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Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

Female genital cosmetic surgery, Gynaecology (626)

Objectives

To provide guidance to health professionals involved in the care of those requesting surgery to change the appearance of their vulva

Audience

Healthcare professionals working in primary and secondary care involved in the care of individuals with a vulva

Please report any inaccuracies or issues with this guideline using our online form

Female genital cosmetic surgery (FGCS) describes a group of surgical procedures designed to change healthy female genitalia for perceived improvement in cosmetic appearance (1).  Labiaplasty is the most common FGCS procedure, and describes a surgical procedure involving partial removal and reduction in the size of the labia minora.  Commonly, there will be reduction bilaterally to both labia minora, but may also be carried out to reduce asymmetry when one is longer than the other. Removal or reduction of the clitoral hood may also be performed ‘hoodectomy’.

Other FGCS procedures include vaginaplasty, liposuction of the labia majora, fat injection to the labia minora and mons pubis, hymenal reconstruction, hair transplantation, and laser therapy. (2)

Why is FGCS requested?

The reasons that FGCS are requested are often to alleviate perceived functional discomfort, improve appearance and increase self-esteem.  It is thought there is pressure on those with a vulva to appear ‘neater’, with a younger, pre-pubescent look being more desirable (3).  Vulvodynia (pain without a clear identifiable cause) is not an indication for FGCS.

What is a normal Vulva?

The size range and symmetry of the adult labia shows a wide variation. It is often useful to support a patient presenting with concerns and discuss the range of ‘normality’. The RCOG ethical paper opinion outlines clinicians have a duty of care to provide this information (1).

It is also essential to discuss the anatomy of the vulva including demonstrating the mons pubis, labia majora, minora, clitoris and hood, urethra, vaginal vestibule, perineum and perianal areas (1). A recent study suggesting up to 40% of patients are unable to correctly identify genital structures, with implications for health care seeking and shared decision making (4).

Useful tools and patient information

Implications of FGCS

The implications of FGCS can stem from unrealistic expectations, with many women being disappointed with the outcome.  Surgery can be marketed as helping urinary function and sexual functioning, however there is a lack of high quality evidence.

Additionally, there can be scarring affecting functioning and appearance.  Importantly, there can be issues with residual pain, change in sensation and altered sexual functioning.  In the short term there can be complications with wound dehiscence (up to 30%) and infection (1).

When can FGCS be offered?

Overall, FGCS should be considered as medically non-essential surgery.  The RCOG recommends   that FGCS should not be undertaken within the NHS unless it is medically indicated, and should not normally be offered to individuals below 18 years of age, due to continued anatomical development during puberty. 

All surgeons who undertake FGCS must be aware that the procedure may be prohibited unless it is necessary for the patient’s physical or mental health, and they must take appropriate measures to ensure compliance with the FGM Acts. (5)

As such, within Greater Glasgow and Clyde Health Board, FGCS is not offered as a cosmetic only procedure.

Exceptions may include where surgery is medically necessary and secondary to another underlying medical conditions.  Examples may include

  • Anatomical Implications secondary to genital Cancer
  • Significant congenital malformations e.g. secondary to congenital adrenal hyperplasia
  • Repair after significant trauma, e.g. secondary to severe adhesions from Lichen Sclerosus

Referrals

Referrals should initially be made to general gynaecology.

Links to educational and supportive information as above should be made available to patients and those working in primary care prior to review in clinic.

The RCOG recognises that often, the ‘desire for labial reduction is a type of displacement for other forms of anxiety or lack of feelings of self-worth, and thus whether counselling may be more appropriate than surgery’.  To this end, psychology referral should be considered in primary care prior to referral to gynaecology.

The patient may then be seen by any gynaecologist. If that gynaecologist is of the opinion that there are no abnormalities of the external genitalia, and there is no evidence of a dermatosis requiring treatment, then the patient should be reassured and discharged from gynaecology.

Women should be directed to the information above if they have not already accessed.  Advice should be regarding general vulval care.

Where surgery may be required (see indications above), an opinion and/or input from the Plastic Surgery Service may be required. Where there are complications arising from previous FGCS, plastic surgery should be involved and consideration given to clinical photography as part of clinical notes.

Editorial Information

Last reviewed: 14/11/2023

Next review date: 31/10/2027

Author(s): Claire Higgins.

Version: 2

Approved By: Gynaecology Clinical Governance Group

Document Id: 626