in consideration of their exceptionality. The requesting clinician must provide information to support the case for being considered an exception, by submitting an individual funding request.