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

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

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Self-care of vaginal pessary for pelvic organ prolapse: a systematic review and meta-analysis

INTRODUCTION

There is no evidence about the efficacy of self-care of vaginal pessary in women with symptomatic pelvic organ prolapse (POP). The aim of this systematic review and meta-analysis is to assess the adherence to pessary treatment among women who engage in self-management of their pessary.

METHODS

We performed a systematic review and meta-analysis, according to PRISMA 2020 guidelines, and selected seven publications for inclusion in the analysis.

RESULTS

Pooled continuation rate of self-cared vaginal pessary was the 76% (95%CI: 66-85%) with a I2-test of 93.3% (p < 0.001). Pooled conversion to POP surgery was the 12% (95%CI: 1-23%) with a I2-test of 96% (p < 0.001). Continuation rate was not statistically different between women who were treated by self-care and non-self-care management of vaginal pessary (RR 1.11, 95%CI 0.96-1.27; p = 0.15), with a related I2-test of 37% (p = 0.21).

CONCLUSION

Self-care vaginal pessary management presented a high continuation rate in women affected by pelvic organ prolapse at a long follow-up. The rate of conversion to surgical management of POP was low. No significant difference in continuation rate were highlighted between women who adopted the self-care or the clinical-based management of pessary.

Clinical and cost-effectiveness of pessary self-management versus clinic-based care for pelvic organ prolapse in women: the TOPSY RCT with process evaluation

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.

Quality of Life after Treatment for Pelvic Organ Prolapse in Real-World Study: Recommendations, Vaginal Pessary, and Surgery

Background and Objectives: Pelvic organ prolapse (POP) is a common condition in women, with its prevalence increasing with age, and can significantly impact the quality of life (QOL) of many individuals. The objective of this study was to assess the overall improvement, quality of life, and continuation of primary treatment for POP over a 24-month period in a real-world setting. Materials and Methods: This is a prospective, observational, follow-up study of women with symptomatic POP who, as a primary treatment, opted for recommendations (lifestyle changes and pelvic floor muscle training), pessary therapy, or surgery. The primary outcome measure was a subjective improvement at the 24-month follow-up, measured with the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcome measures were the continuation rate of the primary treatment method, reason for discontinuation, and the quality of life evaluated with the P-QoL questionnaire. Results: We included 137 women, with 45 women (32.8%) in the recommendations group, 39 (28.5%) in the pessary group, and 53 women (38.7%) in the surgery group. After 24 months, surgery, in comparison with pessary treatment and recommendations, resulted in significantly more women reporting a subjective improvement: 89.6%, 66.7%, and 22.9% (p < 0.001), respectively. Overall, 52% of women from the recommendations group and 36.4% from the pessary group switched to another treatment or discontinued the primary treatment within 24 months. However, women who continued the primary treatment, pessary use, and surgery showed similar subjective improvements (90.5% and 89.6%, respectively) and quality-of-life improvement. Conclusions: The chance of significant improvement was higher following surgery. However, after 24 months, both vaginal pessaries and surgery showed an important quality-of life improvement and can be proposed as primary treatment methods for pelvic organ prolapse.

Self-management of vaginal cube pessaries may be a game changer for pelvic organ prolapse treatment: a long-term follow-up study

INTRODUCTION AND HYPOTHESIS

Loss of anatomical support for the pelvic organs results in pelvic organ prolapse (POP). We hypothesized that daily self-management of a cube pessary might be a safe, feasible long-term treatment in women with symptomatic POP.

METHODS

A cohort of 214 symptomatic POP patients (stage 2+) were enrolled prospectively (January to December 2015). Each patient was size-fitted with a space-filling cube pessary and completed a questionnaire online or by phone ≥5 years after her initial fitting. Change in quality of life (QoL) was measured with the Patient Global Impression of Improvement (PGI-I).

RESULTS

Of 185 women included in our analyses, 174 (94%) were continuing to use their pessary 4 weeks post-insertion. Among those, 143 (82.2%) used the pessary successfully for ≥5 years. A large majority of these patients (88.8% [127 out of 143]) described their condition as much or very much improved compared with their pretreatment status (PGI-I). Adverse secondary effects (ASEs) were infrequent [15.4% (22 out of 143)]; when they did occur, they were mild, including smelly vaginal discharge (15 out of 22) and slight vaginal bleeding caused by the fitting procedure (6 out of 22).

CONCLUSIONS

Daily self-management of cube pessaries was found to be a safe and effective treatment for improving POP-related symptoms and QoL in the long term.

Pessary with perineal suture for treatment of pelvic organ prolapse: description and benefit of the technique

INTRODUCTION AND HYPOTHESIS

Vaginal pessaries are used as a conservative treatment for POP in women who do not want or are not candidates for surgery, or as a preliminary step to surgery. Our goals are: evaluate the evolution of patients with advanced POP and repeated expulsion of the pessary, who underwent perineal suture to try to maintain the device. Describe the epidemiological characteristics of patients treated with pessaries in our environment, with or without perineal closure.

METHODS

Observational, descriptive and prospective study (October 2016-March 2021) that includes 352 women with advanced-stage POP treated with a pessary, of which 55, after repeated expulsion of the pessary, were treated with a pessary and perineal suture.

RESULTS

After pessary insertion associated with perineal closure, 26 patients (47.2%) expelled the pessary and underwent surgery, and 29 (52.8%) kept the device, avoiding surgery. Regarding the women who required perineal suture: The mean age was higher than in the group of patients who did not need this intervention (75.3 vs. 68.3 years), 94.5% had POP ≥ grade III and 100% had a perineal width > 2.5 cm.

CONCLUSIONS

Treatment with pessary and perineal closure avoids surgery in women with advanced age and repeated expulsion. Although age should not be an independent factor that limits surgical treatment or the type of intervention, it would be useful to have scales to quantify the frailty of patients, being able to standardize perineal closure in elderly and/or frail women, and in those who do not want or have contraindications for surgery.

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

OBJECTIVE

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

DESIGN

Multicentre prospective comparative cohort study.

SETTING

Twenty-two Dutch hospitals.

POPULATION

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

METHODS

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

MAIN OUTCOME MEASURE

PGI-I at 24 months.

RESULTS

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

CONCLUSIONS

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

TWEETABLE ABSTRACT

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

Vaginal pessary treatment in women with symptomatic pelvic organ prolapse: a long-term prospective study

OBJECTIVE

To evaluate the 5-year pessary continuation rate and identify clinical risk factors associated with discontinuation in patients with symptomatic pelvic organ prolapse (POP).

METHODS

In this prospective observational study, 312 women with symptomatic POP received pessary treatment between November 2013 and July 2015 in Peking Union Medical College Hospital, China, a tertiary referral center. Patients were initially fitted with a ring pessary with support. Those who failed were fitted with a Gellhorn pessary. A successful pessary fitting was defined as a patient who was fitted and continued to use the pessary 2 weeks later. Patients with successful pessary fitting were followed for 5 years. Data analysis was performed with t tests, nonparametric tests, chi-square tests, and logistic regression.

RESULTS

In total, 265 patients (84.9%) had successful pessary fitting. After 5 years, 180 of 239 patients continued pessary use (75.3% continuation rate), with 26 lost to follow-up. The discontinuation rates decreased over time, from 8.7% at 1 year to 2.7% at 5 years. Total vaginal length < 7.5 cm (TVL, OR = 2.7, 95% CI 1.3-5.7, P = 0.007), improvement in Urinary Impact Questionnaire-7 scores < 50% at 3 months (OR = 2.1, 95% CI 1.1-4.2, P = 0.025), and incapability of self-care (OR = 2.6, 95% CI 1.3-5.1, P = 0.008) were potential discontinuation risk factors.

CONCLUSION

Three-quarters of patients with symptomatic POP had successful pessary treatment at 5-year follow-up. TVL < 7.5 cm, poor urinary symptom relief at 3 months, and incapability of self-care were potential discontinuation risk factors.

Pessary offer documentation in women undergoing surgery for pelvic organ prolapse at a tertiary care hospital

BACKGROUND

Women report similar functional outcomes after pessary treatment or surgery for pelvic organ prolapse (POP).

AIMS

To assess the documentation of pessary counselling in women who underwent surgery for POP. Methods: This was a retrospective cohort study conducted on women who underwent hysterectomy for prolapse. The primary outcome measure was documentation regarding offer of pessary. 'Pessary offer' was defined as documentation that clearly stated that the care provider offered pessary to the patient.

FINDINGS

Over the study period, 81 hysterectomies took place for POP; pessary offer was documented for only 19 (23.5%) case records. Characteristics significantly associated with pessary offer were history of chronic cough (P=0.031), previous pelvic surgery (P<0.001), no secondary indication for surgery (P=0.012), concomitant surgery performed other than hysterectomy (P=0.046), age range (P<0.001) and BMI range (P<0.001).

CONCLUSION

Pessary offer was documented in less than quarter of cases. This denotes a need to strengthen documentation of offer, counselling for pessary, or both of these.

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

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

AIM

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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