1. Dr Nicola Adanna Okeahialam, MD, MRCOG
Urogynaecology Subspecialty Trainee
St Mary’s Hospital, Manchester
Clinical Lecturer, Brunel University, London 
nicola.okeahialam@mft.nhs.uk
 
2. Professor Fiona Reid, MD, MRCOG 
Consultant Urogynaecologist 
St Mary’s Hospital, Manchester
fiona.reid@mft.nhs.uk


Introduction

Women presenting with stress urinary incontinence or pelvic organ prolapse face an increasingly complex landscape of treatment options. The doctor–patient relationship in the UK was traditionally guided by a paternalistic model, based on the assumption that doctors were best placed to determine what constituted a patient’s best interests (Sutherland, 2021). However, following the landmark High Court decision in Montgomery v Lanarkshire Health Board [2015], there was a clear shift towards a shared decision-making approach between clinician and patient. This model ensures that patients are able to make informed decisions regarding treatment choice, based on clear, comprehensive information on all available options, together with the associated risks, benefits and uncertainties. Risk is an important concept in this context, as its importance differs between individuals. The notion of material risk is defined as: 
 
‘in the circumstances of the particular case, a reasonable person in the patient's position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would likely attach significance to it’ (Walton, 2020). 
 
Although Montgomery v Lanarkshire Health Board [2015] pertains to obstetrics, its principles are highly relevant in urogynaecology, particularly following the concerns surrounding mesh procedures for stress urinary incontinence and pelvic organ prolapse, and the significant, unrecognised harm resulting from clinicians failing to listen to women’s voices. On 8 July 2020, 2 years after the use of vaginal mesh was paused, the Cumberlege Report was published. This review found that the information provided to patients undergoing vaginal mesh procedures was inadequate, biased, and sometimes misleading, with key risks such as permanence of implants and difficulty of removal frequently not made clear (Cumberlege, 2020). This further reinforces the importance of a transparent, informed consent process in urogynaecology. From a broader societal perspective, there has been a paradigm shift in urogynaecology, through women’s health activism, patient support groups and social media, which all influence the knowledge, expectations and treatment decisions made by the patients of today (Sridhar and King, 2025). 
 
However, obtaining truly informed consent can be challenging. Patient understanding is a key factor, particularly as comprehension and health literacy directly affect this process (Ownby et al, 2015). Health literacy has been shown to be lower in individuals from an ethnic minority background, those living in socially deprived areas and those with a limiting health condition or disability (Simpson et al, 2020). Although there is limited evidence specifically evaluating the effect of health literacy on obtaining informed surgical consent, lower health literacy is associated with poorer adherence to preoperative instructions (De Oliveira et al, 2015) and poor postoperative outcomes, such as increased length of hospital stay (Wright et al, 2018). However, despite this, in urogynaecology even women with high health literacy may have a poor understanding of pelvic floor disorders (Anger et al, 2012). 


Patient knowledge and understanding

Ensuring that clinicians and patients share a common language and level of understanding is essential, as this alignment significantly reduces distress, and improves rapport, communication and treatment compliance (Williams and Ogden, 2004). However, women’s basic anatomical knowledge of the female external genitalia is poor. A questionnaire-based study of 191 patients attending a general outpatient or urogynaecology department at a UK teaching hospital (El-Hamamsy et al, 2022) found that when shown a diagram of the external female genitalia, only 9% of participants could correctly label all key anatomical structures including the vagina, anus, labia, clitoris, urethra and perineum. Furthermore, only 53% of participants understood (or partially understood) pelvic organ prolapse. A greater knowledge of vulval and pelvic anatomy was strongly associated with better understanding of pelvic organ prolapse. 
A diagnosis of pelvic organ prolapse requires women to have symptoms related to the ‘downward displacement’ of a pelvic organ, such as a ‘vaginal lump/bulge’ or ‘pelvic pressure’ (Haylen et al, 2010). However, common patient misconceptions surrounding pelvic organ prolapse include an overemphasis on the bladder as the sole cause of symptoms (Kiyosaki et al, 2012) and belief that urinary incontinence is a direct symptom of pelvic organ prolapse (El-Hamamsy et al, 2022). Table 1 highlights symptoms that patients thought were associated with pelvic organ prolapse (El-Hamamsy et al, 2022), with only 35% of women describing vaginal bulge. There is still considerable work to do in the speciality to improve the knowledge and understanding of women seeking treatment for stress urinary incontinence and pelvic organ prolapse. 
 

Treatment decisions 

It is estimated that by the age of 80 years, 1 in 10 women will undergo surgery for urinary incontinence or pelvic organ prolapse (Fialkow et al, 2008), with 30% requiring further surgery for symptom recurrence (Olsen et al, 1997). Owing to a lack of clear superiority between treatment options for pelvic organ prolapse and stress urinary incontinence, the decision about which surgical procedure will be carried out is a ‘preference sensitive’ decision, taking into account a patient’s values, goals and preferences (Cox, 2019). An evidence-based practice approach (Sackett et al, 1996) should be used to integrate patients’ values and preferences with the best available clinical evidence and clinical expertise. Figure 1 describes how these factors can guide and influence evidence-based practice, considering institutional factors such as protocols and resource availability.

In 2019, the National Institute for Health and Care Excellence (NICE) introduced patient decision aids, to be used as an adjunct by clinicians to support and enhance discussions regarding surgical options for stress urinary incontinence, uterine prolapse and vaginal vault prolapse (NICE, 2019). Table 2 highlights the surgical procedures described in the relevant NICE patient decision aids. Across other surgical specialties, patient decision aids have been shown to be valuable tools as they significantly improve patient knowledge, manage expectations and guide patients in determining what matters most to them with respect to risk. They also have a positive effect on communication between patients and the clinician (Stacey et al, 2024).

A qualitative study of 30 patients (Athey et al, 2025) showed that although the patient decision aids were considered to be lengthy, potentially limiting accessibility for patients with learning difficulties, 90% recommended that the aids were included in routine clinical care. Moreover, a mixed methods cohort study of 100 women (Bugeja et al, 2025) found that the patient decision aids were associated with high patient certainty regarding treatment decision, as measured by the validated Decision Conflict Scale (O’Connor, 1995). This effect was more pronounced with vaginal vault prolapse, as the associated interquartile ranges for stress urinary incontinence and uterine prolapse were wider, suggesting potential decision conflict among some women. Reduced decision conflict is an important reported benefit of the patient decision aid, as decision conflict has been demonstrated on meta-analysis (Sun, 2004) to increase the odds of post-decision regret, defined as ‘distress or remorse after a healthcare decision’ (Brehaut et al, 2003), approximately six-fold. 
 

Surgical decision making 

Decision making is a complex process. From the surgeon’s perspective a number of factors impact patient counselling and ultimately treatment decisions regarding surgery. These include clinical experience and expertise, surgical training institution, institutional protocols, resource availability, risk aversion and patient characteristics such as age and comorbidities (Gunaratnam and Bernstein, 2018; Anandan and Sivakumar, 2020). 
Table 1. Patient responses to ‘What do you think the symptoms of prolapse are?’
Reproduced by permission from El-Hamamsy et al (2022)
Response N (%)
Bulge symptoms 34 (35.4)
Incontinence 14 (14.6)
Urinary incontinence 8 (8.3)
Faecal incontinence 1 (1.0)
Pain 24 (25.0)
Discomfort 12 (12.5)
Bleeding 7 (7.3)
Sex life disturbance 3 (3.1)

 

Figure 1. Evidence-based medicine (EBM) triad

Table 2. Surgical procedures included in patient decision aids for the National Institute for Health and Care Excellence (2019) guidance 
  Surgical options
Condition Uterine preserving Non-uterine preserving
Uterine prolapse Vaginal sacrospinous hysteropexy with sutures Manchester repair Sacrohysteropexy with mesh Vaginal hysterectomy
Vaginal vault prolapse Sacrospinous fixation of vault Sacrocolpopexy with mesh
Stress urinary incontinence Bulking agents Colposuspension Rectus fascial sling Retropubic mesh tapes

 
Qualitative research evaluating the role of the clinician in the decision-making process regarding surgery for stress urinary incontinence (Cox, 2019) found that both patient characteristics and clinician preferences were significant influencing factors. Patient characteristics that influenced clinicians’ interpretation of procedural benefits and risk included clinical characteristics such as age, body mass index, medical comorbidities, symptom severity, impact on quality of life and the presence of co-existing pelvic organ prolapse or urethra hypermobility. Clinician preferences influencing decision making included surgical familiarity and procedural preference, risk aversion, institutional resource availability and individual interpretation of clinical evidence. Overall, this can lead to a difference in counselling despite patient decision aids. 
 
It is important to note that clinician preferences may also influence surgical technique and outcomes. This was highlighted in the Variation in Surgical Technique study (VaST) (Fairclough et al, 2024) which demonstrated that in anterior pelvic organ prolapse surgery, differences in fascial dissection (Figure 2), fascial repair and vaginal skin closure techniques affected both subjective (measured using the Pelvic Organ Prolapse Symptom Score (POP-SS)) and objective outcomes (assessed using POP-Q measurement Ba at 12 months). 



Figure 2. Photographic illustrations of the methods of fascial dissection. A. Superficial dissection. B. Deep dissection. C. Fascial flap dissection. Reproduced by permission from Fairclough et al (2024).
 

Patient decision making

The risks and benefits of surgery are valued differently by patients. Therefore, it is vital that thorough discussion of the likelihood of a potential outcome occurring is explained in a clear and understandable way, taking into account the patient’s values and personal context. Table 3 details the risks outlined by the British Society of Urogynaecology and the Royal College of Obstetricians & Gynaecologists for procedures offered to treat stress urinary incontinence and pelvic organ prolapse, including colposuspension and vaginal hysterectomy. 
Table 3. Risks associated with colposuspension and vaginal hysterectomy. Adapted from British Society of Urogynaecology (2018), Royal College of Obstetricians & Gynaecologists (2009)
Procedure Level of risk Examples
Colposuspension (British Society of Urogynaecology, 2018) Serious or less frequent risks
  • Damage to bladder/urinary tract – one woman in every 100–200 (uncommon)
  • Difficult bladder emptying requiring intermittent self-catheterisation – one woman in every 100 (uncommon)
  • Bleeding (rare)
  • Infection (including wound, deep pelvic infection, urine infection or chest infection) – five to thirteen women in every 100 (common)
  • Venous thrombosis – fewer than one woman in every 100 (uncommon)
  • Long-term urinary retention requiring intermittent self-catheterisation – one woman in every 100 (uncommon) 
  • Problems with internal permanent stitches (rare)
  Frequent risks
  • Difficulty passing urine – one woman in every 10 (common)
  • Overactive bladder – 17 women in every 100 (very common)
  • Prolapse – one woman in every seven (very common)
  • Pain during sexual intercourse – one woman in every 20–50 (common)
Vaginal hysterectomy (Royal College of Obstetricians & Gynaecologists, 2009) Serious risks
  • Damage to bladder/urinary tract – two women in every 1000 (uncommon)
  • Damage to bowel – five women in every 1000 (uncommon) 
  • Excessive bleeding requiring transfusion or return to theatre – two women in every 100 (common) 
  • New or continuing bladder dysfunction (variable – related to underlying problem) 
  • Pelvic abscess – three women in every 1000 (uncommon) 
  • Failure to achieve desired results; recurrence of prolapse (common) 
  • Although venous thrombosis (common) and pulmonary embolism (uncommon) may contribute to mortality, the overall risk of death within 6 weeks is 37 women in every 100 000 (rare)
  Frequent risks
  • Urinary infection, retention and/or frequency 
  • Vaginal bleeding 
  • Postoperative pain and difficulty and/or pain with intercourse 
  • Wound infection

There is a paucity of data evaluating what matters most to women regarding surgical treatment for stress urinary incontinence and pelvic organ prolapse. A qualitative analysis from the LATITUDE multicentre observational study (Dwyer et al, 2020) including 212 women undergoing a procedure to treat primary stress urinary incontinence found that treatment efficacy and surgical invasiveness were the most commonly selected important factors reported to contribute to decision making (25%). This was followed by surgical recovery (21%), risk of complications (12%), use of mesh (11%), the clinician obtaining consent (9%), media influence (6%), a perceived ‘treatment ladder’ with regards to invasiveness and availability of alternatives should the treatment fail (6%) and aversion to general anaesthesia (4%). 
 
With regards to surgical management of pelvic organ prolapse, an Italian prospective observational study including 222 women (Ferrari et al, 2024) found that factors including a lower perceived risk of surgical complications and the option of a uterine-sparing approach increased the likelihood of opting for surgical management over conservative management three-fold. Only one study has compared surgical procedures for pelvic organ prolapse specifically, looking at sacrospinous hysteropexy and Manchester repair (Schulten et al, 2023). This multicentre study including 137 women demonstrated that, in those undergoing a sacrospinous hysteropexy, important risks influencing decision making included treatment success, dyspareunia and buttock pain. However, with Manchester repair, only dyspareunia was a significant factor. 
 
The NICE (2019) patient decision aid aims to explore patient values and material risks and allow the patient to choose what matters most to them. Table 4 shows the aspects of the patient decision aid where potential outcomes unique to the individual can be identified. 

Table 4. Aspects of the patient decision aids that can be used to identify what is important to the individual patient. Adapted from National Institute for Health and Care Excellence (2019)
Stress urinary incontinence Uterine prolapse Vault prolapse
How troublesome my symptoms are now How troublesome my symptoms are now How troublesome my symptoms are now
How effective the options might be at improving my symptoms How effective the options might be at improving my symptoms How effective the options might be at improving my symptoms
The length of time I would have to spend in the hospital recovering Keeping my uterus (womb) The length of time I would have to spend in the hospital recovering
My plans for pregnancy in the future My plans for pregnancy in the future Risks from any kind of surgery
The possibility of complications from mesh surgery The length of time I would have to spend in the hospital recovering The possibility of complications from mesh surgery
The possibility of damage to other organs Risks from any kind of surgery The possibility of constipation or other bowel problems
The possibility of pelvic organ prolapse The possibility of complications from mesh surgery The possibility of leaking urine, problems emptying my bladder properly or other problems urinating
The possibility of problems emptying my bladder properly of other problems urinating The possibility of damage to other organs The possibility of pain or other problems having sex
The possibility of pain or other problems having sex The possibility of constipation or other bowel problems The possibility of pain in the pelvis or buttocks
The possibility of pain in the pelvis The possibility of leaking urine, problems emptying my bladder properly or other problems urinating  
  The possibility of pain or other problems having sex  
  The possibility of pain in the pelvis or buttocks  
A study of 40 women with stress urinary incontinence using a patient decision aid (Ong et al, 2019) showed that the factor deemed most important when requesting colposuspension or autologous fascial sling was efficacy, whereas recovery time was prioritised in those considering urethral bulking. In those declining those treatments, factors frequently reported as influencing this decision included recovery, risk of self-catheterisation and perceived lack of efficacy. 
 
A further aspect that may influence women’s preferences relates to the risk of bladder or urinary tract injury. Although uncommon, such injuries can lead to vesicovaginal fistula. This is a rare outcome, affecting one in 3861 women in the UK after vaginal hysterectomy (Hilton, 2012), and is associated with considerable morbidity and psychosocial consequences (Alio et al, 2011). Vesicovaginal fistula formation is not explicitly captured within current patient decision aids. However, taking into account the Montgomery v Lanarkshire Health Board [2015] principles, the potential for such an outcome may represent a material risk, depending on an individual’s circumstances and values. This highlights the need for clinicians to supplement patient decision aids with tailored counselling to ensure all risks of significance to the patient are explored, even when not directly documented within the patient decision aid. 
 

Conclusions

Shared decision making in urogynaecology should be a collaborative process in which clinicians support patients to reach an informed and preference-sensitive decision regarding treatment. This approach integrates the clinician’s expertise with the best available evidence, a clear explanation of the associated risks and benefits and, importantly, the patient’s individual goals, values and beliefs.

Table 1 is reproduced from El-Hamamsy et al (2022) and Figure 2 is reproduced from Fairclough et al (2024) by kind permission of the publishers.

Practice points 

  • Always assess baseline anatomical understanding; start from the patient’s level.
  • Document discussions on what matters most to the patient.
  • Present success rates and risks as ranges and with real numbers.
  • Offer all options clearly and without bias.
  • Screen for external influences (media, misinformation).

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