Pelvic organ prolapse (POP) is a common non-life-threatening disease affecting more than half of adult women and may impact women’s everyday activity and quality of life [1]. Clinical practice guidelines guide physicians on clinical decision-making and management [2].  However, variations in national and international guidelines may result in variations in clinical practice. The objective of this study was to systematically evaluate the quality of guidelines on the management of POP using the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument.

Literature searches were conducted on medical databases and organisations’ websites to identify national and international guidelines on the assessment and treatment of POP. Five authors independently assessed guidelines using the validated AGREE II tool. Its six domains include 1) scope and purpose, 2) stakeholder involvement, 3) rigor of development, 4) clarity of presentation, 5) applicability, and 6) editorial independence [3].

Eight national and international guidelines met inclusion criteria (NICE, ACOG, AAGL, RCOG/BSUG, AWMF, AUGS, French, and Mexican). 313 recommendations were identified and arranged into seven clinical practice domains: 
1- Diagnosis of POP: 70 recommendations, with four recommendations featuring in all guidelines, including assessment of POP based on personal history, physical examination, objective assessment using the Pelvic Organ Prolapse Quantification system (POP-Q) and consideration of imaging studies; 2- Conservative management for POP: 29 recommendations, with pelvic floor muscle training and vaginal pessaries recommended in all included guidelines; 3- Surgical management for POP: 112 recommendations, with patient’s detailed counseling, treating only symptomatic POP cases, consideration of apical fixation during surgical treatment and use of biological or synthetic implants in the recurrent cases appearing in all guidelines.
4- Alternative treatments for POP: 62 recommendations, 
5- Perioperative recommendations: 7 recommendations, 
6-Follow-up management: 3 recommendations,
7- Management of complications: 30 recommendations. 

199 recommendations were comparable across guidelines. 31 recommendations were not supported by research evidence.  
The highest median scores were in the domains “Scope and Purpose” and “Rigor of Development”. The lowest median score was for “Applicability” (28.3%). Although the median score of “Editorial Independence” was high (85.4%), variability was also substantial (IQR 12.5–100). The NICE guideline achieved the highest rating in the overall quality assessment.  None of the guidelines was developed with the involvement of women with POP.

Diagnosis and treatment recommendations appear variable.  Applying principles of the AGREE II during guideline development would probably assure that high-quality evidence is considered, and the process implemented meets specific standards.

Variations in quality and deficiencies in certain areas, especially “Applicability” and “Editorial Independence” were identified. Improvements in these critical domains may enhance the quality and clinical impact of clinical practice guidelines. Quality assessment tools help and support to add scientific weight to recommendations to assist clinicians’ everyday practice. Patients must be involved in guideline development.

De Boer TA, Salvatore S, Cardozo L, et al. Pelvic organ prolapse and overactive bladder. Neurourol Urodyn. 2010;29(1):30-39. doi:10.1002/nau.20858
Berg AO, Atkins D, Tierney W. Clinical practice guidelines in practice and education. J Gen Intern Med. 1997;12(S2):S25-S33. doi:10.1046/j.1525-1497.12.s2.4.
Brouwers MC, Kho ME, Browman GP, et al. Development of the AGREE II, part 2: assessment of validity of items and tools to support application. Can Med Assoc J. 2010;182(10):E472-E478. doi:10.1503/cmaj.091716