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Surgical options must be ‘last resort’ for stress incontinence

Offer full range of lifestyle and medical options before surgical mesh/tape surgery, urges NICE

Louise Prime

Thursday, 04 April 2019

Doctors should offer women with stress urinary incontinence the full range of non-surgical options before exploring any surgical operations such as mesh or tape, the National Institute for Health and Care Excellence (NICE) now recommends. Obstetricians and gynaecologists have welcomed the new guidance, as well as the patient decision aids and related user guides that NICE has published, which they said would help women and clinicians to make an informed choice about the best possible treatment for their individual circumstances.

Last July the government announced a period of "high vigilance restriction" on the use of a group of procedures in England, including vaginally inserted mesh and tape to treat stress urinary incontinence and pelvic organ prolapse, following a recommendation by Baroness Cumberlege, who is chairing an independent review of surgical mesh procedures and has heard from women and families affected by them.


In its final guidance on management of urinary incontinence and pelvic organ prolapse in women, NICE recommends that the full range of non-surgical options, including lifestyle interventions, physical therapies and medicines, should be offered to women with these conditions before any surgical operations are explored.

In addition to reiterating recommendations from its previous (2006/2013) guidance – including advising women with overactive bladder to trial caffeine reduction, advising women with urinary incontinence or overactive bladder and a high or low fluid intake to modify their fluid intake, advising women with urinary incontinence or overactive bladder who have a BMI greater than 30 to lose weight, suggesting pelvic floor muscle training, and offering at least six weeks’ bladder training as first-line treatment to women with urgency or mixed urinary incontinence – NICE now recommends that doctors “offer a trial of supervised pelvic floor muscle training of at least three months’ duration as first-line treatment to women with stress or mixed urinary incontinence”.

Furthermore, NICE now recommends that if women and their doctors explore surgical options, and if it is agreed to use surgical mesh/tape, doctors must fully inform women of the risks, and offer follow up within six months of surgery.

NICE also includes detailed guidance on the assessment and management of complications associated with surgery. It recommends that for women who report new-onset symptoms after having mesh surgery for urinary incontinence or pelvic organ prolapse, doctors should evaluate whether the symptoms might be caused by a mesh-related complication – and refer women with a suspected mesh-related complication to a urogynaecologist, urologist or colorectal surgeon for specialist assessment.

In their joint statement the Royal College of Obstetricians and Gynaecologists and The British Society of Urogynaecology said: “Stress urinary incontinence and pelvic organ prolapse are common and often debilitating conditions for which women must have access to a range of safe and effective treatment options.

“We therefore welcome NICE’s final guidance on the management of these conditions, which recommends that the full range of non-surgical options should be offered to women before any surgical procedures.

“We also fully endorse the patient decision aids published by NICE which are important resources for women and clinicians that will help them to understand all treatments available, as well as the benefits and risks associated with each option. These will support women and clinicians to make an informed choice about the best possible treatment for their individual circumstances.”

They added: “It is important to note that the high vigilance restriction remains in place for the use of mesh. While the period of high vigilance continues, healthcare professionals should continue to follow any restrictions.”

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