Predictors for unsuccessful pessary fitting in women with symptomatic pelvic organ prolapse: a prospective study

Value of pelvic examination in women with pelvic organ prolapse: A systematic review

BACKGROUND

Recent recommendations from the French High Authority of Health on pelvic organ prolapse (POP) management underline the value of a pelvic examination.

OBJECTIVES

The aim of this paper was to analyze the literature and identify the best evidence available regarding pelvic examination for women presenting prolapse-associated symptoms in terms of diagnosis and predictability of treatment success.

SEARCH STRATEGY

The databases were queried similarly using Medical Subject Headings (MeSH) and non-MeSH terms broadly related to pelvic examination and POP management.

SELECTION CRITERIA

We included studies assessing the diagnostic contribution of pelvic examination (correlation with symptoms) and its value for assessing the risk of pessary failure or recurrence after reconstructive surgery.

DATA COLLECTION AND ANALYSIS

We assessed peer-reviewed articles on PubMed, Embase, and Cochrane database up to May 2023. The methodological quality of all the included studies was assessed using the ROBINS-E or RoB2 tools.

MAIN RESULTS

In all, 67 studies were retained for the review. Prolapse-associated symptoms are poorly correlated with POP diagnosis. The symptom that is best correlated with the POP stage is the presence of a vaginal bulge (moderate to good correlation). The factors most strongly associated with the risk of recurrence after surgery or pessary failure are clinical: essentially a higher POP stage before surgery, levator ani muscle avulsion, and vaginal and genital measurements.

CONCLUSIONS

In women complaining of prolapse-associated symptoms, a pelvic examination (vaginal speculum and digital vaginal examination) can confirm the presence of POP and identify risk factors for treatment failure or recurrence after surgical management or pessary placement. A higher stage of POP and levator ani muscle avulsion-discernible on pelvic examination-are major risk factors for POP recurrence or treatment failure. These features must be taken into account in the treatment choice and discussed with the patient.

Outcomes of pessary fitting trials for patients with stage IV pelvic organ prolapse: a prospective study

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the efficacy of pessaries in the treatment of stage IV pelvic organ prolapse (POP) and identify the influencing factors.

METHODS

One hundred and fifty-seven patients with stage IV symptomatic POP were admitted to the hospital for pessary fitting. A successful pessary fitting was defined as a patient fitted with a pessary at the initial fitting in whom use continued 2 weeks later. The rates of successful pessary fitting, patient satisfaction, remission of prolapse and urinary symptoms, and the occurrence of factors associated with successful pessary fitting were calculated and predictors of appropriate pessary type selection were analyzed.

RESULTS

A total of 130 patients with stage IV POP had a successful pessary fitting (82.8%). The satisfaction rate associated with the two types of pessaries was more than 90%. The success rate among patients undergoing a ring pessary fitting trial was 44.6%, and 84.3% of the patients were self-managed. Prolapse symptoms significantly improved in 90% of cases, and urinary symptoms improved in 58-93% of cases from baseline. The number of vaginal deliveries, history of hysterectomy and vaginal introitus/total vaginal length (TVL) ratio were independent risk factors associated with unsuccessful pessary fitting.

CONCLUSION

For patients with stage IV POP, the successful fitting rate is as high as 80% or more. More vaginal deliveries, a history of hysterectomy, and a larger vaginal introitus/TVL ratio (ratio  >0.6) were predictors of unsuccessful pessary fitting.

Location and motion of vaginal pessaries in situ in women with successful and unsuccessful pessary treatment for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The objective was to compare the location and motion of pessaries between women with pelvic organ prolapse (POP) with a successful (fitting) and unsuccessful (non-fitting) pessary treatment on dynamic magnetic resonance imaging (dMRI).

METHODS

A cross-sectional exploratory study of 15 women who underwent a mid-sagittal dMRI of the pelvic floor at rest, during contraction and during Valsalva with three different types of pessaries. The coordinates of the pessaries cross section, inferior pubic point (IPP) and sacrococcygeal junction (SCJ) were obtained and the location (position, orientation) and the motion (translation and rotation) were calculated. Differences between the groups and between the pessaries within the groups were compared.

RESULTS

Nine women with a fitting pessary and 6 women with a non-fitting pessary were selected. In the non-fitting group, the pessaries were positioned more caudally and rotated more in clockwise direction and descended more, but not significantly, during Valsalva compared with the fitting group. The Falk pessary was positioned more anteriorly in the fitting group and more cranially in the non-fitting group compared with the ring and ring with support pessary.

CONCLUSIONS

A non-fitting pessary was positioned more caudally at rest; on Valsalva, it rotated more clockwise and moved more caudally, suggesting that the dynamic characteristics of the pessary might play an important role in its effectiveness. Findings of this study serve as a basis for the development of new pessary designs.

Transition to surgery after pessary among female Medicare beneficiaries with pelvic organ prolapse

BACKGROUND

The American College of Obstetricians and Gynecologists recommends offering a vaginal pessary to women seeking treatment of pelvic organ prolapse. However, single-institution series have suggested that a sizable proportion of women fitted with a pessary will transition to surgery within the first year.

OBJECTIVE

This study aimed to estimate the proportion of female US Medicare beneficiaries with pelvic organ prolapse who undergo surgery after pessary fitting, to describe the median time to surgery from pessary fitting, and to identify factors associated with the transition from pessary to surgery.

STUDY DESIGN

The Medicare 5% Limited Data Set was queried from 2011 to 2016 for women aged ≥65 years with a diagnosis of prolapse who underwent pessary fitting. Cases with at least 3 years of follow-up in the Medicare Data Set were followed longitudinally for the primary outcome of surgery for prolapse. The cumulative incidence of prolapse surgery following index pessary fitting was calculated. Characteristics of women who underwent surgery and those who did not were compared using time-varying Cox regression analysis.

RESULTS

Among 2032 women fitted with a pessary, 608 underwent surgery within 7 years. The median time to surgery was 496 days (interquartile range, 187-1089 days). The cumulative incidence of prolapse surgery was 12.2% at 1 year and 30.9% at 7 years. After adjusting for covariates, factors significantly associated with the transition to surgery included previous prolapse surgery (adjusted hazard ratio, 1.50; 1.09-2.07) and a diagnosis of urinary incontinence at the time of pessary fitting (adjusted hazard ratio, 1.20; 0.62-0.99). Factors associated with a lower hazard of surgery included age (adjusted hazard ratio, 0.96 per year; 95% confidence interval, 0.95-0.97), dual Medicare/Medicaid eligibility (adjusted hazard ratio, 0.75; 95% confidence interval, 0.56-1.00), and pessary fitting by a nongynecologist (adjusted hazard ratio, 0.78; 95% confidence interval, 0.62-0.99).

CONCLUSION

In this population of Medicare beneficiaries, within 7 years of pessary fitting, almost one-third of women aged >65 years underwent surgery for prolapse. These results add to our current understanding of the demographics of pessary use in an older population and may aid in counseling older patients presenting for treatment of symptomatic pelvic organ prolapse.

An estriol-eluting pessary to treat pelvic organ prolapse

Pelvic organ prolapse affects up to 50% of parous women. Commonly used treatment options have unwelcome attributes; pessaries can cause erosion and estrogen creams need to be applied frequently, which is inconvenient and difficult to administer. This study involved the development of an estriol-releasing pessary utilising 3D printing molds. We incorporated varying amounts of estriol (1%, 10% and 15%) into the silicone pessary. We optimised the mechanical aspects of the pessary so it had a similar strength to commercially available pessaries. We investigated estriol release from the pessary over 3 months. We explored possible interactions between the drug and polymers via FTIR. The MED-4870 silicone ring with similar mechanical strength to pessaries currently used to treat pelvic organ prolapse. The medical pessaries present a sustained release in simulated vaginal fluid over 3 months. The pessary with 10% estriol delivered the optimal dose at 0.8 mg each week. Mechanical strength of this pessary showed no difference after emersion in simulated vaginal fluid for 3-month, supporting the long-term application. An estriol-loaded pessary was successfully developed to treat pelvic organ prolapse with sustained release of estriol over 3 months. This pessary provides promising potential to treat pelvic organ prolapse and vaginal atrophy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is defined as the descent of one or more of the anterior and posterior vaginal walls, uterus (cervix), or apex of the vagina (vaginal vault or cuff scar after hysterectomy). Although POP can be asymptomatic, if the bulge extends beyond the opening of the vagina, it can have a significant impact on a woman's quality of life. Findings include vaginal bulging toward or through the vaginal introitus that the patient may feel, palpate, or see with a mirror. If a woman is bothered by her prolapse, she should be offered both nonsurgical and surgical treatments.

Parameters associated with unsuccessful pessary fitting for pelvic organ prolapse up to three months follow-up: a systematic review and meta-analysis

Objectives

To clarify which parameters are associated with unsuccessful pessary fitting for pelvic organ prolapse (POP) at up to 3 months follow-up.

Methods

Embase, PubMed and Cochrane CENTRAL library were searched in May 2020. Inclusion criteria were: (1) pessary fitting attempted in women with symptomatic POP; (2) pessary fitting success among the study outcomes with a maximal follow-up of 3 months; (3) baseline parameters compared between successful and unsuccessful group. A meta-analysis was performed using the random effects model.

Main results

Twenty-four studies were included in the meta-analysis. Parameters associated with unsuccessful pessary fitting were: age (OR 0.70, 95% CI 0.56–0.86); BMI (OR 1.35, 95% CI 1.08–1.70); menopause (OR 0.65 95% CI 0.47–0.88); de novo stress urinary incontinence (OR 5.59, 95% CI 2.24–13.99); prior surgery, i.e. hysterectomy (OR 1.88, 95% CI 1.48–2.40), POP surgery (OR 2.13, 95% CI 1.34–3.38), pelvic surgery (OR 1.81, 05% CI 1.01–3.26) and incontinence surgery (OR 1.87, 95% CI 1.08–3.25); Colorectal-Anal Distress Inventory-8 scores (OR 1.92, 95% CI 1.22–3.02); solitary predominant posterior compartment POP (OR 1.59, 95% CI 1.08–2.35); total vaginal length (OR 0.56, 95% CI 0.32–0.97); wide introitus (OR 4.85, 95% CI 1.60–14.68); levator ani avulsion (OR 2.47, 95% CI 1.35–4.53) and hiatal area on maximum Valsalva (OR 1.89, 95% CI 1.27–2.80).

Conclusion

During counselling for pessary treatment a higher risk of failure due to the aforementioned parameters should be discussed and modifiable parameters should be addressed. More research is needed on the association between anatomical parameters and specific reasons for unsuccessful pessary fitting.

Factors associated with unsuccessful pessary fitting and reasons for discontinuation in Korean women with pelvic organ prolapse

Objective

To identify the factors associated with unsuccessful pessary fitting and reasons for pessary discontinuation in Korean women with pelvic organ prolapse (POP).

Methods

The medical records of 234 patients who underwent pessary fitting for the management of symptomatic POP were retrospectively reviewed. A ring pessary with or without support was used. Successful pessary fitting was defined as the ability to wear a pessary for 2 weeks without any discomfort. Factors associated with unsuccessful pessary fitting were determined using a multivariable logistic regression analysis. A Kaplan-Meier survival curve was obtained to examine the probability of continuing pessary use over the follow-up period. The reasons for the discontinuation of pessary were identified.

Results

Two-hundred-and-twenty-five women were included in the analysis. The rate of unsuccessful pessary fitting was 40%. Prior hysterectomy (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.81–9.42) and POP quantification stage III–IV (OR, 2.49; 95% CI, 1.28–4.85) were independent risk factors for unsuccessful pessary fitting. Among the patients with successful pessary fitting, the median time to discontinuation of pessary use was 4 years. The most common causes of discontinued use were vaginal erosion (45.3%) and urinary incontinence (26.5%).

Conclusion

Patients with a history of hysterectomy and advanced-stage POP are at risk for an unsuccessful fitting of the ring pessary. Vaginal erosion is the main reason for discontinued use among patients with successful pessary fitting.

Rectovaginal Fistula in Women With Pessary for Pelvic Organ Prolapse: A Case Series and Literature Review

OBJECTIVE

In this study, we present a series of 2 cases of rectovaginal fistula (RVF) due to the use of a ring-type pessary in the conservative treatment of pelvic organ prolapse and a literature review on the management of RVF related to the use of pessaries.

METHODS

Two patients were selected from the medical records of the urogynecology service, and their demographic and clinical data were retrieved. An updated literature review was included presenting cases of RVF induced by or after use of a pessary.

RESULTS

Both patients evolved with removal of the pessary and correction of the fistula. The surgical procedures of choice were Le Fort Colpocleisis and posterior colporraphy without major complications. In the literature review, we selected 17 studies with a total of 23 cases reporting RVFs induced or followed by the use of pessaries.

CONCLUSIONS

Although the pessary is commonly indicated for the conservative treatment of pelvic organ prolapse, this device is not exempt from generating complications.

Transperineal ultrasound to estimate the appropriate ring pessary size for women with pelvic organ prolapse

Introduction and hypothesis

The objective was to predict the successful ring pessary size based on the levator hiatal area (HA).

Methods

This is a prospective case–control study. Women with symptomatic pelvic organ prolapse (POP) choosing pessary treatment were included. All women underwent an interview, clinical examination, and 3D/4D transperineal ultrasound (TPUS). The ring pessary size used in each trial and the reason for unsuccessful trials were recorded. In addition, levator hiatal area divided by ring pessary size (HARP ratio) was measured at rest, maximum contraction, and maximum Valsalva. The HARP ratios of successful and unsuccessful trials were compared, receiver operating characteristic curves in the prediction of successful trials were constructed, and the cut-off optimizing sensitivity and specificity was identified.

Results

A total of 162 women were assessed and 106 were included with 77 successful trials, 49 unsuccessful trials owing to dislodgment or failure to relieve POP symptoms, and 20 unsuccessful trials owing to pain/discomfort. Rest HARP ratio and Valsalva HARP ratio were significantly smaller in the successful trials versus dislodgment/failure to relieve POP symptoms trials (mean rest HARP ratio [SD]: 2.93 [0.59] vs 3.24 [0.67], p = 0.021; median Valsalva HARP ratio (IQR): 4.65 (1.56) vs 5.32 (2.08), p = 0.004). No significant difference was observed between pain/discomfort trials and successful trials. The best cut-off for the prediction of successful trials was Valsalva HARP ratio ≤ 5.00.

Conclusions

Unsuccessful fitting trials due to dislodgment/failure to relieve POP symptoms are associated with a small ring pessary with respect to the levator HA. A ring pessary that produces a Valsalva HARP ratio > 5.00 has a higher risk of dislodgment/failure to relieve POP symptoms.

Can we predict continued pessary use as primary treatment in women with symptomatic pelvic organ prolapse (POP)? A prospective cohort study

INTRODUCTION AND HYPOTHESIS

The objective of this study was creating a prediction model for continued pessary use in patients with symptomatic pelvic organ prolapse (POP) and evaluating the percentage of continued pessary use after 12 months.

METHODS

We performed a prospective cohort study in patients with symptomatic POP stage ≥ 2. All patients received a pessary as primary treatment. Factors for continuation were identified from baseline characteristics and data from validated disease-specific quality of life (DSQOL) questionnaires. Univariate and multivariate analyses for predictors were performed and a prediction model was made. Improvement of POP was measured using the Patient Global Impression of Improvement (PGI-I) and DSQOL at 12 months' follow-up. Primary outcome was factors related to continued use. Secondary outcomes were the percentage continued pessary use after 12 months, improvement of complaints and DSQOL.

RESULTS

Two hundred ninety-one patients were included; 184 (63%) patients continued pessary use after 12 months. Factors related to continuation following the univariate analysis were age, sexual activity, POP-Q point c ≥ 0 and obstructive micturition. GH < 4 was not significant but added significantly to the prediction model. After multivariate analysis, age, point c ≥ 0 and GH < 4 cm remained predictors for continuation. The ROC showed an AUC of 0.65 (95% CI 0.58-0.71). PGI-I showed 83% perceived their prolapse complaints much or very much improved.

CONCLUSIONS

Continued pessary use was found in 63%. Main predictors for continued pessary use were higher age, more prominent apical compartment prolapse (c ≥ 0) and a GH < 4 cm.

The effect of pessary treatment on puborectalis muscle function

INTRODUCTION AND HYPOTHESIS

The objective was to assess if puborectalis muscle (PRM) function changes in women with pelvic organ prolapse (POP) undergoing pessary treatment.

METHODS

This was a prospective cohort study of women with symptomatic POP choosing pessary treatment. An interview, clinical examination and 3D/4D transperineal ultrasound were performed at baseline and at 3-month follow-up. POP was assessed using the Pelvic Organ Prolapse Quantification system (POPQ). Parameters compared between baseline and follow-up were: hiatal area at rest (HArest), maximal contraction (HActx), and maximal Valsalva maneuver (HAVal), displacement in contraction (DISPL-ctx, i.e., relative difference between HArest and HActx), and displacement in Valsalva (DISPL-Val, i.e., relative difference between and HAVal and HArest). Parameters were compared in women with and those without complete avulsion.

RESULTS

A total of 162 women were assessed and 34 were included. Mean age was 64 years (SD 11.4), and mean BMI 24 kg/m² (SD 3.1). Thirty-one women had a cystocele, 8 a uterine prolapse, and 12 had a posterior compartment prolapse. Twenty-one women (61.8%) had a POP stage II, and 13 (38.2%) a POP stage III. Ring pessaries were most frequently used (97%). In the entire group a statistically significant increase in DISPL-ctx was observed (mean difference 2.1%, p = 0.017). In the no avulsion group HArest and DISPL-ctx increased significantly (mean difference 4.1%, p = 0.016 and 2.7%, p = 0.016 respectively) and the increase in DISPL-ctx was higher than in the avulsion group (mean difference 2.7% vs 0.2%, p = 0.056).

CONCLUSION

Our results show that PRM function changes in women with POP undergoing pessary treatment and suggest that such change occurs mainly in the absence of complete avulsion.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current trends in pessary management of vaginal prolapse: a multidisciplinary survey of UK practice

INTRODUCTION AND HYPOTHESIS

Symptomatic vaginal prolapse affects 6-28% of women and significantly impacts their quality of life. Pessaries for prolapse are used by three-quarters of clinicians as a first-line treatment; however, current clinical use in the UK is unknown and there is a lack of clinical guidance or training. This study is aimed at informing the upcoming UK Clinical Guidance on best practice for the use of pessaries document.

METHODS

A 19-question, anonymised, electronic survey was sent to members of the nine professional bodies delivering pessary care in the UK.

RESULTS

Of 917 respondents, 403 (246 nurses, 134 doctors, 22 physiotherapists and 1 other profession) currently deliver pessary care. PVC/vinyl ring, silicone ring, Gellhorn and shelf pessaries are most popular, and are used frequently by 93% of respondents. Further pessary training was deemed necessary by 62% of those currently providing pessary care, and 70% of those who do not. The most highly rated method for previous and future training is shadowing another clinician. One in three respondents receive no ancillary support and nearly 1 in 7 (predominantly nurses) report the absence of cross-cover arrangements, leaving a gap in care provision.

CONCLUSIONS

Service provision, support and pessary training in the UK vary greatly. This calls for the standardisation of care, training and development of a national guideline. We present a clear rationale and need for a UK guideline on pessary management of vaginal prolapse and a standardised pessary training model for multi-professional use.

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

AIM

To identify factors associated with unsuccessful pessary fitting in a large cohort of patients with symptomatic pelvic organ prolapse (POP).

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Vaginal pessary continuation in symptomatic pelvic organ prolapse patients with prior hysterectomy

OBJECTIVE

To evaluate the success rate of pessary fitting and continuation rate for symptomatic pelvic organ prolapse (POP) patients with a hysterectomy and to explore potential predictors.

METHODS

In this prospective observational study, 119 symptomatic POP patients with a prior hysterectomy received pessary treatment between April 2015 and February 2019. A successful pessary fitting was defined as a patient who was fitted with a pessary and continued to use it 2 weeks later. Patients with successful pessary fitting were followed until February 2020. Data analysis was performed with t tests, nonparametric tests, chi-square tests, and logistic regression.

RESULTS

The success rate of pessary fitting was 63.2%. A history of POP reconstructive surgery (OR = 2.6, 95% CI 1.0-6.7, P = 0.043) and a short total vaginal length <7.3 cm, (OR = 0.5, 95% CI 0.3-0.9, P = 0.014) were potential risk factors for unsuccessful pessary fitting. A total of 78.1% of the patients continued pessary use for a median duration of 26 months. Among patients who discontinued, 75% ceased within 1 year. Older age (OR = 1.1, 95% CI 1.0-1.2, P = 0.038) and prolapse score improvement at 3 months less than 50% (OR = 2.8, 95% CI 1.1-7.2, P = 0.035) were potential risk factors for discontinuation.

CONCLUSIONS

Pessaries remain a useful approach to treat prolapse in women who had a hysterectomy. Patients with POP reconstructive surgery and total vaginal length<7.3 cm should be informed that they might have lower success rate of pessary fitting. Age and prolapse score improvement at 3 months were potential predictors for continuation.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Factors associated with unsuccessful pessary fitting in women with symptomatic pelvic organ prolapse: Systematic review and metanalysis

AIMS

To identify the factors associated with unsuccessful pessary fitting and reasons for discontinuation for women with symptomatic pelvic organ prolapse (POP).

METHODS

This systematic review is registered at the PROSPERO database. We have included all studies, regardless of the study design whose primary outcomes were factors associated with unsuccessful pessary fitting and discontinuation for symptomatic POP women. Exclusion criteria were case series, literature reviews, other forms of conservative treatment. Data selection/extraction was performed by two investigators. For pessary fitting, a meta-analysis was performed for at least two studies pooled in a forest plot. The risk of bias was classified by the ROBINS-I and ROB-2 classification.

RESULTS

From 409 studies retrieved after data search, only twenty-one articles remained for final analysis (18 cohort studies, 1 cross-sectional study, and 2 RCTs). Meta-analysis was performed in nine studies for pessary fitting and the associated factors were: higher body mass index (BMI) (MD = 0.688 [0.233-1.143]; P = .03; i² = 0%), previous reconstructive surgery (OR = 1.705 [1.016-2.860]; P = .043; i² = 69%) and advanced POP (OR = 4.2 [2.9-6.1]; P < .05; i² = 92%). Older age, larger total vaginal length (TVL), and genital hiatus and previous hysterectomy were not associated factors. Regarding discontinuation, thirteen reasons were quoted, and the most frequent were: the desire for surgical treatment (111/3.601), pessary extrusion (385/3.601), and pain/discomfort (163/3.601).

CONCLUSION

Obese, previously reconstructive pelvic surgery, advanced prolapse are at risk for unsuccessful pessary fitting. Pain is the most quoted reason for discontinuation. These pooled data may help clinicians to identify patients that may not succeed in their attempt for pessary treatment.

Pessários vaginais na incontinência urinária: revisão integrativa

Objetivo: Analisar os tipos de pessários, as indicações e o impacto no tratamento da incontinência urinária (IU). Métodos: Trata-se de revisão integrativa com publicações de 2007 a 2017 indexadas nas bases de dados Biblioteca Virtual em Saúde, Medical Literature Analysis and Retrieval System Online, Scopus Info Site, Cumulative Index to Nursing and Allied Health Literature e Web of Science. Resultados: Selecionaram-se oito artigos. Os pessários indicados foram prato, anel, Uresta® e Contiform®. A redução ou resolução da IU de esforço (IUE) em mulheres foi observada por análise de parâmetros objetivos, como avaliação urodinâmica e questionários de qualidade de vida. Destacou-se viabilidade econômica. Evidenciaram-se desajuste, dificuldades no uso, incômodo e manutenção de perdas urinárias entre os motivos de não adesão. Prolapso avançado e comprimento vaginal curto foram preditivos de insucesso. Identificaram-se eventos adversos em baixa incidência: retenção urinária e leucorreia. Conclusão: A terapia pessária é eficaz no tratamento da IUE quando acompanhada por profissionais capacitados. Características individuais e percepções sobre o dispositivo são determinantes no sucesso terapêutico. Estudos de maior amostragem, tempo de seguimento e qualidade, bem como estimulo a publicações nacionais, são necessários para investigação de medidas objetivas de IU, fatores clínicos e demográficos em relação ao sucesso do pessário.

Vaginal pessaries in urinary incontinence: integrative review

Objectives: To analyze the types of pessaries, indications and impact in the treatment of urinary incontinence (UI). Methods: This is an integrative review with publications from 2007 to 2017 indexed in the Biblioteca Virtual em Saúde, Medical Literature Analysis and Retrieval System Online databases, Scopus Info Site, Cumulative Index to Nursing and Allied Health Literature and Web of Science. Results: Eight articles were selected. The pessaries indicated were the dish, ring, Uresta®, and Contiform®. The reduction or resolution of stress UI in women was observed by analysis of objective parameters such as urodynamic evaluation and quality of life questionnaires. Economic viability was highlighted. Disability, difficulties in use, discomfort, and maintenance of urinary losses were evidenced among the reasons for non-adherence. Advanced prolapse and short vaginal length were predictive of failure. Adverse events were identified in low incidence: urinary retention and leukorrhea. Conclusion: Pessary therapy is effective in the treatment of SUI when accompanied by trained professionals. Individual characteristics and perceptions about the device are determinants of therapeutic success. Studies of greater sampling, follow-up time and quality, as well as stimulation to national publications, are necessary for the investigation of objective measures of UI, clinical and demographic factors in relation to the success of the pessary.

Long-term compliance of vaginal pessaries: Does stress urinary incontinence matter?

Vaginal pessary treatment for pelvic organ prolapse (POP) is relatively safe and cost-effective. Since long-term use is an important key to keep the benefit of pessary treatment, we would like to investigate the factors which might affect the compliance of vaginal pessaries. In this retrospective study, 65 women were included, and we found poor compliance in women with severe stress urinary incontinence (SUI) after reduction (1-hour pad test >10 gm vs ≦10 gm, 57.1% vs. 84.3%, P = .027). Besides, women younger than 60 years-old also had poor compliance (age ≦60-year-old vs >60-year-old, 58.3% vs 83.0%, P = .04). Other factors such as POP stage, history of hysterectomy, and types of pessaries, did not show significant influence on the long-term compliance in this study. Therefore, to evaluate the severity of SUI after reduction before providing pessary treatment is important to predict long-term compliance. Meanwhile, long-term pessary treatment seems to be more acceptable to elderly patients.