Management of Women with Pelvic Organ Prolapse GL1080 protocols and... · GL1080 - Management of Women with Pelvic Organ Prolapse 5.4 Pelvic floor exercise (PFE) - Improves many POP

Author: William Kuteesa Date: August 2017

Job Title: Consultant Gynaecologist Review Date: August 2019

Policy Lead: Urgent Care Group Director Version: Version 1

Location: Corporate Governance shared drive – GL1080

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Management of Women with Pelvic Organ Prolapse GL1080

Approval

Approval Group Job Title, Chair of Committee Date

Gynaecology Clinical Governance Mr Alex Swanton Consultant Gynaecologist

August 2017

Change History

Version Date Author, job title Reason

1 August 2017

W Kuteesa Consultant Gynaecologist

Urogynaecology Requirement





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GL1080 - Management of Women with Pelvic Organ Prolapse

Contents 1.0 Purpose........................................................................................................................... 3 2.0 Scope .............................................................................................................................. 3 3.0 Roles and Responsibilities .............................................................................................. 3 4.0 Definitions ....................................................................................................................... 3 5.0 Document content ........................................................................................................... 3 5.1 Introduction ..................................................................................................................... 3 5.2 Pelvic Organ Prolapse (POP) assessment ..................................................................... 3 5.2.1 History. ...................................................................................................................... 3/5 5.2.2 Examination ................................................................................................................. 6 5.2.2 Investigation ................................................................................................................. 6 5.3 POP Management overview ........................................................................................... 4 5.4 Pelvic floor exercises (PFE) ............................................................................................ 5 5.5 Topical vaginal oestrogens ............................................................................................. 5 5.6 Vaginal pessaries ......................................................................................................... 5/6 5.6.1 Pessary follow-up (pessary checks) ............................................................................. 6 5.6.2 Topical oestrogen with vaginal pessaries .................................................................... 6 5.6.3 Self-management of ring pessaries ............................................................................. 7 5.6.4 Management of pessary complications ..................................................................... 7/8 5.7 Surgery ........................................................................................................................... 8 5.7.1 Patients requesting surgery who should be referred to the Pelvic Floor Clinic ............. 8 5.7.2 Vaginal prolapse surgery ............................................................................................. 8 5.7.3 Consent for vaginal surgery ......................................................................................... 8 5.7.4 Laparoscopic/abdominal procedures ........................................................................... 9 5.8 POP management algorithm ......................................................................................... 10 6.0 Consultation Undertaken .............................................................................................. 11 7.0 Dissemination/Circulation/Archiving .............................................................................. 11 8.0 Implementation ............................................................................................................. 11 9.0 Training ......................................................................................................................... 11 10.0 Monitoring of Compliance ........................................................................................... 11 11.0 Supporting Documentation and References ............................................................... 12 12.0 Equality Impact Assessment .................................................................................. 12/13 Other relevant corporate or procedural documents: This document should be read in conjunction with the RBFT guidelines on:

Management of women with lower urinary tract symptoms (urinary incontinence).





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1.0 Purpose

To assist medical and nursing staff in the general management of pelvic organ prolapse (POP).

2.0 Scope

Pelvic Floor Clinic (PFC) staff. General Gynaecology Clinic (GOPD) staff.

3.0 Roles and Responsibilities

Who is responsible for what? Start at Board/CEO level and work down. What are the expectations on directors, managers and staff in fulfilling their obligations?

4.0 Definitions

Clarify what specific terms mean to the Trust in the context of the document. This is important to ensure there is no ambiguity.

5.0 Document content

5.1 Introduction

- The lifetime risk of pelvic organ prolapse surgery in women is between 12-19%. - Up to 76% of women attending GOPD will be found to have some degree of POP1. - Associated symptoms vary in both character and severity. A significant proportion of women will be asymptomatic or experience mild symptoms and will therefore not require treatment. - Decisions on treatment should be patient-led and not restricted by age.

5.2 POP assessment 5.2.1 History Clearly document symptoms to: - Assess the likely success of proposed treatment. - Determine degree of success post-treatment.

Asymptomatic Pain/discomfort. Rubbing/dragging sensation. Superficial dyspareunia/obstruction to sex.

Bowel symptoms: Incomplete bowel emptying/digitates to empty. Faecal urgency/incontinence – refer to pelvic floor colorectal team.





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Bladder symptoms: Incomplete emptying - strains/digitates to empty. Slow flow. Recurrent UTIs. Concomitant urinary leakage – type (see Management of female lower urinary tract symptoms (LUTS) guideline).

5.2.2 Examination

Abdominal/pelvic masses. Genital atrophy. Stage/site of prolapse. Assessment of pelvic floor muscle (absent/present/strength).

5.2.3 Investigation - Pelvic ultrasound scan (USS) for suspected pelvic mass or post-menopausal bleed. - Pre and post-void bladder volume for suspected incomplete emptying associated with: - Recurrent UTI. - Bothersome LUTS. - Renal USS for: - Recurrent UTI (exclude renal pathology). - Complete uterine prolapse (exclude hydronephrosis). - Urodynamics for patients requesting surgical intervention with bothersome concomitant LUTS (refer to Pelvic Floor Clinic). - Defecating proctogram for obstructive defecation in patients with minimal or no rectocele.

5.3 POP management overview

- Dependent on patient preference. Age (the young or elderly) is not a restriction to any management option. Expectant/conservative management

- No treatment. - Pelvic floor exercises. - +/- Bladder training if concomitant overactive bladder (OAB) symptoms. - +/- Topical oestrogens. - Advise weight-loss if indicated. - Address chronic constipation.

Vaginal pessaries

- Ring pessary. - Self-management. - Other types of pessary.

Surgery -

- Vaginal.

- Laparoscopic/Abdominal.





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5.4 Pelvic floor exercise (PFE)

- Improves many POP symptoms (dragging/discomfort). - Reduces risk of POP progression. - Will not reduce the ‘bulge’ of advanced POP. - Improves concomitant stress urinary incontinence symptoms. - Bladder training improves concomitant OAB (urge incontinence etc.). - Please provide/send pelvic floor exercise (+/- bladder training) patient information leaflet. - Better results are achieved with supervised pelvic floor exercises (+/- bladder training). If patient wishes, write a referral to Pelvic Floor physiotherapy. Request that physios refer back to PFC for those women in whom treatment fails. The clinic will then organise a follow-up appointment.

5.5 Topical vaginal oestrogens

- Most post-menopausal women will require topical oestrogens. - Genital tissues are sensitive to reductions in circulating oestrogen. - Intra and extra vaginal oestrogens improve:

Vaginal tissues (reduce/resolve rubbing/discomfort associated with POP). Pelvic floor response to PFE. Natural defences to UTI. In those with concomitant LUTS:

- Improves urethral continence mechanisms. - Improves bladder oversensitivity.

- Estriol creams provide greater genital cover than oestrogen pessaries. - There is no need to prescribe a loading dose (as in BNF). - Recommended dose: 2-3 applications/week (at night) inside and out (with a finger if easier) for 4 months initially, request GP repeat scripts indefinitely. Topical oestrogen contraindications: - Explain to patients that there is very little systemic absorption of oestrogen. - Despite package labelling, there is no evidence in the world literature that topical oestrogen creams are associated with the risks of systemic HRT. - Progestogens are not required with topical oestrogen cream. - A history of breast cancer is a caution. If vaginal oestrogens are thought to be necessary,

ask the patient’s breast oncology team before prescribing.

5.6 Vaginal pessaries - Should be used in conjunction with PFE (+/- bladder training if OAB symptoms). - There is no age restriction to the use of vaginal pessaries. - Pessaries may be used as long-term treatment. - Pessaries may be used as a trial (to evaluate symptom resolution) prior to surgery. - Sexual intercourse is possible with a ring pessary in situ. - Women can learn to self-manage their pessaries. They can then remove and insert the pessary as required (less frequent follow-up). - Shelf/Gellhorn pessaries are reserved for cases of failed ring pessary (usually in patients without a uterus).





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Vaginal pessary advantages: - Avoids surgical risks (30% risk of recurrence). - No contraindications. - Prevents POP progression. - Not a restriction to pregnancy. Vaginal pessary disadvantages: - Requires follow-up. - May cause discharge. - May cause abrasion/ulceration/unscheduled bleeding. - Rarely adherent/erosion into adjacent viscera (if neglected). 5.6.1 Pessary follow-up (pessary checks): - Follow-up for pessary checks can be conducted in GOPD, Pelvic Floor Clinic (PFC) or at GP practices (if the patient and GP agree). - The purpose of regular pessary follow-up is to review symptoms, exclude vaginal abrasion/ulceration and prevent pessary adherence/erosion. - Patients who self-manage their ring pessaries still require an annual speculum examination. - It is not necessary to renew pessaries at every pessary check.

- Pessaries are robust and are for single patient use (not single use). They need to be clean and undamaged for reinsertion. - Discolored pessaries can be reinserted.

Frequency of pessary checks. - Three-month follow-up after initial fitting (GOPD or PFC). - Six-monthly follow-up for well fitting pessaries (no problems) (GOPD, PFC or at GP practice (if the patient and GP agree)). - Annual follow up for women who self-manage their ring pessaries (GP Practice-Nurse speculum check). - Two to three-month follow-up for problems with pessaries (PFC).

5.6.2 Topical oestrogen with vaginal pessaries: - Improves POP symptoms (above). - Improves LUTS (if present). - Protects vaginal skin from pessary abrasion. - Reduces incidence of pessary complications. - Advise vaginal oestrogens for most post-menopausal women who choose pessary management. 5.6.3 Self-management of ring pessaries2. - Promotes patient ownership of the condition. - Patient can remove and insert her ring according to her requirements. - Reduces frequency of follow-up.





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- Only requires annual GP Practice-Nurse speculum check (patient can remove and insert the ring prior to and after the examination). - Easy to learn - PFC will train all interested patients. - Offer this option to all women agile enough to remove and insert a ring pessary. 5.6.4 Management of pessary complications: Unscheduled bleeding: - Assess for evidence of cervical/vaginal trauma. Note: If bleeding occurs in a post-menopausal woman with a uterus: - Follow the 2WW PMB pathway to exclude endometrial pathology even when the likely cause is from a lower genital tract finding e.g. vaginal excoriation (see below). Vaginal skin hypertrophy/excoriation: - Prescribe estriol cream (if not already being used) as above. - Reinsert pessary and review in PFC in 2-3 months. - If progresses/persists after estriol cream, request urogynae consultant review (consider smaller ring and/or 3-4 monthly checks). - If no symptoms/progression, resume 6-monthly checks. Vaginal ulceration: - Do not reinsert ring. - Prescribe estriol cream (if not already being used) apply daily for 2-3 weeks. - Refer to PFC for review. Severe vaginal ulceration +/- patient unable to cope without pessary: - Discuss with Urogynae Consultant/on-call Consultant. - Do not reinsert ring. - Admit. - Catheterise. - Estriol cream soaked pack daily. - Daily review. Adherent pessary Book for removal under GA (ASAP elective list), then consider: - More frequent pessary checks. - Surgical intervention. Vaginal discharge causes: - Commonly secondary to foreign body reaction. - Vaginal atrophy. - Vaginal skin hypertrophy. - Prescribe estriol cream (if not already being used) 2-3/week (as above). - If non-bothersome continue normal pessary follow up. - If bothersome, reinsert pessary and review in PFC in 2-3 months. - Infections are uncommon, consider carefully before prescribing antibiotics. - Antibiotics are not beneficial in the long-term management of persistent vaginal discharge.





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5.7 Surgery - Surgical aims are to resolve symptoms and restore anatomy. - Age is not a restriction to surgical intervention. - Future pregnancy is a restriction to most POP surgery (not sacro-hysteropexy). - Patients with bothersome LUTS should consider urodynamics prior to surgery (if patient wishes, refer to PFC). - Prescribe vaginal oestrogens for most post-menopausal women on booking surgery.

- Intra and extra vaginal oestrogens improve vaginal tissues, thereby improving dissection planes. - Healing may be improved. - Success rates may be improved. - 2-3 applications/week (at night) intra + extra-vaginally (with a finger if easier) for the months prior to surgery.

5.7.1 Women requesting surgery, consider referring the following patients to the Pelvic Floor Clinic: - Patients with POP and additional bothersome LUTS. - Advanced POP with previous failed surgery. - Women under 50 years with advanced vault/uterine prolapse. - Advanced prolapse in women wishing to preserve fertility.

5.7.2 Vaginal prolapse surgery: - Cystocele/rectocele - vaginal (anterior/posterior) repair. - Apical compartment prolapse - Sacrospinous fixation of vault or uterus (SSF). - Vaginal hysterectomy. Please provide/send patient information leaflets. N.B. - Success rates of sacrospinous fixation of the uterus are similar to vaginal hysterectomy3 without hysterectomy risk or operative time.

5.7.3 Consent for vaginal surgery: - It is prudent to take consent for potential repair of all compartments (posterior/anterior/apical) because more advanced prolapse is often found under GA than found during clinic examination. - Most vaginal POP surgery carries a 30% risk of failure (recurrence). - Specific SSF consent: <1 in 100 risk of lifelong buttock numbness/pain. 5.7.4 Laparoscopic/abdominal procedures – Sacro-hysteropexy/Sacro-colpopexy). Refer potential candidates to the Pelvic Floor Clinic Indications: - Women under 50 years with advanced vault/uterine prolapse. - Advanced POP with previous failed surgery. - Advanced prolapse in women wishing to preserve fertility.





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5.8

Symptomatic Pelvic Organ Prolapse

Pelvic Floor Clinic/GOPD Exclude other causes, exam, +/- pelvic/bladder ultrasound.

Consider topical estriol cream for most PM women

Treatment dependent on patient preference

Expectant Management Supervised pelvic floor

exercises (physio) +/- bladder training for OAB

Vaginal Pessaries

+/- PFE/bladder training

Review Pessary 3/12

Discharge to GP

GP 6 monthly pessary checks

(GP/patient agreement)

Nurse-led 6-monthly pessary checks

or self-management

Review 8-10/52

Surgery (Leaflets, consent, vaginal oestrogens)

+/-Urodynamics for patients with

LUTS

Successful Treatment





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6.0 Consultation Undertaken

Gynaecology Clinical Governance Committee – This includes: The Gynaecology Operations Managers, Gynaecology Consultants, Junior and Middle Grade Medical Staff. A copy of the guideline was circulated to all stakeholders for amendments prior to a scheduled clinical governance meeting.

7.0 Dissemination/Circulation/Archiving

A hard copy will be kept in the Pelvic Floor Clinic and GOPD. A hard copy will be given to all junior medical staff at induction. An electronic copy will be e-mailed all medical staff. The Guideline will be available on the Trust intranet (Gynaecology guideline section) and external website. The Trust Secretary will be responsible for archiving old versions of this document.

8.0 Implementation

Medical and nursing staff will be reminded of protocol by Sonning staff and the Gynaecology Consultants.

9.0 Training

There is no mandatory training associated with this guideline.

10.0 Monitoring of Compliance

Aspect of compliance or effectiveness being monitored

Monitoring method

Individual or dept. responsible for the monitoring

Frequency of the monitoring activity

Group/committee which will receive the findings/ monitoring report

Committee/ individual responsible for ensuring that the actions are completed

Departmental audit of numbers and management of POP

Audit

Urogynaecol-ogy Service

Every 2 Years

Gynaecology MDT/Governance

W. Kuteesa

The Trust reserves the right to amend its monitoring requirements in order to meet the changing needs of the organisation.





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11.0 Supporting Documentation and References

Barber M D. Pelvic organ prolapse. Clinical update. BMJ 2016;354:i3853 doi: 10.1136/bmj.i3853. [Online]. Available at: http://www.bmj.com/content/354/bmj.i3853 [Accessed: 2 February 2017].

The Society of Obstetricians and Gynaecologists of Canada (SOGC) Technical Update on Pessary Use. Technical Update No. 294. J Obstet Gynaecol Can 2013;35(7 eSuppl):S1–S11. [Online]. Available at: https://sogc.org/wp-content/uploads/2013/07/gui294CPG1307E.pdf [Accessed: 20 January 2017].

Detollenaere R J. Sacrospinous hysteropexy versus vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse stage 2 or higher: multicentre randomised non-inferiority trial. BMJ 2015; 351:h3717 [Online]. Available at: https://doi.org/10.1136/bmj.h3717 [Accessed: 10 November 2016].

Equality Impact Assessment

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Do different groups have different needs, experiences, issues and priorities in relation to the proposed policy?

N/A N/A N/A For female patients

N/A N/A

Is there potential for or evidence that the proposed policy will not promote equality of opportunity for all and promote good relations between different groups?

- - - - - -

Is there potential for or evidence that the proposed policy will affect different population groups differently (including possibly discriminating against certain groups)?

- - - - - -

Is there public concern (including media, academic, voluntary or sector specific interest) in potential discrimination against a particular population group or groups?

- - - - - -

Name of Policy: Women with pelvic organ prolapse without lower urinary rract symptoms.





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Do different groups (age, disability, race, sexual orientation, gender, religion or belief) have different needs, experiences, issues and priorities in relation to the proposed policy? NO Is there potential for or evidence that the proposed policy will not promote equality of opportunity for all and promote good relations between different groups (age, disability, race, sexual orientation, gender, religion or belief)? NO Is there potential for or evidence that the proposed policy will affect different population groups (age, disability, race, sexual orientation, gender, religion or belief) differently (including possibly discriminating against certain groups)? Affects women only Is there public concern (including media, academic, voluntary or sector specific interest) in potential discrimination against a particular population group or groups (age, disability, race, sexual orientation, gender, religion or belief)? NO Based on the information set out above I have decided that a full equality impact assessment is not necessary. Name, Job title and signature: William Kuteesa

Consultant Gynaecologist Department: Gynaecology Date: 14/8/2017

Documents

Management of Women with Pelvic Organ Prolapse GL1080 protocols and... · GL1080 - Management of Women with Pelvic Organ Prolapse 5.4 Pelvic floor exercise (PFE) - Improves many POP