Overview
This Guidelines summary covers the prevention, assessment, and non-surgical management of pelvic floor dysfunction in young women aged 12–17 years, and women aged 18 years and over.
This summary only includes key recommendations for primary care. Refer to the full guideline for recommendations on raising awareness of pelvic floor dysfunction for all women; and communicating with and providing information to women with pelvic floor dysfunction.
NICE has also produced guidance on urinary incontinence and pelvic organ prolapse in women aged 18 years and over.
Reflecting on Your Learnings
Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.
Risk Factors for Pelvic Floor Dysfunction
When discussing the risk of pelvic floor dysfunction with women, advise them that their risk is higher with any of the characteristics in box 1.
| Box 1: Risk Factors for Pelvic Floor Dysfunction |
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Modifiable risk factors
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- For pregnant women with pelvic floor dysfunction that started before or during their pregnancy, advise them that there is an increased risk that their symptoms will get worse during their pregnancy and that they may persist after this (for preventative and management strategies, see the section on preventing pelvic floor dysfunction and the section on non-surgical management of pelvic floor dysfunction).
- For more detailed guidance on all the benefits and risks of vaginal and caesarean birth (including urinary incontinence, faecal incontinence and injury to the anal sphincter), see the section on benefits and risks of caesarean and vaginal birth in the NICE guideline on caesarean birth.
Preventing Pelvic Floor Dysfunction
Physical Activity and Diet
- Advise women that physical activity and a healthy diet can help prevent pelvic floor dysfunction.
- On levels of physical activity, advise women to follow the standard advice, as covered by:
- On diet, advise women to:
- have a balanced diet (following Public Health England’s Eatwell Guide), and in particular to eat enough fibre, because this can improve stool consistency and prevent symptoms of faecal incontinence
- ensure they have an appropriate fluid intake, increasing or decreasing it if needed.
Weight Loss, Stopping Smoking, Managing Constipation and Diabetes
- For guidance on weight loss, see the NICE guideline on obesity, and (if relevant) the NICE guideline on weight management before, during and after pregnancy.
- Give advice on stopping smoking, using the NICE guideline on tobacco.
- For guidance on managing constipation in young people, see the NICE guideline on constipation in children and young people.
- For guidance on managing diabetes, see the NICE guidelines on:
- type 1 diabetes in adults
- type 2 diabetes in adults
- diabetes (type 1 and type 2) in children and young people.
Pelvic Floor Muscle Training
All Women
- Encourage women of all ages to do pelvic floor muscle training, and explain that it helps to prevent symptoms of pelvic floor dysfunction.
- Encourage women to continue pelvic floor muscle training throughout their life, because long-term training continues to help prevent symptoms.
During and After Pregnancy
- Encourage women who are pregnant or who have recently given birth to do pelvic floor muscle training, and explain that it helps prevent symptoms of pelvic floor dysfunction.
- Consider a 3-month programme of supervised pelvic floor muscle training:
- from week 20 of pregnancy, for pregnant women who have a first-degree relative with pelvic floor dysfunction
- during postnatal care, for women who have experienced any of the following risk factors during birth:
- assisted vaginal birth (forceps or vacuum)
- a vaginal birth when the baby is lying face up (occipito-posterior)
- injury to the anal sphincter.
- Before discharging women from maternity services, and during routine postnatal care, encourage them to do pelvic floor muscle training.
- When designing a pelvic floor muscle training programme, see the NICE guideline on behaviour change for relevant recommendations:
Supervising Pelvic Floor Muscle Training
- Pelvic floor muscle training programmes should be supervised by a physiotherapist or other healthcare professional with the appropriate expertise in pelvic floor muscle training.
- Supervision should involve:
- assessing the woman’s ability to perform a pelvic floor contraction and relaxation
- tailoring the pelvic floor muscle training programme to the woman’s ability to perform a pelvic floor contraction and relaxation, any discomfort felt, and her individual needs and training goals
- encouraging the woman to complete the course, because this will help to prevent and manage symptoms.
Assessment in Primary Care
- At initial assessment in primary care (which may include assessments by physiotherapists, bladder and bowel team members and continence advisors), take a general history from the woman about current and past symptoms or disorders associated with pelvic floor dysfunction, such as:
- urinary incontinence
- emptying disorders of the bladder
- faecal incontinence
- emptying disorders of the bowel
- pelvic organ prolapse
- sexual dysfunction
- chronic pelvic pain.
- Depending on the symptoms described, carry out a focused history, clinical examination and investigations to exclude other causes, such as:
- pelvic masses
- neurological disease
- urinary tract infection
- adverse effects of medication
- diabetes
- cancer (for further information, see the NICE guideline on suspected cancer: recognition and referral)
- fistula
- inflammatory bowel or bladder conditions
- endometriosis
- mobility and cognitive impairment.
- Ask women who have recently given birth about symptoms of pelvic floor dysfunction during routine postnatal care, in hospital and in the community.
- For women who are taking multiple medications, conduct a medication review.
- For guidance on how to do this, see the section on medication review in the NICE guideline on medicines optimisation.
- Depending on the symptoms and the woman’s preferences and circumstances, consider other clinical examinations. For example:
- inspecting the woman’s vulva and vagina for atrophy
- asking them to bear down, to check for visible vaginal or rectal prolapse
- rectal examination to check for impaction, for women who are at risk of this and who cannot give an accurate history of their symptoms (for example, women with cognitive impairments or dementia).
- For more guidance on assessing urinary incontinence and pelvic organ prolapse, see the NICE guideline on urinary incontinence and pelvic organ prolapse in women. (The recommendations in this guideline may also be relevant for women under 18.)
- If the woman has symptoms of faecal incontinence, follow the recommendations on baseline assessment in the NICE guideline on faecal incontinence. (The recommendations in this guideline may also be relevant for women under 18.)
Non-surgical Management of Pelvic Floor Dysfunction
Community-based Multidisciplinary Teams
- After initial assessment in primary care, consider a community-based multidisciplinary team approach for the management of pelvic floor dysfunction.
- The community-based multidisciplinary team (or teams) should have members with competencies related to assessing and managing pelvic floor dysfunction, such as:
- carrying out initial assessments (see the section on assessment in primary care)
- assessments of mobility and personal care issues related to pelvic floor dysfunction
- awareness of the psychosocial implications of pelvic floor dysfunction
- identifying risk factors
- interpreting urinalysis
- conducting and interpreting bladder scans to measure post-void residual volume
- conducting digital assessments of the pelvic floor and pelvic floor muscle contraction and relaxation
- training women and their families and carers in behavioural interventions for pelvic floor dysfunction (such as bladder retraining)
- prescribing and reviewing medications, and knowledge of interactions and side effects related to pelvic floor dysfunction
- supervising a pelvic floor muscle training programme (see the section on supervising pelvic floor muscle training)
- managing the use of pessaries and intravaginal devices
- training and supporting other care providers to assess and manage pelvic floor dysfunction (for example, carers or care home workers)
- identifying which women need referral to specialist care or other services (for young women aged 12 to 17, this may include referral to paediatric services or adolescent gynaecology services).
- Discuss and agree a management plan with women who have suspected or confirmed pelvic floor dysfunction.
Lifestyle Changes
Encouraging Women to Make Lifestyle Changes
- When discussing lifestyle changes with women who have pelvic floor dysfunction:
- motivate them to make changes by focusing discussions on how this will improve their symptoms
- give them regular encouragement to keep up the changes, because it may take weeks or months before they notice a benefit.
Weight Loss
- Advise women with a body mass index (BMI) over 30 kg/m2 that weight loss can help with the following symptoms associated with pelvic floor dysfunction:
- urinary incontinence
- overactive bladder
- pelvic organ prolapse.
- For guidance on weight loss, see the NICE guideline on obesity, and (if relevant) the NICE guideline on weight management before, during and after pregnancy.
- Refer women for weight loss support following the NICE guideline on lifestyle services for weight management in overweight or obese adults and the NICE guideline on lifestyle services for weight management in overweight or obese children and young people.
- Do not wait for women to lose weight before starting other pelvic floor dysfunction management options.
Diet
- For all women with pelvic floor dysfunction:
- explain how a balanced diet (following Public Health England’s Eatwell Guide) and appropriate fluid intake can improve stool consistency, which can help with their symptoms
- follow guidance on maintaining healthy bowel habits in recommendation 1.3.2 of the NICE guideline on faecal incontinence in adults (including for women under 18 or with symptoms other than faecal incontinence).
- Advise women with overactive bladder or urinary incontinence associated with pelvic floor dysfunction to:
- reduce their caffeine intake
- modify their fluid intake (increasing if it is too low, decreasing if it is too high).
Physical Activity
- For women who are doing supervised pelvic floor muscle training and want to be physically active, advise them that supervised exercise (for example, yoga) may help with their symptoms.
- Advise women with pelvic floor dysfunction that there is no evidence to say that unsupervised physical activity (such as walking or swimming) will improve or worsen their symptoms.
Pelvic Floor Muscle Training
For Pelvic Organ Prolapse
- Consider a programme of supervised pelvic floor muscle training for at least 4 months for women with symptomatic pelvic organ prolapse that does not extend greater than 1 cm beyond the hymen upon straining.
For Stress Urinary Incontinence or Mixed Urinary Incontinence
- Offer a programme of supervised pelvic floor muscle training for at least 3 months to women (including pregnant women) with stress urinary incontinence or mixed urinary incontinence.
For Faecal Incontinence With Coexisting Pelvic Organ Prolapse
- Consider a programme of supervised pelvic floor muscle training for at least 4 months for women with faecal incontinence and coexisting pelvic organ prolapse.
Group and Individual Training
- For women who are doing a supervised pelvic floor muscle training programme, offer the choice of group or individual sessions.
Supervising Pelvic Floor Muscle Training
- See the recommendations on supervising pelvic floor muscle training in the section on preventing pelvic floor dysfunction.
Review
- When providing a programme of pelvic floor muscle training, offer at least 1 review to assess progress during the programme, and 1 review at the end of the programme.
Supplementing Pelvic Floor Muscle Training
- For women who are unable to perform an effective pelvic floor muscle contraction, consider supplementing pelvic floor muscle training with biofeedback techniques, electrical stimulation or vaginal cones.
Continuing Pelvic Floor Muscle Training
- If the programme is beneficial, advise women to continue pelvic floor muscle training after the supervised programme ends.
Intravaginal Devices and Pessaries
Intravaginal Devices for Urinary Incontinence
- Consider a trial of intravaginal devices for women with urinary incontinence, only if other non-surgical options have been unsuccessful.
Pessaries for Symptomatic Pelvic Organ [rolapse
- Consider pessaries for women who have symptomatic pelvic organ prolapse.
- Before starting treatment with a pessary for women with symptomatic pelvic organ prolapse:
- discuss with the woman how a pessary could help, and explain it may not help with their urinary and bowel symptoms
- explain that a pessary will only help with their pelvic organ prolapse symptoms while it is in place, and the symptoms will come back when it is removed
- explain that reducing the prolapse with a pessary may cause new stress urinary incontinence.See the third recommendation under the section on pessaries in the NICE guideline on urinary incontinence and pelvic organ prolapse for further discussions to have with women before starting treatment with a pessary.
- If women using a pessary experience new stress urinary incontinence, offer them a choice of treatment for the incontinence or removal of the pessary.
- For more guidance on pessaries for women with symptomatic pelvic organ prolapse, see the section on pessaries in the NICE guideline on urinary incontinence and pelvic organ prolapse.
Review
- For women who are self-managing their intravaginal device or pessary, explain how they can seek advice from a healthcare provider if they have problems.
- For guidance on reviewing pessaries for women who are at risk of complications, for example because of a physical or cognitive impairment, see the fourth recommendation under the section on pessaries in the NICE guideline on urinary incontinence and pelvic organ prolapse.
Psychological Interventions
- Discuss the psychological impact of their symptoms with women who have pelvic floor dysfunction. Take account of this impact when developing a management plan.
- For more guidance on psychological management, see the:
Behavioural Approaches
- Offer supported bladder retraining (combined with other interventions, such as pelvic floor muscle training) to women with urinary frequency, urgency or mixed incontinence.
- For women with faecal incontinence, see the section on diet, bowel habit and toilet access in the NICE guideline on faecal incontinence in adults. (The recommendations in this guideline may also be relevant for women under 18.)
- When choosing a behavioural intervention, take into account that prompted toileting and habit training may be particularly suitable for women with cognitive impairment.
Medicines
- Do not offer vaginal diazepam to treat pelvic floor dysfunction, even for women with high muscle tone.
- For guidance on medicines for urinary incontinence and faecal incontinence associated with pelvic floor dysfunction, see the NICE guideline on urinary incontinence and pelvic organ prolapse in women and the section on medication in the NICE guideline on faecal incontinence in adults. (The recommendations on medicines in these guidelines may also be relevant for women under 18.)
References
References