The pelvic organs are supported by a complex system of muscle, ligaments and nerves (DeLancey, 2005) (Figure 1). Injury or damage to the pelvic support system results in pelvic floor dysfunction (DeLancey, 2005). Two of the most common and definable conditions of pelvic floor dysfunction are pelvic organ prolapse (POP) and urinary incontinence (UI) (National Institute for Health Care Excellence (NICE), 2021), which – despite being extremely common – remain taboo subjects for many (Shaw et al, 2006; Nygaard et al, 2008; Drennan et al, 2011; Ghetti et al, 2015). Many women believe that POP or UI are an inevitable consequence of ageing or following childbirth and, therefore, cannot be treated other than via containment, or are simply too embarrassed to report and seek help for their symptoms (Tinetti et al, 2018). Conversely, there are various treatments and management options available for both conditions, and practice nurses are well situated to identify symptoms and commence management, or signpost patients with POP and UI to appropriate services. Two recent guidelines from NICE (2019; 2021) provide evidence-based recommendations for the assessment and management of POP and UI; they also provide strategies to raise awareness and prevent pelvic floor dysfunction.
What is pelvic organ prolapse?
POP is the downwards descent of one or more of the bowel, bladder, womb or – in women who have had a hysterectomy – the vaginal cuff (Haylen et al, 2016). While not life threatening, POP can cause symptoms of vaginal bulge – a dragging sensation and pain – as well as causing or exacerbating bowel and bladder symptoms and sexual dysfunction (Haylen et al, 2016). Therefore, it is not surprising that POP can significantly impact on women's quality of life and daily functioning (Haylen et al, 2016). As discussed, POP can cause numerous bothersome symptoms; however, the only symptom which has reliably been found to have both positive and negative predictive value for POP is reports of a bulge (Tan et al, 2005). Therefore, it is important women understand that any other symptoms they experience and associate with POP may be unrelated. The prevalence of POP is difficult to establish as many women do not report their symptoms and many others opt for conservative management which is not recorded rigorously (Dwyer et al, 2021). However, it has been established that 10% of UK parous women will have surgical management for prolapse (Abdel-Fattah et al, 2011). Therefore, taking into account the number of women with undiagnosed or conservatively managed prolapse, a significant percentage of the female population will experience prolapse at some point in their life (Schaffer et al, 2005; Dietz, 2008; Abdel-Fattah et al, 2011).
What is urinary incontinence?
While the term UI may seem self-explanatory, there are a number of categories of UI (Table 1). It is imperative to establish what type of UI the woman appears to have, because this determines the most appropriate form of management. Types of UI include stress urinary incontinence (SUI), urgency urinary incontinence (UUI) or a combination of the two, known as mixed urinary incontinence (MUI) (Haylen et al, 2010). Some women experience urgency but do not leak urine; this is known as urinary urgency and is still bothersome for women (Agarwal et al, 2014). The prevalence of UI in the UK female adult population is estimated to be 42% (Hunskaar et al, 2004). Overactive bladder (OAB) is a term used to describe the group of symptoms of urinary urgency, urgency urinary incontinence and increased frequency passing urine when there is no obvious cause for this, such as a urinary tract infection (Haylen et al, 2010). Therefore, OAB can be described as wet or dry depending on whether the woman leaks urine or not (Haylen et al, 2010). As well as UI having a negative impact on women's quality of life (Kwon et al, 2010), there are also significant personal and societal costs to be considered (Turner et al, 2004).
Table 1. Definitions of urinary incontinence
| Urinary incontinence (UI): involuntary loss of urine |
| Stress urinary incontinence (SUI): involuntary loss of urine on effort or physical exertion or on sneezing or coughing |
| Urgency urinary incontinence (UUI): involuntary loss of urine associated with urgency |
| Mixed urinary incontinence (MUI): involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing |
Clarity about symptoms of both urinary incontinence and pelvic organ prolapse
Many women experience both POP and urinary symptoms, with 64% of women undergoing POP surgery having bothersome UI (Lensen et al, 2013). A survey of women with UI found that 60% believed POP caused their urinary symptoms (Melville et al, 2008). Following POP surgery, 39% reported resolution of SUI and 42% UUI; however, for the majority, their symptoms remained (Lensen et al, 2013). Conversely, 27% of women who did not have UI before POP surgery, had developed urinary symptoms afterwards (Lensen et al, 2013). This demonstrates the complex relationship between POP and UI and that it is important that women understand the two problems may not be interrelated, to ensure informed decision making and to manage treatment expectations (Lensen et al, 2013).
Risk factors
A number of risk factors that increase the likelihood of developing POP or UI have been identified (NICE, 2021) (Table 2).
Table 2. Risk factors for urinary incontinence and pelvic organ prolapse
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Some of the risk factors are modifiable, therefore awareness of this risk may enable women to make an informed decision about reducing their risk, for example weight loss. Other risk factors cannot be modified; however, awareness about an increased risk of POP and UI may still enable women to modify other factors which may increase their risk further (NICE, 2021).
Assessment
As with all nursing practice, it is important to act within levels of professional competence (Nursing and Midwifery Council, 2018). Therefore, aspects of assessing women experiencing symptoms of UI or POP may require referral to a colleague. In this instance, it is important to ensure the woman understands the reasons for a referral and does not feel her symptoms are being dismissed or minimised (Abhyankar et al, 2019).
When taking a history from women reporting symptoms of POP or UI, women should be asked:
- How bothersome their symptoms are
- How long they have experienced symptoms
- How frequently they experience symptoms
- If anything appears to exacerbate or improve symptoms.
For women reporting UI, it is important to determine whether they experience leakage of urine and, if so, whether there are any particular triggers. For example, if a woman reports leaking urine when she moves, laughs, coughs or sneezes this would suggest she is experiencing SUI. If a woman is experiencing leakage of urine when she experiences an urge to pass urine this would indicate UUI for example ‘latch key incontinence’ or leaking urine before being able to get to the toilet. It important to remember that some women experience both types of urinary incontinence and therefore have MUI.
A 3-day bladder diary is recommended as a simple but effective method of assessing bladder symptoms and lifestyle factors that may cause or exacerbate symptoms, such as volume and type of fluid intake (NICE, 2019).
Certain conditions can cause or exacerbate POP and UI (Jelovsek et al, 2007; Khandelwal and Kistler, 2013). Therefore, other potential reasons for these symptoms including pelvic masses, neurological disease, a urinary tract infection, diabetes, cancer, a fistula, inflammatory bowel or bladder conditions and endometriosis should be considered (NICE, 2021). Furthermore, due to the potential for drug-induced UI from various medications including alpha blockers used to treat hypertension, antipsychotics, benzodiazepines, antidepressants and hormone replacement therapy (Tsakiris et al, 2008), a medication review should be undertaken (NICE, 2021).
For women with POP symptoms, a vaginal examination should be performed to confirm anatomical presence of prolapse (NICE, 2019). While it is straightforward to identify advanced POP, confirmation of a lower stage of prolapse may be more challenging (Swift et al, 2003). Swift et al (2003) emphasise that inability to visualise significant POP should not result in the women's symptoms being dismissed or minimised, an experience unfortunately reported by women (Abhyankar et al, 2019). Instead, women reporting POP symptoms that cannot be confirmed upon vaginal examination require further investigation and, if necessary, treatment of other potential causes (Swift et al, 2003). For women with UI, it is necessary to perform urinalysis on a midstream specimen of urine to explore the possibility of a urinary tract infection (NICE, 2019). In the instance of visible or non-visible haematuria, there are clear guidelines about the need for specialist referral in the ‘Suspected cancer: recognition and referral’ guidelines (NICE, 2015).
For many women with UI, assessment and conservative management can be initiated in primary care without the need for referral to specialist services. However, there are certain instances where it is necessary to consider specialist referral for women with UI. These include (NICE, 2019):
- Persisting bladder or urethral pain
- Palpable bladder on bimanual or abdominal examination after voiding
- Clinically benign pelvic masses
- Associated faecal incontinence
- Suspected neurological disease
- Symptoms of voiding difficulty
- Suspected urogenital fistulae
- Previous continence surgery
- Previous pelvic cancer surgery
- Previous pelvic radiation therapy.
Lifestyle changes
There is evidence that lifestyle changes may improve symptoms of UI and POP (NICE, 2019; 2021). Specific examples of this are partaking in regular physical activity, and weight loss for women who are obese (NICE, 2019; 2021). Practice nurses are experienced and skilled in encouraging and supporting patients to adopt healthy behaviours (Douglas et al, 2006). Therefore, discussing these lifestyle changes either as initial treatment or while awaiting further management for POP and UI is an important first step and may offer the woman an improvement in her symptoms.
Pelvic floor muscle training
Pelvic floor muscle training (PFMT) is defined as exercises performed to improve the strength, endurance, power and ability to relax the pelvic floor muscles (Bo et al, 2017). All women should be encouraged to regularly perform PFMT, to prevent pelvic floor dysfunction, and women with SUI, MUI and POP should be supported in PFMT to treat their symptoms (NICE, 2021). Despite women being aware of the importance of postnatal PFMT and intending to perform PFMT frequently after delivery, less than half did (Chiarelli et al, 2003). Furthermore, while women understood the importance of PFMT before, during and after pregnancy, most did not understand the need to continue these indefinitely (Chiarelli et al, 2003). This demonstrates that strategies are necessary to increase women's understanding about the benefits of PFMT throughout the lifetime, as well as support to facilitate women to follow a recommended PFMT regime (Chiarelli et al, 2003).
One factor found to increase adherence with PFMT is a supportive and enthusiastic trainer who established clear treatment goals (Dumoulin et al, 2015). A study of women with pelvic floor dysfunction identified that 70% were unable to correctly perform a pelvic floor contraction on instruction (Tibaek and Dehlendorff, 2014). Therefore, during supervised PFMT, the trainer can digitally examine the woman to assess contractions and ensure they are being performed correctly. Therefore supervised PFMT is essential to ensure an effective regime (Bø, 2012). NICE (2021) guidelines recommend women with SUI and MUI receive supervised PFMT for 3 months and suggest women with symptomatic POP receive supervised PFMT for 4 months. Supervision by an appropriately trained health professional with expertise in PFMT is necessary to ensure women are contracting and relaxing the necessary muscles, are supported with an appropriate exercise regime and are encouraged to achieve training goals (NICE, 2021). Supervised PFMT can be provided by specialist physiotherapists or specialist nurses working in primary care. However, a lack of prioritisation and funding in this service nationally has led to barriers accessing community bowel and bladder services (Young, 2021). There is evidence that nurses working in primary care can provide effective, supervised PFMT following training (Waterfield et al, 2021). However, the feasibility and willingness of primary care nurses undertaking an additional role has not yet been fully explored. To summarise, women with UI will benefit, and women with POP may benefit, from supervised PFMT, which does not require referral to secondary care, pending service availability in the community. Practice nurses with a particular interest in pelvic floor dysfunction may consider undertaking training to enable them to provide this important service to their patients.
Primary care management of pelvic organ prolapse
When discussing POP management, it is important to determine whether or not POP symptoms cause bother for the woman. Some women with an advanced level of POP remain unbothered by their symptoms (Jelovsek et al, 2007). In this instance, it is not necessary to advise women to seek treatment unless their POP is obstructing voiding or defecation or there is persistent ulceration or erosion to the vagina (Jelovsek et al, 2007). Women who are bothered by their POP symptoms and wish to pursue treatment can choose between surgical management, which would require referral to secondary care, or conservative management (Jelovsek et al, 2007). Conservative management options for POP include PFMT, lifestyle changes or pessary management (NICE, 2019; 2021).
A pessary is a medical device which can be inserted into the vagina to provide mechanical support to the prolapsed organs. Pessary management has been found to improve POP symptoms and women's quality of life as effectively as surgery and therefore should be discussed with all women who desire POP management, not just those deemed unsuitable for surgical management (Lone et al, 2015; Miceli and Dueñas-Diez, 2019). There are a wide range of pessary types and sizes available, including pessaries suitable for sexually active women (Rantell, 2019) (Figure 2). Therefore, if a pessary is expelled, women should be encouraged to try a different size or type of pessary rather than conclude pessary management will not be effective for them (Jelovsek et al, 2007). Pessary practices in the UK vary (Gorti et al, 2009); however, a pessary should be removed every 6 months (NICE, 2019). At a pessary follow-up appointment, the pessary should be removed and a vaginal examination performed to check the vaginal tissues are healthy, following which either a new pessary or the same pessary can reinserted after washing depending on the pessary type (The UK Clinical Guideline Group for the Use of Pessaries in Vaginal Prolapse, 2021). Pessary care in the UK is typically provided in secondary care (Bugge et al, 2013). However, some women opt for POP surgery rather than pessary management due to the inconvenience of having to regularly attend a hospital for pessary follow-up (Basu et al, 2011). In 2021, the first national guidelines for pessary practice in the UK were published (The UK Clinical Guideline Group for the use of pessaries in vaginal prolapse, 2021). These guidelines offer practice nurses with an interest in pessary care clarification on training and competency requirements and guidance on pessary practices.
It is important to note that for women with POP that descends more than one centimetre beyond the hymen upon straining, PFMT was not found to improve symptoms (NICE, 2021). Therefore, while women with POP more than 1 cm beyond the hymen may wish to consider PFMT to prevent pelvic floor dysfunction with regard to bowel and bladder symptoms, surgical or pessary management of their POP would be advisable if bothersome for them.
Primary care management of urinary incontinence
Once the type of UI has been established, the appropriate management options can be considered. NICE guidelines recommend women with UI consider a trial of caffeine reduction, a known bladder irritant (Arya et al, 2000), and ensure they are drinking the recommended daily amount of fluid (1.5-2 litres) (Stewart, 2009; NICE, 2019; NICE, 2021). As previously discussed, PFMT should be offered as treatment for SUI and MUI (NICE, 2021). NICE (2019) guidelines also recommend bladder retraining for at least 6 weeks as first-line treatment for women with UUI or MUI. Bladder retraining typically involves establishing timed voiding parameters and is delivered alongside PFMT and lifestyle advice regarding fluid modification (NICE, 2021). If lifestyle changes and PFMT do not sufficiently improve OAB symptoms, medication should be offered (NICE, 2019). OAB medication has been found to effectively reduce frequency and UUI (Nabi et al, 2006). However, side effects were common, which may explain the poor adherence and persistence with OAB medication regimes (Nabi et al, 2006; Yeowell et al, 2018). There are a range of OAB medications available; therefore, patient-specific factors need to be considered before prescription, including physical and psychological health, concomitant medication, anticholinergic burden and cost (NICE, 2019). It is important women understand that OAB medication may take 4 weeks or more before urinary symptoms improve (NICE, 2019). Therefore, follow-up should be arranged after 4 weeks and if symptoms have not improved optimally, the dose should be increased or the medication changed to an alternative OAB medication (NICE, 2019).
Conclusion
POP and UI are extremely common conditions which significantly impact on the quality of life of women in the UK (Hunskaar et al, 2004; Abdel-Fattah et al, 2011). However, despite this, many women avoid or delay reporting their symptoms due to embarrassment or because they believe it is normal (Tinetti et al, 2018). Therefore, it is proposed that health professionals normalise discussions about POP and UI by discussing these symptoms when given the opportunity. Practice nurses are well placed to use their skills and knowledge to engage women in these conversations and, if women disclose symptoms, either commence management in primary care or refer them to an appropriate service. NICE guidelines provide recommendations on community-based assessment and management of POP and UI (NICE, 2021). However, additional training may be required to ensure practice nurses and other health professionals working in primary care feel sufficiently confident to define POP and the different types of UI, as well as being able to perform a vaginal examination for women with POP, and an assessment of the pelvic floor, including the woman's ability to contract and relax their pelvic floor muscles.
KEY POINTS:
- Prolapse and urinary incontinence are very common yet under-reported conditions for women in the UK
- There are numerous management options available for both prolapse and urinary incontinence
- Conservative management of prolapse and urinary incontinence can often be initiated in the community, avoiding a treatment delay for the woman
- Practice nurses are well placed to engage in discussions about prolapse and urinary incontinence, raise awareness of lifestyle changes which may improve symptoms and commence conservative management if appropriate
CPD reflective practice:
- Consider whether you find it challenging to discuss pelvic organ prolapse or urinary incontinence with your patients? If so, why might this be?
- The NICE Pelvic floor dysfunction: prevention and non-surgical management guidelines suggest ways to raise awareness of pelvic floor dysfunction, could you introduce any of these strategies into your workplace or practice?
- Consider whether having read this article you will discuss pelvic organ prolapse and/or urinary incontinence differently to your previous practice
- How confident are you in your knowledge of local services to support women with pelvic organ prolapse and urinary incontinence? Do you need to find out more? If so, how will you do this? Under which circumstances would you refer women for additional support?
Further resources
The UK Continence Society (UKCS) is an organisation which aims to raise the standards of continence care in the UK. Membership is £25 per year and this includes access to educational resources to support continence care, a significant discount on annual conference fees, opportunities to apply for research grants and travel and conference bursaries and membership to a network of healthcare professionals with an interest in care for patients with pelvic floor dysfunction. Please contact ukcs@indexcommunications.com if you would like to find out more about UKCS membership (https://www.ukcs.uk.net)