Factors which influence the short-term success of pessary management of pelvic organ prolapse

An integrative review and severity classification of complications related to pessary use in the treatment of female pelvic organ prolapse

INTRODUCTION

Pessary use is the preferred non-surgical treatment option for female pelvic organ prolapse. As pessaries can be used chronically to alter pelvic floor anatomy, consideration of short-and long-term complications is important in patient management. We systematically reviewed articles describing the complications of pessary use to determine frequency and severity.

METHODS

A systematic search via MEDLINE and PubMed using the key terms "complications," "pessary," "pelvic organ prolapse," "side effects" was conducted for the years 1952 to 2014 inclusively. Selected articles cited in the publications identified were also considered. Only full-text material published in English was reviewed. All pessary-related complications described were collated; overall frequency within case reports and case series were calculated and severity was graded using the Clavien-Dindo classification.

RESULTS

In total, 61 articles met the inclusion criteria. The most common complications reported were vaginal discharge/vaginitis, erosion, and bleeding. Complications were related to pessary shape and material, and duration in situ. Clavien-Dindo classification of complication severity found that all 5 grade levels were attributed to pessary use; serious grade 4 and 5 complications included cancer, adjacent organ fistula and death.

CONCLUSION

There are few detailed reports of complications of pessary use relative to the estimated frequency of pessary use worldwide. Prospective studies documenting complications by shape, material, and size, and objectively classifying complication severity are required. As serious grade 4 and 5 complications of pessary use occur, further development of clinical follow-up guidelines for long-term pessary users is justified.

Outcomes of vaginal hysterectomy and constricting colporrhaphy with concurrent levator myorrhaphy and high perineorrhaphy in women older than 75 years of age

OBJECTIVES

We performed constricting anterior and posterior colporrhaphy, levator myorrhaphy, and high perineorrhaphy with concurrent hysterectomy, and investigated the intraoperative complications, and short-term outcomes of these constricting procedures in patients aged 75 years or older.

METHODS

We searched our hospital database for cases, between January 2011 and January 2014, of women aged over 75 years who underwent surgery for pelvic organ prolapse of stage 2 or higher, via vaginal hysterectomy, constricting anterior and posterior colporrhaphy, levator myorrhaphy, and high perineorrhaphy, with or without treatment of urinary incontinence. All volunteers were evaluated via pelvic examination using the pelvic organ prolapse quantification system, the modified Decision Regret Scale-Pelvic Floor Disorders form, the Satisfaction Decision Scale-Pelvic Floor Disorders form, and the Pelvic Floor Distress Inventory form.

RESULTS

Fifty-four patients were included in the study. The mean follow-up time was 24.4 months after constricting surgery (range: 8-44 months). There were four cases (7%) of de novo urge incontinence (the symptoms resolved upon prescription of anticholinergic medication). Two patients developed de novo stress urinary incontinence after the procedure and were treated via transobturator sling surgery using Safyre T(®) polypropylene monofilament slings. No anatomical or subjective recurrence of prolapse was noted during the follow-up period. No patient required additional surgery for recurrence of prolapse.

CONCLUSION

Constricting anterior and posterior colporrhaphy, levator myorrhaphy, and high perineorrhaphy with concurrent hysterectomy is a feasible, safe, and effective surgical option in elderly patients at low anesthesiological risk. The decision to perform an incontinence procedure should be individualized based on preoperative findings after prolapse reduction.

A nationwide survey concerning practices in pessary use for pelvic organ prolapse in The Netherlands: identifying needs for further research

Introduction and hypothesis

To identify practice variation in management of patients with a vaginal pessary for pelvic organ prolapse (POP).

Methods

A nationwide survey was sent to all Dutch gynecologists with a special interest in urogynecology.

Results

The response rate was 59 %. Of the respondents, 13 % had a written protocol for pessary treatment in their department. Pessary treatment was proposed by 69 % of respondents as a treatment option. Counseling about side effects varied. All respondents provided information concerning the possibility of serious vaginal discharge. Concerning this side effect, 15 % of the respondents stated that it occurs in 5 – 20 % of patients, 27 % that it occurs in 20 – 40 % of patients, and 57 % that it occurs in more than 40 % of patients. Another item concerned counseling for the likelihood of vaginal blood loss. All respondents provided information concerning the possibility of vaginal blood loss. Concerning this side effect, 53 % of the respondents stated that it occurs in 5 – 20 % of patients, 33 % that it occurs in 20 – 40 %, and 14 % that it occurs in more than 40 % of patients. Follow-up after initial placement was done by 69 % of the respondents at 2 – 6 weeks, by 2 % at 8 weeks, and by 29 % at 12 weeks or more. Most (98 %) of the respondents extended the interval between visits when the patient had no complaints, and 96 % of the respondents reported that they routinely instruct patients about self-management.

Conclusions

Pessaries are suggested as a treatment option by a majority of gynecologists, but practice varies widely. We consider that the variation in practice is due to a lack of available protocols and lack of evidence.

Patterns of pessary care and outcomes for medicare beneficiaries with pelvic organ prolapse

OBJECTIVES

Using a national data set, we sought to assess patterns of pessary care in older women with pelvic organ prolapse (POP) and subsequent outcomes, including rates of complications and surgical treatment of POP.

METHODS

Public use files from the US Centers for Medicare and Medicaid Services were obtained for a 5% random national sample of beneficiaries from 1999 to 2000. Diagnostic and procedural codes (International Classification of Diseases, Ninth Revision, Clinical Modification and Current Procedural Terminology, 4th Edition) were used to identify women with POP and those treated with pessary. Individual subjects were followed longitudinally for 9 years. Across this duration, patient care and outcomes (eg, return clinic visits, repeated pessary placements, complications, and rate of surgical treatment of prolapse) were assessed.

RESULTS

Of 34,782 women with a condition diagnosed as POP, 4019 women (11.6%) were treated with a pessary. In the initial 3 months after pessary placement, 40% underwent a follow-up visit with the provider who had placed the pessary, and through 9 years after the initial fitting, 69% had such a visit. During this period, 3% of the subjects developed vesicovaginal or rectovaginal fistulas, and 5% had a mechanical genitourinary device complication. Twelve percent of women underwent surgery for POP by 1 year; with 24% by 9 years.

CONCLUSIONS

Pessary can be effectively used for the management of POP in older women. Despite this, a low percentage of Medicare beneficiaries undergo pessary fitting. Lack of continuity of care is associated with a small but unacceptable rate of vaginal fistulas.

Urogenital consequences in ageing women

Various anatomical, physiological, genetic, lifestyle and reproductive factors interact throughout a woman's life span and contribute to pelvic floor disorders. Ageing affects pelvic floor anatomy and function, which can result in a variety of disorders, such as pelvic organ prolapse, lower urinary tract symptoms, dysfunctional bowel and bladder evacuation, and sexual dysfunction. The exact mechanisms and pathophysiological processes by which ageing affects pelvic floor and lower urinary and gastrointestinal tract anatomy and function are not always clear. In most cases, it is difficult to ascertain the exact role of ageing per se as an aetiological, predisposing or contributing factor. Other conditions associated with ageing that may co-exist, such as changes in mental status, can result in different types of pelvic floor dysfunction (e.g. functional incontinence). Pelvic organ dysfunction may be associated with significant morbidity and affect quality of life. These groups of patients often pose difficult diagnostic and therapeutic dilemmas owing to complex medical conditions and concurrent morbidities. In this chapter, we summarise the current evidence on the management of pelvic floor disorders, with emphasis on elderly women and the associations between the ageing process and these disorders. Clinicians with an understanding of the affect of ageing on the pelvic floor and lower urinary and gastrointestinal tract anatomy and function, and the complex interplay of other comorbidities, will be able to investigate, diagnose and treat appropriately there women. A holistic approach may result in substantial improvements in their quality of life.

The cube pessary: an underestimated treatment option for pelvic organ prolapse? Subjective 1-year outcomes

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) is a common condition. The use of pessaries for conservative management of POP is widespread. However, there are little data on the use of cube pessaries. The aim of our study was to evaluate whether self-therapy with the use of vaginal cube pessaries in women with POP can be a well-tolerated, first-line treatment.

METHODS

In a prospective case series, 87 women who suffered from symptomatic POP, stages II-IV, were instructed in self-treatment with a vaginal cube pessary. Differences were analyzed using Wilcoxon's rank sum test or Fisher's exact test.

RESULTS

A pessary could be fitted in 84/87 patients (96.6%); 6 women were lost to follow-up. The remaining 78 patients (92.9%, median age 60 years) completed the study. Sixteen women (20.5%) chose not to continue with the pessary treatment. For these patients, general well-being decreased from a median numeric rating score (NRS) of 4.5 (3-6) to 2.0 (1-3, p < 0.001). In those who continued treatment, general well-being increased from a median NRS of 3.0 (2-5) to 8.0 (7-10, p < 0.001) after 1 year of use. The majority of patients (53) in the present study rated pessary self-care use as "very easy" or "easy" (85.5%). The Patient Global Impression of Improvement (PGI-I) was 2.0 (1-3) at follow-up examination. There were no complications or adverse effects of pessary use.

CONCLUSIONS

Conservative self-treatment with vaginal cube pessaries might be a feasible treatment option for women who suffer from POP.

Quality of Life Questionnaires for the Assessment of Pelvic Organ Prolapse: Use in Clinical Practice

Over the past decade, the use of quality of life (QOL) questionnaires in the evaluation of pelvic organ prolapse (POP) has become a standard part of most clinical studies. Investigators have attempted to correlate QOL scores with objective findings and treatment efficacy and as outcome measures in comparing different treatment modalities. Many of the QOL questionnaires are available in short forms, making them easier to adapt to clinical settings. This article includes an overview of several validated QOL questionnaires and their application in studies whose results provide useful guidelines for health care professionals who diagnose and manage women with POP.

Symptoms, quality of life, and factors affecting women's treatment decisions regarding pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

We performed an investigation of symptoms, quality of life (QOL), and factors affecting women's treatment choice of pelvic organ prolapse (POP).

METHODS

Three hundred and eight women presenting with POP were assessed by Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact Questionnaire (PFIQ), Short Form-36 (SF-36), Pelvic Organ Prolapse Quantification (POP-Q) system, and urodynamic studies. Treatment was arranged according to each woman's preference after counseling. Factors affecting treatment choice were evaluated. Descriptive statistics, chi-square or Fisher exact test, analysis of variance (ANOVA) test, and logistic regression analysis were used.

RESULTS

Patients had high prevalence of urinary, prolapse, and bowel symptoms. Their QOL was impaired, with Urinary Impact Questionnaire (UIQ) higher than the Pelvic Organ Prolapse Impact Questionnaire (POPIQ) score and lower SF-36 score compared with the population norm. Logistic regression analysis indicated that complication from vaginal pessary, urodynamic stress incontinence (USI), stage of prolapse, and Pelvic Organ Prolapse Distress Inventory (POPDI) scoring were factors for choosing surgical treatment.

CONCLUSIONS

Women with POP had great symptomatic distress and impaired QOL. Complication from vaginal pessary, USI, stage of prolapse, and POPDI scores were factors increasing the likelihood of the patient choosing surgical treatment.

Pessary treatment for pelvic organ prolapse and health-related quality of life: a review

Pessaries have been used to treat women with pelvic organ prolapse (POP) since the beginning of recorded history. This review aims to assess the effect of pessary treatment on the disease-specific, health-related quality of life in women with pelvic organ prolapse. After a Medline search using the Mesh term ‘pessary’ and critical appraisal, 41 articles were selected and used in this review. Pessaries are widely used to treat pelvic organ prolapse. It is minimally invasive and appears to be safe. Although there is evidence that the use of pessaries in the treatment of pelvic organ prolapse is effective in alleviating symptoms and that patient satisfaction is high, the follow-up in many published papers is short, and the use of validated urogynaecological questionnaires is limited. Comparison with surgical treatment of pelvic organ prolapse is rare and not assessed in a randomised controlled trial.

Pessary use and management for pelvic organ prolapse

Pessary is a low-risk and effective non-surgical treatment option for pelvic organ prolapse. Indications for pessary include symptomatic prolapse, if surgery is not desired or recommended, and use as a diagnostic tool to predict surgical outcomes. Evidence for pessary selection and management is incomplete so trial and error, expert opinion, and experience remain the best guides for use and management of the pessary. With proper training and understanding of pessary management, most patients can be successfully fitted and taught to manage the pessary either for short- or long-term relief of symptoms. Patient satisfaction is high making pessary an important tool in treating prolapse.

Factors influencing long-term pessary use

INTRODUCTION AND HYPOTHESIS

We aimed to identify factors contributing to successful pessary use for over 1 year.

METHODS

A chart review was conducted composed of 150 women at Montefiore Medical Center, using a pessary for over 1 year. Characteristics of those who continued pessary usage were compared with those who discontinued use by using Chi-square, Fisher's exact test, logistic regression model, receiver-operator characteristic curve, and Kaplan-Meier survival curves.

RESULTS

Thirty-five women (23%) discontinued using pessaries (DP) after a year, while 115 women (77%) continued (CP). There was no difference in multiple characteristics. The DP group had more patients with stress incontinence, p = 0.17. Older age at pessary insertion showed higher continued use (OR = 1.083, CI: 1.033-1.136). Patients with a history of prolapse repair surgery were more likely to discontinue pessary use.

CONCLUSIONS

Age greater than 72 years was associated with continued pessary use and history of hysterectomy or prolapse surgery, and stress incontinence were associated with discontinuation.

Incontinence pessaries: size, POPQ measures, and successful fitting

Introduction and hypothesis

The aim of the study was to determine whether successful incontinence pessary fitting or pessary size can be predicted by specific POPQ measurements in women without advanced pelvic organ prolapse.

Methods

In a multicenter study, women with stress urinary incontinence (SUI) and POPQ stage ≤2 were randomized to three treatment arms: (1) incontinence pessary, (2) behavioral therapy, or (3) both. This study evaluates incontinence pessary size, POPQ measures, and successful fitting in the 266 women assigned to treatment arms 1 and 3.

Results

Two hundred thirty-five women (92%) were successfully fitted with an incontinence ring (n = 122) or dish (n = 113). Hysterectomy, genital hiatus (GH), and GH/total vaginal length (TVL) ratios did not predict unsuccessful fitting (p > 0.05). However, mean TVL was greater in women successfully fitted (9.6 vs. 8.8 cm, p < 0.01). Final pessary diameter was not predicted by TVL, point D, or point C (p > 0.05).

Conclusions

The vast majority of women with SUI can be successfully fitted with an incontinence pessary, but specific POPQ measures were not helpful in determining incontinence pessary size.

Effect of pessary use on genital hiatus measurements in women with pelvic organ prolapse

OBJECTIVE

To compare the size of the genital hiatus in women wearing a pessary for pelvic organ prolapse after consistent pessary use, describe characteristics of patients who continue use, and assess change in pelvic floor symptoms.

METHODS

This was an observational cohort study of 90 women seeking nonsurgical management of symptomatic prolapse. Our primary outcome was change in genital hiatus (in centimeters) after 3 months of consistent pessary use. Pelvic floor symptoms were assessed with the Pelvic Floor Distress Inventory. Change in genital hiatus measurements and Pelvic Floor Distress Inventory scores were assessed using a paired Student t test. Between-group differences were evaluated using the Student t, Mann Whitney U, and Fisher exact tests, where appropriate. Logistic regression was used to assess baseline characteristics predictive of continued pessary use.

RESULTS

The average (+/-standard deviation) age of participants enrolled was 62.8 +/-13.2 years. Median parity was 3, and 87.7% were postmenopausal. Forty-two (47%) continued pessary use at 3 months. After 2 weeks, there was a decrease in the size of the genital hiatus measured with strain from 4.8+/-1.6 cm to 4.1+/-1.2 cm, P<.001, which persisted at 3 months (3.9+/-1.1 cm, P<.001). The greatest change occurred with the Gellhorn pessary. Baseline Pelvic Organ Prolapse Quantification system point Aa was positively associated with continued pessary use at 3 months, and perineal body at rest was negatively associated.

CONCLUSION

After 3 months of pessary use, genital hiatus size decreased significantly. Pessary use results in significant anatomic changes to the genital hiatus in patients with pelvic organ prolapse.

Practicalities and Pitfalls of Pessaries in Older Women

Pelvic floor disorders are known to increase with age. With the number of elderly women more than doubling in the coming decades, gynecologists will need to be skilled in the assessment and treatment of these conditions. Conservative forms of therapy such as pessaries can often be successfully employed. These devices are well suited for elderly patients as they are noninvasive with minimal risk, provide immediate relief of symptoms, and are cost-effective compared with surgery. Although there are some downsides in using pessaries in clinical practice, many of these pitfalls can be appropriately addressed with education and training of clinician and patients.

The PESSRI study: symptom relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries

OBJECTIVE

The aim of this randomized crossover trial was to compare symptom relief and change in life impact for women using the ring with support and Gellhorn pessaries.

STUDY DESIGN

Subjects were randomized to use each pessary for 3 months. Outcome data included a visual analog satisfaction score, and quality of life questionnaires. Analysis included student's t-test, Wilcoxan Signed-rank test and logistical regression.

RESULTS

Subjects were primarily white, parous, postmenopausal women with a mean age of 61. The median POPQ stage was III. We enrolled 134 subjects and collected 3-month data on 94 ring and 99 Gellhorn subjects. There were statistically and clinically significant improvements in the majority of the PFDI and many PFIQ scales with both pessaries, but no clinically significant differences between the two pessaries.

CONCLUSIONS

The ring with support and Gellhorn pessaries are effective and equivalent in relieving symptoms of protrusion and voiding dysfunction.