Specialised Pelvic Floor Services

Clinical Pathways Across the UK and Ireland

Most pelvic floor disorders should be assessed and treated as close to home as possible. Local services should provide assessment, conservative treatment, pelvic health physiotherapy, pessary care and uncomplicated first-line surgery. Referral to a regional pelvic floor MDT is needed when symptoms are complex, treatment has failed, surgery is being repeated, urinary and bowel problems occur together, sacral nerve stimulation is being considered, or a mesh-related complication is suspected. These are the cases where specialised commissioning is most important, because care may be low-volume, high-cost, higher-risk or dependent on concentrated specialist expertise.

The 2021 Pelvic Floor Report and Department of Health guidance on continence services support the same principle: pelvic floor care should function as an integrated pathway, with clear standards, equitable access and coordinated referral routes across community, hospital and specialist services.

NICE guidance (NG210) emphasises prevention, early identification and non-surgical management of pelvic floor disorders. For clinicians, this means assessing symptom impact, offering evidence-based conservative treatment, supporting shared decision-making and escalating when symptoms are complex, persistent, recurrent, painful or resistant to initial management.

When is specialist referral or commissioning is required?

Local services, regional pelvic floor services and mesh complication centres should operate as connected parts of one pathway. This is particularly important when symptoms overlap, previous surgery has failed, or it is unclear whether symptoms are mesh-related. Routine first-line surgical procedures may remain within local pathways. Escalation is needed when surgery is repeat, high-risk, combined with bowel dysfunction, linked to previous mesh, or requires expertise or funding arrangements beyond local services. Within an integrated pelvic floor service, there should be clear pathways that define and allow access to appropriate multidisciplinary expertise.

Within an integrated pelvic floor service, clear pathways should define when patients are managed locally and when they need access to regional, specialist or mesh-related multidisciplinary expertise. These pathways should support timely escalation, shared decision-making and consistent evidence-based care.

NICE Referral Criteria

Specialised complex surgery for urinary incontinence and vaginal or uterine prolapse in women where previous surgery has failed or further repeat surgery is being considered.
Repeat continence surgery, repeat same-site prolapse surgery and complex combined continence and prolapse surgery.
Complex pelvic floor dysfunction involving urinary incontinence, faecal incontinence, rectal prolapse, rectal mucosal prolapse or combined urogynaecology and colorectal surgical input.
Sacral nerve stimulation for faecal incontinence, overactive bladder and urinary retention where national policy criteria, high-cost device funding and prior approval arrangements apply.
Assessment and treatment of mesh complications after surgery for stress urinary incontinence, vaginal prolapse or rectal prolapse, including mesh removal where clinically indicated.

Clinical pathway summary

Provider requirements for hospitals

Hospitals undertaking specialised pelvic floor procedures should be able to demonstrate consultant expertise, MDT decision-making, access to pelvic health physiotherapy and continence nursing, appropriate diagnostics, pain and psychological support, specialist governance and clear links to regional or national centres.

Core requirements include documented referral criteria, MDT review before invasive or repeat procedures, patient information, shared decision-making, formal consent, trained surgical teams, follow-up arrangements, audit, outcome and complication reporting, and compliance with relevant service specifications, device approvals and prior approval processes. For sacral nerve stimulation and other high-cost interventions, clinicians should confirm that national criteria and prior approval requirements are met before treatment, and that funding is agreed for both temporary and permanent devices where applicable.

How commissioning is changing

The Health and Care Act 2022 established Integrated Care Boards (ICB) and enabled the delegation of NHS England’s commissioning functions to local systems. Since then, responsibilities for commissioning primary care and certain specialised services have moved to ICBs.

NHS commissioning is now entering the next phase. Subject to parliamentary approval, from April 2027 most of NHS England’s direct commissioning functions will transfer to ICBs including most specialised services, including all those already delegated. During 2026/27, ICBs will work in partnership with NHS England to lead the commissioning of these services in preparation for full transfer.

Further information regarding theses changes can be found here.

What is TPFS position?

Obviously, it would make sense to have one service specification for the specialised commissioning of all services related to pelvic floor disorders. This must be our aim but there are significant hurdles to overcome before this is achieved. We will continue to work with and advise the Clinical Reference Groups within the Internal Medicine and Women & Newborn National Programmes of Care in order to achieve this goal.

Regional Variation in Commissioning Criteria

England

In England, Integrated Care Boards commission most local pelvic floor services. NHSe retains responsibility for prescribed specialised services, including specialised complex surgery for urinary incontinence and vaginal or uterine prolapse, management of faecal incontinence in adults and designated mesh complication services. Clinicians should manage assessment, pelvic health physiotherapy, pessary care, diagnostics, medicines and uncomplicated first-line procedures through local pathways. Refer to regional or specialised services for repeat or complex continence or prolapse surgery, combined urinary and bowel dysfunction, suspected mesh complications, failed previous surgery or interventions that need to meet national funding criteria such as sacral nerve stimulation.

Scotland

In Scotland, most pelvic floor care is delivered through local NHS Board services. Regional or national specialist arrangements should be used when cases require expertise beyond local provision. Refer for specialist input where there is repeat incontinence or prolapse surgery, combined urinary and bowel dysfunction, suspected mesh-related complications, significant pelvic pain, failed previous surgery or uncertainty about the safest surgical approach.

Wales

In Wales, most pelvic floor care is delivered through Local Health Board services. More complex or low-volume services may be organised through regional or all-Wales arrangements. Clinicians should use local pathways for uncomplicated assessment, conservative care and first-line surgery. Refer for specialist review where surgery is repeat or complex, symptoms involve combined pelvic floor dysfunction, mesh complications are suspected, or multidisciplinary expertise is required.

Northern Ireland

Northern Ireland has an integrated Health and Social Care system, with services planned regionally. Local HSC pathways should be used for routine pelvic floor assessment, conservative treatment and uncomplicated surgery. Specialist referral is most relevant for repeat incontinence or prolapse surgery, combined bladder and bowel dysfunction, suspected mesh complications, sacral nerve stimulation, or cases needing expertise or treatment not available locally.

Republic of Ireland

In Ireland, routine pelvic floor assessment, conservative treatment and uncomplicated surgery are usually managed through local hospital and community pathways, supported by HSE service arrangements. Refer to specialist multidisciplinary services for repeat continence or prolapse surgery, complex pelvic floor dysfunction, significant pelvic pain, combined urinary and bowel symptoms, failed previous surgery or suspected mesh-related complications. Patients with suspected mesh complications should be referred to the HSE National Complex Pelvic Floor Centres at Cork University Maternity Hospital or the National Maternity Hospital in Dublin for multidisciplinary assessment and management.