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

International Urogynecology Consultation Chapter 3 Committee 1 - Pessary Management

INTRODUCTION AND HYPOTHESIS

This manuscript is part of the International Urogynecological Consultation (IUC) on Pelvic Organ Prolapse (POP), Chapter 3, Committee 1 focusing on pessary management of POP.

METHODS

A narrative review was conducted by an international, multi-disciplinary group of clinicians working in the field of pelvic health following a search of the literature using the MeSH terms "pelvic organ prolapse" OR "urogenital prolapse" OR "vaginal prolapse" OR "uterovaginal prolapse" AND "pessary" OR "support device" OR "intravaginal device." Relevant studies, as determined after review using the Covidence manuscript review platform, were included.

RESULTS

A total of 540 articles were reviewed, of which 313 were included for this narrative review. The reported pessary fitting success rate ranges from 41% to 96.6%, and the continuation of successful use rate varied from 21% to 97.7%. The most likely predictors of unsuccessful fitting trials were previous POP surgery, previous hysterectomy, short vaginal length, wide genital hiatus, and posterior compartment involvement. Following successful pessary placement in individuals with POP, vaginal bulge and pressure resolved in over 90%. A significant improvement in obstructive voiding was reported in 40-97% of participants, urinary urgency in 38%, urgency urinary incontinence in 29-77%, and stress urinary incontinence in 9-45%. Older age and women who can self-manage the pessary care or had family support were factors associated with pessary continuation. Common reasons reported for discontinuation included expulsion, vaginal pain/discomfort, unwillingness to continue, erosions, desire for surgery, bleeding, symptoms not improved with pessary, and incontinence. More serious complications (fistula, bowel obstruction, pessary impaction, and vaginal cancer) are rare, and occur usually in older women in whom pessary maintenance has been neglected. There is no high-quality evidence to guide pessary choice. The current literature lacks studies specifically focused on determining the role of preventative measures, i.e., estrogen, pessary type/material as regards to pessary-associated complications (PACs). The review identified a lack of information about the relevant and required training and education (for healthcare professionals and patients) for pessary provision, use, and management.

CONCLUSIONS

There is a considerable body of published work on the use of pessaries for POP, including effectiveness, factors associated with success and failure, and complications. However, there is a dearth of published literature regarding how pessary types are selected by providers, how providers are trained, what defines competency in pessary provision, and what constitutes appropriate patient education related to pessary use and management.

Complications in Pelvic Organ Prolapse With 3-Month Versus 6-Month Pessary Care: Pilot Study

IMPORTANCE

Despite evidence emphasizing the necessity of routine care for women with pelvic organ prolapse (POP) using pessaries, the frequency of follow-up is unclear.

OBJECTIVE

The aim of this study was to compare the presence of complications in women with POP using vaginal pessaries with cleaning and gynecological examination every 3 or 6 months.

STUDY DESIGN

This pilot study was a randomized clinical trial of women with advanced POP using a ring pessary. The women were randomized into 2 groups ("3-month group" and a "6-month group") that returned for evaluation by a health care professional that monitored the vagina, removed the pessary, cleaned it, and reinserted it. Sociodemographic and clinical data were collected. During their follow-up, the women answered a questionnaire regarding the presence of vaginal symptoms and had a physical examination and vaginal sampling for microbiological analysis.

RESULTS

A total of 38 women were randomized into 2 groups: the 3-month group (n = 18) and the 6-month group (n = 20). Baseline characteristics of the groups were similar except for age, which was 70.7 (±7.4) years in the 3-month group and 74.7 (±6.6) years in the 6-month group (P = 0.022). Regarding physical examination, after 12 months of follow-up, 4 women in each group presented erosions or ulcers in each group, but without difference (P = 1). The presence of bacterial vaginosis was more frequent in the group with cleaning every 6 months (P = 0.026).

CONCLUSIONS

The prevalence of ulcerations was similar in both groups with cleaning every 3 or 6 months, but the group with cleaning every 6 months showed a higher prevalence of bacterial vaginosis.

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.

Quality of Life Following Pelvic Organ Prolapse Treatments in Women: A Systematic Review and Meta-Analysis

Introduction: Quality of life (QoL) improvement is one of the main outcomes in the management of pelvic organ prolapse as a chronic illness in women. This systematic review aimed to investigate the impact of surgical or pessary treatment for pelvic organ prolapse (POP) on quality of life. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was applied. Electronic databases, including PubMed, Scopus, and Web of Science, were searched for original articles that evaluated the QoL before and after surgical interventions or pessary in pelvic organ prolapse from 1 January 2012 until 30 June 2022 with a combination of proper keywords. Included studies were categorized based on interventions, and they were tabulated to summarize the results. Results: Overall, 587 citations were retrieved. Of these, 76 articles were found eligible for final review. Overall, three categories of intervention were identified: vaginal surgeries (47 studies), abdominal surgeries (18 studies), and pessary intervention (11 studies). Almost all interventions were associated with improved quality of life. The results of the meta-analysis showed a significant association between the employment of surgical approach techniques (including vaginal and abdominal surgeries) and the quality of life (Pelvic Floor Distress Inventory (PFDI) (MD: −48.08, 95% CI: −62.34 to −33.77, p-value < 0.01), Pelvic Floor Impact Questionnaire (PFIQ) (MD: −33.41, 95% CI: −43.48 to −23.34, p < 0.01)) and sexual activity of patients with pelvic organ prolapse (Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) (MD: 4.84, 95% CI: 1.75 to 7.92, p < 0.01)). Furthermore, narrative synthesis for studies investigating the effect of the pessary approach showed a positive association between the use of this instrument and improvement in the quality of life and sexual activity. Conclusions: The results of our study revealed a significant improvement in the women’s quality of life following abdominal and vaginal reconstructive surgery. The use of pessary was also associated with increased patient quality of life.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Do vaginal pessaries used to treat pelvic organ prolapse impact on sexual function? A systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) is common and associated with sexual dysfunction. Vaginal pessaries are an effective treatment for POP, but their impact on sexual function is not well established. The aim of this systematic review and meta-analysis was to establish the impact of vaginal pessaries used for POP on female sexual function.

METHODS

Systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. A comprehensive search was conducted across Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, CINAHL, ClinicalTrials.gov , The WHO International Clinical Trials Registry Platform, ProQuest Dissertations & Theses, Open Grey and Scopus Citation Database. Randomised controlled trials and cohort studies that assessed sexual function in women pre- and post-pessary treatment for POP were included, assessed for risk of bias and their results synthesised.

RESULTS

A total of 1,945 titles and abstracts were screened, 104 full-text articles were assessed for eligibility, 14 studies were included in the narrative analysis and 7 studies were included in the meta-analysis. The results suggest that, in sexually active women, there is no evidence of a deterioration in sexual function and some evidence of an improvement.

DISCUSSION

This review offers reassurance that in sexually active women who successfully use a pessary for treatment of their prolapse, there is no deterioration in sexual function. There is some evidence of an improvement in sexual function, but given the clinical heterogeneity in the studies included, caution should be taken in generalising these findings.

Does the choice of pelvic organ prolapse treatment influence subjective pelvic-floor related quality of life?

OBJECTIVES

The relationship between pelvic organ prolapse (POP) treatment and subjective pelvic-floor related quality of life (QoL) was examined.

STUDY DESIGN

130 postmenopausal women with symptomatic POP were included: 45 % (59/130) were treated conservatively with pessary and 55 % (71/130) underwent pelvic floor surgery. All participants answered the validated German pelvic floor questionnaire at the time of baseline examination, as well as three months later.

RESULTS

Our results demonstrated a significant improvement regarding mean score in the domains "prolapse" (p = 0.001) and "sexual function" (p = 0.001) three months after prolapse surgery, whereas in the pessary group only the score in the "prolapse" domain improved (p < 0.001). When comparing the two treatment arms after three months, patients reported a significant advancement regarding their "sexual function" domain in the surgery group (p < 0.0001). Furthermore, univariate analysis revealed a significant positive correlation between "prolapse" domain score (correlation coefficient = 0.0001) as well as "bladder" domain score (correlation coefficient <0.001) and POP-Q stage. Additionally, a significant negative correlation between "sexual function" domain score and POP-Q stage was found (correlation coefficient = 0.0001).

CONCLUSION

Our results revealed that three months after prolapse surgery, pelvic-floor related QoL showed significant improvement in the domain "sexual function" compared to three months pessary treatment. Besides, advanced prolapse stage correlated with higher symptom burden and worse sexual function.

ESTROgen use for complications in women treating pelvic organ prolapse with vaginal PESSaries (ESTRO-PESS)-a randomized clinical trial

INTRODUCTION AND HYPOTHESIS

To evaluate the complications of new users' vaginal pessaries (VP), with and without the use of vaginal estrogen after a 6-month follow-up.

METHODS

A parallel, single-blinded, randomized, controlled trial. Symptomatic postmenopausal women (n = 98) with pelvic organ prolapse (POP) (stage 3/4) were recruited from August 2018 to October 2019. Patients were randomized into the local estrogen group (promestriene 3 × for a week) and the control group (no estrogen). They were evaluated for their vaginal symptoms at the baseline, after 3 months, and after 6 months, and a physical examination and vaginal sampling for microbiological analysis were done. Data were analyzed according to an intention-to-treat analysis (ITT). A 5% significance level was established for statistical analysis.

RESULTS

Twenty women discontinued treatment (20.4%), mainly due to pessary extrusion (n = 15) and 5 for other reasons (lost to follow-up, pain, and surgery). Baseline characteristics were not statistically different between the estrogen and control groups. Regarding the presence of complications, the presence of erosion was 10% in the control group, but there was no significant difference between the groups (p = 0.175) after 6 months. Bacterial vaginosis (BV) was more prevalent in the control group, according to the Nugent (p = 0.007) and Amsel (p = 0.014) criteria. Urinary urgency and increased urinary frequency were significantly improved in the estrogen group after 6 months.

CONCLUSION

There was no evident benefit related to complications such as ulcerations, itching, and vaginal discharge/odor from the use of vaginal estrogen in POP women using pessaries.

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

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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