Ring Pessary Research Articles

Factors associated with pessary fitting in women with symptomatic pelvic organ prolapse: A large prospective cohort study.

To identify factors associated with unsuccessful pessary fitting in a large cohort of patients with symptomatic pelvic organ prolapse (POP). This prospective observational study included 611 consecutive women with symptomatic POP in a tertiary-care hospital. Patients were initially fitted with a ring pessary with support. Those who failed were fitted with a Gellhorn pessary. A successful pessary fitting was defined as a patient who was fitted or refitted with a pessary and continued to use it 2 weeks later. Parametric and nonparametric tests were used for the data analysis. A total of 524 patients had successful pessary fittings (85.8% success rate). The success rate of the ring pessary with support was 57.9%, of the Gellhorn pessary was 69.1%. Stage IV prolapse (odds ratio [OR], 2.12), posterior compartment prolapse (OR, 1.92), genital hiatus (OR, 1.41), and vaginal introitus (OR, 1.40) were independent predictors of unsuccessful ring with support pessary fitting. Vaginal length (OR, 0.74/0.60 for ring with support/Gellhorn) and history of POP reconstructive surgery (OR, 2.50/2.58 for ring with support/Gellhorn) were independent predictors of both ring with support and Gellhorn pessary fitting. Stage IV prolapse, posterior compartment prolapse, large genital hiatus, and wide vaginal introitus were risk factors for unsuccessful fitting of ring pessary with support. Short vaginal length and a history of POP reconstructive surgery were risk factors for unsuccessful fitting of both pessaries.

Risk Factors for Dislodgment of Vaginal Pessaries in Women With Pelvic Organ Prolapse: A Cohort Study.

The aim of the study was to evaluate the associated factors associated with pessary dislodgment in women with advanced pelvic organ prolapse (POP). A cohort study with women (N = 98) with advanced POP who chose conservative treatment with ring pessary between December 2016 and 2018 identified by screening. Demographic data, history of POP, urinary, and/or bowel symptoms were collected. A medical visit was scheduled 3 and 6 months after pessary insertion to evaluate symptoms (vaginal discharge, bleeding, pain, discomfort, new-onset urinary, or fecal problems) and any pessary dislodgment. Two groups were created (women who were able to retain the pessary versus who were not able), and univariate and multivariate analysis were performed to look for risk factors for pessary dislodgment. Women who requested to have their pessaries removed during the 6-month follow-up were excluded. Ninety-three women included in the study, 78 successfully continued to use the pessary at 6 months, and 15 had pessary dislodgment (16.1%). Demographic characteristics were similar between the treatment group and the control group. After multivariate analysis, women who had their pessaries dislodged presented higher rates of previous surgery (odds ratio = 8.11; 95% confidence interval = 2.09-31.58; P = 0.003) with advanced Pelvic Organ Prolapse Quantification system staging (odds ratio, 13.41; confidence interval, 1.97-91.36; P = 0.008). The presence of advanced apical POP and previous POP surgery are risk factors for ring pessary dislodgment. This information should guide physicians for counseling patients before pessary insertion.

Predictors of successful ring pessary use in women with pelvic organ prolapse.

Pelvic organ prolapse (POP) is a common chronic health issue. Pessary rings are used for conservative management. To date, there is little evidence on objective anatomical findings as predictors of successful ring pessary management. To determine any association between history, clinical and four-dimensional translabial ultrasound (TLUS)/pelvic floor ultrasound examination and pessary success. From November 2013 to November 1015, all new patients presenting with symptomatic prolapse to a tertiary urogynaecological unit underwent an assessment including interview, clinical examination, that is, International Continence Society POPQ (pelvic organ prolapse quantification) and TLUS. Women with symptomatic prolapse were offered conservative management with a ring pessary. Those who agreed had a ring inserted that day. Successful trial of pessary use was defined as continued use for at least threemonths. Retrospective analysis of imaging data was performed blinded to other data. Statistical analysis was performed to assess the relationship between history, examination and imaging and pessary success. Of 525 patients seen during the inclusion period, 177 had symptomatic prolapse. One hundred and twenty-eight were offered a pessary, 89 accepted. Five had incomplete data, leaving 84. Forty- Two(50%) werestill using the pessary at athree-month follow-up. Predictors associated with failure included being pre-menopausal (P=0.031), a previous hysterectomy (P=0.051), increasing genital hiatus and perineal body (Gh+Pb) (P=0.013), posterior compartment prolapse(P=0.027) and a larger hiatal area on Valsalva on TLUS (P=0.049). Pre-menopausal status (P=0.003), increasing Gh+Pb (P=0.011) and previous hysterectomy (P=0.001) remained significant on multivariate analysis. A history of previous hysterectomy is a predictor of pessary failure as are Gh+Pbon Valsalvaand premenopausal status.

Is it safe and effective to maintain the vaginal pessary without removing it for 2consecutive years?

The study was aimed at evaluating the safety and efficacy of ring pessaries without support under continuous use without periodic removal or replacement for the treatment of advanced pelvic organ prolapse (POP) in women for 2consecutive years. This study was a prospective observational study. A total of 123 women were recruited in a tertiary hospital from January 2013 to January 2016. The primary objective was the percentage of patients maintaining the use of the pessary after 24months. The secondary objectives were the reasons for discontinuation and the adverse events in patients with successful fittings. A total of 115 patients (93.5%) had a successful fitting. Four patients died of non-pessary-related causes during the study and, one patient dropped out the follow-up so that finally, 110 patients were included in the efficacy analysis. Pessary use was maintained by 91.8% of the women at the end of the study. The adverse events rate was low (27.0%). The two main factors of interruption in the pessary use were: age (OR 0.93; 95% CI 0.87-0.99) and history of urinary urge incontinence (OR 0.33; 95% CI 0.11-0.96]). A high success rate and low adverse events rate were achieved in patients with advanced-stage POP with continuous pessary use for 24months, indicating that a ring pessary could also be used without periodic removal for at least the first 2years. This practice could reduce the number of control visits.

Multipurpose, Reusable, Female Contraceptive Device That Enhances the Effectiveness of Fertility Awareness Methods and Controls Stress Incontinence

Introduction: There is a significant deficiency in women’s reproductive health needs: Lack of options of non-hormonal contraceptive Fertility awareness method is the safest and yet it is rarely Women suffer from Stress Incontinence Objectives: To provide women with one device that can be used for 1) Contraception by stopping sperm from entering the cervix, 2) To enhance the effectiveness of Fertility Awareness Methods by accurately detecting ovulation day and 3) Control Stress Urinary Incontinence by supporting the bladder neck. Materials and Methods: We selected the FDA approved FemCap contraceptive device to determine its utility to fulfill the three basic reproductive health needs for women. The FemCap is a safe and effective, time tested, barrier contraceptive The FemCap can collect a large amount of fertile cervical mucous, that is not mixed with vaginal The use of currently available pessaries have significant limitations such as displacement, erosion or even ulceration and urethral The FemCap shows marked similarity to the ring pessary with support. The Rim of the FemCap is similar in shape and function to the ring of the pessary that supports the bladder neck. The outward flaring brim restores the anatomy of the urethra and the vagina. The bowl of the FemCap supports the cervix and prevents it from descending, which is like the supported pessary. Results: 1) The FemCap is a well-established barrier contraceptive device. 2) It is also has proven in pilot studies to enhance the effectiveness of fertility awareness methods and 3) control stress incontinence. Conclusion: It would be ideal and cost effective for women to acquire one multipurpose reusable device that can be used for contraception to enhance fertility awareness and to control stress incontinence.

Acceptance of ring pessary in pelvic organ prolapse

Aims: To evaluate the use of pessaries for women with Pelvic Organ Prolapse irrespectivve POP-Q stages.
 Method: This is retrospective study conducted at Paropakar maternity and Women’s hospital from mid April to mid December 2018 on 114 women with pelvic organ prolapse.
 Result: Total of 114 women with prolapse evaluated. Age of presentation ranged from 36 to 85 years. Twenty cases (17.6%) underwent prolapsed surgery and 71 cases (62.2%) had ring pessary.
 Conclusion: Overall acceptance of vaginal ring pessary is very high. It can be used in the majority of women with patient satisfaction and without noteworthy complication.

Neglected Pessary in Patient with Pelvic Organ Prolapse: A Case Report

Objective: To report the neglected pessary in a patient with pelvic organ prolapse. Pelvic organ prolapse (POP) is one of the most important medical challenges in women especially elderly. One of the conservative treatments of symptomatic POP is pessary placement. Case report: A 84-year-old woman, para 10 was referred to female pelvic floor clinic of an academic hospital for vaginal bleeding and neglected vaginal pessary. Vaginal examination in the pelvic floor clinic revealed an entrapped ring pessary in severely atrophic vaginal mucosa with purulent discharge. Conclusion: Although pessary is the first choice and one of the best conservative treatment for pelvic organ prolapse, it shouldn't be used for poor cooperative patient who cannot comply with regular follow-up visits which may cause harmful complications.

The Use of a Vaginal Pessary to Decide Whether a Mid Urethral Sling should be Added to Prolapse Surgery.

Women with pelvic organ prolapse are at risk for stress urinary incontinence after prolapse surgery. Combining pelvic organ prolapse repair with anti-incontinence surgery reduces the incontinence rate but leads to overtreatment. Performing only pelvic organ prolapse repair leads to under treatment. Is a vaginal ring pessary a useful tool when deciding whether a mid urethral sling should be added to prolapse surgery? We performed a retrospective cohort study in women with symptomatic pelvic organ prolapse but without bothersome stress urinary incontinence who underwent vaginal prolapse repair between January 1, 2008 and December 31, 2017. Preoperatively a pessary was inserted in all women to detect occult stress urinary incontinence. If the pessary revealed bothersome stress urinary incontinence, a concomitant mid urethral sling was proposed. The primary outcome at followup was de novo stress urinary incontinence. Included in study were 220 women. After pessary insertion 132 women (60%) remained continent, 20 (9%) reported nonbothersome stress urinary incontinence and 68 (31%) had bothersome stress urinary incontinence. The latter group was offered combined surgery. At followup bothersome stress urinary incontinence was present in 12 of the 132 women (9%) who had been continent preoperatively and in 7 of the 20 (35%) who had had nonbothersome stress urinary incontinence. In 132 women who were continent with the pessary a total of 11 mid urethral sling procedures would have been needed to prevent postoperative stress urinary incontinence in 1 (number needed to treat was 11). In the 20 women who had nonbothersome stress urinary incontinence only 3 mid urethral sling procedures would have been necessary (number needed to treat was 3). In women with symptomatic pelvic organ prolapse a pessary is a useful tool when deciding whether to add a mid urethral sling.

The effect of time interval of vaginal ring pessary replacement for pelvic organ prolapse on complications and patient satisfaction: A randomised controlled trial

ObjectivesLimited data are available on the effect of the time interval of vaginal ring pessary replacement for pelvic organ prolapse (POP). This study investigated the effect of different replacement intervals on complications and patient satisfaction. Study designA double-blinded, randomized controlled trial was conducted in a tertiary urogynecology center. Women with a vaginal ring pessary for POP (stage I to IV) were randomly allocated to two groups: 3-monthly or 6-monthly ring pessary replacement. All women were blinded to the replacement interval. Investigators were blinded during outcome assessment. Subjects were followed up for 6 months. Main outcome measuresThe primary outcomes were the complication rates and patient satisfaction scores at 6 months. Secondary outcomes were the change in patient-reported symptoms and staging of POP. ResultsOf 101 women were screened from June 2016 to November 2017, 60 were recruited and randomly allocated: 30 to the 3-monthly replacement group and 30 to the 6-monthly replacement group. The overall complication rate in the 6-monthly group was higher than that in the 3-monthly group at the third visit (9 [30%] vs. 3[10.3%]; OR 3.71; 95%CI 0.89–15.58), but the difference was not statistically significant (p = 0.061). There were no statistically significant differences between groups in patient satisfaction scores, other prolapse-related symptoms or staging of POP. ConclusionsWe provide evidence on the effect of replacement interval for a vaginal pessary on complications and patient satisfaction. A higher complication rate was found in the 6-monthly group than in the 3-monthly group, although the difference was not statistically significant. Patient satisfaction scores were similar in both groups.

Effectiveness of ring pessaries versus vaginal hysterectomy for advanced pelvic organ prolapse. A cohort study

This study aimed to evaluate the efficacy of the ring pessary compared with surgery as a primary treatment for advanced pelvic organ prolapse (POP) in non-hysterectomized, postmenopausal women. Our starting hypothesis was that the pessary is as effective as and less risky than surgery. This study was a prospective observational study, which recruited 171 women with symptomatic advanced POP in a tertiary hospital for 30 months. They were treated according their preference with either surgery [77/171 (45.0%)] or vaginal ring pessary without support [94/171 (55.0%)]. The primary outcomes included the discontinuation of pessary use and the incidence of recurrent prolapse throughout the study. Secondary outcomes included complications categorized according to Clavien-Dindo classification. Descriptive statistics were used for demographic data. The mean and standard deviation were calculated for continuous variables, and continuity correction tests, Mann-Whitney U tests, and Fisher's exact tests were used for categorical variables. There was successful use of a pessary in 84.4% (76/90) of cases, and 89.6% (69/77) of patients did not have prolapse recurrence in the surgical group (>POP-Q 2). In the pessary group, the adverse event rate was 31.6%, and all were Clavien-Dindo grade I. Thirty patients [30/77 (39.0%)] had complications in the surgery group: 14.3% were Clavien-Dindo grade I (11/77), 10.4% were grade II (8/77), and 14.3% were grade III (11/77). The pessary is effective and has mild adverse events in non-hysterectomized, postmenopausal women with advanced POP.

The negative predictive value of preoperative urodynamics for stress urinary incontinence following prolapse surgery.

There is no consensus for the evaluation of stress urinary incontinence (SUI) in patients planning pelvic organ prolapse (POP) surgery. We sought to determine the negative predictive value (NPV) of prolapse reduction during preoperative urodynamics (UDS) for postoperative SUI. We performed a retrospective study of 322 women with preoperative UDS and subsequent POP surgery. Abstracted data included demographics, prolapse stage, prior prolapse or incontinence surgery, preoperative SUI complaint, prolapse reduction method, and length of follow-up. Any woman who reported SUI symptoms within 6months from surgery was considered a diagnostic UDS failure. The NPV was calculated by dividing the number of patients who did not demonstrate SUI on UDS and had no postoperative SUI by the number of patients who did not demonstrate SUI on UDS. Patient characteristics (age, race, parity, prolapse stage, prior surgery, and length of follow-up) were similar among those who had urodynamic-proven SUI and those who did not. The NPV of preoperative UDS for postoperative SUI in patients undergoing any POP repair was 97.9.0% [95% confidence interval (CI) 92.7-99.7%]. The NPV remained high in the subset of patients who underwent an apical suspension-98.6% (95% CI 92.7-100.0%)-as well as those without a preoperative SUI complaint-98.6% (95% CI 92.3-100.0%). In most patients (72.9%), a ring pessary with support combined with intraprocedural manipulation allowed for reliable stress testing. Our study supports using preoperative UDS as a screening tool to avoid unnecessary concomitant continence procedures. Further studies are needed to individualize patient preoperative assessment and surgical counseling.

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

The aim of the study was (1) to evaluate continuation rates of vaginal ring pessary for pelvic organ prolapse (POP), and (2) to identify predictors for continued pessary use. This retrospective chart review study was conducted in a tertiary center. Women who had a ring with support pessary successfully fitted between January 2009 and December 2013 and had completed up to 3 years of follow-up care were included in the analysis. Demographic and obstetric data, body weight, pelvic organ prolapse stage, and associated symptoms were evaluated. All the women were followed until February 28, 2017, unless surgery to correct POP surgery was required, pessary use was discontinued, or the women died. A total of 289 women with symptomatic POP (stages II, III, and IV) were evaluated. The median age was 71 years (range 34-83 y), and the median parity was 3 (range 0-8). Among the women with a successful initial fitting, the failure rate was 5.88% (17/289) at 6 months with most of these women choosing to have surgical intervention. This analysis indicates that the probability of the successful continuation of pessary use after 1, 2, 3, 4, and 5 years was 83.0%, 78.2%, 71.3%, 65.3%, and 61.7%, respectively, reported using a Kaplan-Meier plot. The main cause for discontinuation of pessary use before 3 years was the election for surgical intervention. With regard to predictors for continued pessary use, self-care was the only factor that influenced compliance rates after treatment of 3 years. A ring with support pessary can be used successfully to alleviate symptoms of advanced stage prolapse for 3 years or longer. In addition, proper self-management was found to be a strong predictor for prolonged pessary use.

EP22.03: A rare complication of ring pessary: cervical incarceration

EP22.03: A rare complication of ring pessary: cervical incarceration

Ring and Gellhorn pessaries used in patients with pelvic organ prolapse: a retrospective study of 8\xa0years

AimThe aim of this study was to identify factors associated with pessary fitting, continued use of pessary and satisfaction of patients with pelvic organ prolapse.MethodsA retrospective study was conducted in patients who received an initial pessary fitting. The clinical characteristics of these patients were recorded. The Pelvic Floor Disability Index PFDI-20 and PFIQ-7 were used to assess pelvic floor dysfunction and quality of life. Complications, satisfaction degree, and reasons for abandonment were recorded during the follow-up. T test and Chi square test in SPSS version 20 were used to analyze the data.ResultsThree hundred women with symptomatic prolapse were selected for pessary fitting, whose average age was 67.8 ± 10.7 years. For two hundred and forty-nine (83%) women, the fitting was successful, of whom 162 used ring pessaries and 87 used Gellhorn pessaries. Forty-seven patients abandoned using a pessary at the end of our study. Most clinical characteristics were not significantly different between the successful and unsuccessful fitting groups (P > 0.05). The average score of CRADI-8 was lower in successful fitting group (11.9 ± 15.9) than that in unsuccessful fitting group (18.8 ± 19.9) (P < 0.05). 162 patients with successful pessary fitting completed the satisfaction survey, 79% of whom were satisfied or very satisfied. Erosions (24.4%) were the most common complication. Difficulty in inserting or removing (30.4%) and erosions (22.8%) were the main factors, which affected the satisfaction degree.ConclusionsPatients with obvious symptoms of posterior pelvic prolapse are more likely to fit failure. Difficulty in inserting or removing and erosions are the main factors, which lead to the discontinuation of pessary use and decrease in the satisfaction degree.

子宮筋腫による急性尿閉をウォーレス・リング・ペッサリーにて解除し外来管理に成功した3症例

子宮筋腫による急性尿閉をウォーレス・リング・ペッサリーにて解除し外来管理に成功した3症例

Severe Pelvic Organ Prolapse with Large Vaginal Mucosal Defect Underwent Laparoscopic Shull’s Uterosacral Ligament Colpo-Suspension and TVM Operation by Two Stage Surgery

A 75-year-old woman complained of anuria and a sense of discomfort with severe pelvic organ prolapse (POP). We planned tension-free vaginal mesh (TVM) surgery after curing mucosal defects and completing treatment for diabetes mellitus. Anuria and pyelonephritis relapsed repeatedly due to the failure of ring pessary therapy. Surgical treatment was required emergently. We performed a total laparoscopic hysterectomy and uterosacral ligament colpo-suspension (Shull’s method). Although the vaginal apex was supported to a good position, cystocele occurred six months after the initial surgery. A TVM procedure for recurrent cystocele was performed after curing the mucosal defects, and after the improvement of glycemic control. Transvaginal native tissue repair has the advantages of low risk of ureter injury, firm colpo-suspension, and no need for mesh usage. On the other hand, it is not good at treating cystocele. Transvaginal native tissue repair should prove to be a useful surgical option for apical support without mesh.

Feasibility of using pessaries for treatment of pelvic organ prolapse in rural Nepal.

To evaluate the acceptability, feasibility, and outcomes of pessary fitting in rural Nepali communities. A 1-year prospective cohort study was conducted in the Ramechhap district of Nepal in January 2013-January 2014 among women attending a free gynecology health camp. All women with symptomatic pelvic organ prolapse (POP) were offered ring pessaries. Demographic information was collected and questionnaires on POP were completed. A urogynecologic examination was performed. At the 1-year follow-up, women were questioned on pessary use and underwent an examination. Logistic regression was used to identify associations. In total, 411 women attended the health camps, of whom 142 presented with symptomatic POP. Initial fitting was accomplished for 134 (94.4%) of the women. At the 1-year follow-up, 130 (97.0%) women in the cohort were evaluated, and 72 (55.4%) were still using the pessary. The primary reason for discontinuation was the pessary falling out (35/58, 60.3%). The most common complication was vaginal erosion (18/130, 13.8%), observed exclusively among postmenopausal women. Postmenopausal status was a predictor of continued use (odds ratio 3.12, 95% confidence interval 1.45-6.72; P=0.004). Pessaries were found to be an acceptable and feasible option with minimal complications for treating POP in rural Nepal.

Role of pessaries in management of women with pelvic organ prolapse and stress urinary incontinence at a University Hospital in Oman

Introduction: Millions of women have been diagnosed with pelvic floor dysfunction worldwide which covers a range of conditions, most significantly pelvic organ prolapse (POP), urinary incontinence (UI) and faecal incontinence. About 40% of patients with POP could present with SUI and affects the quality of life of women, which is a social and hygienic problem. The extent and consequences of the burden of disease due to pelvic floor dysfunction is poorly understood. Over the past three decades efforts have been made to develop devices with evidence-based designs to control urinary incontinence. We aim to address the role of mechanical intravaginal devices in the management of urinary incontinence coexisting with uterovaginal prolapse at a tertiary academic institute in Oman. Materials and methods: This is a retrospective cohort study of women presenting with SUI with or without POP and managed with pessary at urogynecology clinic, Sultan Qaboos University Hospital, Muscat, Oman. The electronic patient records were reviewed from January 1, 2008 to December 31, 2014. Women with other form of UI other than SUI or who opted for surgical management were excluded. The demographic data (age, parity, BMI, menopausal status, etc.) and clinical data (type and degree of prolapse, type and size of pessary used, presence of other medical conditions, etc.) were collected and analyzed for outcome with SPSS v21. Results: During the study period of 6 years 52 women were managed with pessary for SUI. The mean age of women was 58.9 years, mean parity was six, and mean BMI 29.1 kg/m2. Forty-four patients (84.6%) presented with both SUI and prolapse and eight with SUI only (15.4%). The most common type of prolapse was cystocele seen in 43(82.7%) patients. The main types of pessaries used were incontinence ring pessary (23%) or ring without cover 42.3%. In 44 (84.6%) women, pessary use significantly relieved symptoms and patients were complaint with its use for a long time. The majority of patients experienced no side effects (75%). The most common side effect was spontaneous expulsion of pessary (11.5%) and excessive vaginal discharge (5.8%). Conclusion: Results of this study show that pessary use is an effective conservative treatment for prolapse and SUI in our population. Further follow up will be done to assess the effectiveness of long term pessary use in women having concomitant SUI and POP.

Successful Use of Ring Pessary with Support for Advanced Pelvic Organ Prolapse

Successful Use of Ring Pessary with Support for Advanced Pelvic Organ Prolapse

Laparoscopic Sacrocolpopexy for Treatment of Neovaginal Prolapse Following Gender Reassignment Surgery

Abstract Background: Prolapse of the neovagina is a rarely reported complication of male-to-female transgender surgery and is not commonly encountered by gynecologists. Documented management of such cases is scarce in the literature and includes a few case reports or abstracts. This article reports the current authors' experience treating complete eversion of the neovagina successfully with laparoscopic sacrocolpopexy. Case: A 55-year-old transgender female had complete eversion of her neovagina and symptoms of obstructive defecation syndrome (ODS). Use of a ring pessary was unsuccessful. A magnetic resonance imaging proctogram revealed anismus, and paradoxical contraction of the anal canal and puborectalis muscle. At a pelvic-floor multidisciplinary meeting, biofeedback treatment was recommended for her ODS symptoms as well as laparoscopic sacrocolpopexy. The procedure posed various technical difficulties for this patient, compared to an XX female, including lack of a distinct rectovaginal septum, a narr...