Factors influencing long-term pessary use

Value of pelvic examination in women with pelvic organ prolapse: A systematic review

BACKGROUND

Recent recommendations from the French High Authority of Health on pelvic organ prolapse (POP) management underline the value of a pelvic examination.

OBJECTIVES

The aim of this paper was to analyze the literature and identify the best evidence available regarding pelvic examination for women presenting prolapse-associated symptoms in terms of diagnosis and predictability of treatment success.

SEARCH STRATEGY

The databases were queried similarly using Medical Subject Headings (MeSH) and non-MeSH terms broadly related to pelvic examination and POP management.

SELECTION CRITERIA

We included studies assessing the diagnostic contribution of pelvic examination (correlation with symptoms) and its value for assessing the risk of pessary failure or recurrence after reconstructive surgery.

DATA COLLECTION AND ANALYSIS

We assessed peer-reviewed articles on PubMed, Embase, and Cochrane database up to May 2023. The methodological quality of all the included studies was assessed using the ROBINS-E or RoB2 tools.

MAIN RESULTS

In all, 67 studies were retained for the review. Prolapse-associated symptoms are poorly correlated with POP diagnosis. The symptom that is best correlated with the POP stage is the presence of a vaginal bulge (moderate to good correlation). The factors most strongly associated with the risk of recurrence after surgery or pessary failure are clinical: essentially a higher POP stage before surgery, levator ani muscle avulsion, and vaginal and genital measurements.

CONCLUSIONS

In women complaining of prolapse-associated symptoms, a pelvic examination (vaginal speculum and digital vaginal examination) can confirm the presence of POP and identify risk factors for treatment failure or recurrence after surgical management or pessary placement. A higher stage of POP and levator ani muscle avulsion-discernible on pelvic examination-are major risk factors for POP recurrence or treatment failure. These features must be taken into account in the treatment choice and discussed with the patient.

Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse

PURPOSE

To evaluate long-term continuation rates, adverse events of ring pessary use at a minimum of 5 years follow-up, and factors associated with discontinuation in symptomatic pelvic organ prolapse (POP).

METHODS

Women with symptomatic POP who were treated with vaginal ring pessary and had successful fittings were included. Adverse events and reasons for discontinuation of pessary use were recorded. Patients who were lost to follow-up were defined as discontinuation.

RESULTS

During 12 year-period, 239 of 329 POP patients (72.6%) had successful fittings with ring pessary. The mean age was 67.8 ± 8.9 years (range 27-86) and 70% of patients had advanced stage. The cumulative probability of continued ring pessary use was 84.1%, 64.4%, 49.3%, and 33.5%, at 1, 3, 5, and 10 years, respectively. Most common reason for discontinuation was frequent expulsion (21.6%), followed by vaginal erosion (16.5%), no prolapse improvement (12.4%), and inability or inconvenience to do self-care (9.3%). However, 9 patients (9.3%) had improvement of prolapse and were able to discontinue pessary insertion. Age above 70 years, wide introitus, and incapability of self-care are independent factors associated with long-term discontinuation. Adverse events occurred in 23.4% of patients, 18.8% of them had vaginal erosion, 11.7% vaginal discharge/infection, and 18.4% de novo SUI. However, no statistical significance existed between those who continued and discontinued pessary use due to these adverse events.

CONCLUSION

Ring pessary is an effective treatment in symptomatic POP, with acceptable long-term continuation rates and minor adverse events. Self-care of pessary is very important aiming to minimize adverse events. Advanced age, wide introitus and incapability of self-care were associated factors for long-term discontinuation.

Long-term adherence to pessary use in women with pelvic organ prolapse: A retrospective cohort study

PURPOSE OF THE RESEARCH

Vaginal pessary use is an established, non-surgical treatment option for pelvic organ prolapse. While satisfaction rates are initially high, they seem to decline over time. We aimed to determine the median duration of pessary use among our patients and to evaluate reasons for discontinuation.

METHODS

All patients who were treated with a vaginal pessary for pelvic organ prolapse between 2007 and 2022 at our institution (a maximum observation period of 15 years) were included in this retrospective cohort study. Data were collected from the in-house electronic databases and the date of pelvic floor surgery was defined as the primary endpoint. In case of no documented surgery, the date of the last follow-up visit (for patients lost to follow-up or who discontinued pessary use without subsequent surgery) or the date of final data collection (for those with presumed continued pessary use) was used as the primary endpoint. Duration of pessary use is represented by Kaplan-Meier curves. Effects of possible confounders were investigated by Cox regression models. A Cox regression model was evaluated for patients with the three most common types of pessary: ring, cube and shell. A chi-square test was performed to compare therapy adherence according to pessary type.

PRINCIPAL RESULTS

Data of 779 patients could be included in the statistical analysis. The estimated median duration of pessary use was 173 weeks (95 % CI 104-473) - approximately 3.3 years. Overall, 30 % of patients opted for surgical therapy and the majority of them did so within 4 months of initiation of pessary use (median time: 19 weeks, 95 % CI 16-26). In 5 % of cases a discontinuation of pessary use without subsequent surgery was documented and 18 % were lost to follow-up before a planned visit, thus leaving 47 % of our patients with presumed continued pessary use. Possible confounding factors for discontinuation of pessary use were tested but were found to be non-significant (body mass index, Pelvic Organ Prolapse - Quantification score, pelvic floor training, age, parity, menopausal status, nicotine consumption, incontinence or size of pessary). Reasons for discontinuation of pessary use were documented in 51 % of patients: unspecified patient wish (23 %), pessary use tiredness (10 %), general dissatisfaction with pessary therapy (7 %), unspecified reasons (5 %), pessary self-change not possible (1 %), erosion, bleeding, pain (2 %); none of the pessary types fitted (2 %).

CONCLUSIONS

According to our data, almost half of our patients with pelvic organ prolapse and pessary therapy continued pessary use until a maximum follow-up time of 15 years, whereas about one-third of patients finally opted for surgical repair (a majority of these within 4 months after pessary therapy initiation). The remaining patients were either lost to follow-up or discontinued pessary use without subsequent surgery. The stated reasons for discontinuation of pessary use were mostly non-specific, but only 1 % reported that pessary self-change was not possible. Erosion bleeding or pain was documented in only 2 % of cases as reason for discontinuation. This information helps clinicians to inform their patients with pelvic organ prolapse about expected pessary therapy success and strengthens individual counselling. Furthermore, our data indicates vaginal pessary use for pelvic organ prolapse is feasible and safe for all women and that therapy adherence can extend beyond 5 years.

Complications of Pessaries Amenable to Surgical Correction: Two Case Reports and a Systematic Review of the Literature

BACKGROUND

Forty percent of women will experience prolapse in their lifetime. Vaginal pessaries are considered the first line of treatment in selected patients. Major complications of vaginal pessaries rarely occur.

METHODS

PubMed and Embase were searched from 1961 to 2022 for major complications of vaginal pessaries using Medical Subject Headings (MeSH) and free-text terms. The keywords were pessary or pessaries and: vaginal discharge, incontinence, entrapment, urinary infections, fistula, complications, and vaginal infection. The exclusion criteria were other languages than English, pregnancy, complications without a prior history of pessary placement, pessaries unregistered for clinical practice (herbal pessaries), or male patients. The extracted data included symptoms, findings upon examination, infection, type of complication, extragenital symptoms, and treatment.

RESULTS

We identified 1874 abstracts and full text articles; 54 were assessed for eligibility and 49 met the inclusion criteria. These 49 studies included data from 66 patients with pessary complications amenable to surgical correction. Clavien-Dindo classification was used to grade the complications. Most patients presented with vaginal symptoms such as bleeding, discharge, or ulceration. The most frequent complications were pessary incarceration and fistulas. Surgical treatment included removal of the pessary under local or general anesthesia, fistula repair, hysterectomy and vaginal repair, and the management of bleeding.

CONCLUSIONS

Pessaries are a reasonable and durable treatment for pelvic organ prolapse. Complications are rare. Routine follow-ups are necessary. The ideal patient candidate must be able to remove and reintroduce their pessary on a regular basis; if not, this must be performed by a healthcare worker at regular intervals.

Vaginal Pessary Use and Management for Pelvic Organ Prolapse: Developed by the joint writing group of the American Urogynecologic Society and the Society of Urologic Nurses and Associates. Individual writing group members are noted in the Acknowledgments section

ABSTRACT

Over the past 50 years, pessary use has increased in popularity and has become an essential pelvic organ prolapse (POP) management tool. However, evidence is lacking to define care standardization, including pessary fitting, routine maintenance, and management of pessary-related complications. This clinical consensus statement (CCS) on vaginal pessary use and management for POP reflects statements drafted by content experts from the American Urogynecologic Society and Society of Urologic Nurses and Associates. The purpose of this CCS is to identify areas of expert consensus and nonconsensus regarding pessary fitting, follow-up, and management of pessary complications to improve the safety and quality of care where evidence is currently limited. The American Urogynecologic Society and Society of Urologic Nurses and Associates' vaginal pessary for POP writing group used a modified Delphi process to assess statements that were evaluated for consensus after a structured literature search. A total of 31 statements were assessed and divided into 3 categories: (1) fitting and follow-up, (2) complications, and 3) quality of life. Of the 31 statements that were assessed, all statements reached consensus after 2 rounds of the Delphi survey. This CCS document hopefully serves as a first step toward standardization of pessary care, but the writing group acknowledges that improved research will grow the base of knowledge and evidence providing clinicians a foundation to manage pessary care effectively and confidently.

scRNA-seq reveals aging-related immune cell types and regulators in vaginal wall from elderly women with pelvic organ prolapse

Introduction

In the pathology of pelvic organ prolapse (POP), little is known about the contributing role of pelvic microenvironment. Also, the age-related differences in pelvic microenvironment of POP patients is always ignored. In the present study, we investigated the age-related differences in pelvic microenvironment between Young POP patients and Old POP patients, and the novel cell types and critical regulators which contributes to the age-related differences.

Methods

Single-cell transcriptomic analyses were used to detect the changes in cell composition and gene expression from the pelvic microenvironment of control group (<60 years), Young POP group (<60 years) and Old POP group (>60 years). Then, immunohistochemistry and immunofluorescence were used to verify the novel cell types and critical regulators in the pelvic microenvironment. Furthermore, histopathological alteration and mechanical property alteration in POP with different ages were revealed by vaginal tissue histology and biomechanical testing.

Results

The up-regulated biological process in Old women with POP is mainly related to chronic inflammation, while the up-regulated biological process in Young women with POP is mainly related to extracellular matrix metabolism. Meantime, CSF3+ endothelial cells and FOLR2+ macrophages were found to play a central role in inducing pelvic chronic inflammation. Furthermore, the collagen fiber and mechanical property of POP patients decreased with aging.

Conclusions

Taken together, this work provides a valuable resource for deciphering the aging-related immune cell types and the critical regulators in pelvic microenvironment. With better understanding of normal and abnormal events in this pelvic microenvironment, we provided rationales of personalized medicine for POP patients with different ages.

Rectovaginal Fistula in Women With Pessary for Pelvic Organ Prolapse: A Case Series and Literature Review

OBJECTIVE

In this study, we present a series of 2 cases of rectovaginal fistula (RVF) due to the use of a ring-type pessary in the conservative treatment of pelvic organ prolapse and a literature review on the management of RVF related to the use of pessaries.

METHODS

Two patients were selected from the medical records of the urogynecology service, and their demographic and clinical data were retrieved. An updated literature review was included presenting cases of RVF induced by or after use of a pessary.

RESULTS

Both patients evolved with removal of the pessary and correction of the fistula. The surgical procedures of choice were Le Fort Colpocleisis and posterior colporraphy without major complications. In the literature review, we selected 17 studies with a total of 23 cases reporting RVFs induced or followed by the use of pessaries.

CONCLUSIONS

Although the pessary is commonly indicated for the conservative treatment of pelvic organ prolapse, this device is not exempt from generating complications.

Can we predict continued pessary use as primary treatment in women with symptomatic pelvic organ prolapse (POP)? A prospective cohort study

INTRODUCTION AND HYPOTHESIS

The objective of this study was creating a prediction model for continued pessary use in patients with symptomatic pelvic organ prolapse (POP) and evaluating the percentage of continued pessary use after 12 months.

METHODS

We performed a prospective cohort study in patients with symptomatic POP stage ≥ 2. All patients received a pessary as primary treatment. Factors for continuation were identified from baseline characteristics and data from validated disease-specific quality of life (DSQOL) questionnaires. Univariate and multivariate analyses for predictors were performed and a prediction model was made. Improvement of POP was measured using the Patient Global Impression of Improvement (PGI-I) and DSQOL at 12 months' follow-up. Primary outcome was factors related to continued use. Secondary outcomes were the percentage continued pessary use after 12 months, improvement of complaints and DSQOL.

RESULTS

Two hundred ninety-one patients were included; 184 (63%) patients continued pessary use after 12 months. Factors related to continuation following the univariate analysis were age, sexual activity, POP-Q point c ≥ 0 and obstructive micturition. GH < 4 was not significant but added significantly to the prediction model. After multivariate analysis, age, point c ≥ 0 and GH < 4 cm remained predictors for continuation. The ROC showed an AUC of 0.65 (95% CI 0.58-0.71). PGI-I showed 83% perceived their prolapse complaints much or very much improved.

CONCLUSIONS

Continued pessary use was found in 63%. Main predictors for continued pessary use were higher age, more prominent apical compartment prolapse (c ≥ 0) and a GH < 4 cm.

First-line treatment of pelvic organ prolapse and discontinuation of pessary treatment

INTRODUCTION

The primary objective of this study was to investigate the percentages of women choosing watchful waiting, pessary use or surgery as first-line treatment of pelvic organ prolapse (POP). Second, the rate and cause of discontinuation of pessary use were investigated.

METHODS

A retrospective chart review was conducted on 794 patients referred with POP at a Danish tertiary center for urogynecology at Aalborg University Hospital between 1 January 2014 and 31 December 2015. The following data were registered: age, BMI, previous use of a pessary, total number of births, vaginal births, cesarean sections, previous hysterectomy, prolapse surgery and incontinence surgery, smoking, menopause, sexual status and POP-Q stage in the three vaginal compartments. Pessary treatments were evaluated after 3 months. Additional visits, reason for discontinuation and secondary treatment were noted.

RESULTS

First-line treatment was surgery in 50%, watchful waiting in 33% and pessary use in 17% of patients. Characteristics associated with choosing surgery instead of a pessary were age < 65 years, previous prolapse surgery, prolapse in the anterior or posterior compartment, and POP-Q stage > 2. Characteristics associated with choosing watchful waiting instead of a pessary were age < 65 years and prolapse in the posterior compartment. A total of 33% discontinued pessary treatment within the first 3 months. Discontinuation was associated with age < 65 years, previous hysterectomy and pelvic surgery, and additional visits. Expulsion of the pessary and pain/discomfort were the main causes of discontinuation.

CONCLUSION

This study showed that 50% of patients referred with POP were treated with conservative treatment (watchful waiting and pessary) and thus more women could probably be treated in primary care.

Predictors of successful ring pessary use in women with pelvic organ prolapse

BACKGROUND

Pelvic organ prolapse (POP) is a common chronic health issue. Pessary rings are used for conservative management. To date, there is little evidence on objective anatomical findings as predictors of successful ring pessary management.

AIM

To determine any association between history, clinical and four-dimensional translabial ultrasound (TLUS)/pelvic floor ultrasound examination and pessary success.

MATERIALS AND METHODS

From November 2013 to November 1015, all new patients presenting with symptomatic prolapse to a tertiary urogynaecological unit underwent an assessment including interview, clinical examination, that is, International Continence Society POPQ (pelvic organ prolapse quantification) and TLUS. Women with symptomatic prolapse were offered conservative management with a ring pessary. Those who agreed had a ring inserted that day. Successful trial of pessary use was defined as continued use for at least three months. Retrospective analysis of imaging data was performed blinded to other data. Statistical analysis was performed to assess the relationship between history, examination and imaging and pessary success.

RESULTS

Of 525 patients seen during the inclusion period, 177 had symptomatic prolapse. One hundred and twenty-eight were offered a pessary, 89 accepted. Five had incomplete data, leaving 84. Forty- Two (50%) were still using the pessary at a three-month follow-up. Predictors associated with failure included being pre-menopausal (P = 0.031), a previous hysterectomy (P = 0.051), increasing genital hiatus and perineal body (Gh + Pb) (P = 0.013), posterior compartment prolapse (P = 0.027) and a larger hiatal area on Valsalva on TLUS (P = 0.049). Pre-menopausal status (P = 0.003), increasing Gh + Pb (P = 0.011) and previous hysterectomy (P = 0.001) remained significant on multivariate analysis.

CONCLUSIONS

A history of previous hysterectomy is a predictor of pessary failure as are Gh+Pb on Valsalva and premenopausal status.

A prospective study of pessary use for severe pelvic organ prolapse: 3-year follow-up outcomes

PURPOSE

To estimate the optimal definition of successful pessary use and the long-term success rate of the pessary as well as the complications and factors associated with continued pessary use.

METHODS

Consecutive patients who had symptomatic stage III/IV POP were enrolled. The degrees of POP were assessed by POP-Q. All patients completed the PFIQ-7 questionnaire before pessary use. For the 1-week, 1-month, 3-month, 6-month, 1-year and 3-year follow-up assessments, patients visited the clinic for an examination and to complete the questionnaire. SPSS 18.0 was used for the data analysis. Wilcoxon's signed-rank test was performed to estimate the change in PFIQ-7 scores before and after pessary use. Logistic regression was performed to identify the factors associated with the duration of pessary use.

RESULTS

A total of 60 subjects (average age 68.93 ± 8.98 years) were enrolled. The 3-year success rate of the pessary was 63.33%. The PFIQ-7 score in the 1-month follow-up was significantly decreased (16.22 ± 12.81 vs 1.39 ± 3.39, P = 0.000). During the follow-up, none of the patients experienced any severe complications, and the rate of vaginal erosion was 20% (12/60). The PFIQ-7 score in the 1-month follow-up decreased more than 50% and was associated with continuous pessary use [OR 20.75, P = 0.027, 95% CI (2.28, 189.27)].

CONCLUSIONS

Successful pessary use can be defined as fitting for longer than 3 months. The PFIQ-7 scores should be focused on during the follow-up. The treatment should be changed if the scores decrease less than 50% in the 1-month follow-up.

Vaginal ring pessary use for pelvic organ prolapse: continuation rates and predictors of continued use

OBJECTIVES

The aim of the study was (1) to evaluate continuation rates of vaginal ring pessary for pelvic organ prolapse (POP), and (2) to identify predictors for continued pessary use.

METHODS

This retrospective chart review study was conducted in a tertiary center. Women who had a ring with support pessary successfully fitted between January 2009 and December 2013 and had completed up to 3 years of follow-up care were included in the analysis. Demographic and obstetric data, body weight, pelvic organ prolapse stage, and associated symptoms were evaluated. All the women were followed until February 28, 2017, unless surgery to correct POP surgery was required, pessary use was discontinued, or the women died.

RESULTS

A total of 289 women with symptomatic POP (stages II, III, and IV) were evaluated. The median age was 71 years (range 34-83 y), and the median parity was 3 (range 0-8). Among the women with a successful initial fitting, the failure rate was 5.88% (17/289) at 6 months with most of these women choosing to have surgical intervention. This analysis indicates that the probability of the successful continuation of pessary use after 1, 2, 3, 4, and 5 years was 83.0%, 78.2%, 71.3%, 65.3%, and 61.7%, respectively, reported using a Kaplan-Meier plot. The main cause for discontinuation of pessary use before 3 years was the election for surgical intervention. With regard to predictors for continued pessary use, self-care was the only factor that influenced compliance rates after treatment of 3 years.

CONCLUSION

A ring with support pessary can be used successfully to alleviate symptoms of advanced stage prolapse for 3 years or longer. In addition, proper self-management was found to be a strong predictor for prolonged pessary use.

Managing female pelvic floor disorders: a medical device review and appraisal

Pelvic floor disorders (PFDs) will affect most women during their lifetime. Sequelae such as pelvic organ prolapse, stress urinary incontinence, chronic pain and dyspareunia significantly impact overall quality of life. Interventions to manage or eliminate symptoms from PFDs aim to restore support of the pelvic floor. Pessaries have been used to mechanically counteract PFDs for thousands of years, but do not offer a cure. By contrast, surgically implanted grafts or mesh offer patients a more permanent resolution but have been in wide use within the pelvis for less than 30 years. In this perspective review, we provide an overview of the main theories underpinning PFD pathogenesis and the animal models used to investigate it. We highlight the clinical outcomes of mesh and grafts before exploring studies performed to elucidate tissue level effects and bioengineering considerations. Considering recent turmoil surrounding transvaginal mesh, the role of pessaries, an impermanent method, is examined as a means to address patients with PFDs.

What Are the Clinical Factors That Are Predictive of Persistent Pessary Use at 12 Months?

OBJECTIVE

Urinary incontinence and pelvic organ prolapse are highly prevalent in women and have a significant impact on quality of life. Pessaries are devices that are used as a conservative management option. Many women use pessaries, which avoid surgical intervention with its associated morbidity and cost. However, not all women are good candidates for pessary use. The objective of this study was to determine clinical factors leading to persistent pessary use for incontinence or pelvic organ prolapse in a tertiary care centre at 12 months. Studying patient characteristics for long-term pessary use will contribute to better patient counselling, management, and health resource distribution.

METHODS

This study was a retrospective outpatient chart review of new pessary fittings in patients in a tertiary care urogynaecology clinic between January and June 2014. Any woman over 18 years of age fitted with a pessary at that time was included in the study. All statistical analyses were performed using IBM SPSS Statistics version. 24 (IBM Corp., Armonk, NY) (Canadian Task Force Classification II-3).

RESULTS

A total of 152 women were fitted with pessaries. A multivariable logistic regression analysis found that a patient's diagnosis of prolapse or incontinence (P = 0.01) and a lack of complications (P < 0.0001) were statistically significant for persistent pessary use at 12 months. Patients with prolapse had 7.7 times higher odds (95% CI 1.51-39.35) of using a pessary at 12 months than did patients with incontinence. Patients without complications had 250 times higher odds (95% CI 18.52-2500) of pessary use. Patients who tried two to three pessaries had 16 times higher odds (95% CI 1.80-137.00) of persistent use than patients who trialed just one.

CONCLUSION

This study has found that a lack of complications, the number of pessaries tried, and a primary diagnosis of prolapse are significant factors for continued pessary use at 12 months.

Levator ani muscle avulsion is a risk factor for expulsion within 1 year of vaginal pessary placed for pelvic organ prolapse

OBJECTIVE

The aim of this study was to investigate whether the presence of levator ani muscle (LAM) avulsion is associated with expulsion within 1 year of a vaginal pessary placed for pelvic organ prolapse (POP).

METHODS

This was a prospective observational study of consecutive women with symptomatic POP, who had not received treatment for the condition before the consultation and opted for vaginal pessary placement in our center. Volume acquisition was performed before pessary insertion and offline analysis of the 3D/4D transperineal ultrasound volume data was performed. LAM was assessed on maximum pelvic floor muscle contraction (PFMC) and hiatal dimensions were assessed at rest, on PFMC and on maximum Valsalva. Results were compared between women in whom the pessary was retained for 1 year and those in whom the pessary was expelled within 1 year.

RESULTS

The datasets of 255 women were analyzed including 147 (57.6%) women who had a vaginal pessary continuously in place over 1 year and 108 (42.4%) with pessary expulsion. Mean age was 63.2 (SD, 9.9) years and median parity was 3 (2-4). Eighteen (7.1%) had Stage I, 164 (64.3%) Stage II, 67 (26.3%) Stage III and six (2.4%) Stage IV POP. Women with vaginal pessary expulsion within 1 year had significantly larger hiatal dimensions at rest and on Valsalva, larger hiatal area during rest, PFMC and Valsalva and higher rate of LAM avulsion (53.7% vs 27.2%, P < 0.01) compared with women in whom the pessary was retained for 1 year. After controlling for potential confounders, LAM avulsion remained a risk factor (OR, 3.18, P < 0.01) of vaginal pessary expulsion within 1 year.

CONCLUSIONS

Women in whom a vaginal pessary was expelled within 1 year of placement for POP had a larger hiatus. Presence of LAM avulsion was associated with a three-fold increase in the risk of expulsion of a vaginal pessary within 1 year. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Post-hysterectomy vaginal vault prolapse

Post-hysterectomy vaginal vault prolapse (PHVP) is a recognised although rare complication following both abdominal and vaginal hysterectomy and the risk is increased in women following vaginal surgery for urogenital prolapse. The management of PHVP remains challenging and whilst many women will initially benefit from conservative measures, the majority will ultimately require surgery. The purpose of this paper is to review the prevalence and risk factors associated with PHVP as well to give an overview of the clinical management of this often complicated problem. The role of prophylactic primary prevention procedures at the time of hysterectomy will be discussed as well as initial conservative management. Surgery, however, remains integral in managing these complex patients and the vaginal and abdominal approach to managing PHVP will be reviewed in detail, in addition to both laparoscopic and robotic approaches.

Pessary types and discontinuation rates in patients with advanced pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The aim of this study was to investigate factors associated with long-term pessary use in patients with advanced pelvic organ prolapse (POP).

METHODS

This was a retrospective chart review of patients with POP of stage ≥2 managed with a pessary. Patients were excluded if the date of fitting or follow-up was unavailable. Long-term use was defined as more than 1 year. Patient demographics, pessary fitting, and follow-up visit dates were collected. The primary end point was the duration of use and the prognostic impact of pessary type. Secondary objectives addressed other influencing factors including age, estrogen use, and prolapse stage. The data were analyzed using SPSS version 21.

RESULTS

The final analysis included 311 patients. The mean (± standard deviation, SD) duration of pessary use was 7.0 ± 0.72 years (median 5.7 years). Long-term use was found in 76 % (164) of these patients. Factors associated with longer use were age >65 years (p = 0.004) and estrogen use (p = 0.048). The estimated mean (± SD) durations of use of the Gellhorn, open ring, ring with support, cube and donut pessaries were 10.5 ± 0.7 years, 3.4 ± 0.6 years, 1.8 ± 0.2 years, 1.8 ± 0.3 years and 1.7 ± 0.5 years, respectively. The Gellhorn pessary was associated with significantly longer use than other pessary types (10.5 ± 0.7, p < 0.0000001); this finding was independent of age, prolapse stage, hysterectomy, and vaginal estrogen use.

CONCLUSIONS

In this retrospective analysis, the duration of use was longest with the Gellhorn pessary. Older age and vaginal estrogen use were associated with longer pessary use.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Predictors of unsuccessful pessary fitting in women with prolapse: a cross-sectional study in general practice

Introduction and hypothesis

Pelvic organ prolapse is a common condition. There is inconsistency between predictors of unsuccessful pessary fitting in urological/gynaecological clinics. Research in general practice is scarce. The aim was to estimate the proportion of women in general practice with a symptomatic pelvic organ prolapse and unsuccessful pessary fitting, and to identify characteristics associated with unsuccessful pessary fitting.

Methods

A cross-sectional study in general practice (n = 20) was carried out among women (≥55 years) with symptomatic prolapse (n = 78). Multivariate logistic regression analysis was used to identify predictors of unsuccessful pessary fitting.

Results

In total, 33 women (42 %) had unsuccessful pessary fitting. Factors associated with unsuccessful pessary fitting were age (per year, OR 0.93 [95 % CI 0.87–1.00]), body mass index (per kg/m², OR 1.14 [95 % CI 1.00–1.30]), and having underactive pelvic floor muscles (OR 2.60 [95 % CI 0.81–8.36]).

Conclusions

Pessary fitting was successful in 58 %, indicating that pessary treatment may be suitable for many, but not for all women in general practice with symptomatic prolapse. The condition of the pelvic floor probably plays a role in the success of pessary fitting, as demonstrated by the association with underactive pelvic floor muscles, and body mass index. The association with age may reflect the higher acceptance of conservative treatments for prolapse in older women. This is the first study on predictive factors for unsuccessful pessary fitting in general practice. Therefore, further research should seek to confirm these associations before we can recommend the use of this information in patient counselling.

Effect of vaginal estrogen on pessary use

INTRODUCTION AND HYPOTHESIS

Many providers recommend concurrent estrogen therapy with pessary use to limit complications; however, limited data exist to support this practice. We hypothesized that vaginal estrogen supplementation decreases incidence of pessary-related complications and discontinuation.

METHODS

We performed a retrospective cohort study of women who underwent a pessary fitting from 1 January 2007 through 1 September 2013 at one institution; participants were identified by billing code and were eligible if they were postmenopausal and had at least 3 months of pessary use and 6 months of follow-up. All tests were two sided, and P values < 0.05 were considered statistically significant.

RESULTS

Data from 199 women were included; 134 used vaginal estrogen and 65 did not. Women who used vaginal estrogen had a longer median follow-up time (29.5 months) compared with women who did not (15.4 months) and were more likely to have at least one pessary check (98.5 % vs 86.2 %, P < 0.001). Those in the estrogen group were less likely to discontinue using their pessary (30.6 % vs 58.5 %, P < 0.001) and less likely to develop increased vaginal discharge than women who did not [hazard ratio (HR) 0.31, 95 % confidence interval (CI) 0.17-0.58]. Vaginal estrogen was not protective against erosions (HR 0.93, 95 % CI 0.54-1.6) or vaginal bleeding (HR 0.78, 95 % CI 0.36-1.7).

CONCLUSIONS

Women who used vaginal estrogen exhibited a higher incidence of continued pessary use and lower incidence of increased vaginal discharge than women who did not.

Vaginal pessaries for treatment of pelvic organ prolapse in elderly women

PURPOSE OF REVIEW

Pelvic organ prolapse (POP) is a common clinical condition that is highly prevalent in the geriatric female population. The condition can have substantial negative influence on multiple symptom and quality-of-life parameters. There are various treatment options for POP, including observation, pessary placement, and surgical treatments with either vaginal reconstruction or colpocleisis resulting in vaginal vault closure. This review examines current literature about pessary use for treatment of POP in elderly women.

RECENT FINDINGS

Pessary use appears to be successful for many women and is often associated with improvements in various clinical parameters, including decreased sensation of vaginal bulge and enhanced quality of life. Some patients may experience improvements in bladder or bowel symptoms, although a small percentage may develop new urinary incontinence, constipation, or other defecation problems. Complications of pessary use are generally minor and can usually be successfully treated with targeted therapy such as vaginal estrogen supplementation. Continuity of clinical care is important to help maintain clinical success and prevent potential complications.

SUMMARY

Pessaries are a viable conservative form of treatment for POP for many older women. Pessary use can lead to substantial improvements in quality of life and other clinical outcomes in geriatric patients.

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.

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.

Quality of life in women who use pessaries for longer than 12 months

OBJECTIVES

Pessaries are an effective treatment for pelvic organ prolapse and urinary incontinence; however, few data exist describing long-term pessary use. Our aim was to describe symptom bother and quality of life (QoL) in women using pessaries for urinary incontinence and/or prolapse for at least 12 months.

METHODS

Consecutive women who met inclusion criteria were approached for this observational cross-sectional study. Wilson and Cleary's Health-Related Quality of Life Model guided the inclusion of biologic, functional, and individual factors that impact the health-related QoL. Consenting participants completed a generalized QoL index, the Center for Epidemiologic Depression Symptoms, Medical Outcomes Study Social Support Survey, and condition-specific measures; the Pelvic Floor Distress Inventory (PFDI-20-SF) and the Pelvic Floor Impact Questionnaire.

RESULTS

Fifty-six women, mean age 74.4 years (range, 47-89 years), completed the survey. Mean length of time for pessary use was 4.5 years (1-15 years). Most of the women (n = 31, 55.4%) returned to the clinic for pessary care every 3 months. There was no difference in generalized QoL nor condition-specific total PFDI-20 in women performing self-care versus routine follow-up. Almost one third (29%) of participants reported complications related to pessary use (eg, vaginal erosion), and 41%were considering surgical repair in the near future. Women who were considering surgery had higher PFDI-20 scores relating to more bothersome prolapse symptoms than those not considering surgery (Pelvic Organ Prolapse Distress Inventory 6, 33.91 vs 24.73, P = 0.03).

CONCLUSIONS

Pessaries can be used to control pelvic floor symptoms for extended periods. Complication rates in this study were lower than previously reported, even in women not doing self-care. Not surprisingly, women considering surgical intervention reported greater symptom bother despite pessary use.

Geriatric gynecology: promoting health and avoiding harm

Age increases vulnerability, commonly accompanied by greater reliance on others and susceptibility to maltreatment. Physiologic processes become less resilient; the potential for harm from medical care increases. Awareness of frailty, functional, social, and potential maltreatment issues enables early referrals to help the patient maintain her independence. Health issues that may impede both gynecologic care and self-sufficiency include sensory deficits, physical disability, and cognitive impairment. Speaking slowly and providing contextual information enhance patient comprehension. Cancer screening depends on life expectancy. Osteoporosis treatment requires managing fall risk. Gynecologic symptoms more likely have multiple contributing factors than one etiology. Incontinence is a particularly complex issue, but invariably includes bladder diary assessment and pelvic floor muscle training. Function and frailty measures best predict perioperative morbidity. Communication with the patient, her family, other providers, and health care organizations is an important frontier in avoiding errors and adverse outcomes.

Nonsurgical management of pelvic organ prolapse

Although surgical management of symptomatic pelvic organ prolapse (POP) is common and often necessary, conservative treatments such as pessaries, pelvic floor muscle training, or both can usually result in symptomatic improvement. When treating patients with POP, health care practitioners should focus primarily on identification and alleviation of POP-related symptoms. It is appropriate to offer nonsurgical management to most people with POP. This article reviews the objective and subjective evaluation and nonsurgical management of POP, emphasizing a simple, practical approach to pessary fitting and management.

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.