Recommendations

Guidance

1.1 Raising awareness of pelvic floor dysfunction for all women
1.2 Risk factors for pelvic floor dysfunction
1.3 Preventing pelvic floor dysfunction
1.4 Communicating with and providing information to women with pelvic floor dysfunction
1.5 Assessment in primary care
1.6 Non-surgical management of pelvic floor dysfunction
Terms used in this guideline

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

What is pelvic floor dysfunction?

Pelvic floor dysfunction is a condition in which the pelvic floor muscles around the bladder, anal canal, and vagina do not work properly. This guideline covers the following symptoms and disorders when they are associated with pelvic floor dysfunction:

urinary incontinence
emptying disorders of the bladder
faecal incontinence
emptying disorders of the bowel
pelvic organ prolapse
sexual dysfunction
chronic pelvic pain.

The 3 most common and definable symptoms are urinary incontinence, faecal incontinence and pelvic organ prolapse.

Who does this guideline cover?

This guideline covers young women aged 12 to 17 and women aged 18 and over. When recommendations refer to 'women' without specifying an age range, that means they cover this entire population.

1.1 Raising awareness of pelvic floor dysfunction for all women

1.1.1

When producing resources on pelvic floor dysfunction, include:

the symptoms of pelvic floor dysfunction
visual aids to help identify potential causes of symptoms (for example, by showing the anatomy of pelvic organs)
when to get help
where to go for help (including self-referral to community-based multidisciplinary teams, where available)
an outline of risk factors, prevention and management options (including non-surgical management and lifestyle changes).

1.1.2

Consider providing information on pelvic floor dysfunction in the following formats and settings:

Formats
- print, broadcast and online adverts
- information given alongside over-the-counter continence products
- leaflets in the community (for example, at GP surgeries, family planning clinics and exercise classes)
- videos and information on social media
- interactive online resources (for example, the NHS app).
Settings
- as part of general exercise programmes
- in leaflets on gynaecological cancer treatment or gynaecological surgery (such as hysterectomies)
- as part of existing programmes, for example, cervical screening or national or local NHS health checks
- contact with a healthcare practitioner with pelvic floor dysfunction knowledge
- giving advice to people with contacts in the community (such as exercise and fitness instructors and teachers), so they can provide information on pelvic floor dysfunction themselves
- on community and health trust websites
- information provided by healthcare charities.

1.1.3

Tailor information and communication about pelvic floor dysfunction for different age groups and characteristics (for example, pregnancy).

1.1.4

Consider covering pelvic floor dysfunction in the syllabus for healthcare and other professionals, such as trainee nurses, physiotherapists, doctors, midwives and teachers.

1.1.5

Local authorities should consider designing pelvic floor dysfunction information programmes for specific communities when there is evidence of healthcare inequalities (for example, in how services are provided and accessed, or rates of uptake). This can be done by:

finding more effective ways to provide information (for example, by attending community meetings)
involving members of the community as champions
using webinars to reach women who are unable to attend meetings in person.

1.1.6

For women using maternity services, include information on pelvic floor dysfunction, how to prevent it, the symptoms, and how to access local services:

in the booking information pack or patient portal
at all midwife consultations and reviews
at all consultations with an obstetrician
in hospital postnatal wards.

1.1.7

Health visitors, midwives and GPs should discuss pelvic floor dysfunction with women at each postnatal contact.

1.1.8

Teach young women (between 12 and 17) in education settings about pelvic floor anatomy, pelvic floor muscle exercises and how to prevent pelvic floor dysfunction.

1.1.9

Provide information on pelvic floor dysfunction for older women within primary and intermediate care services, and within care homes and supported living communities. This could be done:

when women ask for advice about perimenopause and menopause
as part of general health assessments
as part of comprehensive geriatric health assessments.

1.1.10

For guidance on tailoring communication, information and shared decision making for people using health and social care services, see the:

NICE guideline on shared decision making
NICE guideline on patient experience in adult NHS services
NICE guideline on babies, children and young people's experience of healthcare
NICE guideline on people's experience in adult social care services
NHS Accessible Information Standard (in particular, for guidance on making information accessible).

1.1.11

For guidance on planning and developing digital and mobile tools to provide tailored information, see the NICE guideline on behaviour change: digital and mobile health interventions.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on raising awareness of pelvic floor dysfunction for all women.

Full details of the evidence and the committee's discussion are in evidence review A: community information strategies.

1.2 Risk factors for pelvic floor dysfunction

1.2.1

When discussing the risk of pelvic floor dysfunction with women, advise them that their risk is higher with any of the characteristics in box 1.

Box 1 Risk factors for pelvic floor dysfunction

Modifiable risk factors

A body mass index (BMI) over 25 kg/m²
Smoking
Lack of exercise
Constipation
Diabetes

Non-modifiable risk factors

Age (risk increases with increasing age)
Family history of urinary incontinence, overactive bladder or faecal incontinence
Gynaecological cancer and any treatments for this
Gynaecological surgery (such as a hysterectomy)
Fibromyalgia
Chronic respiratory disease and cough (chronic cough may increase the risk of faecal incontinence and flatus incontinence)

Related to pregnancy:

Being over 30 years when having a baby
Having given birth before their current pregnancy

Related to labour:

Assisted vaginal birth (forceps or vacuum)
A vaginal birth when the baby is lying face up (occipito-posterior)
An active second stage of labour taking more than 1 hour
Injury to the anal sphincter during birth

1.2.2

For pregnant women with pelvic floor dysfunction that started before or during their pregnancy, advise them that there is an increased risk that their symptoms will get worse during their pregnancy and that they may persist after this (for preventative and management strategies, see the section on preventing pelvic floor dysfunction and the section on non-surgical management of pelvic floor dysfunction.

1.2.3

For more detailed guidance on all the benefits and risks of vaginal and caesarean birth (including urinary incontinence, faecal incontinence and injury to the anal sphincter), see the section on benefits and risks of caesarean and vaginal birth in the NICE guideline on caesarean birth.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk factors for pelvic floor dysfunction.

Full details of the evidence and the committee's discussion are in:

1.3 Preventing pelvic floor dysfunction

Physical activity and diet

1.3.1

Advise women that physical activity and a healthy diet can help prevent pelvic floor dysfunction.

1.3.2

On levels of physical activity, advise women to follow the standard advice, as covered by:

1.3.3

On diet, advise women to:

have a balanced diet (following Public Health England's Eatwell Guide), and in particular to eat enough fibre, because this can improve stool consistency and prevent symptoms of faecal incontinence
ensure they have an appropriate fluid intake, increasing or decreasing it if needed.

1.3.4

For guidance on training to help health and social care practitioners recognise and respond to diet, physical activity and hydration needs in older people with social care needs and multiple long-term conditions, see the section on training health and social care practitioners in the NICE guideline on older people with social care needs and multiple long-term conditions.

Weight loss, stopping smoking, managing constipation and diabetes

1.3.5

For guidance on weight loss, see the NICE guideline on obesity, and (if relevant) the NICE guideline on weight management before, during and after pregnancy.

1.3.6

Give advice on stopping smoking, using the NICE guideline on tobacco.

1.3.7

For guidance on managing constipation in young people, see the NICE guideline on constipation in children and young people.

1.3.8

For guidance on managing diabetes, see the NICE guidelines on:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on physical activity and diet and other modifiable risk factors.

Full details of the evidence and the committee's discussion are in:

Pelvic floor muscle training

All women

1.3.9

Encourage women of all ages to do pelvic floor muscle training, and explain that it helps to prevent symptoms of pelvic floor dysfunction.

1.3.10

Encourage women to continue pelvic floor muscle training throughout their life, because long-term training continues to help prevent symptoms.

During and after pregnancy

1.3.11

Encourage women who are pregnant or who have recently given birth to do pelvic floor muscle training, and explain that it helps prevent symptoms of pelvic floor dysfunction.

1.3.12

Consider a 3‑month programme of supervised pelvic floor muscle training:

from week 20 of pregnancy, for pregnant women who have a first-degree relative with pelvic floor dysfunction
during postnatal care, for women who have experienced any of the following risk factors during birth:
- assisted vaginal birth (forceps or vacuum)
- a vaginal birth when the baby is lying face up (occipito-posterior)
- injury to the anal sphincter.

1.3.13

Before discharging women from maternity services, and during routine postnatal care, encourage them to do pelvic floor muscle training.

1.3.14

When designing a pelvic floor muscle training programme, see the NICE guideline on behaviour change for relevant recommendations:

Supervising pelvic floor muscle training

1.3.15

Pelvic floor muscle training programmes should be supervised by a physiotherapist or other healthcare professional with the appropriate expertise in pelvic floor muscle training.

1.3.16

Supervision should involve:

assessing the woman's ability to perform a pelvic floor contraction and relaxation
tailoring the pelvic floor muscle training programme to the woman's ability to perform a pelvic floor contraction and relaxation, any discomfort felt, and her individual needs and training goals
encouraging the woman to complete the course, because this will help to prevent and manage symptoms.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on pelvic floor muscle training for preventing pelvic floor dysfunction.

Full details of the evidence and the committee's discussion are in evidence review F: pelvic floor muscle training for the prevention of pelvic floor dysfunction.

1.4 Communicating with and providing information to women with pelvic floor dysfunction

Communication

1.4.1

Agree consultation formats (for example, in person, video or telephone) with each woman with pelvic floor dysfunction, taking into account the need for physical examinations.

1.4.2

When discussing pelvic floor dysfunction:

be aware of potential cultural sensitivities
be aware that women may feel embarrassed discussing their symptoms, and they may believe that healthcare professionals will also be embarrassed
take particular care around terminology:
- for example, avoid using 'faeces' if a woman better understands or prefers 'poo'
- be aware that women may not use the precise technical terms for parts of their pelvic anatomy
tailor information to each woman's level of understanding of anatomy and of the causes of pelvic floor dysfunction.

1.4.3

For general guidance on communicating with patients, see the:

1.4.4

When providing information to women with pelvic floor dysfunction and cognitive impairment, ask them if they want their family, carers and other people to be involved, to support them (as appropriate) and to help reinforce and support management plans.

Information for women with pelvic floor dysfunction

1.4.5

Help women with pelvic floor dysfunction to understand their condition by giving clear and concise information. This should include:

the anatomy of the pelvic floor and pelvic organs (using visual aids when helpful)
possible causes of their symptoms
management options and possible outcomes
an explanation that interventions will be focused on their symptoms, rather than on pelvic floor dysfunction in general
other medical conditions and treatments that can cause or exacerbate their symptoms (see risk factors for pelvic floor dysfunction).

1.4.6

Tailor information to each woman's age, level of understanding and circumstances, because pelvic floor dysfunction can affect women differently at different stages of life. For example:

young women (between 12 and 17)
women who are pregnant or who have given birth
women in perimenopause or postmenopause
women with comorbidities or frailty.

1.4.7

Consider digital information sources (for example, apps or videos) to support women with pelvic floor dysfunction (see guidance on developing digital tools in the NICE guideline on behaviour change: digital and mobile health interventions).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on communicating with and providing information to women with pelvic floor dysfunction.

Full details of the evidence and the committee's discussion are in:

1.5 Assessment in primary care

1.5.1

At initial assessment in primary care (which may include assessments by physiotherapists, bladder and bowel team members and continence advisors), take a general history from the woman about current and past symptoms or disorders associated with pelvic floor dysfunction, such as:

urinary incontinence
emptying disorders of the bladder
faecal incontinence
emptying disorders of the bowel
pelvic organ prolapse
sexual dysfunction
chronic pelvic pain.

1.5.2

Depending on the symptoms described, carry out a focused history, clinical examination and investigations to exclude other causes, such as:

pelvic masses
neurological disease
urinary tract infection
adverse effects of medication
diabetes
cancer (for further information, see the NICE guideline on suspected cancer: recognition and referral)
fistula
inflammatory bowel or bladder conditions
endometriosis
mobility and cognitive impairment.

1.5.3

Ask women who have recently given birth about symptoms of pelvic floor dysfunction during routine postnatal care, in hospital and in the community.

1.5.4

For women who are taking multiple medications, conduct a medication review. For guidance on how to do this, see the section on medication review in the NICE guideline on medicines optimisation.

1.5.5

Depending on the symptoms and the woman's preferences and circumstances, consider other clinical examinations. For example:

inspecting the woman's vulva and vagina for atrophy
asking them to bear down, to check for visible vaginal or rectal prolapse
rectal examination to check for impaction, for women who are at risk of this and who cannot give an accurate history of their symptoms (for example, women with cognitive impairments or dementia).

1.5.6

For more guidance on assessing urinary incontinence and pelvic organ prolapse, see the NICE guideline on urinary incontinence and pelvic organ prolapse in women. (The recommendations in this guideline may also be relevant for women under 18.)

1.5.7

If the woman has symptoms of faecal incontinence, follow the recommendations on baseline assessment in the NICE guideline on faecal incontinence. (The recommendations in this guideline may also be relevant for women under 18.)

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessment in primary care.

Full details of the evidence and the committee's discussion are in:

1.6 Non-surgical management of pelvic floor dysfunction

Community-based multidisciplinary teams

1.6.1

After initial assessment in primary care, consider a community-based multidisciplinary team approach for the management of pelvic floor dysfunction.

1.6.2

The community-based multidisciplinary team (or teams) should have members with competencies related to assessing and managing pelvic floor dysfunction, such as:

carrying out initial assessments (see the section on assessment in primary care)
assessments of mobility and personal care issues related to pelvic floor dysfunction
awareness of the psychosocial implications of pelvic floor dysfunction
identifying risk factors
interpreting urinalysis
conducting and interpreting bladder scans to measure post-void residual volume
conducting digital assessments of the pelvic floor and pelvic floor muscle contraction and relaxation
training women and their families and carers in behavioural interventions for pelvic floor dysfunction (such as bladder retraining)
prescribing and reviewing medications, and knowledge of interactions and side effects related to pelvic floor dysfunction
supervising a pelvic floor muscle training programme (see the section on supervising pelvic floor muscle training)
managing the use of pessaries and intravaginal devices
training and supporting other care providers to assess and manage pelvic floor dysfunction (for example, carers or care home workers)
identifying which women need referral to specialist care or other services (for young women aged 12 to 17, this may include referral to paediatric services or adolescent gynaecology services).

1.6.3

Discuss and agree a management plan with women who have suspected or confirmed pelvic floor dysfunction.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on community-based multidisciplinary teams.

Full details of the evidence and the committee's discussion are in evidence review R: community-based multidisciplinary teams.

Lifestyle changes

Encouraging women to make lifestyle changes

1.6.4

When discussing lifestyle changes with women who have pelvic floor dysfunction:

motivate them to make changes by focusing discussions on how this will improve their symptoms
give them regular encouragement to keep up the changes, because it may take weeks or months before they notice a benefit.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on encouraging women to make lifestyle changes.

Full details of the evidence and the committee's discussion are in evidence review G: information provision related to the management of pelvic floor dysfunction (people's views and experiences).

Weight loss

1.6.5

Advise women with a body mass index (BMI) over 30 kg/m² that weight loss can help with the following symptoms associated with pelvic floor dysfunction:

urinary incontinence
overactive bladder
pelvic organ prolapse.

1.6.6

For guidance on weight loss, see the NICE guideline on obesity, and (if relevant) the NICE guideline on weight management before, during and after pregnancy.

1.6.7

Refer women for weight loss support following the NICE guideline on lifestyle services for weight management in overweight or obese adults and the NICE guideline on lifestyle services for weight management in overweight or obese children and young people.

1.6.8

Do not wait for women to lose weight before starting other pelvic floor dysfunction management options.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on weight loss.

Full details of the evidence and the committee's discussion are in evidence review J: weight loss interventions.

Diet

1.6.9

For all women with pelvic floor dysfunction:

explain how a balanced diet (following Public Health England's Eatwell Guide) and appropriate fluid intake can improve stool consistency, which can help with their symptoms
follow guidance on maintaining healthy bowel habits in recommendation 1.3.2 of the NICE guideline on faecal incontinence in adults (including for women under 18 or with symptoms other than faecal incontinence).

1.6.10

Advise women with overactive bladder or urinary incontinence associated with pelvic floor dysfunction to:

reduce their caffeine intake
modify their fluid intake (increasing if it is too low, decreasing if it is too high).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on diet.

Full details of the evidence and the committee's discussion are in evidence review K: dietary factors for the management of symptoms.

Physical activity

1.6.11

For women who are doing supervised pelvic floor muscle training and want to be physically active, advise them that supervised exercise (for example, yoga) may help with their symptoms.

1.6.12

Advise women with pelvic floor dysfunction that there is no evidence to say that unsupervised physical activity (such as walking or swimming) will improve or worsen their symptoms.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on physical activity.

Full details of the evidence and the committee's discussion are in evidence review L: physical activity for the management of symptoms.

Pelvic floor muscle training

For pelvic organ prolapse

1.6.13

Consider a programme of supervised pelvic floor muscle training for at least 4 months for women with symptomatic pelvic organ prolapse that does not extend greater than 1 cm beyond the hymen upon straining.

For stress urinary incontinence or mixed urinary incontinence

1.6.14

Offer a programme of supervised pelvic floor muscle training for at least 3 months to women (including pregnant women) with stress urinary incontinence or mixed urinary incontinence.

For faecal incontinence with coexisting pelvic organ prolapse

1.6.15

Consider a programme of supervised pelvic floor muscle training for at least 4 months for women with faecal incontinence and coexisting pelvic organ prolapse.

Group and individual training

1.6.16

For women who are doing a supervised pelvic floor muscle training programme, offer the choice of group or individual sessions.

Supervising pelvic floor muscle training

1.6.17

See the recommendations on supervising pelvic floor muscle training in the section on preventing pelvic floor dysfunction.

Review

1.6.18

When providing a programme of pelvic floor muscle training, offer at least 1 review to assess progress during the programme, and 1 review at the end of the programme.

Supplementing pelvic floor muscle training

1.6.19

For women who are unable to perform an effective pelvic floor muscle contraction, consider supplementing pelvic floor muscle training with biofeedback techniques, electrical stimulation or vaginal cones.

Continuing pelvic floor muscle training

1.6.20

If the programme is beneficial, advise women to continue pelvic floor muscle training after the supervised programme ends.

Full details of the evidence and the committee's discussion are in evidence review M: pelvic floor muscle training for the management of symptoms.

Intravaginal devices and pessaries

Intravaginal devices for urinary incontinence

1.6.21

Consider a trial of intravaginal devices for women with urinary incontinence, only if other non-surgical options have been unsuccessful.

Pessaries for symptomatic pelvic organ prolapse

1.6.22

Consider pessaries for women who have symptomatic pelvic organ prolapse.

1.6.23

Before starting treatment with a pessary for women with symptomatic pelvic organ prolapse:

discuss with the woman how a pessary could help, and explain it may not help with their urinary and bowel symptoms
explain that a pessary will only help with their pelvic organ prolapse symptoms while it is in place, and the symptoms will come back when it is removed
explain that reducing the prolapse with a pessary may cause new stress urinary incontinence.

See recommendation 1.7.8 in the NICE guideline on urinary incontinence and pelvic organ prolapse for further discussions to have with women before starting treatment with a pessary.

1.6.24

If women using a pessary experience new stress urinary incontinence, offer them a choice of treatment for the incontinence or removal of the pessary.

1.6.25

For more guidance on pessaries for women with symptomatic pelvic organ prolapse, see the section on pessaries in the NICE guideline on urinary incontinence and pelvic organ prolapse.

Review

1.6.26

For women who are self-managing their intravaginal device or pessary, explain how they can seek advice from a healthcare provider if they have problems.

1.6.27

For guidance on reviewing pessaries for women who are at risk of complications, for example because of a physical or cognitive impairment, see recommendation 1.7.9 in the NICE guideline on urinary incontinence and pelvic organ prolapse.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on intravaginal devices and pessaries.

Full details of the evidence and the committee's discussion are in evidence review N: physical devices for the management of pelvic floor dysfunction.

Psychological interventions

1.6.28

Discuss the psychological impact of their symptoms with women who have pelvic floor dysfunction. Take account of this impact when developing a management plan.

1.6.29

For more guidance on psychological management, see the:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on psychological interventions.

Full details of the evidence and the committee's discussion are in evidence review O: psychological therapy for women with pelvic floor dysfunction.

Behavioural approaches

1.6.30

Offer supported bladder retraining (combined with other interventions, such as pelvic floor muscle training) to women with urinary frequency, urgency or mixed incontinence.

1.6.31

For women with faecal incontinence, see the section on diet, bowel habit and toilet access in the NICE guideline on faecal incontinence in adults. (The recommendations in this guideline may also be relevant for women under 18.)

1.6.32

When choosing a behavioural intervention, take into account that prompted toileting and habit training may be particularly suitable for women with cognitive impairment.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on behavioural approaches.

Full details of the evidence and the committee's discussion are in evidence review P: behavioural approaches to the management of symptoms.

Medicines

1.6.33

Do not offer vaginal diazepam to treat pelvic floor dysfunction, even for women with high muscle tone.

1.6.34

For guidance on medicines for urinary incontinence and faecal incontinence associated with pelvic floor dysfunction, see the NICE guideline on urinary incontinence and pelvic organ prolapse in women and the section on medication in the NICE guideline on faecal incontinence in adults. (The recommendations on medicines in these guidelines may also be relevant for women under 18.)

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on medicines.

Full details of the evidence and the committee's discussion are in evidence review Q: pharmacological management.

Terms used in this guideline

Pelvic floor muscle training

Exercise to improve pelvic floor muscle strength, endurance, power, relaxation, or a combination of these. For more information, see the definition of pelvic floor muscle training in the International Continence Society and International Urogynecological Association's joint report on the terminology for the conservative and non-pharmacological management of female pelvic floor dysfunction.