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

Pessary management practices for pelvic organ prolapse among Australian health care practitioners: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

Vaginal pessaries are a low-cost, effective treatment for pelvic organ prolapse (POP) and an alternative to surgery. Whilst traditionally pessary management (PM) has been provided by medical professionals, particularly gynaecologists, recent international studies found other professionals, including physiotherapists and nurses, may be involved. It is unknown which health care practitioners (HCPs) provide PM for POP in Australia or the distribution of services.

METHODS

In a cross-sectional study design, a self-reported electronic survey investigated Australian HCPs providing PM for POP. Purposive and snowball sampling targeted HCPs, professional organisations and health care facilities. Descriptive statistics described PM in relation to HCP professional profile, PM provision and geographical location.

RESULTS

There were 536 respondents (324 physiotherapists, 148 specialists, 33 general practitioners (GPs) and 31 nurses providing PM. Most worked within metropolitan regions (n = 332, 64%), 140 (27%) in rural, 108 (21%) in regional and 10 (2%) in remote areas. Most worked privately (n = 418, 85%), 153 (46%) worked publicly and 85 (17%) in both. Ring pessaries were most commonly used, followed by cube and Gellhorn. HCPs reported variable training in PM, and 336 (69%) had no mandatory workplace competency standard; however, 324 (67%) wanted further training. Women travelled long distances to access services.

CONCLUSIONS

Doctors, nurses and physiotherapists provided PM in Australia. HCPs had variable training and experience in PM, with rural and remote HCPs particularly wanting further training. This study highlights the need for accessible PM services, standardised and competency-based training for HCPs, and governance structures ensuring safe care.

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.

Does monthly self-management of vaginal ring pessaries reduce the rate of adverse events? A clinical audit

Objective

To determine the rate of adverse events (AE) in women who self-manage their vaginal ring pessary on a monthly basis. We hypothesised that the AE rate would be lower compared to previously published traditional management protocols.

Study design

Audit study of 75 women with pelvic organ prolapse and/or stress incontinence, who were fitted with a vaginal ring pessary during a five-year period, and who have self-managed their vaginal rings for at least two years, in a tertiary referral urogynaecology clinic.

Main outcome measures

AEs included vaginal bleeding, malodorous vaginal discharge, extrusion of the device, pain/discomfort, and disorders of defaecation or de novo urinary incontinence. AEs that led to discontinuation of usage were termed “major”.

Results

Of the 75 women who were taught to self-manage their ring pessary, 68 were initially successful. At a median follow-up of 50.5 months [IQR 43–76 months; median 4.2 years], 36 women (52.9%) were still using their ring pessary. Five women (7.4%) had vaginal erosions and bleeding leading them to cease pessary use (four proceeded to surgery). Three minor AEs were identified (4.4%), resolving after discontinuation of ring use two weeks. Thus, the overall AE rate was 11.8% (8/68).

Conclusions

In contrast to previous published AE rates of 43–56% in women having ring changes at a clinic every 4–6 months, the AE rate was 12% in the women who performed monthly self-management of vaginal ring pessaries. Such information should be made available to patients considering a vaginal ring pessary.

Theoretical and practical development of the TOPSY self-management intervention for women who use a vaginal pessary for pelvic organ prolapse

BACKGROUND

Pelvic organ prolapse (POP) is a common condition in women, where the downward descent of pelvic organs into the vagina causes symptoms which impacts quality of life. Vaginal pessaries offer an effective alternative to surgery for the management of POP. However, the need for regular follow-up can be burdensome for women and requires significant healthcare resources. The TOPSY study is a randomised controlled trial which aims to determine the clinical and cost-effectiveness of self-management of vaginal pessaries. This paper describes the theoretical and practical development of the self-management intervention.

METHODS

The intervention was developed using the MRC complex intervention framework, normalisation process theory (NPT) and self-management theory. The intervention aims to boost perceived self-efficacy in accordance with Bandura's social cognitive theory and is guided by the tasks and skills Lorig and Hollman describe as necessary to self-manage a health condition.

RESULTS

The TOPSY intervention was designed to support women to undertake the medical management, role management and emotional management of their pessary. The six self-management skills described by Lorig and Hollman: problem-solving, decision-making, resource utilisation, formation of a patient-provider partnership role, action planning and self-tailoring, are discussed in detail, including how women were supported to achieve each task within the context of pessary self-management. The TOPSY intervention includes a self-management support session with a pessary practitioner trained in intervention delivery, a follow-up phone call 2 weeks later and ongoing telephone or face-to-face support as required by the woman initiated by contacting a member of the research team.

CONCLUSIONS

The TOPSY study intervention was developed utilising the findings from a prior service development project, intervention development and self-efficacy theory, relevant literature, clinician experience and feedback from pessary using women and members of the public. In 2022, the findings of the TOPSY study will provide further evidence to inform this important aspect of pessary management.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN62510577 . Registered on June 10, 2017.

Vaginal Pessary for Pelvic Organ Prolapse: A French Multidisciplinary Survey

Objective: Pessary fitting and follow-up for women with pelvic organ prolapse (POP) can be performed by different health care practitioners (HCPs). We aimed to investigate knowledge and current practices among the main HCPs involved in pessary use in France. Materials and Methods: We sent an electronic questionnaire about pessary use to the members of eight French learned societies between April and October 2020. Results: During the study period, 1017 HCPs responded to the questionnaire: 712 (70.0%) were doctors, 208 (20.4%) physiotherapists, 95 (9.3%) midwives, and 7 (0.6%) nurses. Of the respondents, 69.1% claimed to be comfortable with pessary fitting and follow-up, and 54.1% think that a pessary can be offered as a first-line treatment in the management of POP. However, 60.1% reported that the main indications for pessaries were "older women," 71.3% for women with contraindications to surgery, and 60.5% for women waiting for surgery. 23.9% do not prescribe local estrogen therapy with a pessary for postmenopausal women. The main pessaries used are the ring and cube types (63.7 and 57.5%, respectively). Wide introitus (53.3%), difficulties of use (56.3%), a short vagina (41.4%), and major unmasked urinary incontinence (47.2%) are considered to be the main risk factors for pessary failure. The most common complications related to pessaries reported by the patients are vaginal discharge (48.6%) and pain or discomfort (40.6%). Up to 43.4% of respondents considered that a follow-up visit every 3-6 months was optimal. The need for training ranged from 42.8% for nurses to 65.2% for general practitioners. Conclusions: This national multidisciplinary survey revealed that HCPs in France are on the whole comfortable with pessaries and mainly prescribe the ring and cube form. Even if opinion about pessaries appears to be changing, HCPs would welcome additional training to improve knowledge and practices.

Pessary or surgery for a symptomatic pelvic organ prolapse: the PEOPLE study, a multicentre prospective cohort study

OBJECTIVE

To compare the 24-month efficacy of pessary or surgery as the primary treatment for symptomatic pelvic organ prolapse (POP).

DESIGN

Multicentre prospective comparative cohort study.

SETTING

Twenty-two Dutch hospitals.

POPULATION

Women referred with symptomatic POP of stage ≥2 and moderate-to-severe POP symptoms.

METHODS

The primary outcome was subjective improvement at the 24-month follow-up according to the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcomes included improvement in prolapse-related symptoms measured with the Pelvic Floor Distress Inventory (PFDI-20), improvement in subjective severeness of symptoms according to the Patient Global Impression of Severity (PGI-S) scale and crossover between therapies. The primary safety outcome was the occurrence of adverse events.

MAIN OUTCOME MEASURE

PGI-I at 24 months.

RESULTS

We included 539 women, with 335 women (62.2%) in the pessary arm and 204 women (37.8%) in the surgery arm. After 24 months, subjective improvement was reported by 134 women (83.8%) in the surgery group compared with 180 women (74.4%) in the pessary group (risk difference 9.4%, 95% CI 1.4-17.3%, P < 0.01). Seventy-nine women (23.6%) switched from pessary to surgery and 22 women (10.8%) in the surgery group underwent additional treatment. Both groups showed a significant reduction in bothersome POP symptoms (P ≤ 0.01) and a reduction in the perceived severity of symptoms (P ≤ 0.001) compared with the baseline.

CONCLUSIONS

Significantly more women in the surgery group reported a subjective improvement after 24 months. Both therapies, however, showed a clinically significant improvement of prolapse symptoms.

TWEETABLE ABSTRACT

Pessary treatment and vaginal surgery are both efficacious in reducing the presence and severity of prolapse symptoms, although the chance of significant improvement is higher following surgery.

Vaginal pessary for pelvic organ prolapse: A survey among french gynecological surgeons

OBJECTIVE

Because pessaries may offer symptomatic improvement for women with pelvic organ prolapse (POP), the study aimed to assess the opinion and knowledge of participants to a french general surgical gynecological congress, about this device.

MATERIAL AND METHODS

An anonymous survey was carried out near 150 surgeons attending a congress by handing them a questionnaire.

RESULTS

The average age of the 70 respondents was 50 years. 87.7 % were comfortable with fitting and monitoring pessary, 54.3 % think that a pessary can be offered as a first-line treatment in the management of POP. However, main indications of vaginal device are still old women and contraindications to surgery ; 31.4 % do not associate local estrogen therapy with a pessary for postmenopausal women.

CONCLUSION

The majority declares to be comfortable with pessaries, is ready to prescribe it as a first-line treatment and use local estrogen if necessary. Even if change of ideas seems to emerge about pessary, a change in beliefs and habits is still necessary. This progress can be achieved through doctors fully informed.

[The use of pessaries for treatment of pelvic organ prolapse: A survey from gynecologists and urologists residents]

INTRODUCTION

Pelvic organ prolapse (POP) is a common condition responsible for symptoms that significantly affect the quality of life in women. Despite its effectiveness, low cost and minor side effects, the pessary is little used in France. The objective of our study was to assess the knowledge, training and practices of residents regarding pessaries.

MATERIAL AND METHODS

This survey was conducted among residents in obstetrics gynecology, medical gynecology and urology in France between March and September 2020.

RESULTS

During the study period, 328 interns responded to the questionnaires. The majority of residents (52.1%) reported never having attended a consultation specializing in pelvicperineology. Only 31.7% felt comfortable having a pessary inserted. According to them, the pessary was indicated in 3 main situations: in case of contraindication to surgery (80%), while awaiting surgery (79%) and in women over 70 years old (62%). The pessary could be offered to all women for only 46.9% of them. Almost 53% of residents reported ignoring the main complications of pessaries and 83.5% felt they needed further training on the subject.

CONCLUSION

Interns seem to be generally aware of the use of the pessary. Their knowledge of the indications, complications or even monitoring leads us to believe that it is essential to promote their training so that the pessary becomes an integral part of the first-line therapeutic arsenal in the event of POPs.

Effect of pessary cleaning and optimal time interval for follow-up: a prospective cohort study

INTRODUCTION AND HYPOTHESIS

The objective of this study was to determine the efficacy of routine follow-up visits for pessary cleaning, the effect of extended time intervals between visits and the proportion of patients being able to self-manage their pessary for pelvic organ prolapse (POP).

METHODS

We conducted a prospective cohort study in patients with a stage ≥II POP without previous POP surgery. All patients received a pessary as primary treatment. Our main outcome measure was a difference ≥2 in median visual analogue scale (VAS) scores (for pain, discharge, irritation) 1 week before and 1 week after cleaning. Measurements were performed after 3- and 9-month cleaning intervals. For the evaluation of the effect of cleaning, 132 patients (3 months' follow-up) and 87 patients (12 months' follow-up) were available for analysis. For the evaluation of the effect of the lengthening interval, 123 patients were available.

RESULTS

Self-management was performed in 45.2% of patients at 1 year. In 93.1% of patients, no differences were observed in pre-and post-cleaning VAS scores (effect of cleaning) on vaginal pain. Nor was there a difference in discharge (72.4%) or irritation 85.1% (p = 0.00). No differences were observed in pre-cleaning VAS scores for vaginal pain, discharge and irritation when the interval was lengthened from 3 to 9 months. No serious adverse events occurred.

CONCLUSIONS

There is no proven benefit of regular follow-up visits to clean a pessary. Also, the length of the cleaning interval does not seem to matter.

A review of pessary for prolapse practitioner training

Pelvic organ prolapse is a significant quality of life issue for many women. Prolapse can be managed effectively with a mechanical device called a pessary therefore many women choose this as a conservative treatment option. Despite the extent to which pessaries are used in the UK, there are no clear guidelines regarding the training required for pessary practitioners. This article reviews literature related to pessary practitioner training.

METHODS

13 publications were reviewed.

RESULTS

eight themes were identified, namely 'prevalence of pessary training', 'type of pessary training', confidence in pessary care provision', 'impact on pessary care', 'skills and knowledge required to be a pessary practitioner', 'barriers', 'speciality of pessary care providers', and 'ongoing support'.

CONCLUSION

at present practitioners report a lack of pessary training, which impacts on care. Effective training includes didactic learning of agreed knowledge requirements, practice of clinical skills and ongoing support.

Factors associated with the prescription of vaginal pessaries for pelvic organ prolapse

OBJECTIVE

To identify the factors associated with the prescription of vaginal pessaries (VPs) as a conservative treatment for pelvic organ prolapse (POP).

METHODS

A cross-sectional study was performed during two annual urogynecology and general obstetrics and gynecology meetings in 2017 (São Paulo, SP, Brazil). A 19-item deidentified questionnaire regarding experiences and practices in prescribing VPs for POP patients was distributed among gynecologists. Our primary outcome was the frequency of prescribing VPs as a conservative treatment for POP. The reasons for prescribing or not prescribing VPs were also investigated. Univariate and multivariate analyses with crude and adjusted odds ratios (ORs) were performed for variables associated with the prescription of pessaries.

RESULTS

Three hundred forty completed surveys were analyzed. Half of the respondents (53.53%) were between 30-49 years old; most of them were female (73.53%), were from the Southeast Region (64.12%), were trained in obstetrics and gynecology (80.24%) or urogynecology (61.18%) and worked in private offices (63.42%). More than one-third (36.48%) attended four or more POP cases/week, and 97.65% (n=332) had heard or knew about VPs for POP; however, only 47.06% (n=160) prescribed or offered this treatment to patients. According to the multivariate analysis, physicians aged 18-35 years (OR=1.97[1.00-3.91]; p=0.04), those who participated in a previous urogynecology fellowship (OR=2.34[1.34-4.09]; p<0.01), those with relatively high volumes of POP cases (4 or +) (OR=2.23[1.21-4.47]; p=0.01) and those with PhD degrees (OR=2.75[1.01-7.54]; p=0.05) prescribed more pessaries.

CONCLUSIONS

Most gynecologists did not prescribe VPs. Younger physician age, participation in a previous urogynecology fellowship, a PhD degree, and a relatively high volume of POP cases were associated with increased VP prescription rates.

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.

Person-Centered Care for Patients with Pessaries

Pelvic organ prolapse is a common condition affecting women of any age but more likely to occur in the aging woman. Prolapse has a significant impact on quality of life, sexuality, and body image. Vaginal support pessaries have been used since ancient times and are a safe and effective nonsurgical treatment option. Fitting a pessary results in immediate symptom improvement. A comprehensive evaluation for pessary fitting is time intensive but necessary. Nurse providers perform direct pessary care and have a role in caring for women with prolapse expanding access to care. Caregiver and family involvement is important for pessary care and follow-up.

Documenting pessary offer prior to hysterectomy for management of pelvic organ prolapse

OBJECTIVES

To (1) determine the proportion of hysterectomy cases with documentation of pessary counseling prior to prolapse surgery and (2) identify variables associated with women offered a pessary.

STUDY DESIGN

The Michigan Surgical Quality Collaborative (MSQC) is a hysterectomy improvement initiative. Hysterectomies from 2013 to 2015 in which prolapse was the principal diagnosis were included. "Pessary offer" was defined as documentation showing the patient declined, could not tolerate, or failed a pessary trial. Bivariate analyses were used to compare demographics, medical history, surgical route, concomitant procedures (colpopexy or colporrhaphy), and intra- and postoperative complications between women with and without pessary offer. Hierarchical logistic regression was used to determine factors independently associated with pessary offer. Risk-adjusted pessary offer rates by hospital were calculated.

RESULTS

The adjusted rate of pessary offer was 25.2%, ranging from 3 to 76% per hospital. Bivariate comparisons showed differences between women with and without pessary offer in age, tobacco use, prior pelvic surgery, insurance status, surgical approach, secondary indication for surgery, concomitant prolapse procedure, teaching hospital status and hospital bed size. In logistic regression, odds of pessary offer increased with age > 55 years (OR 1.45, 95% CI 1.12-1.88, p = 0.006), Medicare insurance (OR 1.65, 95% CI 1.30-2.10, p < 0.0001), and a concomitant procedure (OR 1.5, 95% CI 1.16-1.93, p = 0.002). Postoperative urinary tract infections were more common in patients offered a pessary (6.4% vs. 2.5%, p < 0.0001), but other complications were similar.

CONCLUSIONS

Overall, only one-quarter of hysterectomies for prolapse in MSQC hospitals had documentation of pessary counseling-suggesting an opportunity to improve documentation, counseling regarding pessary use, or both.

[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.