SRP 107 Vaginal Vault/Uterine Prolapse

Policy number: SRP 107
Policy name: Vaginal Vault/Uterine Prolapse
Status: Individual Funding Approval
Effective date: 1 April 2024
Next review date: 1 April 2029

Pelvic organ prolapse occurs when one or more of the pelvic organs descend into the vagina, causing a range of symptoms.

Mid and South Essex ICB will only fund surgical interventions for Uterovaginal Prolapse in the following circumstances:

In cases of mild to moderate symptomatic cystoceles where trial of a vaginal ring pessary has failed
In cases of mild to moderate symptomatic rectoceles
In severe cases of prolapse or precedentia

Watchful waiting, with observation for the development of new symptoms or complications is appropriate if the prolapse is minimal (Stage I), or asymptomatic.

Referral for specialist assessment for surgical interventions will only be funded when the following criteria have been met:

Lifestyle interventions should be tried as per NICE guidance. These include avoidance of constipation, avoidance of heavy lifting and weight loss if BMI is greater than 30).
A trial of supervised pelvic floor muscle training for at least 3 months (only in women with stage 1-2 prolapse).
A trial of topical vaginal oestrogen in appropriate patients. For information on choice of products, please see Medicines Optimisation
A trial of vaginal ring pessary in appropriate patients. Trial and ongoing management of pessary can be undertaken in primary care.

Use of mesh (synthetic) is not funded. Current evidence on the safety of transvaginal mesh repair of anterior or posterior vaginal wall prolapse shows there are serious but well-recognised safety concerns. Evidence of long-term efficacy is inadequate in quality and quantity. Therefore, this procedure should only be used in the context of research. NICE IPG599

Women should have sufficient understanding of their treatment, including the benefits, potential risks, and alternative treatment options, including doing nothing.

For women considering surgery, the use of appropriate patient decision aids is highly recommended:

Surgery for uterine prolapse: patient decision aid and user guide
Surgery for vaginal vault prolapse: patient decision aid and user guide

Clinical scenarios where surgery will not be routinely funded	Clinical scenarios where referral for specialist assessment is necessary to determine suitability for surgery
Asymptomatic pelvic organ prolapse	Failure of pessary
Mild pelvic organ prolapse (unless combined with urinary/faecal incontinence)	Women with symptomatic prolapse (including those combined with urethral sphincter incompetence or faecal incontinence)
	Prolapse combined with urethral sphincter incompetence/ urinary incontinence or faecal incontinence
	Women with moderate to severe prolapse who want definitive treatment