Pessary Treatment Research Articles

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.

We investigated the effectiveness and cost-effectiveness of pessary treatment compared with pelvic floor muscle training (PFMT) in women with pelvic organ prolapse over a 2-year period. Randomized controlled trial with women (≥55 y) with symptomatic pelvic organ prolapse, identified by screening. Participants were recruited from 20 primary care practices (October 2009-December 2012). Primary outcome was the difference in change of pelvic floor symptoms (PFDI-20 score) between groups over 24 months. Secondary outcomes included prolapse, urinary, and anorectal symptoms; quality of life; costs; sexual functioning; prolapse stage; pelvic floor muscle function; and participants' perceived symptom improvement. There was a nonsignificant difference in the primary outcome between pessary treatment (n = 82) and PFMT (n = 80) with a mean difference of -3.7 points (95% CI, -12.8 to 5.3; P = 0.42) in favor of pessary treatment. A significantly greater improvement in the prolapse symptom score was, however, seen with pessary treatment (mean difference -3.2 points [95% CI, -6.3 to -0.0; P = 0.05]). Direct medical costs over the 2-year study were $309 and $437 per person for pessary treatment and PFMT, respectively. In older women with symptomatic prolapse, there was no significant difference between pessary treatment and PFMT in reducing pelvic floor symptoms, but specific prolapse-related symptoms did improve more with pessary treatment. Pessary treatment was preferable in the cost-effectiveness analysis. When counseling women for prolapse treatment it should, however, be taken into account that pessary fitting fails in a considerable portion of women and that pessary treatment was associated with more side effects compared with PFMT.

Symptomatic pelvic organ prolapse: Experience at a tertiary urogynaecology clinic

Background. Pelvic organ prolapse (POP) is a common reason for gynaecological consultation, especially in the elderly. Associated symptoms have been shown to negatively affect bladder, bowel and sexual function, as well as general quality of life. Treatment options include either surgical repair with mesh or native tissue, or conservative management with vaginal pessaries. There is a lack of data regarding POP in South African (SA) women. Objectives. To determine the demographic characteristics in patients presenting with symptomatic POP to a tertiary urogynaecology clinic, and to compare patients who opt for surgical treatment with those who request vaginal pessary insertion. Methods. The study was conducted at the urogynaecology clinic at Steve Biko Academic Hospital, Pretoria, SA. Demographic information was recorded after a detailed history, physical examination and completion of a self-administered symptom questionnaire. Results. A total of 305 patients were included in this study. The mean age was 62 (range 24 - 96) years and the mean vaginal parity was 3.7 (range 0 - 13); 147 patients opted for surgical intervention and 158 for pessary treatment. Cystocoele was the most common type of prolapse found on clinical examination. One-quarter of patients were sexually active (25.5%, n=242). Awareness and visualisation or feeling of a lump was the most common symptom reported. Age (p=0.004) and mean vaginal parity (p=0.003) were statistically significant in the pessary group. Finding of a cystocoele was significantly greater in patients who opted for pessary insertion (p=0.005). Conclusion. Patients who opt for vaginal pessary insertion are older and more vaginally parous than patients who opt for surgical intervention, and cystocoele was statistically more significant in women opting for pessary insertion.

Predictors of unsuccessful pessary fitting in women with prolapse: a cross-sectional study in general practice

Introduction and hypothesisPelvic 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.MethodsA 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.ResultsIn 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]).ConclusionsPessary 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.

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

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. 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. 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. 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.

A nationwide survey concerning practices in pessary use for pelvic organ prolapse in The Netherlands: identifying needs for further research.

Introduction and hypothesisTo identify practice variation in management of patients with a vaginal pessary for pelvic organ prolapse (POP).MethodsA nationwide survey was sent to all Dutch gynecologists with a special interest in urogynecology.ResultsThe response rate was 59 %. Of the respondents, 13 % had a written protocol for pessary treatment in their department. Pessary treatment was proposed by 69 % of respondents as a treatment option. Counseling about side effects varied. All respondents provided information concerning the possibility of serious vaginal discharge. Concerning this side effect, 15 % of the respondents stated that it occurs in 5 – 20 % of patients, 27 % that it occurs in 20 – 40 % of patients, and 57 % that it occurs in more than 40 % of patients. Another item concerned counseling for the likelihood of vaginal blood loss. All respondents provided information concerning the possibility of vaginal blood loss. Concerning this side effect, 53 % of the respondents stated that it occurs in 5 – 20 % of patients, 33 % that it occurs in 20 – 40 %, and 14 % that it occurs in more than 40 % of patients. Follow-up after initial placement was done by 69 % of the respondents at 2 – 6 weeks, by 2 % at 8 weeks, and by 29 % at 12 weeks or more. Most (98 %) of the respondents extended the interval between visits when the patient had no complaints, and 96 % of the respondents reported that they routinely instruct patients about self-management.ConclusionsPessaries are suggested as a treatment option by a majority of gynecologists, but practice varies widely. We consider that the variation in practice is due to a lack of available protocols and lack of evidence.

Cost utility of the treatment of stress urinary incontinence.

We sought to investigate the cost utility of nonsurgical versus surgical treatments for stress urinary incontinence (SUI). A decision analysis model was created to compare nonsurgical and surgical treatment options for women with SUI. Decision paths included conservative management, pelvic floor physical therapy (pelvic floor muscle training [PFMT]), PFMT with electrical stimulation, incontinence pessary, and surgical treatment. A Markov model cohort analysis was performed with a cycle length of 1 year starting at age 45 years with a lifetime horizon. Probabilities, success rates, and utilities were obtained from the literature when available or by expert opinion. Cost-utility analysis was performed using US recommendations from a societal perspective. Cost data were obtained from Medicare reimbursement in 2012 US dollars. Incontinence pessary was the most cost-effective treatment option with a cost of $11,411 for 18.9 quality-adjusted life years. At a willingness to pay (WTP) threshold of $50,000, incontinence pessary remained the most cost-effective treatment option. At a WTP threshold of $60,000, surgery became the most cost-effective treatment option. The PFMT and PFMT with electrical stimulation were dominated at any WTP threshold. Surgical correction is likely the most cost-effective treatment option for young healthy women with SUI. Results are driven by the high success rate of minimally invasive slings. More studies are needed to define utility values for heath states experienced by women with SUI. This will enhance our ability to develop more accurate cost-utility models and offer the best treatment for women affected by incontinence.

Procidentia in pregnancy: a systematic review and recommendations for practice.

Pelvic organ prolapse (POP) in pregnancy is a rare condition with decreasing incidence and improved management and outcome world-widerecently. Systematic review of the literature for cases of POP in pregnancy published since 1990 was carried out to identify common factors in presentation, management and outcomes. One case from our own practice was added to the analysis. An extensive search of the Pubmed/Medline, Scopus and Google Scholar databases was performed to identify all cases of POP in pregnancy since 1990. Published case reports of POP in pregnancy were reviewed and summarized in tables to find similarities in history, course, management and outcome of the pregnancies. Of the 43 cases and one case series, 41 case studies were eligible for analysis. Two types of POP in pregnancy were identified: preexisting is less common (14 vs 27 cases), often resolves during pregnancy (5 out of 14) and always recurs after delivery (14 out of 14); acute onset of POP in pregnancy rarely resolves in pregnancy (2 out of 27), but often resolves after delivery (18 out of 27). Most patients were managed with bed rest (20 out of 41), pessary (15 out of 41), manual reduction (6 out of 41) and local treatment (6 out of 41). The most common complications reported include preterm labour (14 out of 41), cervical ulcerations (9 out of 41), infection (3 out of 41) and obstructed labour (4 out of 41). About a half of the women delivered vaginally (22 out of 41), caesarean section due to prolapse was required in 15 cases. Two distinct entities were identified based on similarities regarding onset, course and outcome of POP in pregnancy. Concise recommendations for practice were derived from the analysis of case studies published since 1990.

Economic analysis of use of pessary to prevent preterm birth in women with multiple pregnancy (ProTWIN trial).

To assess the cost-effectiveness of a cervical pessary to prevent preterm delivery in women with a multiple pregnancy. The study design comprised an economic analysis of data from a randomized clinical trial evaluating cervical pessaries (ProTWIN). Women with a multiple pregnancy were included and an economic evaluation was performed from a societal perspective. Costs were estimated between the time of randomization and 6 weeks postpartum. The prespecified subgroup of women with a cervical length (CL) < 25(th) centile (< 38 mm) was analyzed separately. The primary endpoint was poor perinatal outcome occurring up to 6 weeks postpartum. Direct medical costs and health outcomes were estimated and incremental cost-effectiveness ratios for costs to prevent one poor outcome were calculated. Mean costs in the pessary group (n = 401) were € 21,783 vs € 21,877 in the group in which no pessary was used (n = 407) (difference, -€ 94; 95% CI, -€ 5975 to € 5609). In the prespecified subgroup of women with a CL < 38 mm we demonstrated a significant reduction in poor perinatal outcome (12% vs 29%; RR, 0.40; 95% CI, 0.19-0.83). Mean costs in the pessary group (n = 78) were € 25,141 vs € 30,577 in the no-pessary group (n = 55) (difference, -€ 5436 (95% CI, -€ 11,001 to € 1456). In women with a CL < 38 mm, pessary treatment was the dominant strategy (more effective and less costly) with a probability of 94%. Cervical pessaries in women with a multiple pregnancy involve costs comparable to those in women without pessary treatment. However, in women with a CL < 38 mm, treatment with a cervical pessary appears to be highly cost-effective.

Pelvic floor muscle training versus watchful waiting or pessary treatment for pelvic organ prolapse (POPPS): Design and participant baseline characteristics of two parallel pragmatic randomized controlled trials in primary care

Pelvic floor muscle training (PFMT) and pessaries are commonly used in the conservative treatment of pelvic organ prolapse (POP). Because there is a lack of evidence regarding the optimal choice between these two interventions, we designed the “Pelvic Organ prolapse in primary care: effects of Pelvic floor muscle training and Pessary treatment Study” (POPPS). POPPS consists of two parallel open label randomized controlled trials performed in primary care, in women aged ≥55 years, recruited through a postal questionnaire. In POPPS trial 1, women with mild POP receive either PFMT or watchful waiting. In POPPS trial 2, women with advanced POP receive either PFMT or pessary treatment. Patient recruitment started in 2009 and was finished in December 2012. Primary outcome of both POPPS trials is improvement in POP-related symptoms. Secondary outcomes are quality of life, sexual function, POP-Q stage, pelvic floor muscle function, post-void residual volume, patients’ perception of improvement, and costs. All outcomes are measured 3, 12, and 24 months after the start of treatment. Cost-effectiveness will be calculated based on societal costs, using the PFDI-20 and the EQ-5D as outcomes. In this paper the POPPS design, the encountered challenges and our solutions, and participant baseline characteristics are presented. For both trials the target numbers of patients in each treatment group are achieved, giving this study sufficient power to lead to promising results.

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.

Long-term outcomes of the high vaginal uterosacral ligament suspension in treatment of the severe pelvic organ prolapse

To investigate the long-term objective and subjective outcomes of the transvaginal high uterosacral ligament suspension(HUS) in treatment of severe pelvic organ prolapse (POP) . From Jun. 2003 to Mar.2013, 136 patients with severe POP quantitation (POP-Q) stage III-IV underwent transvaginal hysterectomy and HUS operation in the First Affiliated Hospital, General Hospital of People's Liberation Army. And 125 patients (91.9%, 125/136) were followed up at a mean of 5.4 years (range of 4.2-9.2 years) . Anterior colporrhaphy (79.2%, 99/125), posterior colporrhaphy (64.0%, 80/125), the perineorrhaphy (96.0%, 120/125) and tension-free suburethral slings (37.6%, 47/125) were performed concurrently, in which 53 (65%, 53/81) patients with severe cystocele and 5 patients (15%, 5/34) with rectocele were augmented with mesh, respectively. Concurrent operation and complications were studied. The objective success of the operation was defined as the leading vaginal edge above hymen.Subjective results were obtained quality-of-life questionnaires, including pelvic floor distress inventory short form (PFDI-20) and pelvic floor impact questionnaire short form (PFIQ-7). The mean interval of following up was (5.4 ± 1.2) years.Four patients presented mild anterior vaginal wall prolapse, and the recurrence rate were 3.2% (4/125), but no reoperation and pessary treatment were needed. Therefore, the subjective and objective satisfaction rate was 94.4% (118/125) and 96.8% (121/125). The mean scores of PFDI-20 and PFIQ-7 at 5 years after the operations were 8, 7, significantly lower than 62, 64 (P < 0.01). There were 3 cases of ureter obstruction. Tension-free vaginal tape was performed on 47 cases with stress urinary incontinence (SUI) as indicated. The symptom of 2 patients was not improved significantly after the operation, but one was improved after 6 months. The rate of denovo SUI was in 2(1.6%, 2/125) patients, but no further treatment was needed. The transvaginal HUS was then conformed to be a safe, minimal traumatic, highly successful and durable procedure for severe POP, so it is worthy of being popularized for clinical application.

Goal attainment after treatment in patients with symptomatic pelvic organ prolapse

The objectives of this study were to: (1) assess differences in goal attainment of self-described goals after treatment of symptomatic pelvic organ prolapse (POP) for women who chose surgery compared to women who chose pessary; and (2) compare patient global improvement between groups. Women who had symptomatic stage ≥II prolapse presenting for care of POP to the urogynecology clinic at the University of New Mexico were recruited. Patients listed up to 3 goals they had for their treatment. In addition, they completed the short forms of the Pelvic Floor Distress Inventory (PFDI-20), the POP/Urinary Incontinence Sexual Questionnaire, and the Body Image Scale. Goals listed by patients were then categorized into 10 categories. Each of the listed goals was categorized based on a consensus of 5 providers. At 3 months' follow-up patients listed if they had met their self-described goals on a scale of 0-10 and also answered the Patient Global Improvement Index (PGI-I). There were no significant differences between the 2 groups' baseline characteristics. Surgery patients ranked their goal attainment higher than pessary patients for all the 3 goals listed. Similarly, PGI-I scores were also higher in the surgical (2.4 ± 1.1) than the pessary (1.93 ± 0.8) treatment groups (P < .04). Patients in the surgery group also had better symptom improvement as measured by the PFDI-20 (P < .02). Patients who chose surgery had better global improvement and met their goals better compared to patients who chose pessary.

The cube pessary: an underestimated treatment option for pelvic organ prolapse? Subjective 1-year outcomes

Pelvic organ prolapse (POP) is a common condition. The use of pessaries for conservative management of POP is widespread. However, there are little data on the use of cube pessaries. The aim of our study was to evaluate whether self-therapy with the use of vaginal cube pessaries in women with POP can be a well-tolerated, first-line treatment. In a prospective case series, 87 women who suffered from symptomatic POP, stages II-IV, were instructed in self-treatment with a vaginal cube pessary. Differences were analyzed using Wilcoxon's rank sum test or Fisher's exact test. A pessary could be fitted in 84/87 patients (96.6%); 6 women were lost to follow-up. The remaining 78 patients (92.9%, median age 60 years) completed the study. Sixteen women (20.5%) chose not to continue with the pessary treatment. For these patients, general well-being decreased from a median numeric rating score (NRS) of 4.5 (3-6) to 2.0 (1-3, p < 0.001). In those who continued treatment, general well-being increased from a median NRS of 3.0 (2-5) to 8.0 (7-10, p < 0.001) after 1 year of use. The majority of patients (53) in the present study rated pessary self-care use as "very easy" or "easy" (85.5%). The Patient Global Impression of Improvement (PGI-I) was 2.0 (1-3) at follow-up examination. There were no complications or adverse effects of pessary use. Conservative self-treatment with vaginal cube pessaries might be a feasible treatment option for women who suffer from POP.

2146 VAGINAL SUPPORT PESSARIES-HOW LONG IS TO LONG?

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Pelvic Prolapse1 Apr 20132146 VAGINAL SUPPORT PESSARIES-HOW LONG IS TO LONG? Ronen Gold Ronen GoldRonen Gold Tel Aviv, Israel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2055AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pelvic organ prolapse is common and as the population ages it is seen more frequently. Vaginal support pessaries offer an important option for relief. In the absence of a definitive evidence base surveillance practices, standards of appropriate routine intervals for follow up vary and based on expert opinion. The aim of this study was to evaluate 3 different time intervals of pessary follow up visits. METHODS A retrospective case identification study, at a women's health clinic of Israel's largest HMO. All women fitted with ring pessary between 2002-2012 were identified. Data was obtained from electronic medical records. Patients were randomly assigned to 3 urogynecologists who treated all the patients. Patients were fitted with ring pessary and were scheduled for evaluation after 1 month. After that one of the urogynecologists scheduled all his patients for monthly follow up, the second every 2 months and the third every 3-4 months. Main outcome measures: length of use and complications of pessary use: bleeding, extrusion, vaginal discharge, incontinence, recurrent UTIs. RESULTS Of the 333 women fitted with a ring pessary, 275 were successfully using it at 1 month, 252 after 3 months, and 214 at the study end point. Table 1 summarizes patient's demographic data. There were no statistical differences between 3 groups. Table 2 summarized the length of use and pessaries complications.The 3 groups had similar rates of complications . CONCLUSIONS Ring pessary can offer an excellent solution for pelvic organ prolapse for most of the treated women after careful selection. 3-4 months interval between follow up visits is sufficient as shorter intervals doesn't offer any benefit. Table 1. demographic data One month F.U 2 MONTHS F.U 3-4 MONTHS F.U P Number 101 111 121 N.S⁎⁎⁎⁎ Age(y)⁎ 70.3 69.2 72.4 N.S Nu of deliveries(mean) 3.9 N.S Degree of prolapse ⁎⁎ N.S 2 77(76%) 81(73%) 96(79%) N.S 3 24(24%) 30(27%) 25(21%) N.S Previous prolapse operation 10(9.9%) 10(9.9%) 15(12.4%) N.S HRT use⁎⁎⁎ 5(4.9%) 5(4.9%) 7(5.8%) N.S ⁎ at the start of the study. ⁎⁎ According to Baden Walker halfway system. ⁎⁎⁎ prior to pessary treatment ⁎⁎⁎⁎ N.S=statisticaly not significant Table 2. 1 month F.U 2 months F.U 3 months F.U p Mean Length of use( y) 8.3y 8.7y 7.9y N.S discontinuation surgery 9(8.9%) 10(9%) 13(10.7%) N.S No Need 5(4.9%) 7(6.3%) 5(4.1%) N.S death 8(7.9%) 6(5.4%) 9(7.4%) N.S Patients preference 7(6.9%) 10(9%) 5(4.1%) N.S bleeding 8(7.9%) 8(7.2%) 12(9.9%) N.S discharge 7(6.9%) 9(8.1%) 11(9.1%) N.S erosions 2(1.9%) 2(1.8%) 2(1.6%) N.S Rec UTI 1(0.9%) 3(2.7%) 1(0.8%) N.S De novo incontinence 6(5.9%) 4( 3.6) 6(4.9%) N.S Worsening incontinence 4(3.9%) 6(5.4%) 4(3.3%) N.S Need to change pessary size Increased size 3(2.8%) 4(3.6%) 4(3.3%) N.S Deceased size 1(0.95%) 1(0.9%) 3(2.4%) N.S Lost for f.u 7(6.9%) 7(6.3%) 11(9.1%) N.S © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e879 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ronen Gold Tel Aviv, Israel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Vaginal pessaries for pelvic organ prolapse and urinary incontinence: a multiprofessional survey of practice

Vaginal pessaries may offer symptomatic improvement for women with pelvic organ prolapse (POP) or urinary incontinence (UI). This study aimed to investigate multidisciplinary perspectives on vaginal pessary use in clinical practice and to understand the service organisation of vaginal pessary care for women with these conditions. A pretested, anonymous survey was e-mailed to members of the Royal College of Obstetrics and Gynaecology, the Association for Continence Advice and the Association of Chartered Physiotherapists in Women's Health in the UK. A total of 678 respondents, from medical, nursing and physiotherapy professions, consented to survey participation and provided useable data (response rate 20.7 %). Doctors were significantly more likely to report involvement in pessary care than nurses or physiotherapists. Respondents were optimistic about the success of pessary treatment; however, a lower proportion reported using pessaries for UI than for prolapse. The majority of respondents used ring pessaries and shelf pessaries, most recipients were older women, and commonly an indication for fitting a pessary was that the woman was unfit for surgery. More than 15 % of respondents providing pessary care had not received training. Follow-up services for women with pessaries varied considerably. The variation in pessary care delivery and organisation requires further study in order to maximise efficiency and effectiveness. The development of nurse- or physiotherapist-led models of care may be appropriate, but the effectiveness of such models requires testing. Furthermore, to potentially improve outcomes of pessary care, a greater understanding of the availability, content and process of training may be warranted.

Pessary treatment for pelvic organ prolapse and health-related quality of life: a review

Pessaries have been used to treat women with pelvic organ prolapse (POP) since the beginning of recorded history. This review aims to assess the effect of pessary treatment on the disease-specific, health-related quality of life in women with pelvic organ prolapse. After a Medline search using the Mesh term ‘pessary’ and critical appraisal, 41 articles were selected and used in this review. Pessaries are widely used to treat pelvic organ prolapse. It is minimally invasive and appears to be safe. Although there is evidence that the use of pessaries in the treatment of pelvic organ prolapse is effective in alleviating symptoms and that patient satisfaction is high, the follow-up in many published papers is short, and the use of validated urogynaecological questionnaires is limited. Comparison with surgical treatment of pelvic organ prolapse is rare and not assessed in a randomised controlled trial.

Vaginal Evisceration During Pessary Fitting and Treatment With Immediate Colpocleisis

Complications from pessaries are rare and occur predominantly as a result of neglect and loss to follow-up. We report a case of vaginal evisceration at the time of pessary insertion, which was repaired with concomitant colpocleisis. An 82-year-old woman with stage IV pelvic organ prolapse (POP) presented for a routine pessary fitting, which resulted in vaginal evisceration and displacement of the pessary into the abdomen. She was treated successfully with immediate colpocleisis after transvaginal removal of the pessary and repair of the rupture site. Pessary insertion can result in vaginal evisceration. Both POP and vaginal rupture can be successfully treated with removal of the pessary, closure of the vaginal defect, and LeFort colpocleisis all in one session.

Continence Pessary Compared With Behavioral Therapy or Combined Therapy for Stress Incontinence

To compare the effectiveness of a continence pessary to evidence-based behavioral therapy for stress incontinence and to assess whether combined pessary and behavioral therapy is superior to single-modality therapy. This was a multisite, randomized clinical trial (Ambulatory Treatments for Leakage Associated with Stress Incontinence [ATLAS]) that randomly assigned 446 women with stress incontinence to pessary, behavioral therapy, or combined treatment. Primary outcome measures, at 3 months, were Patient Global Impression of Improvement and the stress incontinence subscale of the Pelvic Floor Distress Inventory. A priori, to be considered clinically superior, combination therapy had to be better than both single-modality therapies. Outcome measures were repeated at 6 and 12 months. Primary analyses used an intention-to-treat approach. At 3 months, scores from 40% of the pessary group and 49% of the behavioral group were "much better" or "very much better" on the Patient Global Impression of Improvement (P=.10). Compared with the pessary group, more women in the behavioral group reported having no bothersome incontinence symptoms (49% compared with 33%, P=.006) and treatment satisfaction (75% compared with 63%, P=.02). Combination therapy was significantly better than pessary as shown on the Patient Global Impression of Improvement (53%, P=.02) and Pelvic Floor Distress Inventory (44%, P=.05) but not better than behavioral therapy; it was therefore not superior to single-modality therapy. Group differences were not sustained to 12 months on any measure, and patient satisfaction remained above 50% for all treatment groups. Behavioral therapy resulted in greater patient satisfaction and fewer bothersome incontinence symptoms than pessary at 3 months, but differences did not persist to 12 months. Combination therapy was not superior to single-modality therapy. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00270998.

Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery and pessary treatment for pelvic organ prolapse

This study was undertaken to evaluate the responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women with pelvic organ prolapse undergoing surgical and nonsurgical management. The responsiveness of the prolapse, urinary and colorectal scales of the PFDI and PFIQ were assessed in 2 independent populations: (1) 42 women with stage II or greater prolapse enrolled in an ongoing multicenter randomized trial comparing 2 different pessaries (Pessary group) and (2) 64 women with stage III or greater prolapse who underwent vaginal reconstructive surgery (Surgery group). All subjects completed the PFDI and PFIQ at baseline and again either 3 months (Pessary group) or 6 months (Surgery group) after initiation of treatment. Responsiveness was assessed with standardized response mean (SRM), effect size (ES), and the paired t test. In the Pessary group, there was a significant improvement in the prolapse and urinary scales of the PFDI, with each demonstrating moderate responsiveness (prolapse: SRM 0.69, ES 0.68; urinary: SRM 0.57, ES: 0.50, P < .001 for each). The colorectal scale of the PFDI and each of the 3 scales of the PFIQ demonstrated no significant change in scores with pessary use. In the Surgery group, there was a significant improvement in the prolapse, urinary, and colorectal scales of both the PFDI and PFIQ (P < .01 for each). The prolapse and urinary scales of the PFDI demonstrated excellent responsiveness with SRM and ES 1.20 or greater for the prolapse scale and equal to1.05 for the urinary scales. The colorectal scale of the PFDI and the urinary and prolapse scales of the PFIQ demonstrated moderate responsiveness (SRM 0.61-0.70 and ES 0.56-0.60) after surgery. Subjects who had a recurrence of their prolapse develop after surgery (6%) had significantly less improvement in the prolapse scale of the PFDI than those who did not. After controlling for preoperative prolapse stage and baseline quality of life scores, subjects in the Surgery group had significantly greater improvement in each of the scales of the PFDI and the prolapse and urinary scales of the PFIQ than did the Pessary group (P < .05 for each). The PFDI and PFIQ are responsive to change in women undergoing surgical and nonsurgical treatment for pelvic organ prolapse. The PFDI is more responsive than the PFIQ.

A novel two-stage approach for the management of massive pelvic organ prolapse

SummaryA new two-stage surgical procedure to treat massive pelvic organ prolapse in elderly women is described. Four women in whom previous pessary treatment had failed (two of these had also tried and failed the double ring pessary) or was not possible due to poor pelvic muscle tone or enlarged vaginal introitus underwent manual reduction of prolapse, colpoperineorrhaphy and ring pessary insertion in the first stage followed by a vaginal hysterectomy with or without sacrospinous fixation 6 weeks later. All patients had a favourable outcome in terms of improvement of symptoms and satisfaction with the treatment.