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

Exploring Clinicians' Willingness to Embrace Customizable Pessaries: A Survey Study in the USA

INTRODUCTION AND HYPOTHESIS

This study surveyed urogynecologists and Advanced Practice Providers (APPs) in the USA to gauge their interest and willingness to embrace customizable pessaries as a viable treatment option. We hypothesize that clinicians might be interested in using customizable pessaries in their practice.

METHODS

A cross-sectional survey was conducted among urogynecologists and their APPs who fit pessaries to gain insights into their experiences with standard pessaries and perspectives on the value and feasibility of customizable devices. The survey was distributed through email lists associated with women's health and pelvic floor disorders and gathered data on the difficulty in fitting pessaries and the perceived advantages of integrating customizable options into clinical practice.

RESULTS

There were 122 participants, including 76 physicians and 46 APPs. Thirty-five percent of clinicians advocated for pessaries as a first-line therapy for pelvic floor disorders. APPs were more inclined to recommend pessaries as a primary therapy than physicians (p < 0.01). Fifty-three percent of providers reported occasional difficulties, and 12% reported frequent difficulties fitting patients with standard-shaped pessaries. APPs were significantly more likely to encounter fitting issues due to pessary shape (p = 0.023). Clinicians suggested additional practices, such as modifying pessaries to enhance retention in patients with an enlarged genital hiatus, shortened vaginas, or apical narrowing.

CONCLUSIONS

This study indicates that clinicians are inclined to incorporate customizable pessaries into their treatment protocols for pelvic floor disorders, emphasizing the need for continued innovation in pessary customization that prioritizes a patient-centric approach to pelvic floor disorder management.

Long-Term Self-Management of Vaginal Cube Pessaries Can Improve Sexual Life in Patients with Pelvic Organ Prolapse, Results from a Secondary Analysis

INTRODUCTION AND HYPOTHESIS

Currently, little is known about how daily self-management of cube pessaries influences sexual function. We hypothesized that removing the cube pessary prior to sexual activity did not negatively influence the sexual function, and pessary self-care did not lead to a deterioration of sexual wellbeing.

METHODS

We conducted a planned secondary analysis of a prospective cohort study in which 214 patients with symptomatic pelvic organ prolapse (stage 2+) were enrolled (2015). Each patient was size fitted with a cube pessary and completed a questionnaire online or by phone ≥ 5 years after her initial fitting. Changes in quality of life were measured using the Patient Global Impression of Improvement (PGI-I).

RESULTS

Of the 143 women included in our analyses, 92 (64.3%) were sexually active during the study period. These patients (73.9%; 68 out of 92) described their sexual wellbeing as "better" or "much better" than their pretreatment status. Sexually active patients had a better quality of life as measured by the PGI-I than the sexually inactive patients. Of the sexually active patients, 91.3% (84 out of 92) described their condition as "better" or "much better" than their pretreatment status, whereas 84.3% (43 out of 51) of the sexually inactive patients reported the same improvement. Over 90% of sexually active patients reported that removal of the vaginal cube pessary before sexual activity is not disruptive.

CONCLUSIONS

The overwhelming majority of the patients with symptomatic pelvic organ prolapse using daily self-management of cube pessaries reported that removal of the vaginal cube pessary before sexual activity is not disruptive, and its use was accompanied by improved sexual wellbeing.

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.

Location and motion of vaginal pessaries in situ in women with successful and unsuccessful pessary treatment for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The objective was to compare the location and motion of pessaries between women with pelvic organ prolapse (POP) with a successful (fitting) and unsuccessful (non-fitting) pessary treatment on dynamic magnetic resonance imaging (dMRI).

METHODS

A cross-sectional exploratory study of 15 women who underwent a mid-sagittal dMRI of the pelvic floor at rest, during contraction and during Valsalva with three different types of pessaries. The coordinates of the pessaries cross section, inferior pubic point (IPP) and sacrococcygeal junction (SCJ) were obtained and the location (position, orientation) and the motion (translation and rotation) were calculated. Differences between the groups and between the pessaries within the groups were compared.

RESULTS

Nine women with a fitting pessary and 6 women with a non-fitting pessary were selected. In the non-fitting group, the pessaries were positioned more caudally and rotated more in clockwise direction and descended more, but not significantly, during Valsalva compared with the fitting group. The Falk pessary was positioned more anteriorly in the fitting group and more cranially in the non-fitting group compared with the ring and ring with support pessary.

CONCLUSIONS

A non-fitting pessary was positioned more caudally at rest; on Valsalva, it rotated more clockwise and moved more caudally, suggesting that the dynamic characteristics of the pessary might play an important role in its effectiveness. Findings of this study serve as a basis for the development of new pessary designs.

Toward Patient-specific Pessary to Manage Pelvic Organ Prolapse: Design and Simulation

This study proposed a novel design and personalized approach to developing an intra-vaginal device, also known as a pessary, for the treatment of Pelvic Organ Prolapse (POP). Although POP is likely to have a more diverse dynamic than other health conditions in women, it is currently treated as a "one-shape-fits-all" problem in all cases. Pessaries are conservative devices inserted into the vagina to support its internal structure and predominantly come in a ring shape design. Failure rates as high as 50% within the first year of use have been attributed to the poor design of these pessaries; with symptoms such as irritation, bleeding, and lacerations felt by most users. To address this problem, a new base shape design was proposed and its deformation was examined using Finite Element Analysis (FEA). Based on the anatomical measurements of each patient, the base design can be adjusted accordingly. To demonstrate the effectiveness of the proposed design, a comparative study was conducted with the most commonly used support pessary, also known as the ring pessary. In order to model the large deformation of the pessaries, the hyperelastic constitutive law (Yeoh model) was fitted to the available stress-strain data of SIL 30 (a silicone urethane resin supplied by Carbon Inc.). The results showed that re-directing the reaction forces of the pessary towards the lateral walls, supported by the pelvic bones, could decrease the overall displacement of the pessaries, and provide effective symptomatic relief thereby, delaying or preventing surgical procedures.Clinical relevance- There is a clear clinical need to develop a more effective conservative therapy for managing POP. The personalized pessaries proposed in this paper can be an effective method for providing symptomatic relief and avoiding displacement, compared to the currently available devices on the market. Made-to-measure for each patient, the devices are anatomically suited and can be adjusted throughout a patient's treatment plan to allow for higher compliance and overall success rate.

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.

An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders

AIMS

The terminology of obstetric pelvic floor disorders should be defined and reported as part of a wider clinically oriented consensus.

METHODS

This Report combines the input of members of two International Organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA). The process was supported by external referees. Appropriate clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 12 main rounds of internal and 2 rounds of external review was involved to exhaustively examine each definition, with decision-making by consensus.

RESULTS

A terminology report for obstetric pelvic floor disorders, encompassing 357 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it usable by different specialty groups and disciplines involved in the study and management of pregnancy, childbirth and female pelvic floor disorders. Clinical assessment, investigations, diagnosis, conservative and surgical treatments are major components. Illustrations have been included to supplement and clarify the text. Emerging concepts, in use in the literature and offering further research potential but requiring further validation, have been included as an Appendix. As with similar reports, interval (5-10 year) review is anticipated to maintain relevance of the document and ensure it remains as widely applicable as possible.

CONCLUSION

A consensus-based Terminology Report for obstetric pelvic floor disorders has been produced to support clinical practice and research.

Effect of Pessary vs Surgery on Patient-Reported Improvement in Patients With Symptomatic Pelvic Organ Prolapse: A Randomized Clinical Trial

Importance

Pelvic organ prolapse is a prevalent condition among women that negatively affects their quality of life. With increasing life expectancy, the global need for cost-effective care for women with pelvic organ prolapse will continue to increase.

Objective

To investigate whether treatment with a pessary is noninferior to surgery among patients with symptomatic pelvic organ prolapse.

Design, Setting, and Participants

The PEOPLE project was a noninferiority randomized clinical trial conducted in 21 participating hospitals in the Netherlands. A total of 1605 women with symptomatic stage 2 or greater pelvic organ prolapse were requested to participate between March 2015 through November 2019; 440 gave informed consent. Final 24-month follow-up ended at June 30, 2022.

Interventions

Two hundred eighteen participants were randomized to receive pessary treatment and 222 to surgery.

Main Outcomes and Measures

The primary outcome was subjective patient-reported improvement at 24 months, measured with the Patient Global Impression of Improvement scale, a 7-point Likert scale ranging from very much better to very much worse. This scale was dichotomized as successful, defined as much better or very much better, vs nonsuccessful treatment. The noninferiority margin was set at 10 percentage points risk difference. Data of crossover between therapies and adverse events were captured.

Results

Among 440 patients who were randomized (mean [SD] age, 64.7 [9.29] years), 173 (79.3%) in the pessary group and 162 (73.3%) in the surgery group completed the trial at 24 months. In the population, analyzed as randomized, subjective improvement was reported by 132 of 173 (76.3%) in the pessary group vs 132 of 162 (81.5%) in the surgery group (risk difference, -6.1% [1-sided 95% CI, -12.7 to ∞]; P value for noninferiority, .16). The per-protocol analysis showed a similar result for subjective improvement with 52 of 74 (70.3%) in the pessary group vs 125 of 150 (83.3%) in the surgery group (risk difference, -13.1% [1-sided 95% CI, -23.0 to ∞]; P value for noninferiority, .69). Crossover from pessary to surgery occurred among 118 of 218 (54.1%) participants. The most common adverse event among pessary users was discomfort (42.7%) vs urinary tract infection (9%) following surgery.

Conclusions and Relevance

Among patients with symptomatic pelvic organ prolapse, an initial strategy of pessary therapy, compared with surgery, did not meet criteria for noninferiority with regard to patient-reported improvement at 24 months. Interpretation is limited by loss to follow-up and the large amount of participant crossover from pessary therapy to surgery.

Trial Registration

Netherlands Trial Register Identifier: NTR4883.

Rare complications of pessary use: A systematic review of case reports

Introduction

Pessaries are desirable for its overall safety profiles. Serious complications have been reported; however, there is little summative evidence. This systematic review aimed to consolidate all reported serious outcomes from pessaries usage to better identify and counsel patients who might be at higher risk of developing these adverse events.

Methods

We performed a systematic literature review using search terms such as 'prolapse', 'stress urinary incontinence' and 'pessary or pessaries or pessarium' on PubMed, Embase and CINAHL. A total of 36 articles were identified. Patient-level data were extracted from case reports to further describe complications on an individual level.

Results

Overall median age of the patients was 82 years (range 62-98). The most frequent complications were vesicovaginal fistula (25%, n = 9/36), rectovaginal fistula (19%, n = 7/36), vaginal impaction (11%, n = 4/36) and vaginal evisceration of small bowel through vaginal vault (8%, n = 3/36). In the vesicovaginal fistula cohort, none of the patients had a history of radiation, and two had histories of total abdominal hysterectomy (22%). In the rectovaginal fistula cohort, one patient had a history of pelvic radiation for rectal squamous cell carcinoma, and another had a history of chronic steroid use for rheumatoid arthritis. No other risk factors were reported in the other groups. Ring and Gellhorn were the most represented pessary types among the studies, 16 (44%) and 12 (33%), respectively. No complications were reported with surgical and non-surgical treatment of the complications.

Conclusion

Pessaries are a reasonable and durable treatment for POP with exceedingly rare reports of severe adverse complications. The ideal candidate for pessary should have a good self-care index. Studies to determine causative factors of the more serious adverse events are needed; however, this may be difficult given the long follow-up that is required.

How Satisfied Are Women 6 Months after a Pessary Fitting for Pelvic Organ Prolapse?

BACKGROUND

The non-surgical solution for Pelvic Organ Prolapse (POP) typically consists of a pessary fitting. We aimed to assess patient satisfaction and symptom improvement 6 months after a pessary fitting and to identify risk factors associated with pessary failure.

METHODS

Six months after a pessary fitting, patient satisfaction was assessed by the PGII score; symptoms and quality of life were assessed using validated questionnaires (PFDI-20, ICIQ-SF, PISQ-12, USP, and PFIQ-7).

RESULTS

Of the 190 patients included in the study (mean age of 66.7 years), 141 (74%) and 113 (59%) completed the follow-up questionnaires at 1 and 6 months, respectively. Nearly all the women were menopausal (94.6%) and 45.2% declared being sexually active at inclusion. The satisfaction rate was 84.3% and 87.4% at 1 and 6 months, respectively. The global symptom score PFDI-20 had significantly improved at 6 months. A high body mass index (RR = 1.06, CI_95%: [1.02-1.09]), as well as high PFDI-20 (1.05 [1.01-1.09]), PFIQ7 (1.04 [1.01, 1.08]), and PISQ12 scores at inclusion (0.75 [0.60, 0.93]), as well as higher GH and GH/TVL measurements (1.49 [1.25-1.78] and 1.39 [1.23-1.57], respectively) were associated with pessary failure.

CONCLUSIONS

Pessary seems to be an effective treatment for POP with high patient satisfaction. Higher BMI, higher symptom scores, and greater genital hiatus measurements before insertion are risk factors for failure at 6 months.

Role of Pessaries in the Treatment of Pelvic Organ Prolapse: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the existing evidence on the efficacy of pessaries in improving quality of life when used for the treatment of pelvic organ prolapse (POP).

DATA SOURCES

We searched for the terms "pelvic organ prolapse" and "pessar/y/ies/ium or vaginal support device," and "safety or safe or outcome or complication or efficacy or effective or effectiveness" in PubMed, EMBASE, and CINAHL on March 16, 2020. A search was also performed on ClinicalTrials.gov , with no studies fitting our strict inclusion and exclusion criteria.

METHODS OF STUDY SELECTION

Studies that reported pretreatment and posttreatment mean scores and SDs after pessary treatment for standardized questionnaires were included. Studies performed in pediatric populations, pregnancy, and use of pessaries not for prolapse were excluded. Three reviewers independently screened studies.

TABULATION, INTEGRATION, AND RESULTS

Data abstraction was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data were pooled for meta-analysis when reported by at least three studies. The primary study outcome was change in mean pretreatment and posttreatment questionnaire scores, which included those for the PFDI-20 (Pelvic Floor Distress Inventory- Short Form 20), PFIQ-7 (Pelvic Floor Impact Questionnaire - Short Form 7), and subscale POPIQ (Pelvic Organ Prolapse Impact Questionnaire Long Form). A random-effects model was used to combine estimates and capture between-study heterogeneity using the I 2 -statistic. Eight studies including 627 patients were included for systematic review. The mean (SD) age was 63.0±12.2 years, and the majority of patients had stage III prolapse (48.1%) followed by stage II prolapse (43.2%) when reported. Although variable, the majority of studies conducted 3-month follow-up. A negative change in pretreatment and posttreatment scores was noted, signifying improvement after pessary use: PFDI-20 mean change -46.1 (95% CI -65.4 to -26.8); PFIQ-7 mean change -36.0 (95% CI -46.0 to -26.0); POPIQ-7 (Pelvic Organ Prolapse Impact Questionnaire-7) mean change -16.3 (95% CI -26.8 to -5.7). No significant heterogeneity was found.

CONCLUSION

Based on improvements in standardized questionnaire scores, pessaries are effective treatment options for POP.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42020172618.

Effect of estrogen on vaginal complications of pessary use: a systematic review and meta-analysis

OBJECTIVE

We aimed to systematically review the impact of local estrogen use in combination with a pessary on vaginal complications in postmenopausal women with pelvic organ prolapse (POP).

METHODS

We searched databases including Medline, Embase, PubMed, Clinical Trials and the Cochrane Central Register of Controlled Trials for relevant literature published in English from inception to 31 May 2021. Only randomized controlled trials (RCTs) and cohort studies were included.

RESULTS

In total, five studies were included (three RCTs, one prospective study and one retrospective cohort study). The meta-analysis was performed with subgroups. Our results indicated a significantly lower incidence of bacterial vaginosis (BV) among postmenopausal women who used estrogen than among controls, with a total pooled odds ratio (OR) of 0.29 (95% confidence interval [CI]: 0.11-0.72; I² = 38%; p = 0.008). The summary ORs of the estrogen use group were 0.98 (95% CI: 0.59-1.63; I² = 41%; p = 0.95) for vaginal ulceration, 0.80 (95% CI: 0.42-1.54; I² = 29%; p = 0.50) for vaginal bleeding and 0.74 (95% CI: 0.35-1.58; I² = 35%; p = 0.44) for vaginal discharge.

CONCLUSIONS

Local estrogen in combination with a pessary could decrease the BV rate among postmenopausal women with POP. However, consensus regarding the value of estrogen use for decreasing other pessary complications has not yet been reached. Additional multicenter RCTs with large sample sizes should be conducted to better understand the effect of estrogen use on reducing pessary-related complications.

Mini-review: Modern Concept of Pelvic Organ Prolapse

Symptomatic pelvic organ prolapse (POP) has been increasing in recent years for both developed and developing countries. By 2050, as the adult population grows, the number of women with symptomatic POP will increase by 46%. Due to the increasing number of complications after surgery among women with POP, the current understanding of treatment has become extremely important for researchers and practitioners. There are many novel conservative and surgical treatment approaches under investigation. However, some primary surgical treatments show an approximate 30–50% risk of repeated pelvic floor reconstruction. Therefore, the review aims to summarize several conservative treatment options and identify critical areas of need for future research.

Design, mechanical and degradation requirements of biodegradable metal mesh for pelvic floor reconstruction

Pelvic organ prolapse (POP) is the herniation of surrounding tissue and organs into the vagina and or rectum, and is a result of weakening of pelvic floor muscles, connective tissue,...

Patient-Centered Goals for Treatment of Pelvic Floor Disorders

Purpose of review

To review the current literature on patient centered goals for the treatment of pelvic floor disorders (PFDs).

Recent findings

Patients have a poor understanding of their PFDs, regardless if they had prior PFD treatments or received counseling, emphasizing the need for improved education from healthcare providers. Understanding the patient perspective provides insights into identifying patient goals, which facilitates communication and allows for tailored counseling, management of expectations, and assessment of treatment response. Functional outcomes are consistently important to patients, often listed as their main treatment goals. The achievement of these goals is fundamental to satisfaction. IMPACT and PROMIS are examples of PCO measures that can be utilized in both research and clinical settings. Finally, telemedicine has emerged as a viable alternative to clinic visits that offers improved access to care with no increase in adverse events or dissatisfaction, in order to aid in monitoring and meeting patient treatment goals.

Summary

Patient involvement is fundamental to providing value-based care. Provider understanding of the patient perspective is necessary to guide counseling and treatment. Patient-centered goals offer a way to engage patients, facilitate communication, and improve patient satisfaction. Although there are multiple validated PCO tools, further development and research involving patient input is needed.

Clinical outcomes in patients with advanced pelvic prolapse who underwent LeFort surgery or pessary placement- A prospective cohort study

Background

The aim of the present study was to compare the six-month results in terms of prolapse symptoms in postmenopausal patients with advanced pelvic prolapse (POP) who underwent LeFort colpocleisis surgery or with pessary placement.

Methods

In this prospective cohort study, 110 older women were enrolled from April 2016 to January 2018. The women were diagnosed with stage III or higher genital prolapse according to the POP quantification (POP-Q) system. The patients were divided into two groups: surgical (LeFort colpocleisis surgery; n=55) and non-surgical (pessary placement, n=55). The study population underwent LeFort colpocleisis surgery or pessary placement in two university clinics (Beheshti or Alzahra Hospitals). All patients completed the Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20). The main short-term outcome measurement (six months) was the manifestation of a pelvic prolapse in the groups.

Results

The patients had a mean age of 68.98±8.79 years in the non-surgical group and 64.76±7.04 years in the surgical group. The analytic results showed a significant difference between the two groups (P=0.006). After treatment, the prolapse symptoms improved in both groups (p<0.001). However, the total PFDI-20 score did not show any significant differences at the end of the six-month follow- up (P=0.19).

Conclusion

Both strategies (pessary placement or LeFort colpocleisis surgery) provide a short-term option for the treatment of older women with stage III or higher POP. The findings of this study could assist with treatment options and allow better guidance for older patients with symptomatic POP in the treatment decision process.

Factors associated with unsuccessful pessary fitting and reasons for discontinuation in Korean women with pelvic organ prolapse

Objective

To identify the factors associated with unsuccessful pessary fitting and reasons for pessary discontinuation in Korean women with pelvic organ prolapse (POP).

Methods

The medical records of 234 patients who underwent pessary fitting for the management of symptomatic POP were retrospectively reviewed. A ring pessary with or without support was used. Successful pessary fitting was defined as the ability to wear a pessary for 2 weeks without any discomfort. Factors associated with unsuccessful pessary fitting were determined using a multivariable logistic regression analysis. A Kaplan-Meier survival curve was obtained to examine the probability of continuing pessary use over the follow-up period. The reasons for the discontinuation of pessary were identified.

Results

Two-hundred-and-twenty-five women were included in the analysis. The rate of unsuccessful pessary fitting was 40%. Prior hysterectomy (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.81–9.42) and POP quantification stage III–IV (OR, 2.49; 95% CI, 1.28–4.85) were independent risk factors for unsuccessful pessary fitting. Among the patients with successful pessary fitting, the median time to discontinuation of pessary use was 4 years. The most common causes of discontinued use were vaginal erosion (45.3%) and urinary incontinence (26.5%).

Conclusion

Patients with a history of hysterectomy and advanced-stage POP are at risk for an unsuccessful fitting of the ring pessary. Vaginal erosion is the main reason for discontinued use among patients with successful pessary fitting.

Vaginal pessary in advanced pelvic organ prolapse: impact on quality of life

Introduction and hypothesis

Pelvic organ prolapse (POP) is a highly prevalent dysfunction of the pelvic floor affecting up to 40% of women. The symptoms of POP have a major impact on quality of life. Pessary treatment is a therapy option associated with high levels of satisfaction and few complications.

Objectives

The objective was to assess the impact and efficacy of vaginal pessary use on the quality of life of women with advanced POP stages III and IV.

Materials and methods

A multicenter, longitudinal, prospective observational study was conducted at the Urogynecology Sector of the Hospital Ipiranga and the Hospital Central of the Irmandade da Santa Casa de Misericórdia de São Paulo. A sociodemographic questionnaire was employed and two scales validated in Portuguese (ICIQVS and SF 12) were applied before and 6 months after pessary use. Student´s t test, Mann–Whitney test and Fisher´s exact test were applied, adopting a significance level of 0.05.

Results

The median age of participants was 71.5 (65–76) years and the median number of pregnancies was 4 (3–5). Deliveries were predominantly vaginal (82.5%). Women sexually active (16.49%) showed improvement in sexual function (78.6%). The participants showed improvement in vaginal symptoms (91.8%) and quality of life (92.8%) (p < 0.01) post-treatment. Of the total 97 women, the sample drop-out rate was 9.3% and 88 participants completed the two stages of the study.

Conclusions

Vaginal pessary use had 90.7% efficacy, a high level of treatment satisfaction (75.3%), and a positive impact on the improvement of vaginal and sexual symptoms, quality of life, and mental health.

SHAred DEcision making in Pelvic Organ Prolapse (SHADE-POP); Implementation is not as easy as it seems

OBJECTIVE

Despite the positive effects of decision aids (DAs), implementation remains a significant challenge. The aim of the current study was to determine what barriers clinicians experience using a DA for pelvic organ prolapse (POP).

METHODS

This study was conducted with a qualitative descriptive design including in-depth semi-structured interviews according to COREQ-criteria. Participants included clinicians and patients. Grounded theory analysis was used to describe the main themes.

RESULTS

A total of 9 clinicians and 4 patients participated. Four major themes (1) opinions about shared decision making (SDM), (2) current practice, (3) experience with the DA, (4) suggestions for improvement and one minor theme (5) experience with the study, emerged. Clinicians were predominantly positive about the DA.

CONCLUSION

Despite the positive attitudes of the clinicians in this study, the implementation of a DA is still challenging. The DA is forgotten regularly as improvement of logistics is needed, clinicians assume they already provide good care which might result in a reluctance to change and more engagement of physicians is needed.

PRACTICE IMPLICATIONS

Regular contact with clinicians to remind, help and increase engagement and a decrease of the logistic burden is needed to ensure all patients can fully benefit of the DA.

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.

Vaginal Pessaries for Pelvic Organ Prolapse or Stress Urinary Incontinence: A Health Technology Assessment

BACKGROUND

Pelvic organ prolapse (POP) is the downward descent of the female pelvic organs into or through the vagina. The symptom that most strongly correlates with and is most specific for POP is a feeling of vaginal bulging. Stress urinary incontinence (SUI) is an involuntary loss of urine upon physical exertion or sneezing or coughing. Conservative (non-surgical) treatment options for both conditions include vaginal pessaries. We conducted a health technology assessment of vaginal pessaries for the treatment of POP and SUI, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding vaginal pessaries, and patient preferences and values.

METHODS

We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using ROBIS, the Cochrane Risk of Bias tool, and the Newcastle-Ottawa Scale and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-utility analysis with a 10-year horizon from a public payer perspective. We also analyzed the budget impact of publicly funding vaginal pessaries for individuals with pelvic organ prolapse and/or stress urinary incontinence in Ontario. We explored the underlying values, needs, and priorities of those who have lived experience with POP and/or SUI, as well as the preferences and perceptions of both patients and providers of vaginal pessaries.

RESULTS

We included 15 studies in the clinical evidence review. Compared with no treatment for people with SUI, pessaries were associated with a significant improvement in some symptoms at 14 days follow-up (SUI subscore of Urinary Symptom Profile, mean difference -2.20; 95% CI -3.47 to -0.93; GRADE: Very low). Compared with pelvic floor muscle training (PFMT), pessaries were associated with no difference in improvement at 12 months follow-up for some symptoms (Urinary Distress Inventory subscale of the Pelvic Floor Distress Inventory, risk ratio = 0.86; 95% CI 0.64 to 1.16; GRADE: Low). For people with POP, pessaries were associated with a significant improvement in the Pelvic Organ Prolapse Distress Inventory score and in sexual function compared with PFMT plus feedback/electrical stimulation/lifestyle advice at 12- and 24-month follow ups (GRADE: Low). Pessary continuation rate at 12 months follow up was reported to be 60% (44/74 patients) (GRADE: Very low).When evaluating various POP and SUI treatments in sequential order, pessaries were within the most cost-effective treatment sequence; therefore, it is likely to be a cost-effective intervention for treating POP and SUI. There was a high degree of certainty that pessaries were cost-effective in a population with POP, and a moderate degree of certainty in a population with SUI. When the treatment sequence of pessaries and surgery was compared with surgery alone, the pessaries treatment sequence dominates surgery in the cohort with POP, and in the cohort with SUI pessaries had an incremental cost-effectiveness ratio (ICER) of $1,033 per QALY gained. The annual budget impact of publicly funding vaginal pessaries in Ontario over the next 5 years ranges from $0.3 million in year 1 to $0.5 million in year 5 for POP, and $0.2 million in year 1 to $0.3 million in year 5 for SUI.We included one study in our quantitative evidence review and spoke to 29 people in our direct patient engagement. The evidence indicated that patient preferences vary and that patients accept the risks of their chosen treatment option. The 24 people we spoke with who had direct experience with vaginal pessaries reported that their POP and/or SUI limited their social activities and restricted their activity levels, taking a huge emotional toll. Many were hesitant or even fearful of surgery due to side effects and perceived failure rate of the surgery. Most people reported that pessaries relieved most or all of their symptoms, allowing them to return to their normal daily activities. However, wait times for pessary fittings could be as long as 2 years, and out-of-pocket expenses could be a barrier for people without extended insurance.

CONCLUSIONS

For people with SUI, vaginal pessaries may improve symptoms compared with no treatment, but the evidence is very uncertain. Pessaries may result in little to no difference in longer-term improvement of SUI symptoms compared with PFMT. For people with POP, pessaries may improve some longer-term symptoms, as well as sexual function compared with PFMT. For people with symptomatic POP and SUI, vaginal pessaries may be a cost-effective intervention to be used within a stepped care model (a sequence of interventions followed after the current treatment proves ineffective). We estimate that publicly funding vaginal pessaries in Ontario would result in a total 5-year budget impact of $2.0 million for POP and $1.3 million for SUI. People with POP and/or SUI reported pessary use as being an effective treatment option to manage their symptoms.

Risk Factors for Dislodgment of Vaginal Pessaries in Women With Pelvic Organ Prolapse: A Cohort Study

OBJECTIVE

The aim of the study was to evaluate the associated factors associated with pessary dislodgment in women with advanced pelvic organ prolapse (POP).

METHODS

A cohort study with women (N = 98) with advanced POP who chose conservative treatment with ring pessary between December 2016 and 2018 identified by screening. Demographic data, history of POP, urinary, and/or bowel symptoms were collected. A medical visit was scheduled 3 and 6 months after pessary insertion to evaluate symptoms (vaginal discharge, bleeding, pain, discomfort, new-onset urinary, or fecal problems) and any pessary dislodgment. Two groups were created (women who were able to retain the pessary versus who were not able), and univariate and multivariate analysis were performed to look for risk factors for pessary dislodgment. Women who requested to have their pessaries removed during the 6-month follow-up were excluded.

RESULTS

Ninety-three women included in the study, 78 successfully continued to use the pessary at 6 months, and 15 had pessary dislodgment (16.1%). Demographic characteristics were similar between the treatment group and the control group. After multivariate analysis, women who had their pessaries dislodged presented higher rates of previous surgery (odds ratio = 8.11; 95% confidence interval = 2.09-31.58; P = 0.003) with advanced Pelvic Organ Prolapse Quantification system staging (odds ratio, 13.41; confidence interval, 1.97-91.36; P = 0.008).

CONCLUSIONS

The presence of advanced apical POP and previous POP surgery are risk factors for ring pessary dislodgment. This information should guide physicians for counseling patients before pessary insertion.

Pessaries (mechanical devices) for managing pelvic organ prolapse in women

BACKGROUND

Pelvic organ prolapse is a common problem in women. About 40% of women will experience prolapse in their lifetime, with the proportion expected to rise in line with an ageing population. Women experience a variety of troublesome symptoms as a consequence of prolapse, including a feeling of 'something coming down' into the vagina, pain, urinary symptoms, bowel symptoms and sexual difficulties. Treatment for prolapse includes surgery, pelvic floor muscle training (PFMT) and vaginal pessaries. Vaginal pessaries are passive mechanical devices designed to support the vagina and hold the prolapsed organs back in the anatomically correct position. The most commonly used pessaries are made from polyvinyl-chloride, polythene, silicone or latex. Pessaries are frequently used by clinicians with high numbers of clinicians offering a pessary as first-line treatment for prolapse.  This is an update of a Cochrane Review first published in 2003 and last published in 2013.

OBJECTIVES

To assess the effects of pessaries (mechanical devices) for managing pelvic organ prolapse in women; and summarise the principal findings of relevant economic evaluations of this intervention.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 28 January 2020). We searched the reference lists of relevant articles and contacted the authors of included studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials which included a pessary for pelvic organ prolapse in at least one arm of the study.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed abstracts, extracted data, assessed risk of bias and carried out GRADE assessments with arbitration from a third review author if necessary.

MAIN RESULTS

We included four studies involving a total of 478 women with various stages of prolapse, all of which took place in high-income countries. In one trial, only six of the 113 recruited women consented to random assignment to an intervention and no data are available for those six women. We could not perform any meta-analysis because each of the trials addressed a different comparison. None of the trials reported data about perceived resolution of prolapse symptoms or about psychological outcome measures. All studies reported data about perceived improvement of prolapse symptoms. Generally, the trials were at high risk of performance bias, due to lack of blinding, and low risk of selection bias. We downgraded the certainty of evidence for imprecision resulting from the low numbers of women participating in the trials. Pessary versus no treatment: at 12 months' follow-up, we are uncertain about the effect of pessaries compared with no treatment on perceived improvement of prolapse symptoms (mean difference (MD) in questionnaire scores -0.03, 95% confidence interval (CI) -0.61 to 0.55; 27 women; 1 study; very low-certainty evidence), and cure or improvement of sexual problems (MD -0.29, 95% CI -1.67 to 1.09; 27 women; 1 study; very low-certainty evidence). In this comparison we did not find any evidence relating to prolapse-specific quality of life or to the number of women experiencing adverse events (abnormal vaginal bleeding or de novo voiding difficulty). Pessary versus pelvic floor muscle training (PFMT): at 12 months' follow-up, we are uncertain if there is a difference between pessaries and PFMT in terms of women's perceived improvement in prolapse symptoms (MD -9.60, 95% CI -22.53 to 3.33; 137 women; low-certainty evidence), prolapse-specific quality of life (MD -3.30, 95% CI -8.70 to 15.30; 1 study; 116 women; low-certainty evidence), or cure or improvement of sexual problems (MD -2.30, 95% -5.20 to 0.60; 1 study; 48 women; low-certainty evidence). Pessaries may result in a large increase in risk of adverse events compared with PFMT (RR 75.25, 95% CI 4.70 to 1205.45; 1 study; 97 women; low-certainty evidence). Adverse events included increased vaginal discharge, and/or increased urinary incontinence and/or erosion or irritation of the vaginal walls. Pessary plus PFMT versus PFMT alone: at 12 months' follow-up, pessary plus PFMT probably leads to more women perceiving improvement in their prolapse symptoms compared with PFMT alone (RR 2.15, 95% CI 1.58 to 2.94; 1 study; 260 women; moderate-certainty evidence). At 12 months' follow-up, pessary plus PFMT probably improves women's prolapse-specific quality of life compared with PFMT alone (median (interquartile range (IQR)) POPIQ score: pessary plus PFMT 0.3 (0 to 22.2); 132 women; PFMT only 8.9 (0 to 64.9); 128 women; P = 0.02; moderate-certainty evidence). Pessary plus PFMT may slightly increase the risk of abnormal vaginal bleeding compared with PFMT alone (RR 2.18, 95% CI 0.69 to 6.91; 1 study; 260 women; low-certainty evidence). The evidence is uncertain if pessary plus PFMT has any effect on the risk of de novo voiding difficulty compared with PFMT alone (RR 1.32, 95% CI 0.54 to 3.19; 1 study; 189 women; low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain if pessaries improve pelvic organ prolapse symptoms for women compared with no treatment or PFMT but pessaries in addition to PFMT probably improve women's pelvic organ prolapse symptoms and prolapse-specific quality of life. However, there may be an increased risk of adverse events with pessaries compared to PFMT. Future trials should recruit adequate numbers of women and measure clinically important outcomes such as prolapse specific quality of life and resolution of prolapse symptoms.   The review found two relevant economic evaluations. Of these, one assessed the cost-effectiveness of pessary treatment, expectant management and surgical procedures, and the other compared pessary treatment to PFMT.

Symptomatic and anatomic improvement of pelvic organ prolapse in vaginal pessary users

INTRODUCTION AND HYPOTHESIS

The vaginal pessary is a conservative method for treating pelvic organ prolapse (POP). It is able to reduce symptoms with minimal complications, improving quality of life (QOL). This study's hypothesis was that the use of pessaries decreases quantitative measures and improves women's QOL. We aimed to evaluate the effects of the use of a ring pessary on the quantitative measurements of POP by the Pelvic Organ Prolapse Quantification (POP-Q) and on QOL.

METHODS

Prospective cohort study divided in two stages. In stage I POP-Q and QOL were assessed prior to the use of the ring pessary and in stage II after its use for at least 4 months with pessary removal 72 h before clinical evaluation. Wilcoxon tests were performed for necessary comparisons and Spearman's tests for calculating correlations.

RESULTS

One hundred thirty-six women were evaluated, of which 50 were included. There was a decrease in POP in at least one of the vaginal compartments in the women included. When assessing individual measures (Ba, Bp and C), reductions in all measures were observed. There was also an improvement in the general and specific quality of life of women.

CONCLUSION

The ring pessary proved to be a good therapeutic option, with a reduction in POP-Q measurements and/or absence of POP progression in the short term and an improvement in women's QOL.

Fertility and sexuality issues in congenital lifelong urology patients: female aspects

PURPOSE

With advances in treatment modalities and medical knowledge, girls with congenital urologic disorders are living well into adulthood. Although, sexual and reproductive function in this population is still poorly understood. The aim is to review existing literature about fertility and sexuality in women with congenital genitourinary disorders, including spina bifida (SB), bladder exstrophy-epispadias complex (BEEC) and congenital adrenal hyperplasia (CAH).

METHODS

This review represents the joint SIU-ICUD (Société Internationale d'Urologie-International Consultation on Urological Disease) consultation on congenital lifelong urology. The results of this analysis were first presented at a joint consultation of the SIU and ICUD at the 2018 SIU annual conference in Seoul, South Korea. Appropriate experts were asked to write specific sections regarding sexuality and reproductive function in female patients with these complex congenital urogenital disorders. Each expert performed their own literature review which was reviewed by GDW, AFS, Hadley M. Wood and Dan Wood. Expert opinion was obtained where data are non-existent.

RESULTS

Only about half of the individuals with SB express a satisfactory sex life. In women with BEEC, cosmetic concerns surrounding genital appearance and function may increase psychological distress, including severe depression, suicide and sexual dysfunction. Professional health care is key for improving self-esteem and to interact in the biopsychosocial model of the quality of life. Patients with SB and BEEC should be informed about all the potential risks and difficulties before, during and after pregnancy. Screening for pelvic organ prolapse is important as it can exacerbate their already existing sexual dysfunction, difficulties achieving pregnancy and challenges with clean intermittent catheterization.

CONCLUSIONS

Lifelong multidisciplinary follow-up and management are complex but necessary. As these patients grow into their adolescence, they may have the desire to become involved in personal relationships and have sexual interactions. Their healthcare team needs to be increasingly sensitive to these aspects.

Pessary evaluation for genital prolapse treatment: From acceptance to successful fitting

AIMS

To determine the percentage of women with symptomatic pelvic organ prolapse who opted for pessary and had a successful pessary fitting trial; to identify the most commonly used size of pessary for stage of prolapse; and to identify risk factors associated with unsuccessful fitting.

METHODS

We conducted a prospective cohort study of women with symptoms of genital prolapse referred to a public hospital tertiary care clinic (2013-2019). We used ring and ring with support pessaries for fittings. We collected patient demographics, pelvic organ prolapse quantification, size of pessary used and evaluated factors associated with pessary fittings. We defined unsuccessful fit as failure to continue pessary use at 4 weeks post fitting trial. We used Mann-Whitney and χ² tests to compare variables between groups of successfully and unsuccessfully fitted. Using logistic regression, we built a prediction model for unsuccessful fit.

RESULTS

All 170 women with symptomatic prolapse referred to our clinic accepted to undergo a pessary fitting. More than 70% (n = 124/72.9%) were successfully at 4 weeks. We used an average of 1.7 pessaries (range: 1-6) per patient to identify the best-fitting pessary and #2, 5, 3, 7, and 4 were the sizes commonly used (78.2%). Women with body mass index ≥30 kg/m² (odds ratio [OR]: 4.74; 95% confidence interval [CI], 1.98-11.32; P < .001), total vaginal length <7.5 cm (OR: 3.78; 95% CI, 1.98-11.32; P < .001), and sexually active women (OR: 2.26; 95% CI, 1.04-4.91; P = .035) were associated with increased unsuccessful fitting.

CONCLUSION

The vaginal pessary proved to be an excellent choice, with high acceptance and successful fitting rates.

The extended pessary interval for care (EPIC) study: a failed randomized clinical trial

INTRODUCTION AND HYPOTHESIS

To describe study design flaws and limited outcomes of a randomized trial that intended to compare satisfaction and complication rates between patients managing their pelvic organ prolapse with a pessary at different maintenance intervals.

METHODS

A randomized clinical trial was conducted at two tertiary pessary clinics. After a successful fitting, patients were randomly allocated to follow-up at 3-month or 6-month intervals and followed for 12 months. Symptoms, complications, and pelvic examination characteristics were recorded at each visit. At 6 and 12 months, patient satisfaction with the pessary was also recorded. Sample size calculation was based on the minimal relevant difference in Pessary Satisfaction score (created for this study). With a power of 0.8 and an alpha of 0.05, the minimum number of patients required in each group was 28.

RESULTS

We were unable to reach our sample size as most patients did not meet inclusion criteria. After 2 years we were only able to recruit 20/56 patients, with 9 patients in the 3-month group and 11 patients in the 6-month group. Additionally, seven patients dropped out of the study. Overall satisfaction was high and similar between groups at 6- and 12-month follow-up visits. Pessary complications were noted in both groups but in low numbers.

CONCLUSIONS

Pessary use is associated with high patient satisfaction and low complication rates, regardless of the follow-up interval. The recruitment failure demonstrated that a randomized trial is not feasible for this research question. Optimally, pessary follow-up should be based on patient symptoms and scheduling preference.

Women and healthcare providers' knowledge, attitudes and practice related to pessaries for pelvic organ prolapse: A Systematic review

OBJECTIVE

To identify the knowledge, attitudes and practice of women and healthcare professionals in relation to pessary use for POP.

METHOD

This systematic review was carried out in agreement with PRISMA recommendations. PubMed/MEDLINE, SCOPUS, Virtual Health Library, Web of Science, CAPES Periodicals and CINAHL databases were searched for studies without date or language limitations. Search strategies were developed for identifying studies examining knowledge, attitudes and practice toward vaginal pessaries use. Two reviewers independently screened titles and abstracts to identify eligible studies. Data extraction was performed independently in duplicate into a standardized form. Quality of included studies was assessed using the Joanna Briggs Institute quality assessment tool. The protocol was registered with the PROSPERO International prospective register of systematic reviews [CRD42018114236].

RESULTS

Fourteen studies were included. Knowledge and practice were the main domains investigated among patients and professionals, respectively. The results demonstrated poor patient knowledge; however, in urogynecologic patients, knowledge was better. Previous consultation with a Female Pelvic Medicine and Reconstructive Surgery specialist (p = .001) and a higher level of education (p = .006) were associated with improved knowledge of pessary use. Fear of vaginal discharge, irritation, bleeding, and pain were factors that supported the decision not to use a pessary. Previous consultation with a generalist gynecologist (p = .03)and a lower level of education (p = .03) predicted aversion to pessary use. Providers demonstrated adequate knowledge and recommended pessary in 86.4% to 98.0% of cases. Having specialist and pessary management training were some factors that influenced a better attitude towards pessaries among health professionals.

CONCLUSION

The knowledge, attitudes and practice of women and health care providers about pessary use are seldom investigated. Developing a psychometrically valid instrument for assessment of knowledge, attitudes and practice is desirable to examine the complex interactions between these three constructs, expose barriers to pessary care, and develop targeted educational interventions.

Long-term Outcomes of Self-Management Gellhorn Pessary for Symptomatic Pelvic Organ Prolapse

OBJECTIVE

The aim of this study is to estimate the long-term survival and to identify adverse events associated with the use of Gellhorn pessaries over a 9-year period.

METHODS

This was a retrospective case series study at a tertiary urogynecology unit in Taiwan. Between January 2009 and June 2017, 93 patients who opted for self-management Gellhorn pessaries to treat symptomatic pelvic organ prolapse (POP) and who were continuously followed-up were enrolled. Long-term use was defined as use for longer than 1 year. Length of use, factors that predicted discontinuation, and adverse events were analyzed and reviewed by chart or telephone inquiry.

RESULTS

The cumulative probabilities of continued pessary use at 1 and 5 years were 62.4% and 47.2%, respectively. Of those who discontinued use, 34 (70.8%) participants discontinued use within 1 year, and the mean duration of use was 13.7 months (range, 0-75 months; median, 5 months). Most of the participants stopped using the pessary because of bothersome adverse events such as pessary expulsion, vaginal pain, de novo urinary incontinence, and erosion/infection.

CONCLUSIONS

Self-management Gellhorn pessary was safe and relatively effective and increased patients' autonomy and ability to manage their POP. One third of the patients discontinued use by 1 year, and half of the patients discontinued use at 5 years.

Vaginal Pessaries for Pelvic Organ Prolapse and Their Impact on Sexual Function

INTRODUCTION

Pelvic organ prolapse (POP) is a common condition among parous women and its prevalence increases with age. Vaginal pessaries are one of the management options for women with prolapse. In the current health climate, where there are controversy surrounding surgical procedures, an increasing number of women are considering a pessary over surgical management.

AIM

This article aims to provide an overview of POP, its associated symptoms, and the different types of pessaries available. It will go on to describe how sexual activity (SA) and sexual function (SF) needs to be considered as part of the pessary selection discussion, and common concerns expressed by women.

METHODS

A literature review was undertaken to record the current evidence regarding SA and pessary use, and clinical practice and experience are discussed.

MAIN OUTCOME MEASURES

The main outcome of this study was to consider the preservation or restoration of SF in women using a pessary for prolapse.

RESULTS

There are several pessaries available on the market that enable women to maintain SA, and for many of these it will not be noticeable to their partners. If, however, the woman or their partner finds the pessary uncomfortable or obstructing during intercourse, women can be trained to remove and reinsert their pessary as necessary. The evidence suggests that, for those women who are sexually active with their pessaries in situ, they are happy and continue with this form of management in the long term.

CONCLUSION

Health care professionals need to ensure that SF or the desire to be sexually active (in whatever form that may be) is assessed and discussed as part of routine care and is considered in all decision making. Rantell A. Vaginal Pessaries for Pelvic Organ Prolapse and Their Impact on Sexual Function. Sex Med Rev 2019;7:597-603.

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.

Urinary incontinence and pelvic organ prolapse in primary care

The National Institute for Health and Care Excellence has released an updated guideline on urinary incontinence and pelvic organ prolapse. Angie Rantell explores the changes and recommendations for patients, highlighting which are relevant to management in primary care

In 2019, the National Institute for Health and Care Excellence published a new guideline on urinary incontinence and pelvic organ prolapse. This articles provides an overview of the changes to the recommendations relevant to the primary care setting, mainly related to assessment and conservative management, along with a review of when to refer into specialist services. A brief overview of the changes it has made in secondary care will also be discussed.

Neglected doughnut pessary in the uterine cavity

Vaginal pessary is a practical and effective tool for pelvic organ prolapse management. Nevertheless, serious complications can occur in neglected patients such as vesicovaginal and rectovaginal fistula, erosion and impaction in adjacent structures. We report a case of neglected pessary found in the uterine cavity. The patient was treated with abdominal hysterectomy with in situ doughnut pessary. Proper pessary care and regular follow-up should be emphasised among patients, caregivers and related healthcare personnel to early detect as well as to avoid complications.

Prolapse surgery versus vaginal pessary in women with symptomatic pelvic organ prolapse: which factors influence the choice of treatment?

Objective

To investigate which specific clinical factors influence patients’ choice of prolapse treatment.

Methods

This study includes a total of 510 cases with symptomatic pelvic organ prolapse (POP) of stage II or higher requiring prolapse treatment. Patients were divided into surgery and pessary groups according to their own choice and treatment preference. Primary outcome of interest was to define potential clinical parameters, which contribute to surgical treatment decision.

Results

A total of 252/510 (49%) women decided for prolapse surgery and 258/510 (51%) cases were treated conservatively with vaginal pessary. Hypertension, COPD as well as polypharmacy were parameters, which were statistically significantly more common in the pessary group compared to the surgically managed cases (p <0.05). On the contrary, women undergoing prolapse surgery were significantly younger and showed more advanced POP-Q (pelvic organ prolapse quantification) stages (p < 0.05). Clinical factors, such as BMI (body mass index), parity, mode of delivery and postmenopausal status, did not differ between the two groups (p > 0.05). Multiple logistic regression analysis revealed that advanced POP-Q stage (p < 0.001) as well as the absence of smoking (p < 0.001) were independent factors associated with surgical treatment decision.

Conclusion

Women, who favoured prolapse surgery, were younger and in significant better health condition (less hypertension and COPD), but showed a significantly higher POP-Q stage compared to women choosing pessary treatment. Our data indicate that women with higher POP-Q stage and non-smokers tended to decide for prolapse surgery. This information could help in clinical practice to guide patients for the best possible treatment decision and strengthen individual counselling.

Desire for Continued Pessary Use Among Women of Hispanic and Non-Hispanic Ethnic Backgrounds for Pelvic Floor Disorders

OBJECTIVE

This study aimed to describe the association between patient ethnicity/race and desire to continue using a pessary for the treatment of pelvic floor disorders.

METHODS

We performed a secondary analysis of a randomized trial among women presenting for pessary fitting. The primary outcome was the desire to continue using a pessary at 3 months. Bacterial vaginosis by Nugent score and vaginal symptoms (discharge, itching, pain, sores) were also evaluated. Logistic or multiple linear regression was performed with correction for body mass index, education level, parity, Charlson Comorbidity Index, and randomization to TrimoSan gel.

RESULTS

One hundred fourteen women (41 Hispanic and 73 non-Hispanic) were eligible for this analysis. Women self-identified as white (65/114; 57%), Hispanic (41/114, 36%), Asian (3/114; 2.6%), Native American (4/114; 3.5%), and "other" (1/114, 0.9%) race, with no self-identified African American women (0/114) meeting the inclusion criteria. No significant difference in desire to continue pessary use was found between Hispanic and non-Hispanic women (58.5% vs 63%; P = 0.69; corrected odds ratio [cOR], 1.11; 95% confidence interval [CI], 0.43-2.90) or across races (P = 0.89). Hispanic women had significantly higher risk of bacterial vaginosis (34% vs 16%; P = 0.04; cOR, 2.91; 95% CI, 1.01-8.39), higher Nugent scores (5.4 ± 2.3 vs 4.3 ± 2.3; P = 0.02; corrected coefficient, 1.10; 95% CI, 0.10-2.10), and more vaginal pain (17.1% vs 2.8%; P = 0.01; cOR, 9.14; 95% CI, 1.37-61.17) at 3 months.

CONCLUSIONS

Despite increased vaginal pain and vaginal microbiome disturbances in Hispanic women using a pessary, no significant differences in the desire to continue using the pessary existed.

Treatment of vaginal vault prolapse in The Netherlands: a clinical practice survey

INTRODUCTION AND HYPOTHESIS

A great variety of conservative and surgical procedures to correct vaginal vault prolapse have been reported. The aim of this study was to describe practice pattern variation-the difference in care that cannot be explained by the underlying medical condition-among Dutch gynecologists regarding treatment of vaginal vault prolapse.

METHODS

A clinical practice survey was conducted from March to April 2017. The questionnaire was developed to evaluate treatment of vaginal vault prolapse. All members of the Dutch Society for Urogynaecology were invited to participate in a web-based survey.

RESULTS

One hundred four Dutch gynecologists with special interest in urogynecology responded to the survey (response rate, 44%). As first-choice therapy for vaginal vault prolapse, 78% of the respondents chose pessary treatment, whereas sacrospinous fixation was the second most common therapy choice according to 64% of the respondents. Preferences on how to approach vaginal vault prolapse surgically are conflicting. Overall, the most performed surgery for vaginal vault prolapse is sacrospinous fixation, followed by laparoscopic and robotic sacrocolpopexy.

CONCLUSIONS

Gynecologists in The Netherlands manage vaginal vault prolapse very differently. No standardized method could be determined for the treatment of vaginal vault prolapse in The Netherlands, and we observed practice pattern variations.

Quality of life and vaginal symptoms of postmenopausal women using pessary for pelvic organ prolapse: a prospective study

SUMMARY OBJECTIVE: The use of pessary is an option for the conservative treatment of pelvic organ prolapse (POP). However, here are few studies assess the quality of life (QoL) after inserting the pessary for POP. We have hypothesized that the use of pessary would modify QoL in women with POP. METHODS: A prospective, observational study was performed that included 19 women with advanced POP. Pessary was introduced, and the SF-36 (general quality of life) and ICIQ-VS (vaginal symptoms and quality of life subdomain) questionnaires were applied before the introduction and after six months. A single question about the satisfaction regarding the use of the device was presented (subjective impression). RESULTS: The mean age of the women included was 76 years. Most of them were non-caucasian (52.6%), with no prior pelvic surgery (57.5%), with urinary symptoms (78.9%). A third of the patients reported sexual activity. After treatment, 22.2% of them presented vaginal infection, and 27.7% increased vaginal discharge. Urinary symptoms remained unaltered. Women reported 100% satisfaction after using the pessary (77.7% partial improvement; 22.3% total improvement). SF-36 had significant improvement in three specific domains: general state of health (p=0.090), vitality (p=0.0497) and social aspects (p=0.007). ICIQ-VS presented a reduction in the vaginal symptoms (p < 0.0001) and an improvement in QoL (P < 0.0001). CONCLUSION: The use of pessary for six months improved the QoL and reduced vaginal symptoms for women with advanced POP.

Vaginal pessaries in the management of symptomatic pelvic organ prolapse in rural Kilimanjaro, Tanzania: a pre-post interventional study

INTRODUCTION AND HYPOTHESIS

The objective of this study was to evaluate the outcomes of vaginal pessaries in managing symptomatic pelvic organ prolapse (POP) in a low-income setting.

METHODS

A pre-post interventional study was conducted in the Kilimanjaro region, Tanzania. Seventy-one women with symptoms and a POP stage II or more on the POP quantification test were fitted with a vaginal pessary. Pelvic examination, POP Distress Inventory (POPDI-6) and POP Impact Questionnaire (POPIQ-7) were completed at baseline, after 3 months and after 12-18 months. Changes in the POPDI-6 and POPIQ-7 scores, complications and satisfaction associated with pessary use before and after the intervention were obtained.

RESULTS

Pessary treatment was associated with a reduction in the overall POPDI score from 55.0 (50.0, 60.0) at baseline to 25.0 (25.0, 30.0) after 12-18 months' use. The overall POPIQ score was reduced from 54.2 (41.7, 66.7) at baseline to 25.0 (25.0, 29.2) after 12-18 months' use of the pessary. Vaginal discharge was reported in 72.4 and 32.4% of the women after 3 and 12-18 months' use respectively, whereas 72.4 and 25% of the women had some degree of granuloma, erosion or infection at 3 and 12-18 months respectively. Despite the reported complications, 78% of the women were satisfied with the pessary when interviewed after 12-18 months and 81% wanted to continue using it.

CONCLUSIONS

Vaginal pessary improves symptoms and quality of life associated with symptomatic POP. Therefore, it may be a treatment option in managing POP in low-income countries such as Tanzania.

[The gynecological pessary: Is it really a device of another age, a fig leaf?]

OBJECTIVES

The use of pessary to put back up prolapsed organs to their normal position dates back prior to several millennia. This work aims to discuss its place in our clinical practice through an updated bibliographic review and emphasizes a hands-on approach to pessary fitting and management in terms of indication, pessary type selection, device' size, insertion, removal, follow-up visits and care.

METHODS

A review of the literature, in the light of the latest publications and recommendations of French and international learned societies, as well as our own experience, were analyzed.

RESULTS

This device appears to be as effective as surgical management to relieve symptoms related to urogenital prolapse and restore body image. It can be used temporarily, awaiting a surgical solution or as a therapeutic test (mimicking the effect of a surgical procedure to predict its functional outcome or identifying a masked urinary incontinence). It can also represent an alternative to surgery (patient choice, women who wish to complete childbearing or who are unsuitable for surgery because of medical comorbidities) and thus can be used in first intention. However, despite its moderate cost and its harmlessness, this device remains somewhat little known as regards the practical modalities of its use, which, moreover, appear not consensual.

CONCLUSION

A guide intended for the attention of the patients as well as a film relating to the practical modalities of the device' use were elaborated to improve the knowledge of both professionals and users in order to optimize and secure the care pathway.

Addition of Neostigmine and Tramadol to 1.5 % Lidocaine for paracervical block to reduce post-operative pain in colporrhaphy

Pain is a complex and multi-faceted human perception and several factors could dampen the pain. Therefore, we aimed to comparison of addition of neostigmine and tramadol to 1.5 % lidocaine with paracervical block in reduce of post-operative pain in colporrhaphy. This study was a randomized and double-blind clinical trial for 108 patients’ as candidate for colporrhaphy. Patients were randomly divided in three groups (Neostigmine, tramadol and control).We recorded pain in 2 and 6 and 12 hours after surgery, duration of analgesia and mean of use narcotic drug in 24 hours after surgery for all patients. Mean of narcotic drug used in 24 hours after surgery in neostigmine group was more than tramadol group(p=0/01).Pain in 2 and 6 and 12 hours after surgery in neostigmine group was more than tramadol group (p=0/01). Duration of analgesia in tramadol group was over neostigmine group and also, it was in neostigmine group was more than placebo (p=0/01).Taken together, tramadol could reduce pain in 2 and 6 and 12 hours after surgery and mean of narcotic drug used in 24 hours after surgery and increase duration of analgesia.

The prevalence and treatment pattern of clinically diagnosed pelvic organ prolapse: a Korean National Health Insurance Database-based cross-sectional study 2009-2015

The study aim was to evaluate the prevalence of pelvic organ prolapse using claim data of South Korea and to evaluate treatment patterns. The Korea National Health Insurance Corporation pay medical costs for most diseases. This study used Health Insurance Review & Assessment Service-National Inpatient Sample (HIRA-NIS) 2009–2015. Pelvic organ prolapse was defined by diagnostic code (N81.x). Of the approximately 4.5 million women included in HIRA-NIS 2009–2015, 10,305 women were selected as having pelvic organ prolapse, and the mean age of the pelvic organ prolapse group was 63.9 ± 0.2 years. The prevalence of pelvic organ prolapse was 180 ± 4 per 100,000 population in women older than 50 years old. In logistic regression analysis, constipation increased the prevalence of all pelvic organ prolapse (odds ratio, 4.04; 95% confidence interval, 3.52–4.63; P < 0.01). The number of women requiring pessary only and surgery only were 26 ± 2 per 100,000 population and 89 ± 1 per 100,000 population, respectively, for women over 50 years of age. The prevalence of pelvic organ prolapse was quite lower than in previous studies. Surgery peaked at approximately 70 years of age. Pessary increased dramatically among women after the age of 65.

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.

A case of renal dysfunction caused by pelvic organ prolapse

Pelvic organ prolapse (POP) is the descent of pelvic organs through the vagina, and sometimes causes hydronephrosis. Although the association between POP and hydronephrosis has long been recognized, severe hydronephrosis and renal dysfunction are rarely seen. We report a case of 66-year-old woman who had a vaginal delivery presented with externalized uterine and bladder prolapse during the previous 2 years. She had a 3-day history of hypophagia and vomiting, and laboratory analysis resulted in serum creatinine of 5.75 mg/dL and blood urea of 78.1 mg/dL. The patient was treated urgently with vaginal pessary to return the uterine and bladder into the pelvis. After 2 weeks, her serum creatinine dropped to 3.66 mg/dL, but chronic renal failure persisted. Hydronephrosis caused by POP may lead to renal dysfunction and can advance to irreversible renal damage if left untreated. Important is early evaluation of renal function and images of the kidney and ureter.

Primary treatment of pelvic organ prolapse: pessary use versus prolapse surgery

INTRODUCTION AND HYPOTHESIS

The objective of this study was to compare the functional outcomes after pessary treatment and after prolapse surgery as primary treatments for pelvic organ prolapse (POP).

METHODS

This was a prospective cohort study performed in a Dutch teaching hospital in women with symptomatic POP of stage II or higher requiring treatment. Patients were treated according to their preference with a pessary or prolapse surgery. The primary endpoint was disease-specific quality of life at 12 months follow-up according to the prolapse domain of the Urogenital Distress Inventory (UDI) questionnaire. Secondary outcomes included adverse events and additional interventions. To show a difference of ten points in the primary outcome, we needed to randomize 80 women (power 80%, α 0.05, taking 10% attrition into account).

RESULTS

We included 113 women (74 in the pessary group, 39 in the surgery group). After 12 months, the median prolapse domain score was 0 (10th to 90th percentile 0-33) in the pessary group and 0 (10th to 90th percentile 0-0) in the surgery group (p < 0.01). Differences in other domain scores were not statistically significant. In the pessary group, 28% (21/74) of the women had a surgical intervention versus 3% (1/39) reoperations in the surgery group (p = 0.01).

CONCLUSIONS

In women with POP of stage II or higher undergoing surgery, prolapse symptoms were less severe than in those who were treated with a pessary, but 72% of women who were treated with a pessary did not opt for surgery.

TRIAL REGISTRATION NUMBER

Dutch trial register NTR2856.

Vaginal Pessary in Women With Symptomatic Pelvic Organ Prolapse: A Randomized Controlled Trial

OBJECTIVE

To compare pelvic floor symptoms, quality of life, and complications in women with symptomatic pelvic organ prolapse (POP) with or without vaginal pessaries in addition to those who do pelvic floor exercises for 12 months.

METHODS

This was a parallel-group, single-blind, randomized controlled trial with 12 months of follow-up. Women with symptomatic stage I to stage III POP were randomized to either pelvic floor exercises training (control group) or pelvic floor exercises training and insertion of a vaginal pessary (pessary group). The primary outcome was the change of prolapse symptoms and quality of life by using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaires. Secondary outcomes included bothersome of prolapse symptoms, desired treatment, and any complications.

RESULTS

From December 2011 through November 2014, 311 women were screened and 276 were randomized as follows: 137 to the control and 139 to the pessary group. One hundred thirty-two (95.0%) women in the pessary group and 128 (93.4%) in the control group completed the study. The Pelvic Organ Prolapse Distress Inventory of Pelvic Floor Distress Inventory and the Pelvic Organ Prolapse Impact Questionnaire of Pelvic Floor Impact Questionnaire scores decreased in both groups after 12 months, but the mean score differences were higher in the pessary group (Pelvic Organ Prolapse Distress Inventory: -29.7 compared with -4.7, P<.01; Pelvic Organ Prolapse Impact Questionnaire: -29.0 compared with 3.5, P<.01). Complication rates were low and similar in both groups.

CONCLUSION

We provided further evidence in nonsurgical treatment for POP. Prolapse symptoms and quality of life were improved in women using a vaginal pessary in addition to pelvic floor exercises.

CLINICAL TRIAL REGISTRATION

Centre for Clinical Research and Biostatistics-Clinical Trials Registry, https://www2.ccrb.cuhk.edu.hk/web/?page_id=746, ChiCTR-TRC-11001796.