This relates to treatment for a small portion of the vaginal canal protruding from the opening of the vagina.
Pelvic organ prolapse is bulging of one or more of the pelvic organs into the vagina. These organs are the uterus, vagina, bowel and bladder.
Proposed revisions to the eligibility criteria
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 Restricted procedure.
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
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)
Although not supported by definitive evidence, current opinion is that 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
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
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 above.
Use of slings for management of vaginal prolapse – is not funded by the CCG.