REMEDY : BNSSG referral pathways

Urinary Incontinence & Prolapse

Checked: 14-02-2017 by christopher.moloney Next Review: 01-02-2018

Principles of Management

Current advice from the local gynaecologists is that patients with prolapse symptoms should initially try 3-6 months of supervised pelvic floor exercises prior to consideration for surgery (See self-referral form for gynae physio at St Michael's Hospital). Please see the advice from Mrs Caroline Overton below:

There are 2 references that you can cite when returning referrals with this advice. The first is Hagen et al, The Lancet March 2014. Individualised pelvic floor muscle training in women with pelvic organ prolapse (Poppy); a multi-centre randomised control trial. 447 eligible patients were randomised to intervention or control. Follow up was for 12 months. Women in the intervention group reported fewer prolapse symptoms (i.e. a significantly greater reduction in the pelvic organ prolapse symptom score) at 12 months than those in the controlled group (mean reduction in pelvic organ prolapse score from baseline 3.77 to 2.09). The conclusion was that one to one pelvic floor muscle training for prolapse was effective for improvement of prolapse symptoms. Longer term benefits should be investigated.

The other article to quote is the Cochran Database Systematic Review December 2011 by Hagen and Stark on the conservative prevention and management of pelvic organ prolapse in women. Prolapse symptoms and women reports of treatment outcomes indicated greater improvement in symptoms in the pelvic floor muscle training group compared to the control group.

As a general suggestion, I think that all women should be referred to physiotherapists for supervised pelvic floor muscle training. However those women where the prolapse comes down outside the vagina when standing up, should also be referred to Gynaecology at the same time.

Clinical Guidance

Please refer to the guidelines on Primary care management of urinary incontinence and prolapse (PDF) written by Phil Smith, Consultant Gynaecologist, North Bristol NHS Trust

Referral Guidance

Supervised pelvic floor exercises can be provided by the gynaecology physiotherapy department. If there are also stress incontinence symptoms associated with prolapse then a community continence service may be helpful.

For non-surgical management of prolapse, direct referral by letter to the Nurse-led Pessary Clinic at Southmead Hospital remains a further option if there is no-one within the practice who is able to fit pessaries, or if pessary fitting in primary care has proved difficult or is anticipated to be challenging. For South Bristol, UHB Prolapse and Pessary Clinic is access via gynaecology referral with Clinical Nurse Specialist support. Of note, the new Bioteque silicone pessaries may be removed and replaced by patients, so remain a potential option for sexually active women.

There is some useful advice on management and when to refer on patient.co.uk.

Pelvic Floor Excercises

Refer to the Pelvic Floor Exercises leaflet (PDF) issued by the Bladder & Bowel Foundation.

Vaginal Pessary

Refer to the guidance on fitting a vaginal pessary for pelvic organ prolapse (PDF).