Changes of intravaginal microbiota and inflammation after self-replacement ring pessary therapy compared to continuous ring pessary usage for pelvic organ prolapse

Beyond hormones: 3PM approach to vaginal microbiota dynamics in postmenopausal women

Menopause marks a critical transition characterized by ceased ovarian function and declining estrogen levels, affecting multiple systems with vasomotor symptoms and genitourinary syndrome of menopause (GSM). Recent evidence shows vaginal microbiota undergoes significant alterations during menopause, influencing GSM severity. This comprehensive review examined vaginal microbiota dynamics in postmenopausal women through Predictive, Preventive, and Personalized Medicine (3PM/PPPM), revealing characteristic shifts-increased alpha diversity, reduced Lactobacillus dominance, and transitions toward non-Lactobacillus species-that serve as potential predictive biomarkers for the menopausal state, premature ovarian insufficiency, and GSM symptoms. The analysis evaluated microbiota-based risk stratification strategies for vaginal dysbiosis and demonstrated the effectiveness of both hormonal interventions (systemic/local estrogen, tibolone, ospemifene) and non-hormonal alternatives (probiotics, energy-based devices, pessary) in normalizing microbiota composition and improving vaginal health. The application of PPPM/3PM transformed menopausal healthcare from reactive to proactive precision-based care by establishing microbiota-based biomarkers that predict health risks, enable early targeted interventions tailored to specific microbiota profiles, and guide personalized treatment approaches based on individual microbial compositions. While this paradigm shift significantly advances gynecological medicine, research gaps remain in validating baseline microbiota signatures as predictive biomarkers and establishing standardized screening protocols. Further studies are needed to validate interventions such as probiotics and prebiotics, optimizing strain selection for personalized, evidence-based preventive and therapeutic strategies. Developing standardized yet personalized protocols to restore a balanced vaginal microbiome could help alleviate menopause-related symptoms. Advancing microbiota-based personalized therapeutic approaches is crucial to enhancing the quality of life for postmenopausal women through targeted and individualized vaginal health management.

Updates in Pessary Care for Pelvic Organ Prolapse: A Narrative Review

Pelvic organ prolapse (POP) affects millions of women globally, significantly impacting quality of life. Pessaries serve as a first-line, non-surgical option for symptom relief, particularly among women who wish to avoid or delay surgery. Despite widespread use, challenges persist in fitting, patient education, and long-term adherence, necessitating further advancements in design and care protocols. This narrative review was conducted to explore the role of vaginal pessaries in the management of POP, focusing on efficacy, patient adherence, complications, and emerging innovations. Pessaries demonstrate high initial success rates, but long-term adherence varies. Improper fit, discomfort, and lack of self-management contribute to discontinuation. Complications, including vaginal discharge, erosion, and bleeding, are common but generally manageable. Recent innovations, such as self-removable pessaries, 3D-printed custom designs, and hormone-releasing pessaries, show promise in improving patient experience and adherence. Studies support self-management as a cost-effective strategy that enhances patient autonomy and reduces clinic visits. Pessaries remain a valuable conservative treatment for POP, yet challenges in long-term adherence highlight the need for standardized fitting protocols, better patient education, and continued innovation in design. Future advancements should focus on patient-centered, user-friendly solutions to enhance effectiveness, comfort, and self-care, ultimately empowering women with more accessible and sustainable pelvic health options.

International Urogynecology Consultation Chapter 3 Committee 1 - Pessary Management

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding Factors That Affect Willingness to Self-Manage a Pessary for Pelvic Organ Prolapse: A Questionnaire-Based Cross-Sectional Study of Pessary-Using Women in the UK

INTRODUCTION AND HYPOTHESIS

Pessary self-management offers benefits to women with no increased risk of complications. However, many are unwilling to self-manage, preferring clinician-led care. This study is aimed at exploring factors associated with willingness to self-manage a pessary.

METHODS

Women attending pessary clinic at a UK hospital were asked to complete a questionnaire providing responses on pessary use, comorbidities, female genital self-image, self-management experience and willingness (or not) to learn self-management. Based upon statistical advice we aimed to recruit 90 women. Data were analysed using the non-parametric Kruskal-Wallis test and Chi-squared test. Free text data were analysed thematically.

RESULTS

A total of 89 women completed the questionnaire. Thirty-three women (38%) had previously been taught pessary self-management. Of the remaining women, 12 (21%) were willing to learn, 28 (50%) were not willing and 16 (29%) were unsure. There was no correlation between female genital self-image and willingness to self-manage a pessary. Younger women were more willing to learn self-management (p =  < 0.001). Willing women were motivated by reduced follow-up visits. Self-managing women reported benefits including increased autonomy, cleanliness and giving their body "a break". Reasons discouraging women from self-managing were a lack of confidence; feeling physically unable; wanting clinician-led care; fear of problems or previous problems with their pessary.

CONCLUSIONS

Most women were either unsure about pessary self-management or unwilling to self-manage. Age was the only factor we found that had a significant relationship with willingness to self-manage a pessary. With robust self-management teaching, support and follow-up, it is likely that many of the barriers women report can be overcome.

Vaginal microflora following the use of a disposable home-use vaginal device and a commercially available ring pessary for pelvic organ prolapse management: a randomized controlled trial

PURPOSE

To investigate whether ProVate, a novel, disposable, self-inserted vaginal device for pelvic organ prolapse management, clinically affects the vaginal microflora, as compared with a commercially available ring pessary, to assess its microbiological safety.

METHODS

This interventional, prospective, multi-center, open-label, randomized, controlled, statistically powered (noninferiority), home-use, crossover study was conducted at seven sites. Participants were randomized into either group A (using ProVate and then a new reusable commercially available ring pessary [control]) or B (using control device and then ProVate) with a 1:1 ratio. Noninferiority of ProVate over the control was evaluated for the primary endpoint, which was based on meeting one of the failure criteria: significant change in Lactobacillus spp., Gardnerella vaginalis, Candida morphotypes, or Staphylococcus aureus levels compared to the baseline (significant change: Nugent score ≥ 7 or > 1 scale unit increase in S. aureus or Candida morphotype), bothersome vaginal infection symptoms, or symptoms requiring treatment for infection.

RESULTS

The study included 58 participants (mean age: 64.5 years, 91.4% postmenopausal). There were no significant microfloral changes in terms of the four microorganisms mentioned above, the rate of Nugent score ≥ 7 after use was low and comparable between the two devices, and the rate of patients with a > 1 unit-scale change (increase or decrease) from the baseline to the end-of-use phase in any studied microorganism was comparable between the devices. The failure rate was 15.5% for ProVate and 15.5% for control while using 383 ProVate devices over 1647 days or one control device throughout the study. Two patients had bothersome vaginal complaints and one had overt vaginal infection in the control group, but no such cases were observed in the ProVate group.

CONCLUSION

The primary endpoint of possible vaginal microbial changes, bothersome vaginal symptoms, or treatment-requiring vaginal complaints while using ProVate was successfully met. Our findings show that the vaginal microflora is comparable when using either ProVate or commercially available ring pessary (control) with a relatively low rate of vaginal infections. Trial registration details: ClinicalTrials.gov; URL: https://www.

CLINICALTRIALS

gov/ct2/show/NCT03345121?term=NCT03345121&draw=2&rank=1 ; No. NCT03345121; Registration date, November 17, 2017; initial enrollment started on August 20, 2017.

Pessaries for pelvic organ prolapse: evaluation of vaginal discharge and pain during pessary cleaning in an outpatient setting

INTRODUCTION AND HYPOTHESIS

Pessary treatment for pelvic organ prolapse (POP) is effective and safe, but long-term continuation is low. Pain and vaginal discharge may play a role. This study was aimed at evaluating vaginal discharge and pain during pessary cleaning in an outpatient setting and in continuous pessary use.

METHODS

Women with POP who attended the outpatient clinic for pessary cleaning between January and October 2021 were included. Primary outcome was pain during removal and reinsertion of the pessary, measured by an 11-point numeric rating scale (NRS). Secondary outcome was vaginal discharge, measured by the NRS and Patient Global Impression of Change scale (PGI-C). Multiple linear regression analysis was used to identify associated variables for pain and discharge.

RESULTS

A total of 150 women were included. Mean NRS during pessary removal was 4.3 (± 2.7), with 25% of women scoring a 7 or higher. Mean NRS during reinsertion was 1.8 (± 2.0). A smaller genital hiatus and presence of vaginal atrophy or vulvar skin disease were associated with pain during pessary removal. Mean NRS for vaginal discharge was 2.5 (± 2.3). Twenty-five percent of women reported that their vaginal discharge was "(very) much worse" than before they used a pessary. Presence of vaginal erosions was associated with vaginal discharge in this study population.

CONCLUSIONS

Removing a pessary in an outpatient setting is a painful procedure for many women who use a pessary continuously. Moreover, 25% of these women experience an increase in vaginal discharge while using a pessary. Future research should focus on reducing these disadvantages.

Microbiome alterations in women with pelvic organ prolapse and after anatomical restorative interventions

Pelvic organ prolapse (POP) is a benign gynecological disease in which the pelvic organ descends into the vagina and causes voiding, and defecatory dysfunction, mainly occurs in older women. This study aimed to investigate the vaginal microbiome of POP and associated changes after anatomical restorative pessary or reconstructive pelvic operation. We analyzed the vaginal microbiome using 16S ribosomal RNA gene sequencing and compared the results among patient groups with POP, pessary, and postoperation. We also measured 10 inflammation-related cytokines in vaginal swab samples using multiplex immunoassay. In pelvic organ prolapse, vaginal community status type IV was the most prevalent, which showed a low abundance of Lactobacillus with increased diversity and abundance of anaerobic species. The alpha diversity of species richness was highest in the POP group. The beta diversity distance differed significantly between the three groups (p = 0.001). While human intestinal taxa-associated bacteria were reduced after pessary or operation, vaginitis-associated bacterial composition was altered but vaginal microbiome homeostasis was not improved. IFN-γ, IL-10, IL-12p70, IL-1β, IL-4 and TNF-α levels increased in the pessary group. Therefore, in addition to anatomical restorative treatment, supplementary treatment focusing on the recovery of the vaginal microbiome may be needed to maintain the health of gynecological organs in old age.

Vaginal Pessary Use and Management for Pelvic Organ Prolapse: Developed by the joint writing group of the American Urogynecologic Society and the Society of Urologic Nurses and Associates. Individual writing group members are noted in the Acknowledgments section

ABSTRACT

Over the past 50 years, pessary use has increased in popularity and has become an essential pelvic organ prolapse (POP) management tool. However, evidence is lacking to define care standardization, including pessary fitting, routine maintenance, and management of pessary-related complications. This clinical consensus statement (CCS) on vaginal pessary use and management for POP reflects statements drafted by content experts from the American Urogynecologic Society and Society of Urologic Nurses and Associates. The purpose of this CCS is to identify areas of expert consensus and nonconsensus regarding pessary fitting, follow-up, and management of pessary complications to improve the safety and quality of care where evidence is currently limited. The American Urogynecologic Society and Society of Urologic Nurses and Associates' vaginal pessary for POP writing group used a modified Delphi process to assess statements that were evaluated for consensus after a structured literature search. A total of 31 statements were assessed and divided into 3 categories: (1) fitting and follow-up, (2) complications, and 3) quality of life. Of the 31 statements that were assessed, all statements reached consensus after 2 rounds of the Delphi survey. This CCS document hopefully serves as a first step toward standardization of pessary care, but the writing group acknowledges that improved research will grow the base of knowledge and evidence providing clinicians a foundation to manage pessary care effectively and confidently.

What is known from the existing literature about self-management of pessaries for pelvic organ prolapse? A scoping review

OBJECTIVES

Pelvic organ prolapse can be managed with a pessary. However, regular follow-up may deter women due to the inconvenience of frequent appointments, as well as preventing autonomous decision making. Pessary self-management may be a solution to these issues. However, there remains a number of uncertainties regarding pessary self-management. This scoping review aims to map available evidence about pessary self-management to identify knowledge gaps providing the basis for future research.

DESIGN

Scoping review as detailed in the review protocol.

DATA SOURCES

A search of MEDLINE, CINAHL, EMBASE and PsycINFO databases and a handsearch were undertaken during May 2021 to identify relevant articles using the search terms 'pessary' and 'self-management' or 'self-care'.

DATA EXTRACTION AND SYNTHESIS

Data relevant to pessary self-management was extracted and the Mixed Methods Appraisal Tool used to assess empirical rigour. Thematic analysis was performed to evaluate the results.

RESULTS

The database search identified 82 publications. After duplicates and articles not meeting the inclusion and exclusion criteria were removed, there were 23 eligible articles. A hand search revealed a further 19 articles, resulting in a total of 42 publications.Findings relevant to pessary self-management were extracted and analysed for the emergence of themes. Recurrent themes in the literature were; the characteristics of self-managing women; pessary care; factors associated with decision making about self-management; teaching self-management and cost benefit.

CONCLUSIONS

Pessary self-management may offer benefits to some women without increased risk. Some women do not feel willing or able to self-manage their pessary. However, increased support may help women overcome this. Further in-depth exploration of factors which affect women's willingness to self-manage their pessary is indicated to ensure better understanding and support as available for other conditions.