Episode 38: Management of Female Urinary Incontinence and Pelvic Organ Prolapse

0:00 Speaker 1 Welcome back to the Deep Dive. Today we are tackling something that I think keeps a lot of registrars up at night. It's a massive document. It's heavily politically charged and honestly, if you are sitting in the Mr. Cog Part 2 anytime soon, it is basically your Bible for urogynecology. 0:17 We are diving into NICE Guideline Ng 123. 0:20 Speaker 2 Right, Urinary incontinence and pelvic organ prolapse and women management, which I know doesn't sound like a thriller title right off the bat. 0:28 Speaker 1 It really doesn't. 0:29 Speaker 2 But given the history behind this specific document, it kind of is. I mean, it really shook things up. 0:34 Speaker 1 It did. It's not just a standard clinical update. This guideline dropped back in 2019 and it replaced the old CG 171 and it essentially marks a complete paradigm shift in how women's pelvic health is managed in the UK. 0:47 Speaker 2 Yeah, we are talking about the direct fallout from the mesh scandal, the complete restructuring of surgical governance and really a total overhaul of that old school doctor knows best mentality. 0:58 Speaker 1 Exactly, and that is the context you have to have in your head before you even read the first recommendation. This guideline was born out of a profound crisis of confidence. 1:06 Speaker 2 It was. And for the exam candidates listening right now, yes, you absolutely need to know the algorithms, but to actually score high and more importantly, to be a safe consultant on the ward, you need to understand the philosophy of Ng 123. 1:19 Speaker 1 Right. It prioritizes patient safety and patient autonomy above pretty much everything else. Definitely. So our mission for this deep dive is to get you exam ready, but also to just make sense of all the noise. We have pull a lot of sources for this, the full NICE guideline, the extensive evidence reviews and all the clinical updates running right through to 2025, especially regarding the new tech appraisals for overactive bladder meds. 1:45 Speaker 2 There is a lot to get through. 1:47 Speaker 1 So we're going to break this down logically. We'll start with the organization of services, which is the MDT stuff, then initial assessment and diagnosis. 1:54 Speaker 2 Then the non. 1:55 Speaker 1 Management, right? And then finally, we will wade into the big scary world of surgical management and of course, mesh complications. 2:02 Speaker 2 And as we go, we will really try to highlight the exam discriminators, you know, those highly specific little details that the RCLG loves to test in the Part 2 because they prove you actually understand how to apply the guideline in real life rather than just memorizing A bulleted summary. 2:19 Speaker 1 Let's start with the bureaucracy, which I know sounds incredibly dry, but it's actually fascinating here. The organization of services. The guideline talks extensively about MDT, some multidisciplinary teams. Right now if you work in oncology, MDT's are just standard Tuesday morning stuff. 2:35 But why is nice making such a massive fuss about them for incontinence and prolapse? 2:41 Speaker 2 It is entirely about date keeping and governance. In the past, a single surgeon could essentially operate in a complete silo. A woman comes into the clinic with a leak. You book her in, you put in a tape. Job done. 2:52 Speaker 1 And nobody else ever reviews the. 2:53 Speaker 2 Case exactly. But given the severe complication rates we have seen nationally, that is just no longer an acceptable way to practice. So the guideline splits the governance into two distinct tiers. You have the local MDT and the regional MDT. 3:05 Speaker 1 OK, let's distinguish those for the listeners. If I am a generalist or maybe a specialty trainee in a standard district General Hospital, what exactly is the local MDT for? 3:16 Speaker 2 The local MDT is your bread and butter. Its primary role is to review proposed treatments for primary conditions. So if you have a patient with straightforward stress urinary incontinence or SUI or maybe overactive bladder or just a primary prolapse, if you are thinking about doing any invasive procedure for those standard primary issues, that case must be discussed at the local MDT. 3:41 Speaker 1 And who actually has to be in the room for that? Is it just three surgeons agreeing with each other? 3:45 Speaker 2 Absolutely not, and that is a massive key exam point. You cannot have a core 8 local MDT without three very specific groups of people present. First, you need 2 consultants with expertise in urogynecology or urology. Second, you need a specialist nurse, but the third mandatory person is the most interesting 1 You must have a pelvic floor specialist physiotherapist. 4:05 Speaker 1 That is interesting. Why is the physio absolutely mandatory for a surgical MDT? 4:10 Speaker 2 Because they act as the voice of conservative management. Having a physio physically in the room stops the surgeons from jumping the gun. I see if a surgeon stands up and says right, I want to do a Co post suspension for this lady. The physio sitting right there to ask, well hold on, has she actually completed three months of supervised pelvic floor muscle training? 4:32 Because I haven't seen her name on my clinic list. 4:34 Speaker 1 It's a built in safety check. It ensures that surgery truly remains the second or third line option, not the default first line. 4:41 Speaker 2 Exactly. Keeps everyone honest. 4:43 Speaker 1 So if the local MDT is handling the standard primary stuff, who gets escalated to the regional MDT? 4:49 Speaker 2 The regional MDT is reserved for the 2 hard basket. It's for the high risk, highly complex cases. 4:55 Speaker 1 So we are thinking repeat. 4:57 Speaker 2 Yes, if a woman has had surgery before and it failed. So repeat continent surgery or a recurrent prolapse that automatically goes regional. Also if she has suspected mesh complications or if she has complex bowel issues sitting alongside her bladder issues. 5:11 Speaker 1 What about younger women, like someone who might want to get pregnant later on? 5:15 Speaker 2 Great catch. Yes, absolutely. If a young woman desperately needs prolapse or incontinence surgery, but she has not completed her family, that is a mandatory regional discussion. 5:25 Speaker 1 Because the risks of operating on a pelvis that might later become gravid are just too high to decide locally. 5:30 Speaker 2 Precisely. You need a much wider consensus. 5:33 Speaker 1 And I assume the guest list for this regional meeting is a bit more extensive than the Local 1. 5:37 Speaker 2 It is significantly broader. You still have your core urogenicologists and urologists, but now you add a radiologist with highly specific pelvic floor expertise, somebody who can actually read and interpret dynamic pelvic MRI's properly. 5:51 Speaker 1 Not just standard reporting. 5:52 Speaker 2 Right. You also need a colorectal surgeon and crucially, you must have ready access to pain specialists and clinical psychologists. 6:01 Speaker 1 The psychology element really stands out to me in this guideline. It seems to actively acknowledge that chronic pelvic pain isn't just a mechanical failure you can fix with a scalpel, It is a life altering condition. 6:12 Speaker 2 It really is. Chronic mesh pain, for example, is an incredibly complex pain syndrome. You can't just cut the mesh out and expect the brain to immediately stop registering that pain. You need a completely holistic approach. 6:25 Speaker 1 Which means addressing the central sensitization of the nervous system. 6:28 Speaker 2 Exactly so for the exam. Remember this distinction. Local is for primary procedures and standard care. Regional is for repeats, complications and complex comorbidities. 6:40 Speaker 1 Before we leave the admin side of things, there is a very strict must do regarding data collection the National Registry. 6:48 Speaker 2 Yes, this is non negotiable now. Every single procedure. 6:51 Speaker 1 That's terrifying. 6:52 Speaker 2 It was a clinical governance nightmare. So now the guideline mandates you record the NHS number, the exact procedure details and if you do use mesh you must record the manufacturer, the unique product ID code and even the specific type of sutures you use to fix it. 7:08 Speaker 1 And it is not just implanted say goodbye either, is it? 7:11 Speaker 2 No, the mandatory follow up is stringent. You need to collect registry data on short term and long term outcomes. We are talking five years plus. 7:20 Speaker 1 So they're tracking the adverse events long term. 7:22 Speaker 2 Yes, they want to know about chronic pain. Re operations, mesh erosions. If your trust isn't seeding this data into the registry, you basically shouldn't be operating. It is a strict governance requirement. 7:34 Speaker 1 OK, let's move from the boardroom to the actual clinic. Part 2 Initial assessment and diagnosis. You have a patient walk into your clinic. She sits down and says I'm leaking. Where do we start according to an ICE? 7:47 Speaker 2 We start with immediate categorization. The guideline wants you to put a clinical label on it right away based purely on the history she gives you. 7:53 Speaker 1 So we are looking at the three main types. 7:56 Speaker 2 It's exactly Is it stress urinary incontinence SUI, which is leaking when you cough, sneeze, laugh or jump? Is it urgency or overactive bladder OAB, which is that sudden compelling desire to pass urine that you just can't defer? 8:11 Or is it mixed urinary incontinence MUI? 8:14 Speaker 1 Mixed is always the tricky one, right? Because they are dealing with both a weak sphincter and an overactive detrusor muscle at the same time. How do you decide what to actually treat first? 8:24 Speaker 2 The rule of thumb here, and this is a classic exam question answer, is treat the bother. You literally ask the patient which symptom ruins your day more. Usually the urgency is vastly more bothersome than the occasional stress leak when she sneezes, so you direct your initial conservative treatment at whichever symptom is predominantly ruining her quality of life. 8:43 Speaker 1 Makes sense. So we do the history, we categorize, we do a standard abdominal exam, then we move to the pelvic exam. There is a very specific instruction in the guideline about the digital assessment of the pelvic floor muscles. 8:53 Speaker 2 Yes, there is. And this is something that gets missed in busy clinics all the time. But it is explicitly in the guideline. When you do the vaginal examination, you have to ask the woman to squeeze your fingers. You are assessing whether she can voluntarily contract those pelvic floor muscles. 9:10 Speaker 1 Why does that matter so much right at the first visit? 9:13 Speaker 2 Because the absolute first line treatment you're going to offer is pelvic floor muscle training or PFMT. If she cannot neurologically isolate and physically contract those muscles while you are examining her, sending her home with a photocopied leaflet or just telling her to do her kegels is completely useless. 9:31 Speaker 1 Because she's probably just bearing down or squeezing her glutes. 9:34 Speaker 2 Exactly. She needs biofeedback or electrical stimulation to actually teach her brain how to find the muscles first. You cannot train a muscle you cannot feel. 9:42 Speaker 1 That is such a crucial clinical Pearl. Now let's talk about the humble urine dipstick. It seems like the most basic day one test in medicine, but I feel like there is a massive trap here for candidates. 9:53 Speaker 2 Oh, there's a massive trap, and it is called asymptomatic bacteriuria. As doctors, we are terrified of missing a UTI, but we are also notoriously terrible at overtreating harmless bacteria. The guideline gives us a very strict algorithm to follow. 10:11 Speaker 1 Walk us through this algorithm because I know this trips people up in OSCE, OK? 10:15 Speaker 2 Let's break it down. Scenario A The woman has classic UPI symptoms, Dysuria frequency, suprapubic pain. You dip her urine and it shows positive leukocytes and nitrites. 10:26 Speaker 1 Easy, you send a midstream culture and you start empirical antibiotics. 10:29 Speaker 2 Right, exactly. Scenario B. She has all those painful symptoms, but the dipstick is completely negative for leukocytes and nitrites. 10:34 Speaker 1 This is where people get lazy and A&E and just say well the dip is clear so it's not a UTI, go home. 10:39 Speaker 2 Correct, and that is entirely wrong. If she is symptomatic, you still send a formal culture. You might hold off on prescribing the antibiotics right that second until the lab result is back, or you might treat if she is in severe distress. But you do not ever ignore the clinical symptoms just because a piece of paper turned negative. 10:56 Speaker 1 And the big trap is scenario C, right? 10:58 Speaker 2 Scenario C is the killer. She comes to clinic for a routine incontinence follow up. She has absolutely no symptoms of a UTI. No pain, no burning, nothing. But the protocol says dip the urine. So you dip it and it lights up like a Christmas tree. Leukocytes and nitrites are wildly positive. 11:16 What is your next move? 11:17 Speaker 1 The knee jerk instinct is always to treat the abnormal tests. 11:20 Speaker 2 And the guideline explicitly says stop, do not treat, do not even send a culture to the lab. 11:26 Speaker 1 Because of colonization. 11:27 Speaker 2 Exactly. In older women especially, the bladder is very frequently colonized by harmless bacteria that are just minding their own business. If you throw a course of trimethoprimatous labor, you are breeding antimicrobial resistance, disrupting her gut microbiome and achieving absolutely nothing for her incontinence. 11:44 You only treat if there are clinical symptoms. 11:46 Speaker 1 That is a very clear do not do. Speaking of which, I really love the list of legacy tests we are now supposed to officially throw in the bin. 11:53 Speaker 2 Oh, the historical relics list. 11:55 Speaker 1 Yes. 11:56 Speaker 2 The guidelines says do not use the Q-tip test. That is an old test where you put a lubricated cotton swab into the urethra. Ask the patient to strain and measure the angle of the stick to check for urethral hypermobility. 12:09 Speaker 1 It sounds incredibly uncomfortable. 12:11 Speaker 2 It is painful and it is clinically useless for modern management. Also, do not do a Bonnie test or a Marshall test. 12:18 Speaker 1 What about pad tests? I still see those mentioned in some older textbooks. 12:22 Speaker 2 Not for routine assessment anymore. Weighing wet incontinence pads on a scale is undignified for the patient, and honestly, it doesn't correlate well with the actual bother the patient feels. Leaking 10 grams might devastate one woman's social life, but another might not care. 12:37 Speaker 1 And cystoscopy. 12:39 Speaker 2 Do not use cystoscopy just to diagnose basic incontinence. You cannot see a weak sphincter from the inside of the bladder. It's a structural functional issue, not a mucosal 1. 12:48 Speaker 1 OK, here is the big one for Part 2, the urodynamics debate. I feel like 10 or 15 years ago literally every woman who sneezed and leaked got a catheter, a pressure transducer, and a full voiding study before anyone would even look at a scalpel. 13:00 Speaker 2 You are absolutely right, it used to be a rigid of practice. You do your dynamics before any continent surgery. But Ng 123 changed everything and it was largely based on the findings of the value trial. 13:12 Speaker 1 Yes, let's talk about the value trial. It's a huge landmark paper. Why is it so important for this specific guideline? 13:18 Speaker 2 It was a massive randomized controlled trial looking at women with straightforward, uncomplicated stress incontinence. They split them into two groups. Half got preoperative urodynamics, half just got a clinical office evaluation and then they all had surgery. 13:32 Speaker 1 And the result. 13:33 Speaker 2 The outcomes post surgery were completely identical. Doing the invasive urodynamic testing did not change the surgeon's operative plan and it did not improve the clinical success rate. All it did was add financial cost, physical discomfort and a real risk of introducing a UTI. 13:48 Speaker 1 So what does the nice guideline actually dictate now? 13:52 Speaker 2 It states very clearly do not perform multi channel filling and voiding systemicry before primary surgery if the diagnosis is uncomplicated as you want. 14:00 Speaker 1 Wow, so just trust the clinical picture. 14:02 Speaker 2 Exactly. If she tells you she leaks when she coughs, and you physically see her leak when she coughs during your exam, and she has never had pelvic surgery before, you believe her. You do not need an expensive computer to prove what your eyes just saw. 14:18 Speaker 1 But there are always exceptions in medicine. When do we still need to hook them up to the machine? 14:23 Speaker 2 The exceptions are essentially for the complex or murky cases. So if the clinical diagnosis is unclear, if she has urged predominant mixed urinary incontinence because there you really want to make sure you aren't missing severe detrusor over activity. 14:36 Speaker 1 Because operating on severe detrusor over activity can make the urgency vastly worse, right? 14:41 Speaker 2 Yes it can be disastrous. Also you do urodynamics if she has symptoms avoiding dysfunction like hesitancy or poor stream, or crucially if she's had previous SUI surgery. 14:52 Speaker 1 Right, because if that first surgery failed, the local anatomy is completely altered by scar tissue. You aren't dealing with a virgin pelvis anymore. 14:59 Speaker 2 Precisely. You need a physiological road map before you go back in, but for the straightforward first timer with pure stress leakage, put the catheters away. 15:07 Speaker 1 OK, let's move into Part 3, non surgical management. So we have diagnosed them. We are not cutting yet. What is the very first step on the ladder? 15:17 Speaker 2 Lifestyle interventions. I know it sounds boring compared to surgery, but it genuinely works. You start with caffeine reduction. Caffeine is a direct chemical irritant to the detrusor muzzle. 15:28 Speaker 1 So cutting out the five cups of tea a day. 15:30 Speaker 2 Exactly modifying fluid intake, whether they are drinking way too much or actually too little, which concentrates the urine and irritates the bladder. And the big one is weight loss. 15:39 Speaker 1 How much does BMI actually matter for stress incontinence? 15:42 Speaker 2 Hugely ABMI over 30 increases resting intra abdominal pressure significantly, which puts constant downward mechanical stress in the pelvic floor. There is robust evidence showing that losing even 5 to 10% of total body weight can completely resolve stress incontinence in some women without them ever needing another treatment. 16:00 Speaker 1 That is amazing and then we have pelvic floor muscle training or PFMT. Is this just telling them to go home and squeeze while waiting for the bus? 16:08 Speaker 2 No, and this is the magic word for the Mr. Co gig exam. Supervised. The guideline specifies you must offer a trial of supervised PFMT for at least three months as first line treatment for SUI or mixed UI. 16:22 Speaker 1 Supervised, meaning they are actively seeing a specialist physiotherapist. 16:26 Speaker 2 Yes, someone who is physically assessing their technique and progressively increasing the load of the exercises. Skeletal muscles do not hypertrophy overnight. It takes a solid 12 weeks of consistent, progressive load to build up that supportive muscle bulk under the urethra. 16:42 Speaker 1 And the guideline actually gives a specific regimen too, doesn't it? 16:44 Speaker 2 It does at least 8 maximal contractions performed 3 times a day. But again, as we said earlier, you must check they can actually perform a voluntary contraction fluenced before you send them off to do this. 16:54 Speaker 1 Let's shift gears to pharmacological management. Specifically for overactive bladder OAB, we have a very distinct pharmacological bladder to climb here. Where do we start? 17:04 Speaker 2 We start with the anticholinergics. These drugs work by blocking the muscarinic acetylcholine receptors in the detruser muscle. They effectively stop the bladder from spontaneously squeezing when it shouldn't be. 17:15 Speaker 1 But there's a massive catch with these drugs, particularly for our older demographic. 17:20 Speaker 2 A huge catch. We refer to it as the anticholinergic burden. Many of these older medications like immediate release oxybutynin easily cross the blood brain barrier. 17:30 Speaker 1 And acetylcholine isn't just in the bladder. 17:32 Speaker 2 Exactly. Acetylcholine is an essential neurotransmitter for memory processing and cognition in the hippocampus. If you pharmacologically block it in the bladder to stop leaks, you might simultaneously be blocking it in the brain. There's now a very well proven link between high long term anicholinergic burden and an increased risk of cognitive decline in dementia. 17:53 Speaker 1 So treating her bladder symptoms might literally be fogging her brain. 17:57 Speaker 2 Yes. So the guideline is very cautious here. It says assess the total anti cholinergic load. Be extremely careful prescribing these to frail older women. You should offer the drug with the lowest acquisition cost first, which is usually generic coltridine or Salafinansen, but you must explicitly counsel the patient about the side effects, dry mouth, severe Constipation and the cognitive risks. 18:18 Speaker 1 If those standard anticholinergics don't work, or if the side effects are just intolerable, what is rung #2 on our ladder? 18:24 Speaker 2 Then we move to the beta 3 agonists like Mirabigran or the newer 1 Fibron. These are fantastic because they work on a completely different pathway. Instead of blocking the squeezing action, they actively stimulate the beta 3 adrenergic receptors, which tells the bladder to relax and expand during the filling phase. 18:44 Speaker 1 And crucially, they don't cross into the brain the same way. 18:46 Speaker 2 Right, they completely avoid the cognitive side effects, which makes them an incredibly safe option for the elderly. But they are significantly more expensive, which is why Nice places them as second line after you've tried or ruled out the cheaper anticholinergics. 19:01 Speaker 1 What about the post menopausal woman who comes in with severe urgency? Is there a different approach? 19:07 Speaker 2 Always always look for janitornary syndrome of menopause vaginal atrophy. If you examine her in the Volvo and vaginal tissues are thin, pale, friable and dry. Prescribing topical vaginal estrogen can work absolute miracles for urgency and frequency. 19:22 Speaker 1 Just by restoring the local tissue health. 19:24 Speaker 2 Yes, it plumps up the tissues, improves local blood flow and calms down the sensory nerves around the degreegone of the bladder. It is incredibly low risk and very high reward. 19:35 Speaker 1 Now what happens when all the pills fail? The patient is still rushing to the toilet 10 times a day. We are moving to the invasive options for OAB. Let's talk about Botox. 19:44 Speaker 2 Botulinum toxin Taipei This is highly effective. You take the patient today's surgery, use a flexible cystoscope, and inject the toxin directly into the detruser muscle in about 20 different spots. It chemically paralyzes patches of the muscle to stop the uncontrollable spasms. 20:00 Speaker 1 But you can paralyze it a bit too much, right? 20:02 Speaker 2 That is the primary risk, iatrogenic urinary retention. The bladder just stops squeezing entirely and she can't pee at all. Before you draw up a single unit of Botox, the woman must fully understand and accept the risk that she might need to perform clean intermittent self catheterization, or CISC. 20:18 Speaker 1 So she has to be willing to pass a tube into her own bladder multiple times a day. 20:22 Speaker 2 Yes, and if she is physically unable to do that, maybe due to severe arthritis in her hands, or if she's psychologically terrified of the idea, you generally cannot offer her Botox. 20:35 Speaker 1 That's a hard stop. 20:36 Speaker 2 It absolutely is. You cannot risk putting her into retention with no exit strategy. The starting dose, by the way, is 100 units. You do not jump straight to 200 units on the first try because the risk of retention is strictly dose dependent. You inject 100 reviewer at 12 weeks and if it worked but wore off too fast then you can discuss escalating to 200 units for the next round. 20:56 Speaker 1 And if she refuses Botox because of the catheter risk, what's left? 20:59 Speaker 2 Then you are looking at neuromodulation. The main one is Sacral Nerve Stimulation or SNS. It is essentially A pacemaker for the bladder. You implant an electrode near the S3 nerve root and it sends electrical pulses that modulate the reflex pathways. 21:12 Speaker 1 Or there's PTNS, right? Percutaneous tibial nerve stimulation. 21:15 Speaker 2 Yes, PTNS is brilliant. It's like medical acupuncture for the bladder. You insert a tiny needle near the tibial nerve at the ankle and run a current through it. Because the tibial nerve shares the same spinal root as the pelvic nerves, it indirectly calms the bladder down. 21:29 Speaker 1 But just to be clear, for the exams, transcutaneous PTNS where you just slap a Tenon S machine pad on the skin. 21:36 Speaker 2 Not recommended. The clinical evidence just isn't robust enough. It has to be the percutaneous needle version to be effective. 21:42 Speaker 1 Right, let's get into the heavy and highly controversial stuff. Part 4 surgical management of stress urinary incontinence. This is where this nice guideline really flexes its muscles. 21:54 Speaker 2 This is the absolute epicenter of the mesh issue. The guideline has completely torn up and reshuffled the historical hierarchy of SUI procedures. 22:02 Speaker 1 OK so paint the picture. I have a patient, she has done her three months of supervised physio, it failed. She is still leaking when she runs and she wants surgery. What are the top tier options I am laying out on the desk for her now? 22:14 Speaker 2 You have three main primary options to discuss. Number one is the Culpo suspension, either open or laparoscopic #2 is the autologous rectus fascial sling and #3 is the retropubic mid urethral mesh sling. 22:29 Speaker 1 Everyone listening should notice what is glaringly absent from that list. 22:33 Speaker 2 The trans obturator tape The TOT is gone. Let's. 22:36 Speaker 1 Break these top three down first before we get to why the TOT is banished. Colpo suspension. This is a really old school operation, isn't? 22:43 Speaker 2 It it is. It's the classic Birch colpo suspension. It was the absolute gold standard for decades before the quick mesh tapes arrived. You enter the retro pubic space of Resius, either via an open abdominal incision or laparoscopically, and you place permanent sutures into the vaginal fascia on either side of the bladder neck. 23:01 Speaker 1 And you anchor those where? 23:02 Speaker 2 You anchor them up to the iliopectineal ligament, also known as Cooper's ligament, on the pelvic sidewall. It physically elevates and stabilizes the bladder neck. 23:10 Speaker 1 Why is this big surgery suddenly back in fashion? 23:13 Speaker 2 Because it uses sutures, not large sheets of synthetic mesh, so there is no permanent plastic foreign body eroding through the vaginal mucosa. It has fantastic long term data. We have 20-30 years of follow up showing it works, but the trade off is that it's a much bigger operation with a longer recovery time and more post operative pain compared to a simple day case tape. 23:34 Speaker 1 OK, then option 2, the autologous fascial sling. 23:37 Speaker 2 This is a beautiful operation, but technically demanding you harvest a strip of the patient's own fascia. Usually take a strip from the rectus sheath in her lower abdomen. You then pass that native strip of tissue under the urethra like a hammock to support it. 23:51 Speaker 1 Autologous, meaning it's her own living tissue. 23:53 Speaker 2 Exactly. There is 0 synthetic material involved. The body's immune system recognizes it as self, so the risk of mesh erosion or foreign body rejection is basically nonexistent. But again, you are making a transverse abdominal incision just to harvest the graft, so there's definite donor site morbidity and pain. 24:11 Speaker 1 And finally, option 3, the retro pubic mesh sling, the classic DVT. This is still allowed. 24:16 Speaker 2 It is still a valid option, yes, but the consent process required now is incredibly extensive. You have to use the official Nicey patient decision aid and explicitly explain that this is a permanent plastic implant that cannot be easily removed if things go wrong. 24:32 Speaker 1 Now let's address the elephant in the room. Why is the retro pubic approach allowed but the trans obturator wore TOT approach is explicitly a do not do? 24:40 Speaker 2 It all comes down to the anatomical trajectory and the complication profile. The TOT uses trocars that pass laterally through the obturator format. That puts the mesh in very close proximity to the adductor muscles of the thigh and the obturator nerve bundle. 24:55 Speaker 1 Which leads to pain. 24:56 Speaker 2 Exactly. Yeah, the long term registry data showed that TOT's had significantly higher rates of intractable chronic groin and thigh pain. On top of that, they actually had slightly lower long term cure rates for the incontinence itself compared to the retropubic. 25:09 Speaker 1 Route so nicely looked at the data and said why would we ever recommend an inferior procedure that carries a unique risk of chronic nerve pain? 25:17 Speaker 2 Exactly. So TOT is a strict do not offer unless there is a highly specific anatomical reason you cannot safely access the rectal pubic space. Like if she has a frozen pelvis from previous severe endometriosis or multiple previous open surgeries. 25:33 But for a routine primary Case, No TOT. 25:36 Speaker 1 Let's talk about the physical mesh itself. The guideline is incredibly specific. It mandates the use of quote type 1 macroporous polypropylene mesh. Why does it have to be type 1 and what does macropores actually mean biologically? 25:50 Speaker 2 This is a bit of basic science that is crucial to understand. Macropores simply means the holes woven into the mesh are relatively large. Specifically, they must be larger than 75 microns. 26:00 Speaker 1 Why does the exact Micron size of the hole matter? 26:02 Speaker 2 Because of how the immune system fights infection, you want the body's immune cells, specifically the macrophages, to be able to freely pass inside the pores of the mesh to clean up any colonizing bacteria. A human macrophage is roughly 20 to 30 microns in diameter. If a manufacturer uses a micro pores mesh with tiny little holes, bacteria which are only about 1 Micron can easily slip inside the pores and hide, but the macrophages are too fat to follow them in. 26:28 Speaker 1 Oh wow, so the bacteria are essentially shielded from the immune system? 26:32 Speaker 2 Exactly. The mesh pores become a safe haven for bacteria to form a chronic biofilm. It leads to smoldering chronic infections and delayed massive erosions. Type 1 macro pores mesh prevents this by allowing full host tissue in growth and unimpeded immune cell access. 26:49 That is why it's the only type permitted. 26:50 Speaker 1 That is a fantastic physiological explanation. What about the single incision slings? The so-called mini slings that don't exit the skin. 26:57 Speaker 2 Not recommended for routine clinical use at all. They are strictly restricted to formal research trials. We just do not have the 10 year longitudinal data yet to prove they are as safe or as durable as the traditional slings. 27:08 Speaker 1 What if a woman is very frail and cannot undergo A Kulpo suspension or a mesh sling? What about urethral bulking agents? 27:15 Speaker 2 Bulking agents are the soft surgical option. Use a cystoscope to inject a synthetic hydrogel directly into the submucosal tissues of the urethra. It literally bulks up the walls to physically seal the gap. 27:27 Speaker 1 Since very non invasive. 27:29 Speaker 2 It is. The pros are great, no incisions that can be done under local anesthetic and it is extremely safe. The cons however are significant. It just doesn't work as well objectively and the material degrades over time. You have to be very honest during consent and tell the patient you will highly likely need to come back and have this topped up every one to two years. 27:48 It is not a permanent fix. 27:50 Speaker 1 But excellent for a medically complex 85 year old. 27:53 Speaker 2 Exactly. It has this perfect niche. 27:55 Speaker 1 All right, let's pivot away from continents and look at Part 5, pelvic organ prolapse. The physical assessment is pretty standard, using the POPQ system to measure the descent, but there is a really practical clinical tip in the guideline about examining these women. 28:09 Speaker 2 Yes, if a woman comes in complaining of a heavy dragging sensation, or explicitly says she feels a bulge wiping herself, but you examine her in the standard supine position on the couch and see absolutely nothing, you cannot just tell her she is fine, you have to stand her up. 28:26 Speaker 1 Because gravity changes everything. 28:28 Speaker 2 Gravity is your best diagnostic tool for prolapse. Have her stand up or even ask her to squat and bear down. Prolapses often reduce completely when the patient lies flat. Never dismiss a patient's symptoms just because the anatomy looks normal when she is resting horizontally. 28:44 Speaker 1 Moving to non surgical management for prolapse, we have lifestyle changes like weight loss, minimizing heavy occupational lifting, treating chronic Constipation to stop the straining and again supervised PFMT for 16 weeks from mild stage 1 or two prolapse. But the workhorse here is the vaginal pessary. 29:00 Speaker 2 Pessaries are the absolute mainstay of conservative prolapse management. A ring, a Gellhorn, whichever fits. But they require strict ongoing maintenance. The guideline is very rigid on this. You must change or at least remove, clean and inspect the pessary at a minimum of every six months. 29:14 Speaker 1 What exactly happens if a patient slips through the cracks and leaves a ring pessary in for three years? 29:20 Speaker 2 A neglected pessary is a disaster. The continuous pressure on the vaginal mucosa causes ischemia, The tissue ulcerates and the plastic can literally erode straight through the vaginal wall into the bladder, creating a vesicovaginal fistula or into the rectum. 29:36 That's horrifying. It gets worse sometimes. The vaginal epithelium grows completely over the pessary, incarcerating it becomes physically embedded in the tissue and you have to take them to theater to surgically cut it out. Wow. This is why if you fit a pessary in a woman with cognitive impairment like dementia or severe physical disability who cannot manage it herself, you cannot just discharge her to her GP. 29:58 Your clinic must have an active, robust recall system to ensure that device is checked every single six months. 30:04 Speaker 1 Let's talk about when pessaries fail or aren't tolerated. Part 6. Surgical management of prolapse. This is where the sweeping mesh ban is most famous globally. 30:12 Speaker 2 Yes, let's divide this logically by the anatomical compartments. You have the anterior wall which is the bladder dropping down into the vagina forming A cystocell, and the posterior wall which is the rectum pushing up forming a rectocell. The absolute golden rule here for the exams is native tissue repair only. 30:30 Speaker 1 So that means a standard anterior culporphy or posterior culporphy, strictly no mesh. 30:36 Speaker 2 Zero mesh The use of transvaginal mesh kits for fixing vaginal wall prolapse is effectively banned outside of high level research protocols. The complication rates we saw with those kits, the severe vaginal erosions, the shrinkage, the crippling dispariunia, they were just unacceptably high compared to any anatomical benefit. 30:57 A well performed native tissue implication works well enough with a fraction of the severe risks. 31:01 Speaker 1 What about the central compartment if the uterus itself is prolapsing down the canal? 31:05 Speaker 2 You have a fundamental choice to make with the patient. Do you take the uterus out with a vaginal hysterectomy or do you put it back up where it belongs with a hystereopexy? 31:12 Speaker 1 Historically, the uterus was almost always removed, wasn't it? 31:15 Speaker 2 It was a default, but this guideline is actually very supportive of uterine preservation. You do not have to amputate a perfectly healthy organ just because the ligament stretching it have failed. 31:26 Speaker 1 This brings us to a procedure that sounds like it belongs in the Industrial Revolution, the Manchester repair. 31:32 Speaker 2 The Manchester Repair is very old school, but it is a brilliant physiological operation. Women with long standing uterine prolapse often develop a severely elongated cervix. In a Manchester repair, you amputate that elongated cervical portion, and then you use the strong uterosacral ligaments to essentially hike the rest of the uterus back up into the pelvis. 31:53 Speaker 1 It sounds like a great native tissue option, but why is it contraindicated if a younger woman still wants to have children? 31:59 Speaker 2 Because of that cervical amputation, moving out much of the service can lead to severe cervical incompetence causing mid trimester miscarriages or alternatively cervical stenosis which can complicate labor. If she wants future pregnancies, you avoid the Manchester. 32:13 Speaker 1 What about a vault prolapse? This is where she has already had a hysterectomy years ago, and now the blind top of the vagina of the vault is turning inside out and falling down. 32:23 Speaker 2 This is the one major exception for prolapse, where synthetic mesh is still widely considered the gold standard, but the route is critical. The procedure is a sacral culpexy. This is typically done laparoscopically or robotically. You attach AY shaped strap of mesh to the vaginal vault and suspend it up to the anterior longitudinal ligament on the sacral promontory. 32:45 Speaker 1 But wait a minute, why is mesh considered perfectly safe and acceptable here on the vault, but completely banned for use on the anterior vaginal wall? 32:53 Speaker 2 It's all about the surgical approach and the local bacterial environment. An abdominal sacral perplexia is performed in the sterile environment of the peritoneal cavity. The mesh is attached to the thick fibrous tissue of the vault from above. Conversely, the band vaginal mesh kits were placed via an incision in the vagina, heavily contaminated with normal flora and laid directly directly underneath the incredibly thin, friable vaginal epithelium. 33:17 The structural barrier is just too thin and the bacterial load is too high, which is why the vaginal mesh eroded through the skin so frequently. The erosion rate for abdominal mesh is vastly, profoundly lower. 33:29 Speaker 1 That makes perfect sense anatomically. If you don't want to use mesh at all for a vault prolapse, what is the native tissue alternative? 33:36 Speaker 2 A vaginal sacrospinus fixation. You dissect through the vaginal wall, find the sacrospinous ligament deep in the pelvis, and stitch the vault directly to it using heavy permanent sutures. No synthetic mesh required. 33:48 Speaker 1 So to summarize the absolute no mesh zones for the MRC cog exam, SUI surgery, trans obturator tape TOT is out, vaginal prolapse repairs meshes out. But for vault or uterine suspension, abdominal mesh is still very much in play. 34:02 Speaker 2 That is a perfect airtight summary for the clinical OS ES. 34:06 Speaker 1 OK, we need to tackle part 7 mesh complications. We have to talk about this because frankly, it's the entire reason this new stripped guideline even exists. What does a mesh complication actually look like in a primary care clinic? 34:21 Speaker 2 The tricky part is that the symptoms can be incredibly vague and nonspecific. You are looking out for chronic, unremitting pain in the groin, the medial thigh, the lower back, or deep in the pelvis. Recurrent UTI's that don't clear up unexplained vaginal bleeding or offensive discharge. 34:37 Speaker 1 And pain during intercourse. 34:38 Speaker 2 Yes, severe dispariunia. And importantly, you must ask about a spantryunia. That is where the male partner experiences penile pain or scratching during penetrative sex because he's physically rubbing against a rigid piece of exposed plastic mesh in her vagina. 34:52 Speaker 1 If AGP or a general general gynecologist suspects a mesh complication based on that history, what is their immediate action? You. 34:58 Speaker 2 Refer immediately. You do not try to trim it or fix it yourself in a minor OPS room unless you are a sub specialist. Every single suspected mesh complication must be referred to a tertiary center and discussed at that regional MDT we talked about at the start. 35:12 Speaker 1 How do the specialists actually manage it once it gets to them? Let's say you examine her and there is just a tiny little exposure of mesh visible. 35:20 Speaker 2 The guideline differentiates by size. If it is a very small asymptomatic vaginal exposure, meaning less than 1 centimeter in diameter, and it's not acutely tender, you can legitimately try conservative management first. 35:35 Speaker 1 So topical treatments. 35:36 Speaker 2 Yes, prescribe a course of topical vaginal estrogen cream to promote epithelial growth and just wait and see. Sometimes the healthy tissue will proliferate and completely heal over that small defect. 35:47 Speaker 1 And if it is a large exposure over a centimeter or if it is causing her crippling pain. 35:52 Speaker 2 Then you are entering the territory of surgical removal. But this is where the consultation becomes incredibly difficult and nuanced. The intuitive thought for the patient is just take the plastic out and my pain will go away. You have to explain that it is rarely that simple. 36:05 Speaker 1 Why is removing it so notoriously difficult? 36:07 Speaker 2 Because the mesh was explicitly engineered to permanently integrate into her human tissue, removing it is not like pulling a smooth catheter out. It's like trying to remove chewing gum that has been ground into a shaggy carpet. Oh. 36:21 Speaker 1 Wow, you. 36:22 Speaker 2 Cannot just pull it. You have to meticulously, painstakingly dissect it out of the surrounding muscles, nerves and blood vessels. The surgical risk of causing a massive hemorrhage or permanently damaging the urethra or the bowel during that dissection is very real. 36:36 Speaker 1 And even if you do get it out successfully, does the pain stop? 36:40 Speaker 2 Not always. Sometimes you remove every visible fiber of mesh, but the patient's pain persists completely unchanged because the central nervous system has undergone central sensitization. The pain pathways are permanently rewired. Or you remove the mesh and suddenly her original massive incontinence or prolapse comes back with an absolute vengeance. 36:59 Speaker 1 So the consent for removal must be terrifying. The patient needs to explicitly understand that surgery might not fix the pain and it will likely bring back the original leak. 37:07 Speaker 2 Yes, it is a profoundly difficult conversation, and the guideline notes that sometimes a partial removal, just carefully excising the small exposed segment in the vagina, is surgically much safer and just as clinically effective for symptom relief as attempting a dangerous total radical excision. 37:25 Speaker 1 Which perfectly illustrates why these decisions cannot be made by one rogue surgeon. They absolutely must go through a massive regional MDT with dedicated chronic pain specialist heavily involved. 37:36 Speaker 2 Exactly. You're treating a complex chronic pain patient, not just a structural anatomical defect. 37:41 Speaker 1 Wow. We have covered a truly huge amount of ground today, from the granular minutiae of macrophage pore sizes to the complex psychology of chronic pain syndromes. 37:52 Speaker 2 It is a remarkably dense guideline, but if you step back it follows a very clear logical thread throughout. Safety first, robust evidence based medicine and absolute patient choice. 38:03 Speaker 1 Let's do a rapid fire consolidation to wrap this up for the exam candidates listening on their commute. What are the absolute fails if you don't know them? Points from Ng 123. 38:11 Speaker 2 OK Rapid fire #1 MDTS, you must know the mandatory membership. A pelvic floor physio is mandatory and the local MDTA, pain specialist and psychologist are mandatory in the regional MDT. 38:22 Speaker 1 Got it #2. 38:24 Speaker 2 #2 is urodynamics. Do not perform them for straightforward, uncomplicated primary stress incontinence. Trust your clinical exam site, the value trial if you want to impress the examiner. 38:34 Speaker 1 #3 the surgery hierarchy. 38:36 Speaker 2 SUI surgery retropubic mesh is still an option, but it requires heavy specific consent. The trend opterator tape TOT is out. Native tissue procedures like the Culpo suspension and autologous fascial slings are highly prioritized now. 38:49 Speaker 1 #4 the drugs. 38:51 Speaker 2 OAB Medications always calculate the total anticholinergic cognitive burden, especially in frail elderly women. Use beta 3 agonist like Mirbigran if they are at risk of dementia. 39:01 Speaker 1 #5 the prolapse rules. 39:03 Speaker 2 No synthetic mesh ever for primary anterior or posterior vaginal wall repairs. Native tissue only. 39:09 Speaker 1 And lastly, the governance. 39:11 Speaker 2 The National Registry. If you perform many of these procedures, you must actively consent the patient and record the exact device details into the national database. No data, no surgery. 39:22 Speaker 1 Brilliant summary. As we close out, what is your final kind of philosophical take away from dissecting this document? 39:30 Speaker 2 My biggest take away is that the era of medical paternalism is completely dead in your arch an ecology. This guideline officially mandates shared decision making in your clinical OSC ES. If a standardized patient comes in and you just confidently tell her what operation she's going to have, you will fail the station. 39:46 Speaker 1 You have to act as a guide, not a dictator. 39:48 Speaker 2 Exactly. You have to lay out the entire menu. You have options, you weigh the efficacy against the potential severe risks, and you help her choose what fits her life. Acknowledging the deep uncertainty of long term outcomes is now a mandatory part of a Good clinical consultation. 40:02 Speaker 1 That is a huge professional shift to internalize. Thank you so much for guiding us through the absolute maze that is Ng 123. 40:09 Speaker 2 It was my absolute pleasure. Best of luck to everyone with the revision. 40:12 Speaker 1 And to our listeners, before you go into clinc tomorrow, definitely go onto the NEC website and download their official patient decision aids for S UI and prolapse. They are incredibly well designed and honestly, they make for fantastic Cheat Sheets for structuring your explanations of risks in the exam. We will see you next time on the deep dive. 40:29 Stay curious.