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Manoukian S, Mason H, Hagen S, Kearney R, Goodman K, Best C, Elders A, Melone L, Dwyer L, Dembinsky M, Khunda A, Guerrero KL, McClurg D, Norrie J, Thakar R, Bugge C. Cost-Effectiveness of 2 Models of Pessary Care for Pelvic Organ Prolapse: Findings From the TOPSY Randomized Controlled Trial. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:889-896. [PMID: 38492924 DOI: 10.1016/j.jval.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 02/21/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVES Pelvic organ prolapse is the descent of one or more reproductive organs from their normal position, causing associated negative symptoms. One conservative treatment option is pessary management. This study aimed to to investigate the cost-effectiveness of pessary self-management (SM) when compared with clinic-based care (CBC). A decision analytic model was developed to extend the economic evaluation. METHODS A randomized controlled trial with health economic evaluation. The SM group received a 30-minute SM teaching session, information leaflet, 2-week follow-up call, and a local helpline number. The CBC group received routine outpatient pessary appointments, determined by usual practice. The primary outcome for the cost-effectiveness analysis was incremental cost per quality-adjusted life year (QALY), 18 months post-randomization. Uncertainty was handled using nonparametric bootstrap analysis. In addition, a simple decision analytic model was developed using the trial data to extend the analysis over a 5-year period. RESULTS There was no significant difference in the mean number of QALYs gained between SM and CBC (1.241 vs 1.221), but mean cost was lower for SM (£578 vs £728). The incremental net benefit estimated at a willingness to pay of £20 000 per QALY gained was £564, with an 80.8% probability of cost-effectiveness. The modeling results were consistent with the trial analysis: the incremental net benefit was estimated as £4221, and the probability of SM being cost-effective at 5 years was 69.7%. CONCLUSIONS Results suggest that pessary SM is likely to be cost-effective. The decision analytic model suggests that this result is likely to persist over longer durations.
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Affiliation(s)
- Sarkis Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University.
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University
| | - Suzanne Hagen
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | | | - Kirsteen Goodman
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | - Catherine Best
- Faculty of Health Sciences and Sport, University of Stirling
| | - Andrew Elders
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | - Lynn Melone
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | - Lucy Dwyer
- Manchester University NHS Foundation Trust
| | - Melanie Dembinsky
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | | | | | - Doreen McClurg
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh
| | | | - Carol Bugge
- Department of Nursing and Community Health, Glasgow Caledonian University
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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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Strohbehn K, Wadensweiler PM, Richter HE, Grimes CL, Rardin CR, Rosenblatt PL, Toglia MR, Siddiqui G, Hanissian P. Effectiveness and safety of a novel, collapsible pessary for management of pelvic organ prolapse. Am J Obstet Gynecol 2024:S0002-9378(24)00591-X. [PMID: 38761837 DOI: 10.1016/j.ajog.2024.05.009] [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: 01/08/2024] [Revised: 04/12/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Pessaries are an effective treatment for pelvic organ prolapse, yet currently available pessaries can cause discomfort during removal and insertion. An early feasibility trial of an investigational, collapsible pessary previously demonstrated mechanical feasibility during a brief 15-minute office trial. Longer-term, patient-centered safety and efficacy data are needed. OBJECTIVE This study aimed to assess the effectiveness and safety of the investigational vaginal pessary for pelvic organ prolapse at 3 months. STUDY DESIGN This was a prospective, 7-center, open-label equivalence study with participants serving as their own controls. Subjects were current users of a Gellhorn or ring pessary with ≥stage 2 prolapse. Subjective and objective data were collected at baseline for 1 month while subjects used their current pessary. Data were then collected throughout a 3-month treatment phase with the study pessary. The primary outcome was change in Pelvic Floor Distress Inventory-20 score. Secondary outcome measures included objective assessment of prolapse support, changes in the Pelvic Floor Impact Questionnaire-7, and pain with insertion and removal, measured using a visual analog scale. Data from subjects fitted with the study pessary were analyzed using an intention-to-treat approach, and those who dropped out were assigned scores at the upper limit of the predefined equivalence limits. Secondary per protocol analyses included subjects who completed treatment. The study was powered to 80% with a minimal important change equivalence limit of 18.3 points on the Pelvic Floor Distress Inventory-20 scale. Square root transformations were used for nonparametric data, and P values were adjusted for multiple comparisons. RESULTS A total of 78 subjects were enrolled, however, 16 withdrew before study pessary placement. The study pessary was fitted in 62 subjects (50 ring and 12 Gellhorn pessary users), and 48 (62%) completed the 3-month intervention. The change in Pelvic Floor Distress Inventory-20 scores at 3 months demonstrated equivalence when compared with the subjects' baseline scores (mean difference, -3.96 [improvement]; 90% confidence interval, -11.99 to 4.08; P=.002). Among those completing study, the Pelvic Floor Distress Inventory-20 scores, equivalence was not demonstrated and scores favored the study pessary (mean difference, -10.45; 90% confidence interval, -20.35 to 0.54; P=.095). Secondary outcomes included objective measures of support, which were similar (mean difference: Ba, 0.54 cm; Bp, 0.04 cm, favoring study pessary; improvement in mean Pelvic Floor Impact Questionnaire-7 scores for those who completed the trial: before, 32.23; after, 16.86; P=.019), and pain with insertion and removal, which was lower with the study pessary than with the subject's own pessary (mean difference visual analog scale score insertion, 9.91 mm; P=.019; removal, 11.23 mm; P=.019). No serious adverse events related to the pessary were reported. CONCLUSION Equivalence was demonstrated in the primary outcome of the study pessary when compared with current, noncollapsible pessaries in terms of change in severity and bother of pelvic floor symptoms. Among participants who completed the trial, the Pelvic Floor Impact Questionnaire-7 improved with study pessary use and change in Pelvic Floor Distress Inventory-20 scores were nonequivalent, favoring the study pessary. Subjects reported significantly lower pain scores with both pessary insertion and removal with the novel collapsible pessary when compared with their standard pessary.
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Affiliation(s)
- Kris Strohbehn
- Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH.
| | - Paul M Wadensweiler
- Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Cara L Grimes
- Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Charles R Rardin
- Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | | | - Marc R Toglia
- Main Line Health, Jefferson Medical College, Media, PA
| | | | - Paul Hanissian
- Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
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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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Zhou Y, Sun T, Ju A, Zhu L. Outcomes of pessary fitting trials for patients with stage IV pelvic organ prolapse: a prospective study. Int Urogynecol J 2024; 35:59-67. [PMID: 37542565 PMCID: PMC10810943 DOI: 10.1007/s00192-023-05594-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/07/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to evaluate the efficacy of pessaries in the treatment of stage IV pelvic organ prolapse (POP) and identify the influencing factors. METHODS One hundred and fifty-seven patients with stage IV symptomatic POP were admitted to the hospital for pessary fitting. A successful pessary fitting was defined as a patient fitted with a pessary at the initial fitting in whom use continued 2 weeks later. The rates of successful pessary fitting, patient satisfaction, remission of prolapse and urinary symptoms, and the occurrence of factors associated with successful pessary fitting were calculated and predictors of appropriate pessary type selection were analyzed. RESULTS A total of 130 patients with stage IV POP had a successful pessary fitting (82.8%). The satisfaction rate associated with the two types of pessaries was more than 90%. The success rate among patients undergoing a ring pessary fitting trial was 44.6%, and 84.3% of the patients were self-managed. Prolapse symptoms significantly improved in 90% of cases, and urinary symptoms improved in 58-93% of cases from baseline. The number of vaginal deliveries, history of hysterectomy and vaginal introitus/total vaginal length (TVL) ratio were independent risk factors associated with unsuccessful pessary fitting. CONCLUSION For patients with stage IV POP, the successful fitting rate is as high as 80% or more. More vaginal deliveries, a history of hysterectomy, and a larger vaginal introitus/TVL ratio (ratio >0.6) were predictors of unsuccessful pessary fitting.
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Affiliation(s)
- Ying Zhou
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, No. 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Tianshu Sun
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, No. 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Aijing Ju
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, No. 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Lan Zhu
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, No. 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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Brandt CH, Yamolaei M, Wu C, Hansen UD, Rasch V. Adherence to support pessary in the treatment of pelvic organ prolapse: a retrospective study conducted among 1,371 women. Int Urogynecol J 2024; 35:69-75. [PMID: 37548745 PMCID: PMC10810921 DOI: 10.1007/s00192-023-05616-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/04/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to investigate the adherence to pessary treatment in women with pelvic organ prolapse (POP) who were found eligible for this treatment by the urogynecologist, at the first visit at the Department of Gynecology and Obstetrics, Odense University Hospital. METHODS Data were extracted from the women's medical records. Frequency tabulations were performed to describe the women's reasons for pessary discontinuation by age group. Binominal logistic regression analysis was conducted to investigate how women's age, POP characteristics, urogynecological history, and their pessary experience and management were associated with continued pessary use. RESULTS This study included 1,371 women treated with support pessary. Of these, 850 women continued pessary treatment and 521 women underwent surgical treatment. A history of hysterectomy (OR: 0.68, 95% CI: 0.51-0.90, p = 0.008), urinary incontinence (OR: 0.71, 95% CI: 0.56-0.89, p = 0.003), and previous pessary use (OR: 0.75, 95% CI: 0.56-0.99, p = 0.047) were significant factors associated with discontinuation. Further, women aged 81-99 years were significantly more likely to continue pessary treatment (OR: 1.77, 95% CI: 1.15-2.74, p = 0.009). "POP surgery," "prolapse stage," and "prolapse predominant compartment" were not associated with discontinuation. Approximately 38% of women aged 26-54 years discontinued owing to personal preference. CONCLUSIONS Hysterectomy, incontinence, and previous pessary use are significant predictors of pessary discontinuation. Increasing age is significantly associated with pessary continuation.
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Affiliation(s)
- Cecilie Helstrup Brandt
- Medical Faculty, University of Southern Denmark, 55 Campusvej, 5230, Odense, Denmark.
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark.
| | - Mahsa Yamolaei
- Medical Faculty, University of Southern Denmark, 55 Campusvej, 5230, Odense, Denmark
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Chunsen Wu
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ulla D Hansen
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Vibeke Rasch
- Medical Faculty, University of Southern Denmark, 55 Campusvej, 5230, Odense, Denmark
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Boogaard LL, Triepels CPR, Verhamme LM, van Kuijk SMJ, Donners JJAE, Kluivers KB, Maal TJJ, Weemhoff M, Notten KJB. Location and motion of vaginal pessaries in situ in women with successful and unsuccessful pessary treatment for pelvic organ prolapse. Int Urogynecol J 2023; 34:2293-2300. [PMID: 37119269 PMCID: PMC10506932 DOI: 10.1007/s00192-023-05555-9] [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: 01/18/2023] [Accepted: 04/03/2023] [Indexed: 05/01/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to compare the location and motion of pessaries between women with pelvic organ prolapse (POP) with a successful (fitting) and unsuccessful (non-fitting) pessary treatment on dynamic magnetic resonance imaging (dMRI). METHODS A cross-sectional exploratory study of 15 women who underwent a mid-sagittal dMRI of the pelvic floor at rest, during contraction and during Valsalva with three different types of pessaries. The coordinates of the pessaries cross section, inferior pubic point (IPP) and sacrococcygeal junction (SCJ) were obtained and the location (position, orientation) and the motion (translation and rotation) were calculated. Differences between the groups and between the pessaries within the groups were compared. RESULTS Nine women with a fitting pessary and 6 women with a non-fitting pessary were selected. In the non-fitting group, the pessaries were positioned more caudally and rotated more in clockwise direction and descended more, but not significantly, during Valsalva compared with the fitting group. The Falk pessary was positioned more anteriorly in the fitting group and more cranially in the non-fitting group compared with the ring and ring with support pessary. CONCLUSIONS A non-fitting pessary was positioned more caudally at rest; on Valsalva, it rotated more clockwise and moved more caudally, suggesting that the dynamic characteristics of the pessary might play an important role in its effectiveness. Findings of this study serve as a basis for the development of new pessary designs.
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Affiliation(s)
- Lars L Boogaard
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands.
- 3D Lab, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Charlotte P R Triepels
- Department of Obstetrics and Gynaecology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Luc M Verhamme
- 3D Lab, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Judith J A E Donners
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Kirsten B Kluivers
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Thomas J J Maal
- 3D Lab, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mirjam Weemhoff
- Department of Obstetrics and Gynaecology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Kim J B Notten
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
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Calles Sastre L, Almoguera Pérez-Cejuela B, Pereira Sánchez A, Herrero Gámiz S, Magrina JF, Ríos Vallejo M, Pérez Medina T. Complications of Pessaries Amenable to Surgical Correction: Two Case Reports and a Systematic Review of the Literature. J Pers Med 2023; 13:1056. [PMID: 37511669 PMCID: PMC10381278 DOI: 10.3390/jpm13071056] [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: 04/25/2023] [Revised: 06/11/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Forty percent of women will experience prolapse in their lifetime. Vaginal pessaries are considered the first line of treatment in selected patients. Major complications of vaginal pessaries rarely occur. METHODS PubMed and Embase were searched from 1961 to 2022 for major complications of vaginal pessaries using Medical Subject Headings (MeSH) and free-text terms. The keywords were pessary or pessaries and: vaginal discharge, incontinence, entrapment, urinary infections, fistula, complications, and vaginal infection. The exclusion criteria were other languages than English, pregnancy, complications without a prior history of pessary placement, pessaries unregistered for clinical practice (herbal pessaries), or male patients. The extracted data included symptoms, findings upon examination, infection, type of complication, extragenital symptoms, and treatment. RESULTS We identified 1874 abstracts and full text articles; 54 were assessed for eligibility and 49 met the inclusion criteria. These 49 studies included data from 66 patients with pessary complications amenable to surgical correction. Clavien-Dindo classification was used to grade the complications. Most patients presented with vaginal symptoms such as bleeding, discharge, or ulceration. The most frequent complications were pessary incarceration and fistulas. Surgical treatment included removal of the pessary under local or general anesthesia, fistula repair, hysterectomy and vaginal repair, and the management of bleeding. CONCLUSIONS Pessaries are a reasonable and durable treatment for pelvic organ prolapse. Complications are rare. Routine follow-ups are necessary. The ideal patient candidate must be able to remove and reintroduce their pessary on a regular basis; if not, this must be performed by a healthcare worker at regular intervals.
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Affiliation(s)
- Laura Calles Sastre
- Department of Gynecologic Surgery, Puerta de Hierro University Hospital, Majadahonda, 28222 Madrid, Spain
| | | | - Augusto Pereira Sánchez
- Department of Gynecologic Surgery, Puerta de Hierro University Hospital, Majadahonda, 28222 Madrid, Spain
| | - Sofía Herrero Gámiz
- Department of Gynecologic Surgery, Puerta de Hierro University Hospital, Majadahonda, 28222 Madrid, Spain
| | - Javier F Magrina
- Department of Medical and Surgical Gynecology, Mayo Clinic Hospital, Phoenix, AZ 85054, USA
| | - Mar Ríos Vallejo
- Department of Gynecologic Surgery, Puerta de Hierro University Hospital, Majadahonda, 28222 Madrid, Spain
| | - Tirso Pérez Medina
- Department of Gynecologic Surgery, Puerta de Hierro University Hospital, Majadahonda, 28222 Madrid, Spain
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Abstract
Pelvic organ prolapse (POP) is defined as the descent of one or more of the anterior and posterior vaginal walls, uterus (cervix), or apex of the vagina (vaginal vault or cuff scar after hysterectomy). Although POP can be asymptomatic, if the bulge extends beyond the opening of the vagina, it can have a significant impact on a woman's quality of life. Findings include vaginal bulging toward or through the vaginal introitus that the patient may feel, palpate, or see with a mirror. If a woman is bothered by her prolapse, she should be offered both nonsurgical and surgical treatments.
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Affiliation(s)
- Sarah Collins
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and reconstructive Surgery Northwestern University, Feinberg School of Medicine Chicago, 250 E. Superior, Chicago, IL 60611, USA
| | - Christina Lewicky-Gaupp
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and reconstructive Surgery Northwestern University, Feinberg School of Medicine Chicago, 250 E. Superior, Chicago, IL 60611, USA.
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Manzini C, van der Vaart CH, van den Noort F, Grob ATM, Withagen MIJ. Pessary fitting for pelvic organ prolapse: parameters associated with specific reasons for failure. Int Urogynecol J 2022; 33:2037-2046. [DOI: 10.1007/s00192-021-05053-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 11/17/2021] [Indexed: 01/01/2023]
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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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Translabial ultrasound indices of failed pessary fittings in women with symptomatic pelvic organ prolapse. Menopause 2022; 29:390-396. [DOI: 10.1097/gme.0000000000001939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/14/2021] [Indexed: 11/26/2022]
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13
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Factors associated with unsuccessful pessary fitting and reasons for discontinuation in Korean women with pelvic organ prolapse. Obstet Gynecol Sci 2021; 65:94-99. [PMID: 34897264 PMCID: PMC8784938 DOI: 10.5468/ogs.21232] [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: 07/16/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To identify the factors associated with unsuccessful pessary fitting and reasons for pessary discontinuation in Korean women with pelvic organ prolapse (POP). Methods The medical records of 234 patients who underwent pessary fitting for the management of symptomatic POP were retrospectively reviewed. A ring pessary with or without support was used. Successful pessary fitting was defined as the ability to wear a pessary for 2 weeks without any discomfort. Factors associated with unsuccessful pessary fitting were determined using a multivariable logistic regression analysis. A Kaplan-Meier survival curve was obtained to examine the probability of continuing pessary use over the follow-up period. The reasons for the discontinuation of pessary were identified. Results Two-hundred-and-twenty-five women were included in the analysis. The rate of unsuccessful pessary fitting was 40%. Prior hysterectomy (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.81–9.42) and POP quantification stage III–IV (OR, 2.49; 95% CI, 1.28–4.85) were independent risk factors for unsuccessful pessary fitting. Among the patients with successful pessary fitting, the median time to discontinuation of pessary use was 4 years. The most common causes of discontinued use were vaginal erosion (45.3%) and urinary incontinence (26.5%). Conclusion Patients with a history of hysterectomy and advanced-stage POP are at risk for an unsuccessful fitting of the ring pessary. Vaginal erosion is the main reason for discontinued use among patients with successful pessary fitting.
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Xu H, Wu W, Wang X, Xia Z. A predictive model of choosing pessary type for women with symptomatic pelvic organ prolapse. Menopause 2021; 28:1279-1286. [PMID: 34636355 PMCID: PMC8547748 DOI: 10.1097/gme.0000000000001849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate clinical factors including translabial ultrasound parameters, which are predictive for choosing pessary type (Ring or Gellhorn) in the fitting trial, and to establish a predictive model. METHODS A retrospective study was conducted on symptomatic women with pelvic organ prolapse (POP) at the Pelvic Floor Disease Diagnosis and Treatment Center (Liaoning Province, China) between May 2018 and December 2020 who were successfully fitted with pessaries. This retrospective study was supplemented with a prospective cohort study on women seeking pessary for first-line treatment of POP at the above tertiary center between December 2020 and April 2021 for validation. Enrolled participants were grouped by their fitted type of pessary. Demographic and clinical parameters between groups, including pelvic organ prolapse quantification and translabial ultrasound, were analyzed using logistic regression. A receiver operating characteristic curve was calculated using predictive values obtained by regression as the predictor for choosing pessary type in the pessary fitting trial. RESULTS The 181 participants included in the retrospective analysis were randomly divided into the "Development" and "Validation" datasets. In the "Development" set, multivariable logistic regression analyses showed that a younger age (odds ratio [OR]: 0.950; 95% confidence interval [CI]: 0.908-0.995; P = 0.026), a larger hiatal circumference on Valsalva (OR: 1.348; 95% CI: 1.103-1.647; P = 0.004), and a higher POP-Q stage (OR: 2.963; 95% CI: 1.210-7.255; P = 0.017) were independent predictors for successful fitting with the Gellhorn pessary. The predictive model was P = exp(Z)/[1 + exp(Z)], Z = -0.051 × Age (y) + 0.298 × hiatal circumference on Valsalva (cm) + 1.086 × pelvic organ prolapse stage (2, 3, or 4) - 5.490. The area under the receiver operating characteristic curves (AUC) was 0.776 (P < 0.001) and 0.705 (P < 0.001) based on the "Development" dataset and "Validation" datasets, respectively. The AUC was 0.815 (P < 0.001) based on the prospective cohort validation. CONCLUSIONS For severe POP, women with younger age and larger hiatal circumference, Gellhorn pessaries should be their first choice instead of ring ones in pessary fitting trials.
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Affiliation(s)
- Hainan Xu
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Wenjing Wu
- Nursing Department, Liaoning Maternal and Child Health Hospital, Shenyang City, Liaoning Province, China
| | - Xinlu Wang
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Zhijun Xia
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
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Transperineal ultrasound to estimate the appropriate ring pessary size for women with pelvic organ prolapse. Int Urogynecol J 2021; 33:1981-1987. [PMID: 34586439 PMCID: PMC9270306 DOI: 10.1007/s00192-021-04975-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/06/2021] [Indexed: 01/10/2023]
Abstract
Introduction and hypothesis The objective was to predict the successful ring pessary size based on the levator hiatal area (HA). Methods This is a prospective case–control study. Women with symptomatic pelvic organ prolapse (POP) choosing pessary treatment were included. All women underwent an interview, clinical examination, and 3D/4D transperineal ultrasound (TPUS). The ring pessary size used in each trial and the reason for unsuccessful trials were recorded. In addition, levator hiatal area divided by ring pessary size (HARP ratio) was measured at rest, maximum contraction, and maximum Valsalva. The HARP ratios of successful and unsuccessful trials were compared, receiver operating characteristic curves in the prediction of successful trials were constructed, and the cut-off optimizing sensitivity and specificity was identified. Results A total of 162 women were assessed and 106 were included with 77 successful trials, 49 unsuccessful trials owing to dislodgment or failure to relieve POP symptoms, and 20 unsuccessful trials owing to pain/discomfort. Rest HARP ratio and Valsalva HARP ratio were significantly smaller in the successful trials versus dislodgment/failure to relieve POP symptoms trials (mean rest HARP ratio [SD]: 2.93 [0.59] vs 3.24 [0.67], p = 0.021; median Valsalva HARP ratio (IQR): 4.65 (1.56) vs 5.32 (2.08), p = 0.004). No significant difference was observed between pain/discomfort trials and successful trials. The best cut-off for the prediction of successful trials was Valsalva HARP ratio ≤ 5.00. Conclusions Unsuccessful fitting trials due to dislodgment/failure to relieve POP symptoms are associated with a small ring pessary with respect to the levator HA. A ring pessary that produces a Valsalva HARP ratio > 5.00 has a higher risk of dislodgment/failure to relieve POP symptoms.
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Pizzoferrato AC, Nyangoh-Timoh K, Martin-Lasnel M, Fauvet R, de Tayrac R, Villot A. Vaginal Pessary for Pelvic Organ Prolapse: A French Multidisciplinary Survey. J Womens Health (Larchmt) 2021; 31:870-877. [PMID: 34569823 DOI: 10.1089/jwh.2021.0229] [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] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Anne-Cécile Pizzoferrato
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Caen University Hospital, Caen, France
| | - Krystel Nyangoh-Timoh
- Inserm, LTSI-UMR 1099 Unit, Department of Obstetrics and Gynecology, Rennes Hospital, Rennes University 1, Rennes, France
| | - Mathilde Martin-Lasnel
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Caen University Hospital, Caen, France
| | - Raffaèle Fauvet
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Caen University Hospital, Caen, France.,Inserm U1086 ANTICIPE Unit, Caen Normandie University, Caen, France
| | - Renaud de Tayrac
- Department of Obstetrics and Gynaecology, Carémeau University Hospital, Nîmes, France
| | - Anne Villot
- Department of Obstetrics and Gynecology, Cotentin Public Hospital Center, Cherbourg, France
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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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Manzini C, van den Noort F, Grob ATM, Withagen MIJ, van der Vaart CH. The effect of pessary treatment on puborectalis muscle function. Int Urogynecol J 2021; 32:1409-1417. [PMID: 33847771 PMCID: PMC8042456 DOI: 10.1007/s00192-021-04766-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/10/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to assess if puborectalis muscle (PRM) function changes in women with pelvic organ prolapse (POP) undergoing pessary treatment. METHODS This was a prospective cohort study of women with symptomatic POP choosing pessary treatment. An interview, clinical examination and 3D/4D transperineal ultrasound were performed at baseline and at 3-month follow-up. POP was assessed using the Pelvic Organ Prolapse Quantification system (POPQ). Parameters compared between baseline and follow-up were: hiatal area at rest (HArest), maximal contraction (HActx), and maximal Valsalva maneuver (HAVal), displacement in contraction (DISPL-ctx, i.e., relative difference between HArest and HActx), and displacement in Valsalva (DISPL-Val, i.e., relative difference between and HAVal and HArest). Parameters were compared in women with and those without complete avulsion. RESULTS A total of 162 women were assessed and 34 were included. Mean age was 64 years (SD 11.4), and mean BMI 24 kg/m2 (SD 3.1). Thirty-one women had a cystocele, 8 a uterine prolapse, and 12 had a posterior compartment prolapse. Twenty-one women (61.8%) had a POP stage II, and 13 (38.2%) a POP stage III. Ring pessaries were most frequently used (97%). In the entire group a statistically significant increase in DISPL-ctx was observed (mean difference 2.1%, p = 0.017). In the no avulsion group HArest and DISPL-ctx increased significantly (mean difference 4.1%, p = 0.016 and 2.7%, p = 0.016 respectively) and the increase in DISPL-ctx was higher than in the avulsion group (mean difference 2.7% vs 0.2%, p = 0.056). CONCLUSION Our results show that PRM function changes in women with POP undergoing pessary treatment and suggest that such change occurs mainly in the absence of complete avulsion.
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Affiliation(s)
- Claudia Manzini
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Frieda van den Noort
- Robotics and Mechatronics, Faculty of electrical engineering mathematics and computer science, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Anique T M Grob
- Multimodality Medical Imaging Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Mariëlla I J Withagen
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Carl H van der Vaart
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
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Martin-Lasnel M, Nyangoh-Timoh K, Fauvet R, Pizzoferrato AC. [The use of pessaries for treatment of pelvic organ prolapse: A survey from gynecologists and urologists residents]. ACTA ACUST UNITED AC 2021; 49:763-766. [PMID: 33774264 DOI: 10.1016/j.gofs.2021.03.030] [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: 11/19/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- M Martin-Lasnel
- Département de gynécologie-obstétrique, hôpital universitaire de Caen Normandie, Caen, France.
| | - K Nyangoh-Timoh
- Inserm, LTSI-UMR 1099, département of obstetrics and gynecology, Rennes Hospital, Rennes, University 1, Rennes, France
| | - R Fauvet
- Département de gynécologie-obstétrique, hôpital universitaire de Caen Normandie, Caen, France; Université Caen Normandie, Inserm U1086 « ANTICIPE », unité de recherche Interdisciplinaire pour la prévention et le traitement des cancers, Axe 2 : biologie et thérapies innovantes des cancers localement agressifs (BioTICLA), 14000 Caen, France
| | - A-C Pizzoferrato
- Département de gynécologie-obstétrique, hôpital universitaire de Caen Normandie, Caen, France
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Harvey MA, Lemieux MC, Robert M, Schulz JA. Guideline No. 411: Vaginal Pessary Use. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:255-266.e1. [PMID: 33248302 DOI: 10.1016/j.jogc.2020.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To review the use, care, and fitting of pessaries. TARGET POPULATION Women requiring the use of vaginal pessaries for pelvic organ prolapse and/or stress urinary incontinence. Use may also be indicated for women with certain pregnancy-related clinical scenarios, including incarcerated uterus. OPTIONS Pessaries are an option for women presenting with prolapse and/or stress urinary incontinence. In addition, certain types of pessaries can be considered for patients with cervical insufficiency or incarcerated uterus. OUTCOMES Most women with prolapse or stress urinary incontinence can be successfully fitted with a pessary and experience excellent symptom relief, high satisfaction rates, and minimal complications. BENEFITS, HARMS, AND COSTS Women with pelvic organ prolapse and/or stress urinary incontinence may choose to use a pessary to manage their symptoms rather than surgery or while waiting for surgery. Major complications have been seen only when pessaries are neglected. Minor complications such as vaginal discharge, odour, and erosions can usually be successfully treated. EVIDENCE Medline was searched for relevant articles up to December 2018. This is an update of the SOGC technical update published in 2013, which was the first internationally published guidance on pessary use. Subsequently, an Australian guideline on the use of pessaries for the treatment of prolapse was published later in 2013. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the approach of the Canadian Task Force on Preventive Health Care (Appendix A). INTENDED AUDIENCE Gynaecologists, obstetricians, family physicians, physiotherapists, residents, and fellows. SUMMARY STATEMENTS RECOMMENDATION.
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Risk Factors for Dislodgment of Vaginal Pessaries in Women With Pelvic Organ Prolapse: A Cohort Study. Female Pelvic Med Reconstr Surg 2021; 27:e247-e251. [PMID: 32487886 DOI: 10.1097/spv.0000000000000882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the associated factors associated with pessary dislodgment in women with advanced pelvic organ prolapse (POP). METHODS A cohort study with women (N = 98) with advanced POP who chose conservative treatment with ring pessary between December 2016 and 2018 identified by screening. Demographic data, history of POP, urinary, and/or bowel symptoms were collected. A medical visit was scheduled 3 and 6 months after pessary insertion to evaluate symptoms (vaginal discharge, bleeding, pain, discomfort, new-onset urinary, or fecal problems) and any pessary dislodgment. Two groups were created (women who were able to retain the pessary versus who were not able), and univariate and multivariate analysis were performed to look for risk factors for pessary dislodgment. Women who requested to have their pessaries removed during the 6-month follow-up were excluded. RESULTS Ninety-three women included in the study, 78 successfully continued to use the pessary at 6 months, and 15 had pessary dislodgment (16.1%). Demographic characteristics were similar between the treatment group and the control group. After multivariate analysis, women who had their pessaries dislodged presented higher rates of previous surgery (odds ratio = 8.11; 95% confidence interval = 2.09-31.58; P = 0.003) with advanced Pelvic Organ Prolapse Quantification system staging (odds ratio, 13.41; confidence interval, 1.97-91.36; P = 0.008). CONCLUSIONS The presence of advanced apical POP and previous POP surgery are risk factors for ring pessary dislodgment. This information should guide physicians for counseling patients before pessary insertion.
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Directive clinique n° 411 : Utilisation des pessaires. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:267-280.e1. [PMID: 33248301 DOI: 10.1016/j.jogc.2020.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIF Passer en revue l'utilisation, l'entretien et l'ajustement des pessaires. POPULATION CIBLE Les femmes qui ont besoin d'utiliser un pessaire en raison d'un prolapsus génital et/ou d'une incontinence urinaire d'effort. L'utilisation peut être indiquée chez les femmes enceintes dans certains scénarios cliniques liés à la grossesse, dont l'incarcération utérine et le risque de travail préterme liée à l'incompétence du col. OPTIONS Les pessaires constituent une option pour les femmes atteintes d'un prolapsus et/ou d'une incontinence urinaire d'effort. De plus, certains types de pessaires peuvent être utilisés chez des patientes atteintes d'incompétence du col ou d'une incarcération utérine. ISSUES Il est possible de trouver un pessaire efficace chez la plupart des femmes atteintes d'un prolapsus génital ou d'une incontinence urinaire d'effort de façon à obtenir un excellent soulagement des symptômes, un taux de satisfaction élevé et des complications minimes. BéNéFICES, RISQUES ET COûTS: Les femmes atteintes d'un prolapsus génital et/ou d'une incontinence urinaire d'effort peuvent choisir d'utiliser un pessaire pour traiter leurs symptômes au lieu de subir une intervention chirurgicale ou dans l'attente d'une telle intervention. Des complications majeures ont été observées seulement en cas de soins de pessaire négligés. Les complications mineures (telles que les pertes vaginales, les odeurs et les érosions) sont généralement traitables avec succès. DONNéES PROBANTES: Des recherches ont été effectuées dans la base de données Medline afin de récupérer les articles pertinents publiés jusqu'en décembre 2018. Le présent document constitue une mise à jour de la mise à jour technique de la SOGC publiée en 2013, laquelle a été la première directive clinique publiée à l'international relativement à l'utilisation des pessaires. Une ligne directrice australienne sur l'utilisation des pessaires pour le traitement du prolapsus a été publiée plus tard en 2013. MéTHODES DE VALIDATION: Les auteures ont évalué la qualité des données probantes et la solidité des recommandations au moyen des critères du cadre méthodologique du Groupe d'étude canadien sur les soins de santé préventifs (annexe A). PROFESSIONNELS CONCERNéS: Gynécologues, obstétriciens, médecins de famille, physiothérapeutes, résidents et moniteurs cliniques (fellows). DÉCLARATIONS SOMMAIRES: RECOMMANDATION.
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Dwyer L, Stewart E, Rajai A. A service evaluation to determine where and who delivers pessary care in the UK. Int Urogynecol J 2020; 32:1001-1006. [PMID: 32945903 DOI: 10.1007/s00192-020-04532-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 09/02/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Pessaries offer effective conservative management for symptoms of pelvic organ prolapse and are frequently used in the UK. Previous publications have highlighted a lack of evidence-based pessary guidelines. There is also a dearth of evidence regarding who UK pessary practitioners are and the training received. METHODS A Freedom of Information request was sent to 167 healthcare organisations in the UK. Requested information included the number of pessaries inserted or changed, the grade and profession of pessary practitioners and training requirements at the organisation. RESULTS Responses were received from 128 organisations. One hundred and ten had provided information for practitioners managing pessaries. At 66% (72) of organisations, pessary care was provided by both doctors and nurses of varying grades. At 23% of organisations either solely doctors or solely nurses provided pessary care. At the remaining 9% there was a multidisciplinary approach to pessary care. At 3 hospitals, unregistered healthcare professionals provided pessary care. At the majority of organisations, respondents undertook supervised practise to gain skills in pessary management. Additional methods of training cited were learning through observation or achieving set competencies. Twenty-six percent received didactic training. At 21% of organisations there were no training requirements. CONCLUSIONS At most organisations, there was a multidisciplinary approach to pessary care. It is questionable whether unregistered healthcare professionals should be delegated responsibility for pessary care. A standardised approach to pessary practitioner training is advocated to ensure that women receive safe, evidence-based pessary care. The UK Clinical Guidance Group for the Use of Pessaries in Vaginal Prolapse is currently developing national evidence-based guidelines to support pessary practitioners in their practice, including training requirements.
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Affiliation(s)
- Lucy Dwyer
- Saint Mary's Hospital, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Hathersage Road, Manchester, M13 9WL, UK
| | - Ellie Stewart
- Department of Gynaecology, West Suffolk NHS Foundation Trust, Hardwick Lane, Bury St Edmunds, Suffolk, IP33 2QZ, UK.
| | - Azita Rajai
- Centre for Biostatistics, Division of Population Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Research and Innovation, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Nowgen Building, Grafton Street, Manchester, M13 9WL, UK
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Ma C, Xu T, Kang J, Zhang Y, Ma Y, Liang S, Zhu L. Factors associated with pessary fitting in women with symptomatic pelvic organ prolapse: A large prospective cohort study. Neurourol Urodyn 2020; 39:2238-2245. [PMID: 32936968 DOI: 10.1002/nau.24477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/24/2020] [Indexed: 11/08/2022]
Abstract
AIM To identify factors associated with unsuccessful pessary fitting in a large cohort of patients with symptomatic pelvic organ prolapse (POP). METHODS This prospective observational study included 611 consecutive women with symptomatic POP in a tertiary-care hospital. 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 or refitted with a pessary and continued to use it 2 weeks later. Parametric and nonparametric tests were used for the data analysis. RESULTS A total of 524 patients had successful pessary fittings (85.8% success rate). The success rate of the ring pessary with support was 57.9%, of the Gellhorn pessary was 69.1%. Stage IV prolapse (odds ratio [OR], 2.12), posterior compartment prolapse (OR, 1.92), genital hiatus (OR, 1.41), and vaginal introitus (OR, 1.40) were independent predictors of unsuccessful ring with support pessary fitting. Vaginal length (OR, 0.74/0.60 for ring with support/Gellhorn) and history of POP reconstructive surgery (OR, 2.50/2.58 for ring with support/Gellhorn) were independent predictors of both ring with support and Gellhorn pessary fitting. CONCLUSIONS Stage IV prolapse, posterior compartment prolapse, large genital hiatus, and wide vaginal introitus were risk factors for unsuccessful fitting of ring pessary with support. Short vaginal length and a history of POP reconstructive surgery were risk factors for unsuccessful fitting of both pessaries.
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Affiliation(s)
- Congcong Ma
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Tao Xu
- Department of Epidemiology and Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jia Kang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ye Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yidi Ma
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Shuo Liang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Lan Zhu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Vaginal pessary continuation in symptomatic pelvic organ prolapse patients with prior hysterectomy. ACTA ACUST UNITED AC 2020; 27:1148-1154. [PMID: 32881830 DOI: 10.1097/gme.0000000000001633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the success rate of pessary fitting and continuation rate for symptomatic pelvic organ prolapse (POP) patients with a hysterectomy and to explore potential predictors. METHODS In this prospective observational study, 119 symptomatic POP patients with a prior hysterectomy received pessary treatment between April 2015 and February 2019. A successful pessary fitting was defined as a patient who was fitted with a pessary and continued to use it 2 weeks later. Patients with successful pessary fitting were followed until February 2020. Data analysis was performed with t tests, nonparametric tests, chi-square tests, and logistic regression. RESULTS The success rate of pessary fitting was 63.2%. A history of POP reconstructive surgery (OR = 2.6, 95% CI 1.0-6.7, P = 0.043) and a short total vaginal length <7.3 cm, (OR = 0.5, 95% CI 0.3-0.9, P = 0.014) were potential risk factors for unsuccessful pessary fitting. A total of 78.1% of the patients continued pessary use for a median duration of 26 months. Among patients who discontinued, 75% ceased within 1 year. Older age (OR = 1.1, 95% CI 1.0-1.2, P = 0.038) and prolapse score improvement at 3 months less than 50% (OR = 2.8, 95% CI 1.1-7.2, P = 0.035) were potential risk factors for discontinuation. CONCLUSIONS Pessaries remain a useful approach to treat prolapse in women who had a hysterectomy. Patients with POP reconstructive surgery and total vaginal length<7.3 cm should be informed that they might have lower success rate of pessary fitting. Age and prolapse score improvement at 3 months were potential predictors for continuation.
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Vasconcelos CTM, Gomes MLS, Geoffrion R, Saboia DM, Bezerra KDC, Vasconcelos Neto JA. Pessary evaluation for genital prolapse treatment: From acceptance to successful fitting. Neurourol Urodyn 2020; 39:2344-2352. [PMID: 32846016 DOI: 10.1002/nau.24493] [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: 02/21/2020] [Revised: 07/30/2020] [Accepted: 08/14/2020] [Indexed: 11/06/2022]
Abstract
AIMS To determine the percentage of women with symptomatic pelvic organ prolapse who opted for pessary and had a successful pessary fitting trial; to identify the most commonly used size of pessary for stage of prolapse; and to identify risk factors associated with unsuccessful fitting. METHODS We conducted a prospective cohort study of women with symptoms of genital prolapse referred to a public hospital tertiary care clinic (2013-2019). We used ring and ring with support pessaries for fittings. We collected patient demographics, pelvic organ prolapse quantification, size of pessary used and evaluated factors associated with pessary fittings. We defined unsuccessful fit as failure to continue pessary use at 4 weeks post fitting trial. We used Mann-Whitney and χ2 tests to compare variables between groups of successfully and unsuccessfully fitted. Using logistic regression, we built a prediction model for unsuccessful fit. RESULTS All 170 women with symptomatic prolapse referred to our clinic accepted to undergo a pessary fitting. More than 70% (n = 124/72.9%) were successfully at 4 weeks. We used an average of 1.7 pessaries (range: 1-6) per patient to identify the best-fitting pessary and #2, 5, 3, 7, and 4 were the sizes commonly used (78.2%). Women with body mass index ≥30 kg/m2 (odds ratio [OR]: 4.74; 95% confidence interval [CI], 1.98-11.32; P < .001), total vaginal length <7.5 cm (OR: 3.78; 95% CI, 1.98-11.32; P < .001), and sexually active women (OR: 2.26; 95% CI, 1.04-4.91; P = .035) were associated with increased unsuccessful fitting. CONCLUSION The vaginal pessary proved to be an excellent choice, with high acceptance and successful fitting rates.
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Affiliation(s)
| | - Maria Laura Silva Gomes
- Department of Nursing, Faculty of Pharmacy, Dentistry, and Nursing, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Roxana Geoffrion
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dayana Maia Saboia
- Department of Nursing, Faculty of Pharmacy, Dentistry, and Nursing, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Karine de Castro Bezerra
- Department of Nursing, Faculty of Pharmacy, Dentistry, and Nursing, Federal University of Ceará, Fortaleza, Ceará, Brazil
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de Albuquerque Coelho SC, Brito LGO, de Araujo CC, Juliato CRT. Factors associated with unsuccessful pessary fitting in women with symptomatic pelvic organ prolapse: Systematic review and metanalysis. Neurourol Urodyn 2020; 39:1912-1921. [PMID: 32649024 DOI: 10.1002/nau.24458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/01/2020] [Indexed: 11/10/2022]
Abstract
AIMS To identify the factors associated with unsuccessful pessary fitting and reasons for discontinuation for women with symptomatic pelvic organ prolapse (POP). METHODS This systematic review is registered at the PROSPERO database. We have included all studies, regardless of the study design whose primary outcomes were factors associated with unsuccessful pessary fitting and discontinuation for symptomatic POP women. Exclusion criteria were case series, literature reviews, other forms of conservative treatment. Data selection/extraction was performed by two investigators. For pessary fitting, a meta-analysis was performed for at least two studies pooled in a forest plot. The risk of bias was classified by the ROBINS-I and ROB-2 classification. RESULTS From 409 studies retrieved after data search, only twenty-one articles remained for final analysis (18 cohort studies, 1 cross-sectional study, and 2 RCTs). Meta-analysis was performed in nine studies for pessary fitting and the associated factors were: higher body mass index (BMI) (MD = 0.688 [0.233-1.143]; P = .03; i2 = 0%), previous reconstructive surgery (OR = 1.705 [1.016-2.860]; P = .043; i2 = 69%) and advanced POP (OR = 4.2 [2.9-6.1]; P < .05; i2 = 92%). Older age, larger total vaginal length (TVL), and genital hiatus and previous hysterectomy were not associated factors. Regarding discontinuation, thirteen reasons were quoted, and the most frequent were: the desire for surgical treatment (111/3.601), pessary extrusion (385/3.601), and pain/discomfort (163/3.601). CONCLUSION Obese, previously reconstructive pelvic surgery, advanced prolapse are at risk for unsuccessful pessary fitting. Pain is the most quoted reason for discontinuation. These pooled data may help clinicians to identify patients that may not succeed in their attempt for pessary treatment.
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Affiliation(s)
| | - Luiz Gustavo Oliveira Brito
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Camila Carvalho de Araujo
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
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Umachanger JK, Marcussen ML, Bøggild H, Kjærgaard N, Glavind K. First-line treatment of pelvic organ prolapse and discontinuation of pessary treatment. Int Urogynecol J 2020; 31:1813-1819. [PMID: 32447418 DOI: 10.1007/s00192-020-04338-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/08/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The primary objective of this study was to investigate the percentages of women choosing watchful waiting, pessary use or surgery as first-line treatment of pelvic organ prolapse (POP). Second, the rate and cause of discontinuation of pessary use were investigated. METHODS A retrospective chart review was conducted on 794 patients referred with POP at a Danish tertiary center for urogynecology at Aalborg University Hospital between 1 January 2014 and 31 December 2015. The following data were registered: age, BMI, previous use of a pessary, total number of births, vaginal births, cesarean sections, previous hysterectomy, prolapse surgery and incontinence surgery, smoking, menopause, sexual status and POP-Q stage in the three vaginal compartments. Pessary treatments were evaluated after 3 months. Additional visits, reason for discontinuation and secondary treatment were noted. RESULTS First-line treatment was surgery in 50%, watchful waiting in 33% and pessary use in 17% of patients. Characteristics associated with choosing surgery instead of a pessary were age < 65 years, previous prolapse surgery, prolapse in the anterior or posterior compartment, and POP-Q stage > 2. Characteristics associated with choosing watchful waiting instead of a pessary were age < 65 years and prolapse in the posterior compartment. A total of 33% discontinued pessary treatment within the first 3 months. Discontinuation was associated with age < 65 years, previous hysterectomy and pelvic surgery, and additional visits. Expulsion of the pessary and pain/discomfort were the main causes of discontinuation. CONCLUSION This study showed that 50% of patients referred with POP were treated with conservative treatment (watchful waiting and pessary) and thus more women could probably be treated in primary care.
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Affiliation(s)
| | | | - Henrik Bøggild
- Public Health and Epidemiology Group, Aalborg University and Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Kjærgaard
- Department of Gynecology, Aalborg University Hospital, Aalborg, Denmark
| | - Karin Glavind
- Department of Gynecology, Aalborg University Hospital, Aalborg, Denmark
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Li B, Chen Q, Zhang J, Yu C, Zhang L, Chen L. A prospective study of pessary use for severe pelvic organ prolapse: 3-year follow-up outcomes. Arch Gynecol Obstet 2020; 301:1213-1218. [PMID: 32274637 DOI: 10.1007/s00404-020-05526-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 03/28/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To estimate the optimal definition of successful pessary use and the long-term success rate of the pessary as well as the complications and factors associated with continued pessary use. METHODS Consecutive patients who had symptomatic stage III/IV POP were enrolled. The degrees of POP were assessed by POP-Q. All patients completed the PFIQ-7 questionnaire before pessary use. For the 1-week, 1-month, 3-month, 6-month, 1-year and 3-year follow-up assessments, patients visited the clinic for an examination and to complete the questionnaire. SPSS 18.0 was used for the data analysis. Wilcoxon's signed-rank test was performed to estimate the change in PFIQ-7 scores before and after pessary use. Logistic regression was performed to identify the factors associated with the duration of pessary use. RESULTS A total of 60 subjects (average age 68.93 ± 8.98 years) were enrolled. The 3-year success rate of the pessary was 63.33%. The PFIQ-7 score in the 1-month follow-up was significantly decreased (16.22 ± 12.81 vs 1.39 ± 3.39, P = 0.000). During the follow-up, none of the patients experienced any severe complications, and the rate of vaginal erosion was 20% (12/60). The PFIQ-7 score in the 1-month follow-up decreased more than 50% and was associated with continuous pessary use [OR 20.75, P = 0.027, 95% CI (2.28, 189.27)]. CONCLUSIONS Successful pessary use can be defined as fitting for longer than 3 months. The PFIQ-7 scores should be focused on during the follow-up. The treatment should be changed if the scores decrease less than 50% in the 1-month follow-up.
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Affiliation(s)
- Bin Li
- Department of Gynecology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, People's Republic of China
| | - Qiaohua Chen
- Department of Burns and Cutaneous Surgery, the First Affiliated Hospital of the Air Force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Jing Zhang
- Department of Gynecology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, People's Republic of China
| | - Cuige Yu
- Department of Gynecology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, People's Republic of China
| | - Lu Zhang
- Department of Gynecology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, People's Republic of China
| | - Lihong Chen
- Department of Gynecology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, People's Republic of China.
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Radnia N, Hajhashemi M, Eftekhar T, Deldar M, Mohajeri T, Sohbati S, Ghanbari Z. Patient Satisfaction and Symptoms Improvement in Women Using a Vginal Pessary for The Treatment of Pelvic Organ Prolapse. J Med Life 2019; 12:271-275. [PMID: 31666830 PMCID: PMC6814872 DOI: 10.25122/jml-2019-0042] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pelvic organ prolapse is a common complaint among older women. Vaginal pessary insertion is an appropriate treatment as a non-surgical method with few complications. This paper is a prospective observational study of 68 patients with pelvic organ prolapse that was carried out at the Imam Khomeini Hospital's Pelvic Floor clinic. The degree of pelvic organ prolapse was graded according to the Pelvic Organ Prolapse Quantification (POP-Q) System. For all patients, the Pelvic Floor Distress Inventory-20 (PFDI-20) questionnaire was completed before vaginal pessary insertion, and after approximately 6 months of treatment. After 6-8 months, we found out that vaginal discharge was significantly increased and the feeling of fullness in the vagina was significantly decreased. However, sexual dissatisfaction, the feeling of incomplete evacuation, fecal and urinary incontinence, frequent urination, and pain or discomfort in the genital region were not significantly different after using a pessary. Approximately half a year later, 96.7% of the women with a successful pessary fitting trial were satisfied and reported a significant improvement in symptoms. Further studies with larger sample size, a different type of pessary, and a longer follow-up duration are recommended to evaluate all the symptoms associated with pelvic organ prolapse and its treatment.
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Affiliation(s)
- Nahid Radnia
- Department of Obstetrics & Gynecology, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Maryam Hajhashemi
- Department of Obstetrics & Gynecology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Tahereh Eftekhar
- Department of Obstetrics & Gynecology, Vali-e-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Deldar
- Department of Obstetrics & Gynecology, Vali-e-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Taraneh Mohajeri
- Department of Obstetrics & Gynecology, Mashhad Islamic Azad University of Medical Sciences, Mashhad, Iran
| | - Samira Sohbati
- Department of Obstetrics & Gynecology, Kerman University of Medical Sciences, Kerman, Iran
| | - Zinat Ghanbari
- Department of Obstetrics & Gynecology, Vali-e-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Powers SA, Burleson LK, Hannan JL. Managing female pelvic floor disorders: a medical device review and appraisal. Interface Focus 2019; 9:20190014. [PMID: 31263534 DOI: 10.1098/rsfs.2019.0014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2019] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Shelby A Powers
- Department of Physiology, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Mailstop 634, Greenville, NC 27834-4354, USA
| | - Lindsey K Burleson
- Department of Physiology, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Mailstop 634, Greenville, NC 27834-4354, USA
| | - Johanna L Hannan
- Department of Physiology, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Mailstop 634, Greenville, NC 27834-4354, USA
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Hsieh MF, Tsai HW, Liou WS, Lo CC, Lin ZH, An YF, Lin HY. Long-term compliance of vaginal pessaries: Does stress urinary incontinence matter? Medicine (Baltimore) 2019; 98:e15063. [PMID: 30946355 PMCID: PMC6455947 DOI: 10.1097/md.0000000000015063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Vaginal pessary treatment for pelvic organ prolapse (POP) is relatively safe and cost-effective. Since long-term use is an important key to keep the benefit of pessary treatment, we would like to investigate the factors which might affect the compliance of vaginal pessaries. In this retrospective study, 65 women were included, and we found poor compliance in women with severe stress urinary incontinence (SUI) after reduction (1-hour pad test >10 gm vs ≦10 gm, 57.1% vs. 84.3%, P = .027). Besides, women younger than 60 years-old also had poor compliance (age ≦60-year-old vs >60-year-old, 58.3% vs 83.0%, P = .04). Other factors such as POP stage, history of hysterectomy, and types of pessaries, did not show significant influence on the long-term compliance in this study. Therefore, to evaluate the severity of SUI after reduction before providing pessary treatment is important to predict long-term compliance. Meanwhile, long-term pessary treatment seems to be more acceptable to elderly patients.
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Affiliation(s)
- Ming-Fang Hsieh
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Hsiao-Wen Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung
- School of Medicine, National Yang-Ming University, Taipei
- Department of Nursing, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Wen-Shiung Liou
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung
- School of Medicine, National Yang-Ming University, Taipei
| | - Ching-Chuan Lo
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Zi-Han Lin
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Ya-Fen An
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Hsin-Yin Lin
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung
- School of Medicine, National Yang-Ming University, Taipei
- Department of Nursing, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
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Abstract
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.
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Affiliation(s)
- Gwendolyn L Hooper
- Graduate Nursing, Capstone College of Nursing, The University of Alabama, Box 870358, Tuscaloosa, AL 35487-0358, USA.
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Successful long-term use of Gellhorn pessary and the effect on symptoms and quality of life in women with symptomatic pelvic organ prolapse. Menopause 2019; 26:145-151. [DOI: 10.1097/gme.0000000000001197] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mao M, Ai F, Zhang Y, Kang J, Liang S, Xu T, Zhu L. Predictors for unsuccessful pessary fitting in women with symptomatic pelvic organ prolapse: a prospective study. BJOG 2018; 125:1434-1440. [PMID: 29700950 DOI: 10.1111/1471-0528.15260] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2018] [Indexed: 11/27/2022]
Affiliation(s)
- M Mao
- Department of Obstetrics and Gynaecology; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - F Ai
- Department of Obstetrics and Gynaecology; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - Y Zhang
- Department of Obstetrics and Gynaecology; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - J Kang
- Department of Obstetrics and Gynaecology; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - S Liang
- Department of Obstetrics and Gynaecology; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - T Xu
- Department of Epidemiology and Statistics; Institute of Basic Medical Sciences; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
| | - L Zhu
- Department of Obstetrics and Gynaecology; Peking Union Medical College Hospital; Peking Union Medical College; Chinese Academy of Medical Sciences; Beijing China
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Barsky M, Kelley R, Bhora FY, Hardart A. Customized Pessary Fabrication Using Three-Dimensional Printing Technology. Obstet Gynecol 2018; 131:493-497. [DOI: 10.1097/aog.0000000000002461] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dueñas JL, Miceli A. Effectiveness of a continuous-use ring-shaped vaginal pessary without support for advanced pelvic organ prolapse in postmenopausal women. Int Urogynecol J 2018; 29:1629-1636. [DOI: 10.1007/s00192-018-3586-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 01/29/2018] [Indexed: 11/29/2022]
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Cheung RY, Lee LL, Chung TK, Chan SS. Predictors for dislodgment of vaginal pessary within one year in women with pelvic organ prolapse. Maturitas 2018; 108:53-57. [DOI: 10.1016/j.maturitas.2017.11.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/26/2017] [Accepted: 11/09/2017] [Indexed: 11/24/2022]
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Cheung RYK, Lee JHS, Lee LL, Chung TKH, Chan SSC. Levator ani muscle avulsion is a risk factor for expulsion within 1 year of vaginal pessary placed for pelvic organ prolapse. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:776-780. [PMID: 28078670 DOI: 10.1002/uog.17407] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/04/2017] [Accepted: 01/06/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The aim of this study was to investigate whether the presence of levator ani muscle (LAM) avulsion is associated with expulsion within 1 year of a vaginal pessary placed for pelvic organ prolapse (POP). METHODS This was a prospective observational study of consecutive women with symptomatic POP, who had not received treatment for the condition before the consultation and opted for vaginal pessary placement in our center. Volume acquisition was performed before pessary insertion and offline analysis of the 3D/4D transperineal ultrasound volume data was performed. LAM was assessed on maximum pelvic floor muscle contraction (PFMC) and hiatal dimensions were assessed at rest, on PFMC and on maximum Valsalva. Results were compared between women in whom the pessary was retained for 1 year and those in whom the pessary was expelled within 1 year. RESULTS The datasets of 255 women were analyzed including 147 (57.6%) women who had a vaginal pessary continuously in place over 1 year and 108 (42.4%) with pessary expulsion. Mean age was 63.2 (SD, 9.9) years and median parity was 3 (2-4). Eighteen (7.1%) had Stage I, 164 (64.3%) Stage II, 67 (26.3%) Stage III and six (2.4%) Stage IV POP. Women with vaginal pessary expulsion within 1 year had significantly larger hiatal dimensions at rest and on Valsalva, larger hiatal area during rest, PFMC and Valsalva and higher rate of LAM avulsion (53.7% vs 27.2%, P < 0.01) compared with women in whom the pessary was retained for 1 year. After controlling for potential confounders, LAM avulsion remained a risk factor (OR, 3.18, P < 0.01) of vaginal pessary expulsion within 1 year. CONCLUSIONS Women in whom a vaginal pessary was expelled within 1 year of placement for POP had a larger hiatus. Presence of LAM avulsion was associated with a three-fold increase in the risk of expulsion of a vaginal pessary within 1 year. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Y K Cheung
- Department of Obstetrics & Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - J H S Lee
- Department of Obstetrics & Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - L L Lee
- Department of Obstetrics & Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - T K H Chung
- Department of Obstetrics & Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - S S C Chan
- Department of Obstetrics & Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Successful use of the Gellhorn pessary as a second-line pessary in women with advanced pelvic organ prolapse. Menopause 2017. [DOI: 10.1097/gme.0000000000000909] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clinical use of ring with support pessary for advanced pelvic organ prolapse and predictors of its short-term successful use. Menopause 2017; 24:954-958. [DOI: 10.1097/gme.0000000000000859] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Robert M, Schulz JA, Harvey MA. Mise à jour technique sur l'utilisation des pessaires. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:S264-S276. [DOI: 10.1016/j.jogc.2016.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Effectiveness and cost-effectiveness of pessary treatment compared with pelvic floor muscle training in older women with pelvic organ prolapse: 2-year follow-up of a randomized controlled trial in primary care. Menopause 2016; 23:1307-1318. [DOI: 10.1097/gme.0000000000000706] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Predictors of unsuccessful pessary fitting in women with prolapse: a cross-sectional study in general practice. Int Urogynecol J 2016; 28:307-313. [PMID: 27525693 PMCID: PMC5306061 DOI: 10.1007/s00192-016-3107-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/22/2016] [Indexed: 11/03/2022]
Abstract
Introduction and hypothesis Pelvic organ prolapse is a common condition. There is inconsistency between predictors of unsuccessful pessary fitting in urological/gynaecological clinics. Research in general practice is scarce. The aim was to estimate the proportion of women in general practice with a symptomatic pelvic organ prolapse and unsuccessful pessary fitting, and to identify characteristics associated with unsuccessful pessary fitting. Methods A cross-sectional study in general practice (n = 20) was carried out among women (≥55 years) with symptomatic prolapse (n = 78). Multivariate logistic regression analysis was used to identify predictors of unsuccessful pessary fitting. Results In total, 33 women (42 %) had unsuccessful pessary fitting. Factors associated with unsuccessful pessary fitting were age (per year, OR 0.93 [95 % CI 0.87–1.00]), body mass index (per kg/m2, OR 1.14 [95 % CI 1.00–1.30]), and having underactive pelvic floor muscles (OR 2.60 [95 % CI 0.81–8.36]). Conclusions Pessary fitting was successful in 58 %, indicating that pessary treatment may be suitable for many, but not for all women in general practice with symptomatic prolapse. The condition of the pelvic floor probably plays a role in the success of pessary fitting, as demonstrated by the association with underactive pelvic floor muscles, and body mass index. The association with age may reflect the higher acceptance of conservative treatments for prolapse in older women. This is the first study on predictive factors for unsuccessful pessary fitting in general practice. Therefore, further research should seek to confirm these associations before we can recommend the use of this information in patient counselling.
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Ding J, Song XC, Deng M, Zhu L. Which factors should be considered in choosing pessary type and size for pelvic organ prolapse patients in a fitting trial? Int Urogynecol J 2016; 27:1867-1871. [DOI: 10.1007/s00192-016-3051-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
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de Albuquerque Coelho SC, de Castro EB, Juliato CRT. Female pelvic organ prolapse using pessaries: systematic review. Int Urogynecol J 2016; 27:1797-1803. [DOI: 10.1007/s00192-016-2991-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 02/18/2016] [Indexed: 11/24/2022]
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Natural history of pessary use in women aged 65 – 74 versus 75 years and older with pelvic organ prolapse: a 12-year study. Int Urogynecol J 2016; 27:1201-7. [DOI: 10.1007/s00192-016-2970-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
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Pizarro-Berdichevsky J, Clifton MM, Goldman HB. Evaluation and Management of Pelvic Organ Prolapse in Elderly Women. Clin Geriatr Med 2015; 31:507-21. [DOI: 10.1016/j.cger.2015.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ding J, Chen C, Song XC, Zhang L, Deng M, Zhu L. Changes in Prolapse and Urinary Symptoms After Successful Fitting of a Ring Pessary With Support in Women With Advanced Pelvic Organ Prolapse: A Prospective Study. Urology 2015; 87:70-5. [PMID: 26375847 DOI: 10.1016/j.urology.2015.07.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/16/2015] [Accepted: 07/20/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To estimate the percentage of improvement in prolapse and urinary symptoms and adverse effects in women with advanced pelvic organ prolapse (POP) after 3 months of use of a ring pessary with support. MATERIALS AND METHODS In this prospective study, 109 consecutive women with advanced POP were fitted with a ring pessary with support; 73 (73/109, 67.0%) of the women had a successful 3-month pessary fitting trial. Prolapse symptoms, urinary symptoms, and urinary flow parameters were assessed at baseline and at 3 months. Adverse effects were assessed within 3 months. McNemar's test and paired-sample t tests were performed. RESULTS Prolapse and urinary symptoms improved from baseline to 3 months, including bulging (90.4% to 23.3%; P <.001) and pressure (64.4% to 13.7%; P <.001). Voiding difficulty improved in 97.8% of the women (45/46; P <.001), splinting improved in 100% (19/19; P <.001), urge urinary incontinence improved in 76.9% (30/39; P <.001), and stress urinary incontinence improved in 58.1% (18/31; P = .025) after 3 months. After pessary treatment, the differences in maximum flow rate, mean flow rate, void volume, and postvoid residual at baseline and 3 months were statistically significant (P <.05). Vaginal discharge (32/73, 43.8%) was the most common adverse event. Vaginal ulcers developed in 7 (7/73, 9.6%) of the women. CONCLUSION The ring pessary with support was successfully fitted in patients with advanced POP with a high success rate and few complications. The pessary could resolve more than half of the prolapse and urinary symptoms. Therefore, initial conservative treatment with a ring pessary with support in advanced POP is worthwhile.
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Affiliation(s)
- Jing Ding
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
| | - Chun Chen
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Chen Song
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lei Zhang
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Mou Deng
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lan Zhu
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
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