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Pizzoferrato AC, Sallée C, Thubert T, Fauconnier A, Deffieux X. Value of pelvic examination in women with pelvic organ prolapse: A systematic review. Int J Gynaecol Obstet 2024. [PMID: 38778697 DOI: 10.1002/ijgo.15697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Recent recommendations from the French High Authority of Health on pelvic organ prolapse (POP) management underline the value of a pelvic examination. OBJECTIVES The aim of this paper was to analyze the literature and identify the best evidence available regarding pelvic examination for women presenting prolapse-associated symptoms in terms of diagnosis and predictability of treatment success. SEARCH STRATEGY The databases were queried similarly using Medical Subject Headings (MeSH) and non-MeSH terms broadly related to pelvic examination and POP management. SELECTION CRITERIA We included studies assessing the diagnostic contribution of pelvic examination (correlation with symptoms) and its value for assessing the risk of pessary failure or recurrence after reconstructive surgery. DATA COLLECTION AND ANALYSIS We assessed peer-reviewed articles on PubMed, Embase, and Cochrane database up to May 2023. The methodological quality of all the included studies was assessed using the ROBINS-E or RoB2 tools. MAIN RESULTS In all, 67 studies were retained for the review. Prolapse-associated symptoms are poorly correlated with POP diagnosis. The symptom that is best correlated with the POP stage is the presence of a vaginal bulge (moderate to good correlation). The factors most strongly associated with the risk of recurrence after surgery or pessary failure are clinical: essentially a higher POP stage before surgery, levator ani muscle avulsion, and vaginal and genital measurements. CONCLUSIONS In women complaining of prolapse-associated symptoms, a pelvic examination (vaginal speculum and digital vaginal examination) can confirm the presence of POP and identify risk factors for treatment failure or recurrence after surgical management or pessary placement. A higher stage of POP and levator ani muscle avulsion-discernible on pelvic examination-are major risk factors for POP recurrence or treatment failure. These features must be taken into account in the treatment choice and discussed with the patient.
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Affiliation(s)
- Anne-Cécile Pizzoferrato
- Department of Obstetrics and Gynecology, CHU de Poitiers, Poitiers, France
- Université de Poitiers, CIC-Inserm, DECLAN, Poitiers, France
| | - Camille Sallée
- Department of Obstetrics and Gynecology, Limoges University Hospital, Limoges, France
| | - Thibault Thubert
- Department of Obstetrics and Gynecology, Nantes University Hospital, Nantes, France
| | - Arnaud Fauconnier
- Department of Obstetrics and Gynecology, Intercommunal Hospital Center of Poissy Saint-Germain-en-Laye, Poissy, France
- Paris-Saclay University, Montigny-le-Bretonneux, France
| | - Xavier Deffieux
- Paris-Saclay University, Montigny-le-Bretonneux, France
- Department of Obstetrics and Gynecology, Antoine Béclère Hospital, Clamart, France
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Manchana T. Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse. Arch Gynecol Obstet 2024; 309:2203-2209. [PMID: 38189963 DOI: 10.1007/s00404-023-07299-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/07/2023] [Indexed: 01/09/2024]
Abstract
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.
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Affiliation(s)
- Tarinee Manchana
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand.
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Bugge C, Hagen S, Elders A, Mason H, Goodman K, Dembinsky M, Melone L, Best C, Manoukian S, Dwyer L, Khunda A, Graham M, Agur W, Breeman S, Culverhouse J, Forrest A, Forrest M, Guerrero K, Hemming C, McClurg D, Norrie J, Thakar R, Kearney R. Clinical and cost-effectiveness of pessary self-management versus clinic-based care for pelvic organ prolapse in women: the TOPSY RCT with process evaluation. Health Technol Assess 2024; 28:1-121. [PMID: 38767959 PMCID: PMC11145464 DOI: 10.3310/nwtb5403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Background Pelvic organ prolapse is common, causes unpleasant symptoms and negatively affects women's quality of life. In the UK, most women with pelvic organ prolapse attend clinics for pessary care. Objectives To determine the clinical effectiveness and cost-effectiveness of vaginal pessary self-management on prolapse-specific quality of life for women with prolapse compared with clinic-based care; and to assess intervention acceptability and contextual influences on effectiveness, adherence and fidelity. Design A multicentre, parallel-group, superiority randomised controlled trial with a mixed-methods process evaluation. Participants Women attending UK NHS outpatient pessary services, aged ≥ 18 years, using a pessary of any type/material (except shelf, Gellhorn or Cube) for at least 2 weeks. Exclusions: women with limited manual dexterity, with cognitive deficit (prohibiting consent or self-management), pregnant or non-English-speaking. Intervention The self-management intervention involved a 30-minute teaching appointment, an information leaflet, a 2-week follow-up telephone call and a local clinic telephone helpline number. Clinic-based care involved routine appointments determined by centres' usual practice. Allocation Remote web-based application; minimisation was by age, pessary user type and centre. Blinding Participants, those delivering the intervention and researchers were not blinded to group allocation. Outcomes The patient-reported primary outcome (measured using the Pelvic Floor Impact Questionnaire-7) was prolapse-specific quality of life, and the cost-effectiveness outcome was incremental cost per quality-adjusted life-year (a specifically developed health Resource Use Questionnaire was used) at 18 months post randomisation. Secondary outcome measures included self-efficacy and complications. Process evaluation data were collected by interview, audio-recording and checklist. Analysis was by intention to treat. Results Three hundred and forty women were randomised (self-management, n = 169; clinic-based care, n = 171). At 18 months post randomisation, 291 questionnaires with valid primary outcome data were available (self-management, n = 139; clinic-based care, n = 152). Baseline economic analysis was based on 264 participants (self-management, n = 125; clinic-based care, n = 139) with valid quality of life and resource use data. Self-management was an acceptable intervention. There was no group difference in prolapse-specific quality of life at 18 months (adjusted mean difference -0.03, 95% confidence interval -9.32 to 9.25). There was fidelity to intervention delivery. Self-management was cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained, with an estimated incremental net benefit of £564.32 and an 80.81% probability of cost-effectiveness. At 18 months, more pessary complications were reported in the clinic-based care group (adjusted mean difference 3.83, 95% confidence interval 0.81 to 6.86). There was no group difference in general self-efficacy, but self-managing women were more confident in pessary self-management activities. In both groups, contextual factors impacted on adherence and effectiveness. There were no reported serious unexpected serious adverse reactions. There were 32 serious adverse events (self-management, n = 17; clinic-based care, n = 14), all unrelated to the intervention. Skew in the baseline data for the Pelvic Floor Impact Questionnaire-7, the influence of the global COVID-19 pandemic, the potential effects of crossover and the lack of ethnic diversity in the recruited sample were possible limitations. Conclusions Self-management was acceptable and cost-effective, led to fewer complications and did not improve or worsen quality of life for women with prolapse compared with clinic-based care. Future research is needed to develop a quality-of-life measure that is sensitive to the changes women desire from treatment. Study registration This study is registered as ISRCTN62510577. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/82/01) and is published in full in Health Technology Assessment; Vol. 28, No. 23. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Carol Bugge
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Suzanne Hagen
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Andrew Elders
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Kirsteen Goodman
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | | | - Lynn Melone
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Catherine Best
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Stirling, UK
| | - Sarkis Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Lucy Dwyer
- The Warrell Unit, Saint Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Aethele Khunda
- South Tees Hospitals NHS Foundation Trust, James Cook University Hospital, Middlesbrough, UK
| | - Margaret Graham
- Health Sciences & Sport, University of Stirling, Stirling, UK
| | - Wael Agur
- School of Medicine, Dentistry and Nursing, NHS Ayrshire & Arran, University of Glasgow, Kilmarnock, UK
| | - Suzanne Breeman
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | | | - Angela Forrest
- Patient and public representative of the TOPSY trial, UK
| | - Mark Forrest
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Karen Guerrero
- Department of Urogynaecology, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Christine Hemming
- Grampian University Hospitals NHS Trust, Aberdeen Maternity Hospital and Aberdeen Royal Infirmary, Aberdeen, UK
| | - Doreen McClurg
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - John Norrie
- Usher Institute of Population Health Sciences and Informatics, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Ranee Thakar
- Croydon Health Services NHS Trust, Croydon University Hospital, Croydon, UK
| | - Rohna Kearney
- The Warrell Unit, Saint Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
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Dykes N, Lim YN, Zilberlicht A, Dwyer PL. Are older patients with prolapse likely to continue pessary use? A retrospective observational study. Int Urogynecol J 2023; 34:2919-2923. [PMID: 37572122 DOI: 10.1007/s00192-023-05627-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/10/2023] [Indexed: 08/14/2023]
Abstract
INTRODUCTION AND HYPOTHESIS To review the outcomes and complications of vaginal prolapse management with pessaries in women aged 75 years or older, to ascertain whether pessaries are providing satisfactory long-term outcomes for older women. METHODS A retrospective observational study was performed on women aged 75 years or older presenting to a tertiary Urogynaecology service with vaginal prolapse who opted for management with a vaginal pessary. Demographic and clinical data were collected by reviewing clinical files. The primary outcome was the proportion of women who opted for pessary management who later required prolapse surgery. Secondary outcomes included pessary complications and risk factors for failure. Kaplan-Meier survival estimates were performed to analyse pessary failure. RESULTS Of the 218 women who presented with prolapse, 78% opted for pessary management, and pessary fitting was successful in 84%. Sixty-nine percent of women who opted for initial pessary management underwent surgery later, with a mean time from pessary insertion to surgery of 21.6 months. Vaginal erosions were reported in 42% of pessary users. Risk factors for pessary failure were younger age and previous history of hysterectomy or prolapse surgery. CONCLUSIONS Although vaginal pessary use was the preferred first-line management choice for vaginal prolapse in most older women, surgery for prolapse was ultimately required in two-thirds of those conservatively managed. As three-quarters of older women presenting with prolapse had surgery as either a primary or secondary procedure; patients need to be advised of the high chance of requiring surgery at a later stage if they opt for pessary management.
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Affiliation(s)
- Nicola Dykes
- Department of Obstetrics and Gynaecology, North Shore Hospital, Te Whatu Ora Waitemata, 124 Shakespeare Road, Takapuna, Auckland, 0620, New Zealand.
- Department of Urogynaecology, Mercy Hospital for Women, Melbourne, Australia.
| | - Yik N Lim
- Department of Urogynaecology, Mercy Hospital for Women, Melbourne, Australia
| | - Ariel Zilberlicht
- Department of Obstetrics and Gynecology, Carmel Medical Center, Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Peter L Dwyer
- Department of Urogynaecology, Mercy Hospital for Women, Melbourne, Australia
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Kakkar A, Reuveni-Salzman A, Bentaleb J, Belzile E, Merovitz L, Larouche M. Adverse events associated with pessary use over one year among women attending a pessary care clinic. Int Urogynecol J 2023; 34:1765-1770. [PMID: 36715742 DOI: 10.1007/s00192-023-05462-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/01/2023] [Indexed: 01/31/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The primary objective was to determine the adverse event rate associated with pessary use. Secondary objectives were to determine discontinuation, patient satisfaction, and factors associated with adverse events. METHODS A retrospective observational study included patients attending a nurse-led pessary clinic with ≥ 1 year follow-up. Patients were fitted with a pessary by a urogynecologist and pessary care by a nurse was performed every 3-4 months. Demographic characteristics, pessary fitting, adverse events, their management and discontinuation were recorded. Pearson Chi-square and Fisher exact tests assessed the association between predetermined risk factors and pessary complications or discontinuation. Relative risk and 95% confidence intervals were computed. RESULTS 215 women were followed for a mean (standard deviation) of 4.4 (1.9) years. Mean age was 73.8 (8.7) years. Adverse event rate was 83.7%; most commonly vaginal discharge, vaginal bleeding and erosions. Women with cardiovascular risk factors were less likely to develop pessary-related adverse events (79.7% vs. 91.9%, p = 0.03). Gellhorn and donut pessaries were more commonly associated with pessary erosions than ring with support pessaries or incontinence rings (RR 2.37 [1.67; 3.38]). Thirty-five (16.3%) women discontinued pessary use at a mean of 3.3 (1.7) years after initial fitting. Having a pessary erosion was not associated with discontinuation (p = 0.698), but recurrent erosions were (p = 0.012). CONCLUSION Adverse events were common among women continuing to use pessaries past 1 year, but adherence and satisfaction rates remained high after 4.4 years. Pessary type and absence of cardiovascular factors were associated with pessary-related adverse events.
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Affiliation(s)
- Arshia Kakkar
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Adi Reuveni-Salzman
- Division of Urogynecology, Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada
| | - Jouhayna Bentaleb
- Division of Urogynecology, Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada
| | - Eric Belzile
- St. Mary's Research Centre, 4Th Floor Hayes Pavilion, 3830 Lacombe, Montreal, QC, H3T 1M5, Canada
| | - Lisa Merovitz
- Division of Urogynecology, Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada
| | - Maryse Larouche
- Division of Urogynecology, Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada.
- St. Mary's Research Centre, 4Th Floor Hayes Pavilion, 3830 Lacombe, Montreal, QC, H3T 1M5, Canada.
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Kuruma A, Kodama M, Kawashima A, Horai M, Endo M, Nonomura N, Kimura T. Massive full-thickness mucosal defect of the anterior vaginal wall in ring pessary treatment. Eur J Obstet Gynecol Reprod Biol 2023; 283:167-168. [PMID: 36882342 DOI: 10.1016/j.ejogrb.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/30/2022] [Accepted: 02/28/2023] [Indexed: 03/06/2023]
Affiliation(s)
- Airi Kuruma
- Osaka University Graduate School of Medicine, Department of Obstetrics and Gynecology, 2-2, Yamadaoka, Suita City, Osaka 5650871, Japan
| | - Michiko Kodama
- Osaka University Graduate School of Medicine, Department of Obstetrics and Gynecology, 2-2, Yamadaoka, Suita City, Osaka 5650871, Japan.
| | - Atsunari Kawashima
- Osaka University Graduate School of Medicine, Department of Urology, 2-2, Yamadaoka, Suita City, Osaka 5650871, Japan
| | - Megumi Horai
- Osaka University Graduate School of Medicine, Department of Obstetrics and Gynecology, 2-2, Yamadaoka, Suita City, Osaka 5650871, Japan
| | - Masayuki Endo
- Osaka University Graduate School of Medicine, Department of Obstetrics and Gynecology, 2-2, Yamadaoka, Suita City, Osaka 5650871, Japan
| | - Norio Nonomura
- Osaka University Graduate School of Medicine, Department of Urology, 2-2, Yamadaoka, Suita City, Osaka 5650871, Japan
| | - Tadashi Kimura
- Osaka University Graduate School of Medicine, Department of Obstetrics and Gynecology, 2-2, Yamadaoka, Suita City, Osaka 5650871, Japan
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Pessary Management Approach Affects Likelihood of Surgery. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:879-886. [PMID: 36409646 DOI: 10.1097/spv.0000000000001253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE It is unknown whether the pessary management type influences the need for surgery. OBJECTIVE The aim of this study was to evaluate the rate of surgical treatment for pelvic organ prolapse or stress urinary incontinence with the type of pessary management (self-management or office management). STUDY DESIGN We conducted a retrospective cohort study that included first-time pessary users treated at a tertiary urogynecologic clinic from 2012 to 2014 for pelvic organ prolapse, stress urinary incontinence, or both. For the primary outcome, we explored the relationship between pessary management type and the likelihood of surgery using multivariable Cox proportional hazards models. Secondary outcomes assessed relationships between patient factors (eg, demographics and clinical attributes) and pessary management type using multivariable logistics regression models. RESULTS There were 218 patients included in our analysis. Of all pessary users, 59 (27.1%) required office management and 159 (72.9%) participated in self-management. Surgery was performed in 22 (35.1%) office-managed patients and 33 (19.3%) self-managed patients. Women who self-managed their pessaries were significantly less likely to undergo surgery than those who received office management (multivariable hazards ratios, 0.416; P = 0.005). In the multivariable logistic regression model for pessary management type, increasing age (odds ratio [OR], 1.098; P ≤ 0.0001), increasing body mass index (OR, 1.078; P < 0.05), and increasing genital hiatus (OR, 1.547; P < 0.05) were associated with increased odds of pessary office management compared with self-management. CONCLUSIONS In a urogynecology clinic setting, pessary self-management is associated with lower rates of surgical treatment compared with office management. Factors associated with office management include increased age, body mass index, and large genital hiatus.
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Ziv E, Erlich T. Novel, disposable, self-inserted, vaginal device for the non-surgical management of pelvic organ prolapse: efficacy, safety, and quality of life. BMC Womens Health 2022; 22:459. [DOI: 10.1186/s12905-022-02057-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/03/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background
We evaluated a novel disposable, collapsible, ring-shaped vaginal device that is self-inserted within an applicator and removed with a string. The device was developed to overcome the drawbacks of existing ring pessaries for non-surgical pelvic organ prolapse management (POP).
Methods
The primary objective efficacy endpoint of this prospective, interventional, multicenter, self-controlled, and home-use study was the proportion of subjects with improved staging on the Pelvic Organ Prolapse Quantification (POP-Q) scale. Subjective efficacy was assessed using the POP symptoms alleviation score. Safety was evaluated by recording the rate and incidence of adverse events (AEs) in a daily diary, and quality of life (QoL) was evaluated using the modified Pelvic Floor Impact (PFIQ-7) and Pelvic Floor Disability Index (PFDI-20) questionnaires.
Results
A total of 94 usage cycles were observed in a group of 52 participants (mean age 60.2 ± 10.5 years, 81.1% postmenopausal) who used the device for 3558 days. Of these, 24 participants completed one usage cycle, 14 completed two usage cycles, and 14 completed three usage cycles with 28–45 days of ProVate use in each usage cycle. All patients experienced greater than two POP-Q stage reductions. The descent was completely reduced to POP-Q stage 0 in 97.8% of participants. The POP symptom alleviation questionnaire showed significant subjective efficacy (P < 0.0001). The modified PFDI-20 and PFIQ-7 scores also improved substantially (P < 0.0001 for both). There were 91 nonserious device-related AEs: 98.9% were mild and 87.9% anticipated, with no vaginal infection, and one case of urinary tract infection.
Conclusion
The novel device substantially reduces prolapse and provides significant subjective POP symptom relief and QoL improvement, with minimal AEs. The device may enable women to self-manage their prolapse with a small, disposable device that minimizes self-touching and frequent dependency on the clinic.
Trial registration
Clinical.Trials.gov, NCT02239133, posted September 12, 2014 (retrospectively registered).
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Dabic S, Sze C, Sansone S, Chughtai B. Rare complications of pessary use: A systematic review of case reports. BJUI COMPASS 2022; 3:415-423. [PMID: 36267197 PMCID: PMC9579882 DOI: 10.1002/bco2.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/31/2022] [Accepted: 05/25/2022] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Stefan Dabic
- Department of Urology Weill Cornell Medicine/New York Presbyterian New York New York USA
| | - Christina Sze
- Department of Urology Weill Cornell Medicine/New York Presbyterian New York New York USA
| | - Stephanie Sansone
- Department of Urology Weill Cornell Medicine/New York Presbyterian New York New York USA
| | - Bilal Chughtai
- Department of Urology Weill Cornell Medicine/New York Presbyterian New York New York USA
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Predictors for long-term adherence to vaginal pessary in pelvic organ prolapse: a prospective study. Int Urogynecol J 2022; 33:3237-3246. [DOI: 10.1007/s00192-022-05133-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 02/07/2022] [Indexed: 10/18/2022]
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Manzini C, Morsinkhof LM, van der Vaart CH, Withagen MIJ, Grob ATM. Parameters associated with unsuccessful pessary fitting for pelvic organ prolapse up to three months follow-up: a systematic review and meta-analysis. Int Urogynecol J 2022; 33:1719-1763. [PMID: 35037973 PMCID: PMC9270314 DOI: 10.1007/s00192-021-05015-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/05/2021] [Indexed: 11/30/2022]
Abstract
Objectives To clarify which parameters are associated with unsuccessful pessary fitting for pelvic organ prolapse (POP) at up to 3 months follow-up. Methods Embase, PubMed and Cochrane CENTRAL library were searched in May 2020. Inclusion criteria were: (1) pessary fitting attempted in women with symptomatic POP; (2) pessary fitting success among the study outcomes with a maximal follow-up of 3 months; (3) baseline parameters compared between successful and unsuccessful group. A meta-analysis was performed using the random effects model. Main results Twenty-four studies were included in the meta-analysis. Parameters associated with unsuccessful pessary fitting were: age (OR 0.70, 95% CI 0.56–0.86); BMI (OR 1.35, 95% CI 1.08–1.70); menopause (OR 0.65 95% CI 0.47–0.88); de novo stress urinary incontinence (OR 5.59, 95% CI 2.24–13.99); prior surgery, i.e. hysterectomy (OR 1.88, 95% CI 1.48–2.40), POP surgery (OR 2.13, 95% CI 1.34–3.38), pelvic surgery (OR 1.81, 05% CI 1.01–3.26) and incontinence surgery (OR 1.87, 95% CI 1.08–3.25); Colorectal-Anal Distress Inventory-8 scores (OR 1.92, 95% CI 1.22–3.02); solitary predominant posterior compartment POP (OR 1.59, 95% CI 1.08–2.35); total vaginal length (OR 0.56, 95% CI 0.32–0.97); wide introitus (OR 4.85, 95% CI 1.60–14.68); levator ani avulsion (OR 2.47, 95% CI 1.35–4.53) and hiatal area on maximum Valsalva (OR 1.89, 95% CI 1.27–2.80). Conclusion During counselling for pessary treatment a higher risk of failure due to the aforementioned parameters should be discussed and modifiable parameters should be addressed. More research is needed on the association between anatomical parameters and specific reasons for unsuccessful pessary fitting.
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Affiliation(s)
- Claudia Manzini
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,, Utrecht, The Netherlands
| | - Lisan M Morsinkhof
- Magnetic Detection and Imaging, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - C Huub van der Vaart
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mariëlla I J Withagen
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Anique T M Grob
- Multi-Modality Medical Imaging, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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12
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Host inflammatory response in women with vaginal epithelial abnormalities after pessary use. Int Urogynecol J 2021; 33:2151-2157. [PMID: 34748034 DOI: 10.1007/s00192-021-05001-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Vaginal epithelial abnormalities (VEA) are a common complication associated with pessary use. The objective of this study was to determine if there is a host pro-inflammatory response associated with pessary use and VEA. METHODS Patients wearing pessaries for at least two weeks for the management of pelvic organ prolapse and/or urinary incontinence were screened for eligibility. Vaginal swabs were collected from women with VEA (cases) and without VEA (controls). Cases were matched to controls in a 1:3 ratio. Cytokine analysis of the collected samples was performed using multiplex analysis to determine the concentrations of interleukin (IL)6, interferon alpha 2 (IFNα2), tumor necrosis factor alpha (TNFα) and IL1β. A cross-sectional analysis was performed, comparing vaginal cytokine concentrations in women with and without VEA. RESULTS We enrolled 211 patients in this analysis: 50 cases and 161 controls. The median concentrations (pg/mL) of the four cytokines for cases and controls respectively were; IL6: 6.7 (IQR <2.9 [the lower limit of detection, LLD]-14.2) and < 2.9 (LLD) (IQR <2.9 [LLD]-5.5), IFNα2: 8.2 (IQR 6.1-13.9) and 7.9 (IQR 3.9-13.6), TNFα: 15.2 (IQR 6.1-30.4) and 4.68 (IQR <2.3 [LLD]-16.3), IL1β 195.7 (IQR 54.5-388.6) and 38.5 (IQR 6.7-154.9). The differences in median cytokine levels were statistically higher in cases for IL6, TNFα, and IL1β (all p < 0.001) compared to controls. Older age (OR: 1.062, 95% CI, 1.015-1.112), lower BMI (OR: 0.910, 95% CI, 0.839-0.986) and presence of VEA at last check (OR: 5.377, 95% CI, 2.049-14.108) were associated with higher odds of having VEA on multivariate analysis. CONCLUSION Pro-inflammatory cytokines, specifically IL6, TNFα, and IL1β, are elevated in pessary-wearing patients who have VEA. Additional prospective studies are needed to assess baseline vaginal inflammatory profiles before and after pessary placement to understand VEA formation in pessary patients.
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13
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Thys S, Hakvoort R, Milani A, Roovers JP, Vollebregt A. Can we predict continued pessary use as primary treatment in women with symptomatic pelvic organ prolapse (POP)? A prospective cohort study. Int Urogynecol J 2021; 32:2159-2167. [PMID: 34002267 DOI: 10.1007/s00192-021-04817-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/18/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Susanne Thys
- Spaarne Gasthuis, Hoofddorp, The Netherlands. .,Academic Medical Center, Amsterdam University Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | | | | | - Jan Paul Roovers
- Academic Medical Center, Amsterdam University Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
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14
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Bouchard ME, Rousseau E, Fortier LC, Girard I. Pathophysiology of Vaginal Erosions in Women Using Pessary: A Pilot Study Examining Vaginal Microbiota. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:943-948. [PMID: 33933709 DOI: 10.1016/j.jogc.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Many women with pelvic organ prolapse opt for a pessary, and some of these women develop erosions of the vaginal mucosa. Ongoing erosions might lead to the discontinuation of this otherwise effective, non-invasive, and inexpensive treatment. The objectives of this study were to investigate the differences in vaginal pH and variations of the vaginal microbiota among pessary and non-pessary users. METHODS For this descriptive observational study, 30 women, followed in our urogynecology clinic, were recruited to form 3 equal groups: 2 groups of women using a pessary (with and without erosions) and 1 control group of women not using a pessary. Vaginal pH was measured distally and next to the erosion. Vaginal swabs were used to investigate the vaginal microbiota by sequencing the V4 region of the 16S ribosomal RNA gene and analyzing the data with Qiime2. Descriptive statistics were reported using the median values. Vaginal pH comparisons between groups were made using a Kruskal-Wallis test with Dunn's correction for multiple comparisons. RESULTS The pH of the vagina was more alkaline in women with erosions compared with women in the other 2 groups (P < 0.01). Also, the pH of the distal vagina was not different from the pH next to the erosion (P = 0.25). Patients with erosions displayed significant differences in their vaginal microbiota, which contained a much greater bacterial diversity with an increase in gram-negative bacteria (e.g., Bacteroidetes, Actinobacteria) and a decrease in lactobacilli. CONCLUSION In our study, women with vaginal erosions had significantly higher vaginal pH and more complex vaginal microbiota than women in the control groups. Treatments focusing on lowering the vaginal pH and/or re-establishing the vaginal microbiota should be considered.
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Affiliation(s)
| | - Eric Rousseau
- Department of Obstetrics and Gynaecology, Université de Sherbrooke, Sherbrooke, QC
| | | | - Isabelle Girard
- Department of Obstetrics and Gynaecology, Université de Sherbrooke, Sherbrooke, QC
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15
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Vaginal pessary treatment in women with symptomatic pelvic organ prolapse: a long-term prospective study. ACTA ACUST UNITED AC 2021; 28:538-545. [PMID: 33625108 DOI: 10.1097/gme.0000000000001751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the 5-year pessary continuation rate and identify clinical risk factors associated with discontinuation in patients with symptomatic pelvic organ prolapse (POP). METHODS In this prospective observational study, 312 women with symptomatic POP received pessary treatment between November 2013 and July 2015 in Peking Union Medical College Hospital, China, a tertiary referral center. Patients were initially fitted with a ring pessary with support. Those who failed were fitted with a Gellhorn pessary. A successful pessary fitting was defined as a patient who was fitted and continued to use the pessary 2 weeks later. Patients with successful pessary fitting were followed for 5 years. Data analysis was performed with t tests, nonparametric tests, chi-square tests, and logistic regression. RESULTS In total, 265 patients (84.9%) had successful pessary fitting. After 5 years, 180 of 239 patients continued pessary use (75.3% continuation rate), with 26 lost to follow-up. The discontinuation rates decreased over time, from 8.7% at 1 year to 2.7% at 5 years. Total vaginal length < 7.5 cm (TVL, OR = 2.7, 95% CI 1.3-5.7, P = 0.007), improvement in Urinary Impact Questionnaire-7 scores < 50% at 3 months (OR = 2.1, 95% CI 1.1-4.2, P = 0.025), and incapability of self-care (OR = 2.6, 95% CI 1.3-5.1, P = 0.008) were potential discontinuation risk factors. CONCLUSION Three-quarters of patients with symptomatic POP had successful pessary treatment at 5-year follow-up. TVL < 7.5 cm, poor urinary symptom relief at 3 months, and incapability of self-care were potential discontinuation risk factors.
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16
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Hagen S, Kearney R, Goodman K, Melone L, Elders A, Manoukian S, Agur W, Best C, Breeman S, Dembinsky M, Dwyer L, Forrest M, Graham M, Guerrero K, Hemming C, Khunda A, Mason H, McClurg D, Norrie J, Karachalia-Sandri A, Thakar R, Bugge C. Clinical and cost-effectiveness of vaginal pessary self-management compared to clinic-based care for pelvic organ prolapse: protocol for the TOPSY randomised controlled trial. Trials 2020; 21:837. [PMID: 33032644 PMCID: PMC7542756 DOI: 10.1186/s13063-020-04738-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/25/2020] [Indexed: 11/13/2022] Open
Abstract
Background Pelvic organ prolapse (or prolapse) is a common condition in women where the pelvic organs (bladder, bowel or womb) descend into the vagina and cause distressing symptoms that adversely affect quality of life. Many women will use a vaginal pessary to treat their prolapse symptoms. Clinic-based care usually consists of having a pessary fitted in a primary or secondary care setting, and returning approximately every 6 months for healthcare professional review and pessary change. However, it is possible that women could remove, clean and re-insert their pessary themselves; this is called self-management. This trial aims to assess if self-management of a vaginal pessary is associated with better quality of life for women with prolapse when compared to clinic-based care. Methods This is a multicentre randomised controlled trial in at least 17 UK centres. The intervention group will receive pessary self-management teaching, a self-management information leaflet, a follow-up phone call and access to a local telephone number for clinical support. The control group will receive the clinic-based pessary care which is standard at their centre. Demographic and medical history data will be collected from both groups at baseline. The primary outcome is condition-specific quality of life at 18 months’ post-randomisation. Several secondary outcomes will also be assessed using participant-completed questionnaires. Questionnaires will be administered at baseline, 6, 12 and 18 months’ post-randomisation. An economic evaluation will be carried out alongside the trial to evaluate cost-effectiveness. A process evaluation will run parallel to the trial, the protocol for which is reported in a companion paper. Discussion The results of the trial will provide robust evidence of the effectiveness of pessary self-management compared to clinic-based care in terms of improving women’s quality of life, and of its cost-effectiveness. Trial registration ISRCTN Registry ISRCTN62510577. Registered on June 10, 2017.
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Affiliation(s)
- Suzanne Hagen
- Research Unit, Glasgow Caledonian University, Glasgow, UK.
| | - Rohna Kearney
- The Warrell Unit, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,University Institute of Human Development, Faculty of Medical Human Sciences, University of Manchester, Manchester, UK
| | | | - Lynn Melone
- Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Andrew Elders
- Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Sarkis Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Wael Agur
- NHS Ayrshire & Arran, Crosshouse Hospital, Kilmarnock, UK.,School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Catherine Best
- NMAHP Research Unit, unit 13 Scion House, University of Stirling Innovation Park, Stirling, UK
| | - Suzanne Breeman
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | | | - Lucy Dwyer
- The Warrell Unit, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,University Institute of Human Development, Faculty of Medical Human Sciences, University of Manchester, Manchester, UK
| | - Mark Forrest
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Margaret Graham
- Patient and Public Involvement (PPI) representative, Dunlop, UK
| | - Karen Guerrero
- Department of Urogynaecology, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Christine Hemming
- Aberdeen Maternity Hospital & Aberdeen Royal Infirmary, Grampian University Hospitals NHS Trust, Aberdeen, UK
| | - Aethele Khunda
- South Tees Hospitals NHS Foundation Trust, James Cook University Hospital, Middlesbrough, UK
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Doreen McClurg
- Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - John Norrie
- Usher Institute of Population Health Sciences and Informatics, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | | | - Ranee Thakar
- Croydon Health Services NHS Trust, Croydon University Hospital, Croydon, UK
| | - Carol Bugge
- Health Sciences & Sport, University of Stirling, Stirling, UK
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17
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Masood Z, Imtiaz R, Husain S, Husain S, Izhar R. Pessary offer documentation in women undergoing surgery for pelvic organ prolapse at a tertiary care hospital. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:870-873. [PMID: 32790563 DOI: 10.12968/bjon.2020.29.15.870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Women report similar functional outcomes after pessary treatment or surgery for pelvic organ prolapse (POP). AIMS To assess the documentation of pessary counselling in women who underwent surgery for POP. Methods: This was a retrospective cohort study conducted on women who underwent hysterectomy for prolapse. The primary outcome measure was documentation regarding offer of pessary. 'Pessary offer' was defined as documentation that clearly stated that the care provider offered pessary to the patient. FINDINGS Over the study period, 81 hysterectomies took place for POP; pessary offer was documented for only 19 (23.5%) case records. Characteristics significantly associated with pessary offer were history of chronic cough (P=0.031), previous pelvic surgery (P<0.001), no secondary indication for surgery (P=0.012), concomitant surgery performed other than hysterectomy (P=0.046), age range (P<0.001) and BMI range (P<0.001). CONCLUSION Pessary offer was documented in less than quarter of cases. This denotes a need to strengthen documentation of offer, counselling for pessary, or both of these.
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Affiliation(s)
- Zubaida Masood
- Associate Professor, Department of Gynaecology and Obstetrics, Abbasi Shaheed Hospital and Karachi Medical and Dental College, Karachi, Pakistan
| | - Rahila Imtiaz
- Assistant Professor, Department of Gynaecology and Obstetrics, Abbasi Shaheed Hospital and Karachi Medical And Dental College, Karachi, Pakistan
| | - Samia Husain
- Senior Registrar, Department of Gynaecology and Obstetrics, Holy Family Hospital and School of Nursing, Karachi, Pakistan
| | - Sonia Husain
- Postgraduate, Department of Gynaecology and Obstetrics, Abbasi Shaheed Hospital and Karachi Medical and Dental College, Karachi, Pakistan
| | - Rubina Izhar
- Professor, Department of Gynaecology and Obstetrics, Abbasi Shaheed Hospital and Karachi Medical and Dental College, Aziz Medical Center, Karachi, Pakistan
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18
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Grimes CL, Balk EM, Crisp CC, Antosh DD, Murphy M, Halder GE, Jeppson PC, Weber LeBrun EE, Raman S, Kim-Fine S, Iglesia C, Dieter AA, Yurteri-Kaplan L, Adam G, Meriwether KV. A guide for urogynecologic patient care utilizing telemedicine during the COVID-19 pandemic: review of existing evidence. Int Urogynecol J 2020; 31:1063-1089. [PMID: 32342112 PMCID: PMC7185267 DOI: 10.1007/s00192-020-04314-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/17/2022]
Abstract
Introduction and hypothesis The COVID-19 pandemic and the desire to “flatten the curve” of transmission have significantly affected the way providers care for patients. Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) must provide high quality of care through remote access such as telemedicine. No clear guidelines exist on the use of telemedicine in FPMRS. Using expedited literature review methodology, we provide guidance regarding management of common outpatient urogynecology scenarios during the pandemic. Methods We grouped FPMRS conditions into those in which virtual management differs from direct in-person visits and conditions in which treatment would emphasize behavioral and conservative counseling but not deviate from current management paradigms. We conducted expedited literature review on four topics (telemedicine in FPMRS, pessary management, urinary tract infections, urinary retention) and addressed four other topics (urinary incontinence, prolapse, fecal incontinence, defecatory dysfunction) based on existing systematic reviews and guidelines. We further compiled expert consensus regarding management of FPMRS patients in the virtual setting, scenarios when in-person visits are necessary, symptoms that should alert providers, and specific considerations for FPMRS patients with suspected or confirmed COVID-19. Results Behavioral, medical, and conservative management will be valuable as first-line virtual treatments. Certain situations will require different treatments in the virtual setting while others will require an in-person visit despite the risks of COVID-19 transmission. Conclusions We have presented guidance for treating FPMRS conditions via telemedicine based on rapid literature review and expert consensus and presented it in a format that can be actively referenced.
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Affiliation(s)
- Cara L Grimes
- Departments of Obstetrics and Gynecology and Urology, New York Medical College, 19 Bradhurst Avenue, Suite 2700 South Hawthorne, Valhalla, NY, 10532, USA.
| | - Ethan M Balk
- Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, RI, USA
| | - Catrina C Crisp
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, TriHealth, Cincinnati, OH, USA
| | - Danielle D Antosh
- Department of Obstetrics and Gynecology, Division of Urogynecology, Houston Methodist Hospital, Houston, TX, USA
| | - Miles Murphy
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Gabriela E Halder
- Department of Women's Health, Dell Medical School, University of Texas Austin, Austin, TX, USA
| | - Peter C Jeppson
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM, USA
| | - Emily E Weber LeBrun
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Florida, Gainesville, FL, USA
| | - Sonali Raman
- Department of Women's Health, Female Pelvic Medicine and Reconstructive Surgery, St. Elizabeth Healthcare, Fort Thomas, KY, USA
| | - Shunaha Kim-Fine
- Section of Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Cheryl Iglesia
- Department of Obstetrics and Gynecology, Georgetown University School of Medicine, Washington, DC, USA
| | - Alexis A Dieter
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ladin Yurteri-Kaplan
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Gaelen Adam
- Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, RI, USA
| | - Kate V Meriwether
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM, USA
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Gerjevic KA, Erekson E, Strohbehn K, Jacobs KA, Hanissian PD, Aarts JW. Information Priorities for Deciding on Treatment of Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg 2020; 25:372-377. [PMID: 30063484 DOI: 10.1097/spv.0000000000000572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The objective of this study was to elicit information priorities from women considering treatment for pelvic organ prolapse (POP). STUDY DESIGN This is a cross-sectional study of women before and after treatment of stage II or higher POP. Women were recruited either at the conclusion of their initial evaluation (before treatment) or at postoperative or pessary maintenance visits (after treatment). Women completed a written survey that used a Likert scale to rank potentially frequently asked questions (FAQs) that could be important information to use in decision making for POP. RESULTS Among the 100 women surveyed, 32 women wanted to pursue surgical options and 18 women wanted to pursue nonsurgical treatment options in the before treatment group. In the after treatment group, 35 women had undergone surgery and 15 women were using a pessary.Overall, women ranked FAQs about treatment success (overall Likert score, 1.11±0.35), quality of life after treatment (1.18±0.41), and complications and side effects (1.20±0.57) as the most important information when making a decision. Women were least concerned with FAQs regarding cost (2.39±1.48), impact on sexual function (2.21±1.4), and impact on hormones (2.20±1.27). CONCLUSIONS Women with POP identified the most important FAQs related to treatment success and complications, quality of life, and understanding how the treatment works. This information will be used to develop a comprehensive decision aid for women considering treatment options for POP.
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Affiliation(s)
- Kristen A Gerjevic
- From the Department of Obstetrics and Gynecology, The Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Elisabeth Erekson
- From the Department of Obstetrics and Gynecology, The Geisel School of Medicine at Dartmouth, Lebanon, NH.,The Dartmouth Institute for Health Policy and Clinical Practice, The Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Kris Strohbehn
- From the Department of Obstetrics and Gynecology, The Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Kathryn A Jacobs
- From the Department of Obstetrics and Gynecology, The Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Paul D Hanissian
- From the Department of Obstetrics and Gynecology, The Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Johanna W Aarts
- The Dartmouth Institute for Health Policy and Clinical Practice, The Geisel School of Medicine at Dartmouth, Lebanon, NH.,Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
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Long-term Outcomes of Self-Management Gellhorn Pessary for Symptomatic Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg 2019; 26:e47-e53. [PMID: 31393340 DOI: 10.1097/spv.0000000000000770] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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21
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Moving On: How Many Women Opt for Surgery After Pessary Use for Prolapse? Female Pelvic Med Reconstr Surg 2019; 26:387-390. [DOI: 10.1097/spv.0000000000000731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yang J, Han J, Zhu F, Wang Y. Ring and Gellhorn pessaries used in patients with pelvic organ prolapse: a retrospective study of 8 years. Arch Gynecol Obstet 2018; 298:623-629. [PMID: 29978415 PMCID: PMC6096563 DOI: 10.1007/s00404-018-4844-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/29/2018] [Indexed: 11/30/2022]
Abstract
Aim The aim of this study was to identify factors associated with pessary fitting, continued use of pessary and satisfaction of patients with pelvic organ prolapse. Methods A retrospective study was conducted in patients who received an initial pessary fitting. The clinical characteristics of these patients were recorded. The Pelvic Floor Disability Index PFDI-20 and PFIQ-7 were used to assess pelvic floor dysfunction and quality of life. Complications, satisfaction degree, and reasons for abandonment were recorded during the follow-up. T test and Chi square test in SPSS version 20 were used to analyze the data. Results Three hundred women with symptomatic prolapse were selected for pessary fitting, whose average age was 67.8 ± 10.7 years. For two hundred and forty-nine (83%) women, the fitting was successful, of whom 162 used ring pessaries and 87 used Gellhorn pessaries. Forty-seven patients abandoned using a pessary at the end of our study. Most clinical characteristics were not significantly different between the successful and unsuccessful fitting groups (P > 0.05). The average score of CRADI-8 was lower in successful fitting group (11.9 ± 15.9) than that in unsuccessful fitting group (18.8 ± 19.9) (P < 0.05). 162 patients with successful pessary fitting completed the satisfaction survey, 79% of whom were satisfied or very satisfied. Erosions (24.4%) were the most common complication. Difficulty in inserting or removing (30.4%) and erosions (22.8%) were the main factors, which affected the satisfaction degree. Conclusions Patients with obvious symptoms of posterior pelvic prolapse are more likely to fit failure. Difficulty in inserting or removing and erosions are the main factors, which lead to the discontinuation of pessary use and decrease in the satisfaction degree. Electronic supplementary material The online version of this article (10.1007/s00404-018-4844-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Junfang Yang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Garden North Road No. 49, Haidian District, Beijing, 100191, China
| | - Jinsong Han
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Garden North Road No. 49, Haidian District, Beijing, 100191, China.
| | - Fuli Zhu
- Department of Obstetrics and Gynecology, China Academy of Chinese Medical Sciences Xiyuan Hospital, Beijing, China
| | - Yu Wang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
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Nohuz E, Jouve E, Clement G, Jacquetin B. [The gynecological pessary: Is it really a device of another age, a fig leaf?]. ACTA ACUST UNITED AC 2018; 46:540-549. [PMID: 29786534 DOI: 10.1016/j.gofs.2018.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- E Nohuz
- Service de gynécologie-obstétrique, centre hospitalier de Thiers, route du Fau, 63300 Thiers, France; EA 4681, PEPRADE, université Auvergne Clermont, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France.
| | - E Jouve
- Service de gériatrie, centre hospitalier Guy-Thomas, centre hospitalier de Riom, boulevard Étienne-Clémentel, 63200 Riom, France.
| | - G Clement
- Département de médecine générale, faculté de médecine, université d'Auvergne, place Henri-Dunant, 63001 Clermont-Ferrand, France.
| | - B Jacquetin
- Service de gynécologie-obstétrique, pôle Femme et Enfant, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France.
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Allègre L, Abdirahman S, Hedde A, Fatton B, de Tayrac R. [Could we perform vaginal mesh surgery for treatment of pelvic organ prolapse in elderly women?]. Prog Urol 2018; 28:221-229. [PMID: 29339140 DOI: 10.1016/j.purol.2017.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 12/10/2017] [Accepted: 12/15/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Prevalence of pelvic organ prolapse will increase with the aging of the population. Concerning the treatment of pelvic organ prolapse, transvaginal route is often preferred for elderly women. However few data are available concerning transvaginal mesh surgery in this population. The aim of this study was to compare efficiency and complications of transvaginal mesh surgery between women aged over 75 and younger women. MATERIALS AND METHODS A monocentric, retrospective study included all women who underwent anterior sacrospinous suspension with mesh for treatment of pelvic organ prolapse. The primary endpoint was anatomical success at the last follow-up, defined by a pelvic organ prolapse stage 0 or 1 of POP-Q classification. The secondary endpoints were rate of complications and urinary, colorectal and sexual functional results. RESULTS We included 329 patients, 69 were under 75 years old and 260 were aged over 75. The median of follow-up was 12 months (IQR: 6). The rate of anatomical success was significantly higher in patients aged over 75: 92% versus 85% in younger patients (P=0.02). However this difference was no more significant in multivariate analysis after inclusion of confusions factors (P=0.82). The rate of perioperative complications was low and similar in the 2 groups even in multivariate analysis. CONCLUSION Utero-vaginal suspension using bilateral vaginal anterior sacrospinous fixation with mesh seems to achieve at least similar results between women aged more than 75 years and younger women. There is no excess risk of complications in elderly women. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- L Allègre
- Service de gynécologie obstétrique, CHU de Nîmes, place du Professeur-Robert-Debré, 30900 Nîmes, France.
| | - S Abdirahman
- Service de gynécologie obstétrique, CHU de Nîmes, place du Professeur-Robert-Debré, 30900 Nîmes, France
| | - A Hedde
- Service de gynécologie obstétrique, CHU de Nîmes, place du Professeur-Robert-Debré, 30900 Nîmes, France
| | - B Fatton
- Service de gynécologie obstétrique, CHU de Nîmes, place du Professeur-Robert-Debré, 30900 Nîmes, France
| | - R de Tayrac
- Service de gynécologie obstétrique, CHU de Nîmes, place du Professeur-Robert-Debré, 30900 Nîmes, France
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Aubé M, Tu LM. Current trends and future perspectives in pelvic reconstructive surgery. WOMEN'S HEALTH (LONDON, ENGLAND) 2018; 14:1745506518776498. [PMID: 29772955 PMCID: PMC5960843 DOI: 10.1177/1745506518776498] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 02/19/2018] [Accepted: 04/18/2018] [Indexed: 11/17/2022]
Abstract
Pelvic organ prolapse is a prevalent disorder with a high lifetime incidence of surgical repair. Pelvic organ prolapse surgery has greatly evolved over the past years, and pelvic floor reconstructive surgeons are faced with a vast array of treatment options for their patients. Our review article illustrates the current trends and future perspectives for the surgical treatment of pelvic organ prolapse.
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Affiliation(s)
- Mélanie Aubé
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Le Mai Tu
- Division of Urology, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
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Sultana CJ. Non-surgical and Surgical Management of Pelvic Organ Prolapse in the Older Woman. CURRENT GERIATRICS REPORTS 2017. [DOI: 10.1007/s13670-017-0203-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Patients with pelvic organ prolapse (POP) may present with a large combination of symptoms including overactive bladder (OAB) symptoms such as urgency, frequency, and urgency incontinence. The explanation as to why these symptoms are more prevalent in POP patients is not clearly understood, but there seems to be an overall agreement that prolapse-induced bladder outlet obstruction (BOO) may trigger bladder changes resulting in OAB symptoms. Presuming this to be true, many of the studies managing OAB in POP patients have focused on the surgical management of prolapse and its aftermath, which in many of the patients leads to improvement of OAB symptoms. This review presents the most recent studies and evidence looking at management of OAB in the face of POP and seeks to evaluate if there is any association between prolapse severity and OAB symptoms.
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