Mild Female Genital Prolapse (Surgical and Non-Surgical Intervention)
Version:
1.0
Implementation date:
1July 2017
Review Date:
1July 2018
Category:
Restricted / Procedures
The kind of treatment you have will depend on:
  • which organ has moved (prolapse type) and how far (prolapse stage)
  • your age, health and medical history
  • whether you want to have (more) children
The GP may refer a patient to a physiotherapist or a doctor who specialises in women’s pelvic floor problems (called aurogynaecologist). They may recommend one or more of these treatment options:
  • Lifestyle changes to stop doing the things that may cause the prolapse or make it worse. This can include losing weight, quitting smoking, eating and drinking differently, and lifting less. These changes aim to fix prolapses.
  • Physiotherapy to strengthen the pelvic floor that supports your organs. A physiotherapist can design a special pelvic exercise program for you. Physiotherapy aims to fix prolapses.
  • A pessary (a small plastic or silicon support) that is placed inside your vagina to hold up the prolapsed organ. Pessaries don’t fix prolapses but they can reduce or lessen the symptoms of prolapse and help you live more comfortably.
  • Surgery to repair the torn or stretched pelvic floor. There are several types of prolapse surgery but all of them try to fix the prolapse and prevent it from happening again. Some surgeries will mean you can no longer have children.
Treatment is not always successful and sometimes a prolapse will come back.
Condition
Pelvic organ prolapse (POP) is bulging of one or more of the pelvic organs into the vagina. These organs are the uterus, vagina, bowel and bladder.
Access Criteria
Surgical Intervention:
MKCCG makes the following recommendation regarding Mild Female Genital Prolapse (Surgical and Non-Surgical Intervention)is categorised as a Restricted procedure, and therefore a GP or Consultant must seek approval for an individual before treatment is carried out.
Therefore, the CCG will only fund surgery for Female Genital Prolapse (Vaginal Prolapse/ Asymptomatic pelvic organ prolapse/Mild pelvic organ prolapse) where there is evidence of the failure of the non-surgical interventions shown below.
The CCG will then fund surgery for Female Genital Prolapse where the following criteria are met:
  • Women with symptomatic prolapse (including those combined with urethral sphincter incompetence or faecal incontinence)
  • Prolapse combined with urethral sphincter incompetence/urinary incontinence or faecal incontinence
Use of slings for management of vaginal prolapse – is not funded by the CCG.
Obliterative Surgery
  • Corrects POP by moving the pelvic viscera back into the pelvis & closing of the vaginal canal; vaginal intercourse is no longer possible
Non-Surgical Interventions (Clinical Guideline):
The CCG will only fund (Vaginal Prolapse/Asymptomatic pelvic organ prolapse/Mild pelvic organ prolapse) the following non-surgical interventions and will not fund surgical intervention unless these options have been tried and there is evidence that they have been unsuccessful in managing the Female Genital Prolapse. Therefore, this is categorised as Restrictedprocedure, and therefore a GP or Consultant must seek approval for an individual before treatment is carried out.
Patients should be assessed and managed conservatively in primary care with the following interventions:
Watchful waiting, with observation for the development of new symptoms or complications is appropriate if the prolapse is asymptomatic.
Conservative treatment options
Lifestyle modification
  • Treatment of conditions that increase intra-abdominal pressure: constipation, chronic cough, overweight/obesity; reduction of heavy lifting (while Pelvic Organ Prolapse (POP)) has been associated with these factors, the role of lifestyle modification in prevention/treatment has not been investigated)
Pelvic floor muscle exercises
  • Role in managing prolapse unclear; probably not useful if the prolapse ex ends to or beyond the vaginal introitus.
  • Cochrane review 2006: concluded evidence was insufficient (from 3 randomised trials) to judge the value of conservative management of POP, & that further trials were needed
  • The pilot study for the Pelvic Organ Prolapse Physiotherapy (POPPY) multi-centre trial suggested that pelvic floor muscle training delivered by a physiotherapist to symptomatic Stage I or II POP women in an outpatient setting may reduce the severity of prolapse
Local (vaginal) oestrogen creams and oral treatments (see MKCCG formulary)
  • Milton Keynes CCG:
Vaginal pessary insertion:
  • Pessaries are effective & should be considered before surgery in women who have symptomatic prolapse; they can be attempted in all POP cases irrespective of stage.
  • Those participating in active vaginal intercourse should be offered use of pessaries for those women who have symptomatic prolapse. Or to unmask occult urodynamic stress incontinence before surgery.
  • To predict surgical outcomes or unmask occult urodynamic stress incontinence before surgery, as part of the investigation of continent women with POP (so that the decision to perform a concomitant continence procedure along with pelvic reconstruction can then be individually tailored).
  • Risk factors for unsuccessful fitting include: short vaginal length <6 cm and wide introitus fingerbreadths; local oestrogens may play a role in successful fitting.
  • Failure to retain the pessary has been associated with increasing parity and previous hysterectomy; and discontinuation with history of hysterectomy or prolapse surgery, and stress incontinence.
  • Follow-up: no clear consensus on how often to follow up; after 3 months & then every 6 months, if there are no complications.
  • Complications tend to occur in women who are not regularly followed up; self- care of pessary is also important to minimise adverse events; however, many patients find insertion & removal of most pessary types challenging.
Treatments which are undertaken without approval will not be funded.
Procedure Codes / M53 Vaginal Operations to support outlet of female bladder:
M533 / Introduction of tension‐free vaginal tape
M536 / Introduction of transobturator tape
M538 / Other specified operations to support outlet of female bladder
M539 / Unspecified specified operations to support outlet of female bladder
P22 Repair of prolapsed of vagina and amputation of cervix uteri:
P221 / Anterior and posterior colporrhaphy and amputation of cervix uteri
P222 / Anterior colporrhaphy and amputation of cervix uteri NEC
P223 / Posterior colporrhaphy and amputation of cervix uteri NEC
P228 / Other specified repair of prolapse of vagina and amputation of cervix uteri
P229 / Unspecified repair of prolapsed of vagina and amputation of cervix uteri (includes Colporrhaphy and amputation of cervix uteri NEC)
P23 Other repair of prolapse of vagina:
P231 / Anterior and posterior colporrhaphy NEC
P232 / Anterior colporrhaphy NEC
P233 / Posterior colporrhaphy NEC
P234 / Repair of enterocele NEC
P235 / Paravaginal repair
P236 / Anterior colporrhaphy with mesh reinforcement
P237 / Posterior colporrhaphy with mesh reinforcement
P238 / Other specified repair of prolapse of vagina
P239 / Unspecified repair of prolapse
P24 Repair of vault of vagina:
P241 / Repair of vault of vagina using combined abdominal and vaginal approach
P242 / Sacrocolpopexy
P243 / Repair of vault of vagina using abdominal approach NEC
P244 / Repair of vault of vagina using vaginal approach NEC
P245 / Repair of vault of vagina with mesh using abdominal approach
P246 / Repair of vault of vagina with mesh using vaginal approach
P247 / Sacrospinous fixation of vagina
P248 / Other specified repair of vault of vagina
P249 / Unspecified repair of vault of vagina (includes suspension of vagina NEC)
Evidence /
  1. Cochrane review 2004: - Pessary use in women with prolapse; there is no consensus on the use of different types of device, the indications, nor the patterns of replacement & follow-up care; evidence or pessary selection and management is incomplete so trial and error, expert opinion, and experience remain the best guides for use and management of the pessary.
  1. NICE Pathway Urogenital Conditions -
  1. IPG282 - - published January 2009 Insertion of mesh uterine suspension sling (including sacrohysteropexy) for uterine prolapse repair