Impact case study database

UK and International prolapse policy impact

Five to 10% of women will experience symptomatic prolapse during their lifetime. Two decades ago evidence of effectiveness of PFMT as a treatment for prolapse was lacking, practice varied and no national guidance existed. Since then, guidance recommending PFMT as first-line treatment for prolapse, resulting from our research, was incorporated into the 2013 and 2017 International Consultation on Incontinence reviews [S1]. In 2016 our research was adopted by the German, Swiss and Austrian Societies of Gynaecology and Obstetrics [S2]. Subsequently, NICE in 2019 [S3] incorporated the research results [R1-R3] into their prolapse management guidelines. The implementation of these guidelines means that PFMT should be offered to improve outcomes for women with prolapse. Drawing on the research [G1-G3], the Pelvic Obstetric and Gynaecological Physiotherapy (POGP) network of the Chartered Society of Physiotherapists commenced prolapse courses in 2014, teaching physiotherapists to deliver PFMT (18 courses, 450 participants) [S4]. The POGP Chair said “The findings of the trials have enabled evidence-based practice to be taught on the POGP prolapse courses, which started in 2014. The findings from the studies have enhanced the teaching content with robust evidence-based research” [S4]. The POGP also developed a patient information leaflet in 2016 including instruction in PFMT, based on the research, and to date have distributed this to around 50 UK care settings to share with prolapse patients [S5].

Following the halt in September 2018 of the use of transvaginal mesh in prolapse surgery, our research was influential in Scottish Government decision-making on physiotherapy provision for women with prolapse. Prof Hagen presented evidence of the benefits of PFMT [G1-G4] from December 2018 - February 2019 to the Minister for Public Health Sport and Wellbeing, and the lead Consultant in Public Health Medicine who stated “I think finding ways this work is reflected in any developing pathways/other areas is vital” (emails available). This led to a presentation in April 2019 to the Scottish Government-appointed Transvaginal Mesh Implants Oversight Group who recommended a need to “undertake a detailed scoping of [physiotherapy] capacity, including referral rates and sources, to determine current needs and future workforce requirements” [S6, page 27].

Influencing professional awareness of the benefits of PFMT in the UK

Delivery of PFMT is challenged by the large numbers of women with prolapse and the limited number of specialist physiotherapists who traditionally deliver PFMT: the UK has only around 800 such specialists. Finding alternative ways to make this evidence-based intervention more widely available were identified in the PROPEL study [G4]. Events to disseminate its findings in London and Glasgow (12/19 February 2019, materials available), were attended by 120 UK clinicians and service managers [R4]. On learning that different models of PFMT delivery, involving non-specialist staff, were effective and acceptable, participants shared action plans to implement changes to their services (transcripts available). Action plans contained statements such as: “I have some good ideas and emerging evidence to take to the commissioners”; “[I] feel enthusiastic and determined to participate in providing this effective treatment, improve pathways, developing information leaflets for patients/women”. Implementation of such models allows a wider group of existing staff to treat women, giving better access to PFMT, and freeing up specialist teams for complex prolapse cases. This argument was presented to an Oral Hearing of the Independent Medicines and Medical Devices Safety Review of vaginal mesh by the Chartered Society of Physiotherapists who emphasised the importance of the PROPEL findings [G5] in increasing the workforce for PFMT delivery [S7, page 90].

International clinical practice and patient impact

Clinicians treating women worldwide, recognising the need for a brief validated prolapse symptom score, have adopted the POP-SS, developed and validated by Prof Hagen [R5-R7], and the instrument has been translated into Amharic, Turkish, Nepalese, Chinese, Russian and Samoan (publications and emails available). In Nepal this facilitated research into PFMT delivery during pregnancy [S8]. According to a 2020 survey of POP-SS users [S9], with respondents from the UK, Australia, Republic of Ireland, USA, and countries where there is a significant unmet clinical need such as Ethiopia, India, Brazil, Nepal and Turkey, the respondents used the POP-SS to monitor women’s prolapse symptoms (89%), and to share information with patients (78%) and colleagues (60%). Over 70% included the POP-SS within their patient records. For 40%, the POP-SS was used to inform treatment decisions, e.g. whether or not to proceed to surgery. Respondents reported it improved their clinical practice (73%), and treatment outcome (42%), specifically it “allowed management to be more appropriate” and led to “quicker resolution of issues”.