Support Women to Prevent and Manage Pelvic Floor Dysfunction

Dr Claire Davies Discusses the Key Tenets of the New NICE Guideline on Pelvic Floor Dysfunction, Which Aims to Raise Awareness of How to Avoid and Treat the Condition 

Pelvic floor dysfunction is common: approximately 5–6 million women in the UK have experienced symptoms of the condition.^1,2 Around 8% of the female population aged 40 years and older reports bothersome symptoms of pelvic floor dysfunction, with up to 50% of women presenting with prolapse on examination, and 3.2% stating that their symptoms are socially disabling.^1,3 The prevalence of these symptoms increases with age, from 6% among women in their twenties to 40% among women in their sixties.² These issues can have a significant impact on a woman’s quality of life, social engagement, and ability to be physically active.³

Despite this, only one in four women with symptoms of urinary incontinence seeks professional support.¹ NHS pelvic, obstetric, and gynaecological physiotherapy services report an average of just 749 referrals per year per service.⁴ There is significant variation in waiting times for these services—between 2 and 26 weeks—but this still only amounts to approximately 420,000 patients each year.⁴

In December 2021, NICE published NICE Guideline (NG) 210, Pelvic floor dysfunction: prevention and non-surgical management.³ The guideline was produced for two reasons: to raise awareness of pelvic floor dysfunction among women, improving the likelihood that they will make lifestyle changes and start pelvic muscle training; and to educate healthcare professionals in how to treat and prevent the condition, as the Guideline Development Committee noted that, in their experience, this area is not consistently covered in training.³

The guidance frequently refers to the related guidelines Urinary incontinence and pelvic organ prolapse in women: management (NG123)⁵ and Faecal incontinence in adults: management (Clinical Guideline [CG] 49),⁶ as there is much overlap between the three areas.

NG210 is aimed at healthcare professionals, commissioners, women and their families and/or carers, and education providers, but this article focuses on its implementation in primary care. The guideline covers young women aged 12–17 years and women aged 18 years and older, for whom NICE uses the term ‘women’ throughout the guideline. NICE acknowledges that this includes those who do not identify as women, but have female pelvic organs.³

Definition and Symptoms of Pelvic Floor Dysfunction

As the guideline states, ‘pelvic floor dysfunction is a condition in which the pelvic muscles around the bladder, anal canal, and vagina do not work properly’.³ The three most common and defining symptoms are urinary incontinence, faecal incontinence, and pelvic organ prolapse.³ Other symptoms include emptying disorders of the bladder and bowel, sexual dysfunction, and chronic pelvic pain.³

Risk Factors

A list of risk factors for pelvic floor dysfunction is given in the guideline, and is outlined in Box 1.³

Raising Awareness of Pelvic Floor Dysfunction

A significant part of the guideline discusses raising awareness of and preventing pelvic floor dysfunction.³ NICE makes broad recommendations on improving awareness of the condition in various settings and formats, including in schools, in print, and online.³ GPs can consider providing information leaflets and visual anatomical aids, both in their surgery and opportunistically at cervical smears.³ Women should also be asked about pelvic floor dysfunction at postnatal checkups, consultations about perimenopause and menopause, and health assessments for older women.³

Several organisations offer useful information and support online for patients and healthcare practitioners that could be used as part of raising awareness, including the NHS,⁷ the Royal College of Obstetricians and Gynaecologists,⁸ Bladder and Bowel UK,⁹ and Pelvic, Obstetric, and Gynaecological Physiotherapy.¹⁰

Communication with Patients

There are several barriers that may prevent a woman from discussing symptoms of pelvic floor dysfunction with a healthcare professional. In particular, they may be embarrassed about discussing their symptoms, and may believe that the healthcare professional is embarrassed as well.³ There may also be cultural sensitivities, and women may not have a detailed understanding of pelvic anatomy or medical terminology.³

Agree the communication format with the patient—for example, by telephone or face to face—taking into account the need for a physical examination.³ Terminology should be tailored to the woman’s level of understanding of pelvic anatomy—for example, a woman may understand the term ‘poo’ better than the term ‘faeces’.³

To help patients to understand their condition, clinicians can use visual anatomical aids.³ They should give clear and concise information on management options, possible causes, and possible outcomes of a patient’s condition, and should reassure them that management will be focused on their symptoms (as opposed to pelvic floor dysfunction in general).³

Measures to Prevent Pelvic Floor Dysfunction

Both physical activity and a healthy diet can help to prevent pelvic floor dysfunction. As NG210 suggests,³ women should follow the standard advice given in the UK Chief Medical Officers’ physical activity guidelines,¹¹ NICE Public Health Guideline (PH) 44, Physical activity: brief advice for adults in primary care,¹² and PH41, Physical activity: walking and cycling.¹³

Following a balanced diet—particularly one that includes adequate fibre to ensure stool consistency—is important, as is ensuring an adequate fluid intake. The guidance references Public Health England’s Eatwell guide, which gives recommendations on this.^3,14 Weight loss, smoking cessation, management of constipation, and management of diabetes are also relevant for preventing pelvic floor dysfunction.³

Women of all ages, including women who are pregnant or who have recently given birth, should be encouraged to do pelvic floor muscle training throughout their life, as it helps to prevent symptoms.³ The Bladder and Bowel Foundation provides guidance for women that is endorsed by the NHS, which can be accessed here: bit.ly/3aafiQJ.¹⁵

Assessment of Pelvic Floor Dysfunction in Primary Care

The initial assessment of women with suspected pelvic floor dysfunction in primary care may be undertaken by various members of the multidisciplinary team, including doctors, nurses, continence advisors, and physiotherapists.³ Clinical history taking should cover past and present symptoms of pelvic floor dysfunction, as detailed in Box 2.³ Any psychological impact of the symptoms should also be covered in the discussion.³

Consider the following alternative causes when taking the patient’s medical history and performing a physical examination and any further investigations:³

• pelvic masses
• neurological disease
• urinary tract infection
• adverse effects of medication
• diabetes
• cancer (for further information, see NG12, Suspected cancer: recognition and referral)¹⁶
• fistula
• inflammatory bowel or bladder conditions
• endometriosis
• mobility and cognitive impairment.

In line with the recommendations on medicine reviews in NG5, Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, conduct a structured medication review for women taking multiple medications,¹⁷ noting any medications that may worsen urinary incontinence, such as diuretics.³ Depending on symptoms, circumstances, and the patient’s preferences, the assessment may also include a vulval and vaginal examination for atrophy, asking women to bear down to check for visible prolapse, or a rectal examination to look for faecal impaction.³

If there are symptoms of faecal incontinence, conduct the baseline assessments from CG49.^3,6 These assessments consist of relevant medical history taking, a general examination, an anorectal examination, and a cognitive assessment, if appropriate.⁶ Physical examinations can include assessments of anal tone, ability to squeeze the anal sphincter, faecal loading, and perineal descent, as well as visual inspection of the anus.¹⁸

Urinary incontinence should be categorised as stress, mixed, or urgency (overactive bladder) urinary incontinence, and treatment should be targeted accordingly.⁵ In mixed urinary incontinence, treatment should be directed towards the predominant symptom.⁵ When urinary symptoms are present, obtain a urine sample to dipstick test for nitrates, leucocytes, blood, and glucose, and send a midstream specimen of urine for analysis when appropriate.⁵

Management of Pelvic Floor Dysfunction in Primary Care

Nonsurgical Management

Consider referral to a community-based multidisciplinary team for symptom management and supervised pelvic floor training.³ NICE recommends that pelvic floor training is supervised by a physiotherapist or health professional with appropriate expertise, in an individual or group setting.³ This training may need to be supplemented with biofeedback techniques, vaginal cones, or electrical stimulation in women who are unable to perform an effective pelvic floor muscle contraction.³ Women should be encouraged to continue with pelvic floor muscle training after any pelvic floor programme ends.³

It is also important to provide information about lifestyle changes to women with symptoms of pelvic floor dysfunction, and to encourage them to persist with any changes, as symptoms may take weeks or months to improve.³ In patients with a body mass index greater than 30 kg/m², symptoms of urinary incontinence, overactive bladder, and pelvic organ prolapse can all improve with weight loss.³ Women can be referred for weight loss support, and should be encouraged to lose weight, but should also be encouraged to manage their symptoms in other ways while waiting for weight loss.³

Clinicians should give advice on eating a healthy diet, including the importance of maintaining stool consistency through adequate intake of fibre and fluid.³ Women with overactive bladder symptoms or urinary incontinence can be advised to increase their fluid intake if it is too low, and decrease it if it is too high.³ Reducing caffeine intake can also help with symptoms.³

Regarding physical activity, the guidance states that supervised exercise—for example, yoga—may help with symptoms.³ However, there is no evidence that unsupervised exercise will improve or worsen symptoms.³

Pessaries and Intravaginal Devices

A vaginal pessary may be an option for women with pelvic floor dysfunction, where available in primary care or via secondary care referral, and is a particularly useful option for patients with symptomatic pelvic organ prolapse, as indicated in NG123.^3,5 However, before offering a pessary, consider treating vaginal atrophy with oestrogen, as complications of pessaries include expulsion, vaginal discharge, bleeding, and difficulty removing the pessary.⁵

A trial of intravaginal devices could also be considered for women with urinary incontinence, but only if other nonsurgical options have been unsuccessful.³

Medications

Medications for pelvic floor dysfunction and associated conditions are not covered in NG210,³ but are discussed in NG123 and CG49.^5,6 NICE advises offering anticholinergic medications for overactive bladder—for example, oxybutynin, darifenacin, or tolterodine—recommending that practitioners first offer the medication with the lowest acquisition cost.⁵ Mirabegron is recommended by NICE in separate technology appraisal guidance as an option for treating the symptoms of overactive bladder, but only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or who have unacceptable side effects.¹⁹ Transdermal options also exist for patients unable to tolerate oral medicines, and can be offered to those experiencing side effects with oral medication, and intravaginal oestrogens can be offered to postmenopausal women with vaginal atrophy for treating overactive bladder symptoms.⁵ Older women at higher risk of deterioration in their physical or mental health should not be prescribed immediate-release oxybutynin.⁵

Numerous drugs may worsen a patient’s faecal incontinence—for example, nitrates, calcium channel antagonists, penicillins, or metformin—and this should be taken into account when reviewing medication.^6,18 Full details are covered in CG49.^6,18

Referral to Secondary Care

Multidisciplinary teams should include members with the ability to identify which patients need a secondary care referral.³ Criteria for referral directly from GPs are not included in the new guidance on pelvic floor dysfunction; however, NG123 suggests that the issues listed in Box 3 merit referral to secondary care.^5,6 Patients who continue to have episodes of faecal incontinence after initial management, or for whom medicine for overactive bladder is not successful or not tolerated, should also be considered for secondary care referral.^5,6 Women with haematuria or recurrent or persistent unexplained urinary tract infection should be referred to cancer services in line with the recommendations on referral for urinary tract cancer in the NICE guideline on suspected cancer.^5,16

Summary

Pelvic floor dysfunction is an often overlooked and surprisingly common condition that affects millions of women across the UK. Many women feel embarrassed talking about the condition, or are unaware of it. NG210 seeks to combat this by raising awareness among healthcare practitioners and the general public about how to identify, manage, and prevent the condition. Most cases can be managed through nonsurgical interventions, including pelvic floor muscle training, diet and weight interventions, pessaries, and medicines management. The related guidelines on faecal incontinence, pelvic organ prolapse, and urinary incontinence also provide effective guidance for treatment.

Dr Claire Davies

GP, London