Pessary Insertion Research Articles

Vaginal Pessary in Women With Symptomatic Pelvic Organ Prolapse: A Randomized Controlled Trial.

To compare pelvic floor symptoms, quality of life, and complications in women with symptomatic pelvic organ prolapse (POP) with or without vaginal pessaries in addition to those who do pelvic floor exercises for 12 months. This was a parallel-group, single-blind, randomized controlled trial with 12 months of follow-up. Women with symptomatic stage I to stage III POP were randomized to either pelvic floor exercises training (control group) or pelvic floor exercises training and insertion of a vaginal pessary (pessary group). The primary outcome was the change of prolapse symptoms and quality of life by using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaires. Secondary outcomes included bothersome of prolapse symptoms, desired treatment, and any complications. From December 2011 through November 2014, 311 women were screened and 276 were randomized as follows: 137 to the control and 139 to the pessary group. One hundred thirty-two (95.0%) women in the pessary group and 128 (93.4%) in the control group completed the study. The Pelvic Organ Prolapse Distress Inventory of Pelvic Floor Distress Inventory and the Pelvic Organ Prolapse Impact Questionnaire of Pelvic Floor Impact Questionnaire scores decreased in both groups after 12 months, but the mean score differences were higher in the pessary group (Pelvic Organ Prolapse Distress Inventory: -29.7 compared with -4.7, P<.01; Pelvic Organ Prolapse Impact Questionnaire: -29.0 compared with 3.5, P<.01). Complication rates were low and similar in both groups. We provided further evidence in nonsurgical treatment for POP. Prolapse symptoms and quality of life were improved in women using a vaginal pessary in addition to pelvic floor exercises. Centre for Clinical Research and Biostatistics-Clinical Trials Registry, https://www2.ccrb.cuhk.edu.hk/web/?page_id=746, ChiCTR-TRC-11001796.

Vaginal cancer possibly caused by pessary and immunocompromised condition: Multiple risk factors may influence vaginal cancer development

Primary cancer of the vagina is a rare entity, comprising only 1-2% of all gynecologic malignancies. Infection of human papillomavirus, immunocompromised condition, and chronic irritation of the vagina by prolonged pessary usage are known to contribute to the development of vaginal cancer. We experienced a rare case of vaginal cancer that occurred after usage of a vaginal pessary while the patient was prescribed with oral prednisolone for idiopathic interstitial pneumonia. Previous reports of vaginal cancer that occurred after pessary usage are mostly neglected pessaries, but in this case the patient was managed properly. We suspect that her immunocompromised condition, as well as her pessary usage, may have accelerated the development of vaginal cancer. The presence of multiple risk factors could be related to the pathogenesis of vaginal cancer, and therefore proper management is required after pessary insertion for uterine prolapse treatment.

Cervical pessary to prevent preterm birth in women with twin gestation and sonographic short cervix: a multicenter randomized controlled trial (PECEP-Twins)

Spontaneous preterm birth (SPB) is the leading cause of perinatal morbidity and mortality. In twins, the rate of preterm birth is higher than in singletons; interventions to prevent preterm birth are needed in this high-risk population. We sought to test whether a cervical pessary reduces the preterm birth rate in twin pregnancies with sonographic short cervix. A prospective, open-label, multicenter, randomized clinical trial was conducted in 5 hospitals in Spain. The ethics committees of all participating hospitals approved the protocol. The trial was registered as ClinicalTrials.gov, number NCT01242410. Eligible women were scanned in Spain. The primary outcome was SPB <34 weeks of gestation. Neonatal morbidity and mortality were also evaluated. Cervical length was measured in 2287 women; 137 pregnant women with a sonographic cervical length ≤25 mm (of 154 detected with a short cervix) were randomly assigned to receive a cervical pessary or expectant management (1:1 ratio). SPB <34 weeks of gestation was significantly less frequent in the pessary group than in the expectant management group (11/68 [16.2%] vs 26/66 [39.4%]; relative risk, 0.41; 95% confidence interval, 0.22-0.76). Pessary use was associated with a significant reduction in the rate of birthweight <2500 g (P= .01). No significant differences were observed in composite neonatal morbidity outcome (8/136 [5.9%] vs 12/130 [9.1%]; relative risk, 0.64; 95% confidence interval, 0.27-1.50) or neonatal mortality (none) between the groups. No serious adverse effects associated with the use of a cervical pessary were observed. The insertion of a cervical pessary was associated with a significant reduction in the SPB rate. We propose the use of a cervical pessary for preventing preterm birth in twin pregnancies of mothers with a short cervix.

The Value of the Preoperative 1-Hour Pad Test With Pessary Insertion to Predict the Need for a Mid-Urethral Sling Following Pelvic Prolapse Surgery: A Cohort Study.

The Value of the Preoperative 1-Hour Pad Test With Pessary Insertion to Predict the Need for a Mid-Urethral Sling Following Pelvic Prolapse Surgery: A Cohort Study.

Preoperative 1-h pad test with pessary insertion as a predictor of the need for a mid-urethral sling following pelvic prolapse surgery: a prospective cohort study

BackgroundA subgroup of patients with pelvic organ prolapse who do not have symptoms of stress urinary incontinence might show such symptoms after prolapse surgery (ie, occult stress urinary incontinence), and no optimal preoperative screening method is available at present. The aim of this study was to estimate the effectiveness of the preoperative 1-h pad test with pessary insertion as a predictor of the need for a mid-urethral sling after prolapse surgery. Methods206 patients with advanced prolapse who did not self-report urinary incontinence were enrolled in this prospective cohort study. Exclusion criteria included previous or concomitant anti-incontinence surgery. Before pelvic prolapse surgery, a urinary stress test, the 1-hour pad test, and uroflowmetry were done, along with prolapse reduction. The primary outcome was postoperative de-novo urinary incontinence. The median follow-up was 31 months (range 12–48 months). All participants were informed about the procedures and signed informed consent forms. The study was approved by the ethics committee of Peking Union Medical College Hospital, Beijing, China. FindingsOf 206 patients, 45 (22%) had evidence of occult stress urinary incontinence preoperatively, 62 (30%) showed de-novo urinary incontinence postoperatively, and only 13 (6%) opted for mid-urethral slings. Patients with occult stress urinary incontinence had a higher de-novo urinary incontinence rate after surgery than had patients without occult stress urinary incontinence (53·3% vs 23·6%; p=0·0001). Occult stress urinary incontinence (hazard ratio [HR] 4·19 [95% CI 1·99–8·86]; p=0·0001) and concomitant hysterectomy (HR 2·86 [1·02–7·99]; p=0·044) were identified as independent risk factors of de-novo urinary incontinence. We used a receiver operating characteristic curve analysis to assess the effectiveness of the preoperative 1-h pad test. The area under the curve was 0·816 (SD 0·085, 95% CI 0·649–0 ·983); the cutoff value was 1·9 g (sensitivity 80·0%; specificity 83·9%). InterpretationThe preoperative 1-h pad test with prolapse reduction is feasible for screening of occult stress urinary incontinence, and a result of more than 1·9 g might be a practical indicator of a need for mid-urethral slings after pelvic prolapse surgery. FundingNone.

Effects of pelvic organ prolapse ring pessary therapy on intravaginal microbial flora.

The purpose of this paper is to report our evaluation of changes in intravaginal microbial flora after ring pessary therapy for pelvic organ prolapse (POP) using conventional and our clone library method. Thirteen patients with POP who were fitted with a ring pessary participated in this longitudinal study that incorporates data from before and 1 month after beginning ring pessary therapy. Changes in intravaginal microbial flora were evaluated by conventional methods, i.e., vaginal pH, lactobacillary grade (LAC grade), Nugent score, and culture-based bacterial detection methods. In addition, we performed our clone library method using 16S ribosomal RNA (rRNA) sequencing of vaginal fluid. Conventional methods revealed that most patients had abnormal intravaginal microbial flora. Mean numbers of detected bacterial species by the culture-based and our clone library method were 3.1 (1-6) and 11.8 (1-25), respectively. Our clone library method showed that Lactobacillus spp. increased in four and decreased in two cases after ring pessary therapy but reappeared after therapy in two cases; no Lactobacillus spp. were detected in five cases. Our study showed that ring pessary therapy did not always disturb intravaginal microbial flora, especially for patients with Lactobacillus spp. prior to ring pessary insertion. Anaerobic circumstances in the vagina after therapy seem to have induced the growth of anaerobic bacteria.

Cervical pessary placement for prevention of preterm birth in unselected twin pregnancies: a randomized controlled trial

Preterm birth is the leading cause of neonatal death and handicap in survivors. Although twins are found in 1.5% of pregnancies they account for about 25% of preterm births. Randomized controlled trials in singleton pregnancies reported that the prophylactic use of progestogens, cervical cerclage and cervical pessary reduce significantly the rate of early preterm birth. In twin pregnancies, progestogens and cervical cerclage have been shown to be ineffective in reducing preterm birth. The objective of this study was to test the hypothesis that the insertion of a cervical pessary in twin pregnancies would reduce the rate of spontaneous early preterm birth. This was a multicenter, randomized controlled trial inunselected twin pregnancies of cervical pessary placement from 20(+0)-24(+6) weeks' gestation until elective removal or delivery vs. expectant management. Primary outcome was spontaneous birth <34 weeks. Secondary outcomes included perinatal death and a composite of adverse neonatal outcomes (intraventricular haemorrhage, respiratory distress syndrome, retinopathy of prematurity or necrotizing enterocolitis) or need for neonatal therapy (ventilation, phototherapy, treatment for proven or suspected sepsis, or blood transfusion). Analysis was by intention to treat. This trial is registered in the ISRCTN registry, number01096902. A total of 1,180 (56.0%) of the 2,107 eligible women agreed to take part in the trial; 590 received cervical pessary and 590 had expectant management. Two of the former and one of the latter were lost to follow up. There were no significant differences between the pessary and control groups in rates of spontaneous birth <34 weeks (13.6% vs. 12.9%; relative risk 1.054, 95% confidence interval [CI] 0.787-1.413; p=0.722), perinatal death (2.5% vs. 2.7%; relative risk 0.908, 95% CI 0.553-1.491; p=0.702), adverse neonatal outcome (10.0 vs. 9.2%; relative risk 1.094, 95% CI 0.851-1.407; p=0.524) or neonatal therapy (17.9% vs. 17.2%; relative risk 1.040, 95% CI 0.871-1.242; p=0.701). A post hoc subgroup analysis of 214 women with short cervix (≤25 mm) showed no benefit from the insertion of a cervical pessary. In women with twin pregnancy, routine treatment with cervical pessary does not reduce the rate of spontaneous early preterm birth.

The value of the preoperative 1-h pad test with pessary insertion for predicting the need for a mid-urethral sling following pelvic prolapse surgery: a cohort study.

Part of the patients with pelvic organ prolapse but without symptoms of stress urinary incontinence (SUI) may demonstrate SUI after prolapse surgery (occult SUI), and no optimal preoperative screening method is currently available for it. The aim of this study was to estimate the value of the preoperative 1-h pad test with pessary insertion for predicting the need for a mid-urethral sling (MUS) following prolapse surgery. Two hundred and six patients were enrolled for advanced prolapse without complaining of urinary incontinence (UI) in this prospective cohort study. Exclusion criteria included prior or concomitant anti-incontinence surgery. Preoperatively, a stress test, the 1-h pad test and uroflowmetry were performed with prolapse reduction. Primary outcome was postoperative de novo UI. Median follow-up was 31 months (range 12-48 months). Of the 206 patients, 45 (21.8 %) had evidence of occult SUI preoperatively, 62 (30.1 %) exhibited de novo UI postoperatively, and only 13 (6.3 %) opted MUSs. Patients with occult SUI experienced higher de novo UI rate (53.3 vs. 23.6 %; P = 0.000). The OSUI and concomitant hysterectomy were identified as independent risk factors related to de novo UI (P = 0.000, P = 0.044). We performed receiver operating characteristic (ROC) curve analysis to evaluate the value of preoperative 1-h pad test. The area under ROC curve was 0.816 ± 0.085 (95 % CI 0.649-0.983); the cutoff value was 1.9 g (sensitivity 80.0 %, specificity 83.9 %). The preoperative 1-h pad test with prolapse reduction is feasible for screening occult SUI, and more than 1.9 g may be a practical indicator of a postoperative subsequent MUS.

Trends in management of pelvic organ prolapse among female Medicare beneficiaries

In the last decade, many new surgical treatments have been developed to achieve less-invasive approaches to prolapse management. However, limited data exist on how the patterns of care for women with pelvic organ prolapse (POP) may have changed over the last decade, and whether mesh implantation techniques have influenced the type of specific compartment repair performed. We used a national data set to analyze the temporal trends in patterns of care for women with POP. Data were obtained from Public Use Files from the Centers for Medicare and Medicaid Services for a 5% random sample of national beneficiaries with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of POP from 1999 through 2009. Current Procedural Terminology, 4th Edition and International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes were used to evaluate nonsurgical and surgical management trends for this cohort. Types of surgery were categorized by prolapse compartment and combinations of repairs. After 2005, when applicable codes became available, mesh or graft repairs were also analyzed. Over the study time period, the number of women with adiagnosis of POP in any 1 year in our 5% sample of Medicare beneficiaries remained relatively stable (range, 21,245-23,268 per year). Rates of pessary insertion were also consistent at 11-13% over the study period. Of the women with a prolapse diagnosis, 14-15% underwent surgical repair, and there was little change over time in surgical management patterns based on compartment. Most commonly, multiple compartments were repaired simultaneously. There was a rapid increase in mesh use such that in 2009, 41% of all women who underwent surgery (5.8% of the total cohort) had mesh or graft inserted in their repair. Hysterectomy rates for prolapse decreased over time. Rates of vault suspension at the time of hysterectomy for prolapse were low; however, they showed a relative increase over time (22% in 1999 to 26% in 2009). Patterns and rates of prolapse repairs remained relatively unchanged from 1999 through 2009, with an exception ofa rapid rise in mesh use. These data suggest that the majority ofmesh techniques were used for augmentation purposes only, butdid not result in an increase in apical repairs performed in theUnited States. There remains a disappointingly low rate of vault suspension repairs concomitantly at time of hysterectomy for POP.

Effects of a prolonged, 72 hours, interval between mifepristone and gemeprost in second trimester termination of pregnancy: a retrospective analysis

Objective: To evaluate if the 72 hours interval between mifepristone and gemeprost has a similar efficacy compared to the 48 hours interval for second trimester termination of pregnancyStudy Design: Two-hundred and fifteen consecutive pregnant women, admitted to our hospital, for second trimester TOP, were included in this retrospective analysis. Standard protocol was followed for all patients. On the first day of the procedure oral mifepristone 200 mg was administered. After 72 (group A, n = 78) or 48 hours (group B, n = 113) women were admitted for administration of gemeprost 1 mg pessary as per protocol. The induction to abortion time was defined as the interval between the insertion of the first gemeprost pessary and the expulsion of the fetus.Results: There are no significant differences in the number of pessaries in the two groups. The induction to abortion interval was longer in group A than in group B. Twenty-one women required surgical evacuation of the uterus for retained placenta or incomplete abortion without difference between groups.Conclusion: A 48-hours interval between mifepristone and gemeprost leads to better results than a 72-hours interval, with a shorter abortion length and represents the elective method for second trimester TOP.

PFM.36 Arabin Pessary to Prevent Spontaneous Preterm Birth: Experience of a Specialist Preterm Labour Clinic

BackgroundArabin pessary remains a controversial but potential candidate to prevent sPTB in high risk asymptomatic patients. One large randomised controlled trial has promised hope, demonstrating staggering results that, as yet,...

Repeatability of superovulatory response to successive FSH treatments in Merino sheep

The efficiency of a multiple ovulation and embryo transfer program depends on the recovery of a large number of viable embryos per donor ewe at each successive superovulatory treatment. Embryo production, however, is characterized by high individual variability in the ovarian response to hormonal treatment. This study evaluated the repeatability of ovarian response and embryo recovery following three successive superovulatory treatments in 10 four-year-old Merino ewes over a short period of time. Oestrus was synchronized using an intravaginal progesterone pessary inserted on Day 0 and removed on Day 14. FSH was administered to induce superovulation in declining doses twice daily over 3 days as 2(18+14+8)=80mg total commencing on Day 12 after pessary insertion. A dose of 200IU eCG was administered at pessary removal. Vasectomized rams were used for heat detection and laparoscopic AI was performed 12h after oestrus detection. Surgical embryo recovery was performed at Day 8 after pessary removal, following which prostaglandin was administered and the next superovulatory procedures began 5 days later giving a 27-day interval between embryo recoveries. Ovulation rates (mean±SEM) for the three successive superovulatory treatments were 13.8±2.2, 12.1±2.2 and 12.0±2.2 (NS); and total embryos recovered were 8.3±1.4, 6.3±1.4 and 3.9±1.4 (P=0.06), respectively. Consequently, the embryo recovery rates declined from 66.1±7.5% for the first recovery to 41.4±7.5 and 34.5±7.5% for the second and third recoveries (P=0.04). The repeatability was r=0.84 (P<0.05) for ovulation rate, r=0.13 (NS) for total number of embryos and r=0.09 (NS) for number of grade 1 and 2 embryos. The study showed that an average of 16.3±2.6 grades 1 and 2 embryos per donor ewe could be recovered over a period of 2.5 months. The high repeatability of ovarian response to successive superovulatory treatments would have to be associated with a high level of repeatability for the number of transferable embryos recovered for it to be used as a criterion for selecting donors on the basis of their response to the first hormonal treatment.

The Impact of Pessary Use on Bowel Symptoms

The literature states that patients with pelvic organ prolapse have a higher prevalence of bothersome bowel symptoms and that surgical correction of prolapse may improve bowel function. There is limited knowledge regarding the impact of pessary use on bowel function in patients with prolapse. The aim of this study was to evaluate if there is a change in bowel symptoms in patients with prolapse treated with a vaginal pessary. Women who presented for pessary insertion completed the validated questionnaires on the bowel symptom severity and on the effect of bowel symptoms on the quality of life at baseline and again at 12 months of continuous pessary use. Inferential statistics comprised Student t test for evaluating differences in continuous Gaussian data between groups and paired t tests were used to evaluate differences among subjects between the baseline and 12 months of use. One hundred four women participated in the original study, and 43 had complete data for analysis. Women who completed 12 months of pessary use reported significant improvements in both bowel-related symptoms and bowel-related quality of life (95% confidence interval of the difference 1.6-11.4 and 2.0-14.0, respectively). Patients who completed the 12-month follow-up were significantly older and more likely to have stage 3 or 4 prolapse than noncompleters, but there were no differences in body mass index, race, history of prior prolapse surgery, or menopause status. In women with prolapse, the use of a pessary is associated with a decrease in complaints related to bowel symptoms.

A retained Pessary in a 65 year old woman: Case Report

Introduction: Vaginal pessaries are being used as a treatment of uterovaginal prolapse since a long time but forgotten pessaries may cause many complications. They are being used in cases of uterovaginal prolapse if patients are not fit for surgery or refuses for surgery. Case report: Our patient was a 65 year old woman who had pessary insertion 30 years back but luckily she didn’t have any serious complication. Instead her presentation was very unusual. Her pessary was covered on lateral sides by the vaginal epithelium like a loop, which was cut by cautery and the pessary was removed and patient finally underwent vaginal hysterectomy for third degree prolapse. Discussion: Vaginal pessary is a very simple and easy mode of treatment of pelvic organ prolapse and patients are satisfied of their symptoms by it but it can lead to severe complications if not changed in time or forgotten for long time. Before insertion of pessary, patient should be educated about its cleanliness and frequency of changing and should always be called for routine check- up.

A prospective study of pessary treatment for pelvic organ prolapse and health-related quality-of-life

To explore the effects of pessary use on symptomatic improvement and quality-of-life (QOL) in women with pelvic organ prolapse (POP). For this prospective cohort study, 79 patients with symptomatic POP were evaluated for pessary insertion between October 2011 and February 2013. After 3 and 6 months of consistent pessary use, quality of life was assessed with the Chinese version of Short-Form 12-Item Health Survey (SF-12) and pelvic floor impact questionnaire short form (PFIQ-7). Their average age was (66±9) years, average parity (2.4±1.1) and average duration of POP (68±14) months. Among them, 63 (79.7%) continued pessary use at 3 months and 46 (58.2%) at 6 months. The reasons for dropout were inappropriate size, discomfort and urinary retention. Compared with baseline findings, SF-12 and PFIQ-7 demonstrated significant improvement in patient QOL at 3 months and 6 months. Pessary use results in significant changes of QOL for POP patients. And it is a viable noninvasive treatment for pelvic organ prolapse.

Correction of anterior rectal wall prolapses after insertion of a vaginal pessary

Rectoceles are frequently found in patients with intractable evacuatory disorders. Typically, the patients complain of difficulties in evacuation, incomplete evacuation, and sometimes, assisted digitation to aid defecation, fecal incontinence, ‘‘constipation’’, feeling of a mass in the pelvis, pelvic pain and pain on intercourse. Occult rectal prolapse has been found in 33 % of patients with rectoceles and defecatory dysfunction [1]. In 2008, Abendstein et al. [2] performed a three-level repair in patients with ‘‘obstructive defecation’’: posterior sling for repair of the uterosacral ligaments, repair of the rectovaginal fascia and where relevant, repair of the perineal body. He reported normalization of defecation in 45 (94 %) of 48 patients. Of the 27 patients with fecal incontinence, 18 (66 %) reported cure, 5 (19 %) > 50 % improvement and 4, no change. Postoperative proctograms showed resolution of the rectal intussusception in 89 and 94 % reported completely normal defecation after surgery. Abendstein explained cure of the prolapse by reference to Baden Walker’s tent theory [3]: laxity of the ligaments/ fascial structures supporting the vaginal apex/anterior rectal wall allowed the anterior rectal wall to prolapse inwards, resulting in anterior rectal wall intussusception. While Abendstein attributed the prolapse mainly to the uterosacral ligaments (USL), in our opinion, simultaneous repair of all 3 supporting layers, USL (level 1), rectovaginal fascia (level 2) and perineal body (level 3) was the key to his success, as it is explained by the musculo-elastic theory [4]. We inserted a 3 9 6 cm cylindrical Pro Dry pessary (Innocept, Gladbeck, Germany), designed to support the vaginal apex, in a 63-year-old multiparous patient with 3 vaginal deliveries who presented with constipation associated with 1st degree uterine prolapse, 2nd degree rectocele and anterior rectal wall intussusception. Symptoms improved dramatically after pessary insertion. The patient was tested by transperineal ultrasound with a 3.5 MHz curvilinear probe (Bruel & Kjaer Medical, Peabody MA, USA). On testing with transperineal ultrasound, anterior rectal wall intussusception was seen at rest (Fig. 1). After insertion of a pessary, on straining, the pessary is seen to elevate the posterior vaginal fornix with ‘‘stretching’’ up of the intussusceptions (Fig. 1). The ‘‘tent’’ analogy describes how a pessary can restore apical vaginal prolapsed and rectal intussusception. If a tent is not tightly stretched, its apex and walls can prolapse inwards. The 6 9 3 cm ProDry pessary is pushed backwards into the posterior fornix of vagina pushing back the prolapsed apex and simultaneously with it, the attached and prolapsed anterior wall of rectum. The ProDry pessary mimicked the effect of stretching the vaginal apex upwards with a posterior sling [5]. From an anatomical perspective, the close attachment of rectum to the upper part of the posterior vaginal wall and the suspensory USL means that if the ligaments are loose, both rectum and apex may prolapse simultaneously, leading sometimes to anterior rectal wall intussusception. We have shown previously that a firm uterosacral ligament is important in the mechanics of defecation, as it anchors the downward vector which opens out the anorectum [6], which in turn decreases the internal A. Gunnemann Department of Urology, Klinikum Lippe, Detmold, Germany e-mail: alfons.gunnemann@klinikum-lippe.de

PL.44 Repeat Use of Dinoprostone Pessary after Failed Induction of Labour

IntroductionThere is no guideline advising on the management of women in whom induction of labour with first dinoprostone pessary has failed. Repeat cervical ripening with a second pessary is a...

Obstructive uropathy due to prolapsed lower ureters and bladder in patients with severe procidentia: A report of two cases

INTRODUCTIONPelvic organ prolape is not uncommon in multi-parous or elderly women. It is one of the rare but important causes of obstructive uropathy. Herein, we report two cases of severe procidentia that were referred with obstructive uropathy due to prolapsed bladder and ureters. PRESENTATION OF CASEThe first case was a 78-year-old woman, with severe pelvic organ prolape and secondary bilateral hydroureteronephrosis and post-renal failure. She was treated successfully by bilateral nephrostomy insertion and then pessary insertion. The second case was a 75-year-old woman who referred with the same presentation, but treated surgically with burch colposuspention and synchronous bilateral ureteral stent insertion. DISCUSSIONPelvic organ prolapse is not uncommon in old women. In addition to physical problems of procidentia, it may cause acute renal failure (ARF), chronic renal failure (CRF), and finally end stage renal disease (ESRD) if undiagnosed. CONCLUSIONIn every aged female case with obstructive uropathy and/or bilateral hydroureteronephrosis with unknown causes, gynecologic examination should be performed for early detection of possible pelvic organ prolapse. Appropriate management is necessary to prevent renal failure from uterine prolapse (UP).

Arabin cerclage pessary in the management of cervical insufficiency

Objective: To evaluate the use of Arabin cerclage pessary in the management of cervical insufficiency. Methods: The pregnancy outcome of 20 women carrying singleton pregnancy referred for suspected cervical insufficiency and chose Arabin cerclage pessary for treatment from 2009–2011 were reviewed. Pregnancy outcome were analysed according to presence of risk factors, amniotic fluid sludge, cervical length and gestation at pessary insertion. Results: At presentation, mean cervical length was 1.17 cm (range 0–2.33 cm), mean gestation at pessary insertion and delivery was 20.6 (12.9–26.1) weeks and 32.1 (14.7–40.1) weeks, respectively, and mean prolongation of pregnancy was 11.5 (0.5–25.2) weeks. Overall, 5 (25%) had fetal loss between 14.7–23.1 weeks, while 3 (15%) and 12 (60%) delivered before and after 34 weeks gestation, respectively with no perinatal mortality. Compared with women with cervical length <1.5 cm, all those with cervical length ≥1.5 cm had pregnancy prolonged for ≥49 days (100 vs. 54% p = 0.032) and 86% delivered beyond 34 weeks (86 vs. 46% p = 0.085). Conclusions: Arabin cerclage pessary appears to be optimal for treating women at high risk of cervical insufficiency with a cervical length of 1.5–2.5 cm, while it is an acceptable option for high risk women with cervical length <1.5 cm.

Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial

Most previous studies of the use of cervical pessaries were either retrospective or case controlled and their results showed that this intervention might be a preventive strategy for women at risk of preterm birth; no randomised controlled trials have been undertaken. We therefore undertook a randomised, controlled trial to investigate whether the insertion of a cervical pessary in women with a short cervix identified by use of routine transvaginal scanning at 20-23 weeks of gestation reduces the rate of early preterm delivery. The Pesario Cervical para Evitar Prematuridad (PECEP) trial was undertaken in five hospitals in Spain. Pregnant women (aged 18-43 years) with a cervical length of 25 mm or less were randomly assigned according to a computer-generated allocation sequence by use of central telephone in a 1:1 ratio to the cervical pessary or expectant management (without a cervical pessary) group. Because of the nature of the intervention, this study was not masked. The primary outcome was spontaneous delivery before 34 weeks of gestation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00706264. 385 pregnant women with a short cervix were assigned to the pessary (n=192) and expectant management groups (n=193), and 190 were analysed in each group. Spontaneous delivery before 34 weeks of gestation was significantly less frequent in the pessary group than in the expectant management group (12 [6%] vs 51 [27%], odds ratio 0·18, 95% CI 0·08-0·37; p<0·0001). No serious adverse effects associated with the use of a cervical pessary were reported. Cervical pessary use could prevent preterm birth in a population of appropriately selected at-risk women previously screened for cervical length assessment at the midtrimester scan. Instituto Carlos III.