Urinary incontinence and pelvic organ prolapse in women: management

Context

Urinary incontinence is a common symptom that can affect women of all ages, with a wide range of severity and nature. Although it is rarely life-threatening, urinary incontinence can be very detrimental to the physical, psychological and social wellbeing of the women it affects. The impact on families and carers can also be profound, and the resource implications for the health service are considerable. Urinary incontinence is defined by the International Continence Society as 'the complaint of any involuntary leakage of urine'.

Urinary incontinence can be a result of functional abnormalities in the lower urinary tract or of illnesses. Stress urinary incontinence is involuntary urine leakage on effort, exertion, sneezing or coughing. Urgency urinary incontinence is involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay). Mixed urinary incontinence is involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing. Overactive bladder (OAB) is defined as urgency that occurs with or without urgency urinary incontinence and usually with frequency and nocturia. OAB that occurs with incontinence is known as 'OAB wet'. OAB that occurs without incontinence is known as 'OAB dry'. These combinations of symptoms are suggestive of the urodynamic finding of detrusor overactivity, but can be the result of other forms of urethrovesical dysfunction.

Pelvic organ prolapse is defined as symptomatic descent of 1 or more of: the anterior vaginal wall, the posterior vaginal wall, the cervix or uterus, or the apex of the vagina (vault or cuff). Symptoms include a vaginal bulge or sensation of something coming down, urinary, bowel and sexual symptoms, and pelvic and back pain. These symptoms affect women's quality of life.

The prevalence of pelvic organ prolapse is high; in primary care in the UK, 8.4% of women reported vaginal bulge or lump, and on examination prolapse is present in up to 50% of women. One in 10 women will need at least 1 surgical procedure, and the rate of re‑operation is as high as 19%. There is likely to be an increasing need for surgery for urinary incontinence and pelvic organ prolapse because of the ageing population.

The NHS England Mesh Working Group report published in December 2015 raised a number of concerns about the safety and efficacy of surgery for stress urinary incontinence and pelvic organ prolapse using mesh devices. The report made the following recommendations for NICE:

NICE accepted these recommendations and has reviewed the evidence on complications arising from surgery for stress urinary incontinence and managing pelvic organ prolapse and updated this guideline.