RCOG policy positions set out our views and recommendations on the key areas for change across NHS and Government policy to improve women’s health and care. They are made available on our website so that women, RCOG Members and Fellows, other healthcare professionals and wider stakeholders working in women’s health can also view them. If you are interested to hear more about our policy work, you can email email@example.com.
Apply a life course approach to pelvic floor health
Policymakers and those responsible for the design and delivery of services should apply a life course approach to improve women’s pelvic floor health and reduce symptoms of pelvic floor dysfunction.
Improve education on pelvic floor health from a young age
The UK Government and devolved administrations should work towards ensuring that young people receive education around pelvic floor health as part of a comprehensive Relationships and Sex Education (RSE) curriculum.
Ensure access to information about pelvic floor health throughout the life course
Across the UK, Governments should prioritise creating a central, trusted online hub for high-quality information on pelvic floor and why it is important to support women to maintain good pelvic floor health. The provision of high-quality information and support around pelvic floor health in the postnatal period is particularly important.
Improve access to early intervention support and services
Policymakers should outline plans to improve access to early intervention support for women to reduce their risk of future pelvic floor dysfunction. This should include improving access to postnatal pelvic floor support for all women including guidance for maternity professionals in supporting those at greatest risk of future pelvic floor dysfunction, introduction of the Obstetric Anal Sphincter Injury (OASI) care bundle across NHS maternity services, and ensuring access to conservative treatments and support for pelvic floor dysfunction in primary and community care settings throughout the life course.
Maximise opportunities across the health service to provide women with support and information about pelvic floor health
Improving education on pelvic floor health of all healthcare professionals across the system is vital to delivering this ambition.
Timely access to specialist urogynaecology services should be available for all women and people who require them. The NHS and governments across the UK must address the unequal growth of gynaecology waiting lists seen in recent years and set out concrete actions to increase staffing numbers across all key professional groups to meet future demand with a fully funded, long-term plan for the NHS workforce.
You can download a PDF version of our position statement below.
The pelvic floor consists of a group of muscles and ligaments that support the pelvic organs (bladder, bowel and uterus, which is sometimes referred to as the womb). Problems associated with these muscles are called pelvic floor dysfunction, which means the pelvic floor muscles around the bladder, anal canal (rectum) and vagina do not work properly. The three most common and definable symptoms of pelvic floor dysfunction are urinary incontinence, anal incontinence and pelvic organ prolapse (1). Other symptoms listed as associated with pelvic floor dysfunction by the National Institute for Health and Care Excellence (NICE) include emptying disorders of the bladder and the bowel, sexual dysfunction and chronic pelvic pain.
Urinary incontinence is defined as any involuntary leakage of urine (2). The reported commonness of urinary incontinence in women varies widely amongst different studies and is likely to be under-reported due to many women experiencing embarrassment or not knowing where to seek help. One study showed the prevalence of urinary incontinence amongst women at 39.9%. (3) Incontinence is a common symptom that can affect women of all ages, with a wide spectrum of severity and nature.
Anal incontinence is an inability to control bowel movements and is another common symptom of pelvic floor dysfunction. A recent study showed that 14.2% of respondents experienced anal incontinence 6 months after their first delivery, and 13.7% experienced anal incontinence six years after their first delivery (4). OASI is a significant risk factor in the development of anal incontinence (5).
Pelvic organ prolapse is when one or more of the organs in the pelvis slip down from their normal position and bulge into the vagina. This could be the uterus, bowel, bladder or the top of the vagina itself. Prolapse can cause discomfort, and for some women can have a significant impact on their quality of life. In primary care in the UK, 8.4% of women reported vaginal bulge or lump, and on examination prolapse is present in up to 50% of these women (6).
Symptoms of pelvic floor dysfunction can have a huge impact on an individual’s quality of life, and women have shared stories about how symptoms have prevented them from taking part in work, having a social life, impacted their relationships and as a result had a negative impact on their mental health and wellbeing (7). Studies have shown a strong association between urinary incontinence and poor quality of life (8), and clinical guidelines note that symptoms of pelvic organ prolapse (including a vaginal bulge, urinary, bowel and sexual symptoms, and pelvic and back pain) affect women’s quality of life (9).
The economic cost of pelvic floor dysfunction is significant. Studies in Sweden and America have shown that urinary incontinence alone accounts for 2% of healthcare budgets. This does not account for the additional personal costs individuals are likely to incur, such as purchasing continence products. When symptoms mean women have to stop or cut down their hours at work, this will have an impact on their financial wellbeing and that of their families. It is also likely to have a negative impact on the economy through losses to the workforce.
The RCOG recognises that services and support for pelvic floor dysfunction will be accessed by women, gender diverse individuals and people whose gender identity does not align with the sex they were assigned at birth. We believe we must at all times be appropriate, inclusive and sensitive to the needs of everyone.
A life course approach to women’s health designs services around women’s predictable long-term reproductive and post-reproductive healthcare needs and interactions with the health system, and aims to maximise the benefits of prevention and early intervention to improve outcomes. The RCOG has set out the importance of a life course approach to women’s health in our Better for Women report.
There are huge opportunities to improve women’s pelvic floor health by applying a life course approach and placing women at the centre of service design. This means a focus on ensuring girls and women have timely, evidence-based education and information about pelvic floor health, focusing on prevention, improving access to early intervention services and support, and making use of every appropriate contact to give women the information and support they need.
Ensuring women and people have access to high-quality education and information about pelvic floor health is crucial in supporting them to make informed choices. Women need to know how to reduce the modifiable risks associated with pelvic floor dysfunction, and what lifestyle changes they can make to improve their pelvic floor health. This includes maintaining a healthy weight and regular exercise, reducing or stopping smoking, and regularly doing pelvic floor exercises correctly from a young age. Information is also important in raising awareness of symptoms of pelvic floor dysfunction, so women know what to look for and how to seek help from a healthcare professional if they are concerned. However, research shows that many women are not well informed about their pelvic floor, and how to maintain good pelvic floor health.
Polling commissioned by the RCOG found that 88% of UK adult women know what the pelvic floor is, leaving over one in ten who indicated they do not. This increases to nearly one in five in women aged 18-34, which is particularly concerning given that the average age of mothers giving birth in England and Wales is 30.9 years (10). The polling also indicated that a quarter of UK adult women (24%) have never done pelvic floor exercises, and this rises to 29% in women aged 18-34. When asked about confidence in doing pelvic floor exercises, a third of women (33%) indicated they did not feel confident. Older women felt more confident than younger women, with only just over half (55%) of women aged 18-34 feeling confident.
In strategies and plans to improve women’s health in England, Scotland and Wales, the importance of high-quality information provision to improve women’s health outcomes is prioritised. The Women’s Health Strategy for England highlighted the need for more trusted and easier to understand information regarding a range of women’s health issues including gynaecological conditions. The women’s health plan in Wales and the strategy in England both commit to improving and promoting RSE around key areas of women’s health, and this should include teaching all students from a young age about pelvic floor health. This will help ensure that all girls and women better understand their bodies, are informed of where and when to get help and feel confident to talk about their health, reducing stigmas around symptoms like incontinence. The UK Government and devolved administrations should work towards ensuring that young people receive education around pelvic floor health as part of a comprehensive RSE curriculum.
Across the UK, Governments should prioritise creating a central, trusted online hub for high-quality information on pelvic floor and why it is important, to support women to maintain good pelvic floor health. In Scotland, as part of the action around the women’s health plan, NHS Inform now hosts a women’s health platform that provides information on key reproductive life stages. The Women’s Health Strategy for England committed to working with NHS Digital to improve the information on women’s health on the NHS website. Recent RCOG polling showed that over half (57%) of women selected the NHS website as the top source they would turn to for information about pelvic floor health, and polling for our 2019 Better for Women report found that 85% of women think the NHS website is a reliable source of information (11). Women’s health information hubs across all four nations should include comprehensive information on pelvic floor health, with information and support around lifestyle changes and symptoms associated with pelvic floor dysfunction. Information should also be tailored to key life stages that impact women’s pelvic floor health, including pregnancy and the menopause. Videos and free access to apps that support pelvic floor health, such as the Squeezy App, would also allow women to pick a format to access information that best suits them.
Providing women with information about maintaining good pelvic floor health and recognising symptoms at key reproductive life stages is important. Women and people should feel confident in knowing how to reduce their risk of pelvic floor dysfunction, and understand when they should speak to a healthcare professional about concerning symptoms. This is particularly important in the postnatal period, when many women expect to experience some level of leaking following the birth of their baby. The provision of high-quality information and support in the postnatal period is crucial to ensure women seek support as early as possible for symptoms of pelvic floor dysfunction. Healthcare professionals should use key opportunities in the postnatal period, including when women leave hospital and at their 6-week postnatal check, to provide information and support around pelvic floor health.
As set out in our Better for Women report, women have predictable reproductive health needs across the life course which mean they require regular interactions with health professionals. These interactions should be used as opportunities, wherever appropriate, to inform and support women around pelvic floor health throughout the life course, from an early age. This is particularly important at key life stages where the onset of pelvic floor dysfunction is common, such as during pregnancy and the postnatal period and during and following the menopause.
As part of our recent polling, we asked women whether they had ever been spoken to by anyone in the NHS about their pelvic floor or about pelvic floor exercises, and the majority (69%) of women had not. This demonstrates missed opportunities, as we know that when women have the right information about how to maintain a healthy pelvic floor, they can make tangible changes to their lifestyle to prevent the onset or worsening of symptoms associated with pelvic floor dysfunction.
Recent polling showed that, of those who had experienced symptoms caused by a weak pelvic floor, under half (47%) sought help from a healthcare professional, and one in eight of those who did seek help waited over a year to do so. One population-based study showed that despite 40% of respondents suffering urinary incontinence, only 17% sought professional help (12).
Within existing interactions with the healthcare system, there are many opportunities for healthcare professionals to inform and support women to maintain good pelvic floor health. Women have lots of engagement with the health system throughout their lives, including when accessing contraception, for cervical smears and breast screening, at primary care appointments, and during interactions with midwives both ante and postnatally. During existing interactions with the health system, women should be given information about how to maintain good pelvic floor health, as well as information on symptoms of pelvic floor dysfunction, and advice and signposting on what to do if they experience symptoms.
We strongly support the recommendation in the NICE guideline that pelvic floor dysfunction should be included in the syllabus for healthcare professionals such as trainee nurses, physiotherapists, doctors and midwives. Many midwives feel that they would benefit from a better understanding of pelvic floor muscle training (PFMT) in their training and improved support in delivering PFMT more effectively (13). The NHS across all four nations should work with universities and professional bodies to look at how best to ensure the appropriate inclusion of pelvic floor dysfunction in undergraduate and postgraduate training.
Many women develop symptoms of pelvic floor dysfunction during or after pregnancy and childbirth, and risks differ for different modes of birth, alongside other obstetric risk factors. The 2021 NICE evidence review of risk factors for pelvic floor dysfunction identified evidence for risk factors, but notes there is no current guidance regarding the women who are at greatest risk or the interventions that could reduce that risk (14). Such guidance would support healthcare professionals to identify and support women to have a clearer understanding of their individual risk, and provide them with information and access to early intervention services where appropriate. Studies are ongoing to develop tools to predict and communicate with women their risk of future pelvic floor dysfunction (15). National NHS bodies should consider developing guidance to support maternity professionals to identify and support women at greatest risk of future pelvic floor dysfunction, so they have the information and access to services they require antenatally and postnatally to best reduce their modifiable risk factors.
In order to prevent or reduce the symptoms associated with pelvic floor dysfunction, women should be able to access support to maintain good pelvic floor health following pregnancy and birth, and in particular where they are identified as being at higher risk. There is work ongoing to improve access to postnatal pelvic floor health services across the UK, including a commitment by NHS Wales to create new pelvic health care pathways to ensure women have access to physiotherapy and other conservative treatments before surgery is considered (16). In England, the NHS Long Term Plan committed to improving postnatal physiotherapy by ensuring all women have access to multidisciplinary pelvic health clinics and pathways, with clinics providing training and support for local clinicians working with women, such as GPs and midwives (17). In June 2021, NHS England announced plans for pelvic health clinics to be rolled out across England, starting with 14 areas of the country, with a commitment to have services in every part of the country by March 2024 (18). Pathways to ensure all women are able to access postnatal pelvic floor services should be rolled out in the NHS across all four nations, and the RCOG supports the ambition of the roll out of perinatal pelvic floor services in England. Learning and best practice from pilot sites should be shared through a central network, and built into the planned service specification.
OASI is a significant risk factor for pelvic floor dysfunction, with long-term complications including difficulty controlling the bladder and bowel, as well as chronic pain and painful intercourse (19). The RCOG OASI Care Bundle is a set of evidence-based interventions likely to improve outcomes when implemented together. All NHS maternity services across the UK should adopt the OASI Care Bundle, to reduce the incidence of anal incontinence.
Alongside improved support during the perinatal period, access to support to maintain good pelvic floor health should be available throughout women’s lives. Women should be able to access conservative treatments for pelvic floor dysfunction through primary care, such as pessary fittings and access to pelvic floor physiotherapy. This could be delivered through women’s health hubs in primary or community settings, removing barriers to women accessing care. Early intervention is particularly important before, during and after the menopause, when there is an increased risk of pelvic floor dysfunction.
For most women who experience pelvic floor dysfunction, self-management or access to conservative treatments outside of specialist settings can effectively manage their symptoms. For women who need to access specialist services, it is essential that they are able to access high-quality, timely care from a local multi-professional team (20).
The role of the multi-professional team in urogynaecology services is shown to be effective and offers advantages including dynamic links between disciplines, appropriate and timely investigations and referrals, and better coordination of patient-centered care (21). In light of this, adequate investment in recruitment, retention and training of all professional groups working within the service is essential to ensure that women receive the right care, from the right professional, at the right time. Many of the professional groups that make up the multi-professional team are already experiencing significant shortages in available staff, and will be unable to meet predicted future demand.
Despite an ageing population making the demand for urogynaecology services likely to continue to increase, the RCOG 2022 workforce report identified that the number of doctors starting the urogynaecology Advanced Training Skills Modules (ATSM) and the number of doctors completing sub-specialty training (SST) in urogynaecology has fallen by 35% over the last five years. There are currently just 89 subspecialists in urogynaecology trained in the UK (22). The UK Government and devolved administrations should set out plans to expand SST training posts in urogynaecology, and establish SST centres for urogynaecology in regions where there is no access to training.
The RCOG is currently undertaking a Government-funded project to develop a tool to calculate the number of obstetricians required across England and the devolved nations to provide safe, personalised maternity care (23). Governments across the UK should make funding available to broaden the scope of this project to consider future requirements for the gynaecology workforce. This will be crucial to understand future training requirements across the specialty, recognising the interdependencies between obstetrics and gynaecology, and the likelihood of consultants working across both.
Pelvic health physiotherapists make up an essential part of the workforce needed to provide care and support for women around pelvic floor health, as well as other interventions to support good gynaecological health. They are important both as part of multi-disciplinary teams in secondary and tertiary care, and in community and primary care services. The number of pelvic health physiotherapists working across the UK does not meet current or future demand and investment is needed to increase the pipeline of specialists. Despite there being growth in the number of registered physiotherapists, vacancies in the NHS remain significant and more needs to be done to encourage registered physiotherapists to work in the NHS. The RCOG supports the Chartered Society of Physiotherapy recommendations for addressing broader workforce challenges in NHS physiotherapy (24).
Specialist teams should also include an urogynaecology, urology or continence specialist nurse (25). This requires national workforce planning to invest in developing and funding pathways for specialist nursing and a pipeline of general adult nurses to train as specialists. With over 46,000 vacancies for registered nurses in the NHS as of June 2022 (26) (over one in 10 roles) there must be significant action to increase the wider nursing workforce to ensure there is a pipeline for specialist training.
The NHS across all four nations must respond to the growing crisis in NHS workforce numbers, with a fully funded, long-term plan, which sets out concrete actions to increase numbers of all professional groups to meet demand. This should include setting out and providing adequate funding support for training pathways to increase numbers of specialist nurses in continence care and urogynaecology services, specialist midwives and pelvic floor physiotherapists.
For women for whom non-surgical interventions have not reduced symptoms of pelvic floor dysfunction, NICE guidelines set out best practice around surgical procedures which should be offered to women, as well as signposting to decision aids to support women to make informed choices about their options for surgery (26). For women who choose to undergo surgery, access should be equitable and timely.
RCOG’s 2022 report Left for too Long uncovered the unequal growth of elective waiting lists in gynaecology across the UK, compared to other specialties. In England, the waiting list for gynaecology services saw a 106% increase between April 2018 and April 2022. The report found that urogynaecological services were particularly impacted by the pandemic. Surveys and interviews with RCOG members identified a strength of feeling that urogynaecological services had seen the brunt of cuts to planned care created by the pandemic. Between 2019/20 and 2020/21, planned admissions for prolapse fell by 62% and planned admissions for incontinence by 61%, compared to falls of around 55% or less for other gynaecological conditions.
‘Left for too Long’ identified a set of barriers to increasing capacity in gynaecology, which aligned with barriers impacting elective care more widely; access to theatre capacity, staffing (particularly nursing staff in theatres and wards), and availability of beds. The report also identified additional barriers for gynaecological services in the lack of prioritisation they are given in decisions made around distribution and rationing of existing and additional capacity in theatres and wards. The low incidence of serious adverse events associated with urogynaecological conditions, along with societal normalisation of conditions like incontinence in women, has contributed heavily to this lack of prioritisation.
The RCOG continues to call on governments and the NHS to implement the recommendations set out in the Left for too Long report. This should include a review of the current approach to prioritisation of care, to take into account the impact on quality of life of many gynaecological conditions, and ringfenced budgets for recovery in gynaecology services that addresses the unequal growth compared to other specialties. The disproportionate impact on urogynaecology services even within elective gynaecology more broadly must also be addressed.