The UK’s National Institute for Health and Care Excellence (NICE) has published draft guidelines for the clinical management of pelvic organ prolapse and stress urinary incontinence. The guidelines, which are open for public consultation until 19 November recommend that women, first and foremost, be offered lifestyle interventions, physical and behavioural therapies, and medication before surgical options are considered.
Women who do choose to have surgery must be fully informed of the risks and referred to a specialist. NICE also recommends that all procedures and complications associated with vaginal mesh surgery be tracked on a national database.
These guidelines arrive at a time when much controversy surrounds the use of vaginal mesh surgery. In July, all National Health Service hospitals were advised by the Chief Medical Officer to restrict the use of vaginal mesh surgery to patients for whom non-surgical interventions have failed.
This pause was instituted in response to early findings from an ongoing Independent Medicines and Medical Devices Safety Review of concerns raised by patients. Women with the vaginal mesh implants have reported pelvic pain, dyspareunia, infection, organ perforation, nerve damage, and urinary problems, and, in some cases, women have had to have their implant removed. These complications are not uncommon. Thousands of women have had the vaginal mesh implants in the past decade, so the absolute number of women with adverse reactions is very high.
The guidelines emphasise the need for support and information to guide women through treatment options – a welcome step that should be universal practice. Life-changing complications must be taken seriously; for some women, vaginal mesh surgery will be the best option, but risks of complications must be documented and communicated clearly.
A pyramidal approach – lifestyle interventions first for most women and surgery as a last resort for a few – is commendable. But with little evidence of benefit for non-surgical interventions and growing evidence of harm for surgical interventions, more research and stronger evidence are clearly needed. Indeed, such evidence should have been more energetically accumulated before vaginal mesh surgery became so irresponsibly fashionable.
[link url="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32480-2/fulltext?dgcid=raven_jbs_etoc_email"]The Lancet editorial[/link]