Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse

PURPOSE

To evaluate long-term continuation rates, adverse events of ring pessary use at a minimum of 5 years follow-up, and factors associated with discontinuation in symptomatic pelvic organ prolapse (POP).

METHODS

Women with symptomatic POP who were treated with vaginal ring pessary and had successful fittings were included. Adverse events and reasons for discontinuation of pessary use were recorded. Patients who were lost to follow-up were defined as discontinuation.

RESULTS

During 12 year-period, 239 of 329 POP patients (72.6%) had successful fittings with ring pessary. The mean age was 67.8 ± 8.9 years (range 27-86) and 70% of patients had advanced stage. The cumulative probability of continued ring pessary use was 84.1%, 64.4%, 49.3%, and 33.5%, at 1, 3, 5, and 10 years, respectively. Most common reason for discontinuation was frequent expulsion (21.6%), followed by vaginal erosion (16.5%), no prolapse improvement (12.4%), and inability or inconvenience to do self-care (9.3%). However, 9 patients (9.3%) had improvement of prolapse and were able to discontinue pessary insertion. Age above 70 years, wide introitus, and incapability of self-care are independent factors associated with long-term discontinuation. Adverse events occurred in 23.4% of patients, 18.8% of them had vaginal erosion, 11.7% vaginal discharge/infection, and 18.4% de novo SUI. However, no statistical significance existed between those who continued and discontinued pessary use due to these adverse events.

CONCLUSION

Ring pessary is an effective treatment in symptomatic POP, with acceptable long-term continuation rates and minor adverse events. Self-care of pessary is very important aiming to minimize adverse events. Advanced age, wide introitus and incapability of self-care were associated factors for long-term discontinuation.

Effect of structured pelvic floor muscle training on pelvic floor muscle contraction and treatment of pelvic organ prolapse in postpartum women: ultrasound and clinical evaluations

OBJECTIVES

The purpose of this study is to examine the impact of structured pelvic floor muscle training (PFMT) on pelvic floor muscle (PFM) contraction and the treatment of pelvic organ prolapse (POP) in postpartum women.

METHODS

Sixty patients who volunteered for a PFMT assessment at 6-8 weeks after delivery were included in this retrospective analysis. For 5 weeks, all patients had structured PFMT, which included supervised daily pelvic muscle contractions, biofeedback therapy, and electrical stimulation. The main outcomes were POP stage assessed by POP quantification (POP-Q), pelvic organ position and hiatus area (HA) assessed by transperineal ultrasound, PFM contraction assessed by Modified Oxford scale (MOS), surface electromyography (EMG), and sensation of PFM graded using visual analog scale (VAS).

RESULTS

Structured PFMT was associated with better POP-Q scores in Aa, Ba, C, and D (p values were 0.01, 0.001, 0.017, and 0.001 separately). The bladder neck at rest and maximum Valsalva, the cervix position and HA at maximum Valsalva in transperineal ultrasound were significantly better than before (p values were 0.031, < 0.001, 0.043, and < 0.001 separately). PFM contraction assessed by MOS, EMG, and PFM VAS score were significantly improved (all p values were < 0.001). However, no significant improvement was observed in POP-Q stage.

CONCLUSIONS

Structured PFMT can increase PFM function in postpartum women but cannot modify the POP-Q stage. Transperineal ultrasonography is a useful method for evaluating therapy efficacy objectively. More randomized controlled trials are needed before definitive conclusions can be drawn about the effect of structured PFMT on POP in postpartum women.

Vaginal pessary: a culprit for intraperitoneal bladder perforation

Vaginal pessaries are widely considered to be a safe and effective non-surgical management option for women with pelvic organ prolapse. Complications may occur, and are more frequent with improper care and certain device designs and materials. It is imperative to provide information to patients about potential complications. We present the case of a woman in her 70s who presented to the Emergency Department with increasing groin and abdominal pain following a vaginal pessary insertion 2 days prior for grade 3 vaginal vault prolapse. On presentation, her abdomen was markedly distended with guarding. Laboratory investigations showed a significant acute kidney injury with a metabolic acidosis. An initial non-contrast CT showed fluid and inflammatory changes surrounding the bladder, and bladder perforation was suspected. A subsequent CT cystogram showed extravasation of contrast from the bladder into the peritoneal cavity, in keeping with an intraperitoneal bladder rupture. The patient underwent an emergency bladder repair in theatre.

Quality of Life after Treatment for Pelvic Organ Prolapse in Real-World Study: Recommendations, Vaginal Pessary, and Surgery

Background and Objectives: Pelvic organ prolapse (POP) is a common condition in women, with its prevalence increasing with age, and can significantly impact the quality of life (QOL) of many individuals. The objective of this study was to assess the overall improvement, quality of life, and continuation of primary treatment for POP over a 24-month period in a real-world setting. Materials and Methods: This is a prospective, observational, follow-up study of women with symptomatic POP who, as a primary treatment, opted for recommendations (lifestyle changes and pelvic floor muscle training), pessary therapy, or surgery. The primary outcome measure was a subjective improvement at the 24-month follow-up, measured with the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcome measures were the continuation rate of the primary treatment method, reason for discontinuation, and the quality of life evaluated with the P-QoL questionnaire. Results: We included 137 women, with 45 women (32.8%) in the recommendations group, 39 (28.5%) in the pessary group, and 53 women (38.7%) in the surgery group. After 24 months, surgery, in comparison with pessary treatment and recommendations, resulted in significantly more women reporting a subjective improvement: 89.6%, 66.7%, and 22.9% (p < 0.001), respectively. Overall, 52% of women from the recommendations group and 36.4% from the pessary group switched to another treatment or discontinued the primary treatment within 24 months. However, women who continued the primary treatment, pessary use, and surgery showed similar subjective improvements (90.5% and 89.6%, respectively) and quality-of-life improvement. Conclusions: The chance of significant improvement was higher following surgery. However, after 24 months, both vaginal pessaries and surgery showed an important quality-of life improvement and can be proposed as primary treatment methods for pelvic organ prolapse.

A randomized clinical trial comparing internal and external pessaries in the treatment of pelvic organ prolapse in postmenopausal women: A pilot study

INTRODUCTION AND HYPOTHESIS

Internal vaginal pessary is among the leading treatments for pelvic organ prolapse (POP); however, it has a high adverse event rate. An external pessary was recently developed as an alternative. The study's objective was to compare the efficacy of external and internal pessaries in treating POP in postmenopausal women.

METHODS

This parallel randomized (1:1 ratio) open-blind study included 40 symptomatic women with stage 2 or 3 POP. They were randomized into two groups: group 1 (internal pessary) and group 2 (external pessary) (n = 20 in each); and evaluated at the start of and 3 months after the treatment. Statistical analysis was performed to compare the results within and between the groups before and after the 3-month treatment.

RESULTS

The groups were homogeneous, except for the variables previous pregnancies (p = 0.030) and POP-Q score of apical prolapse (p = 0.023) whose values were higher in group 2. A significant improvement in quality of life was observed in both groups after 3 months of follow-up; however, internal pessaries were found to be more effective (p < 0.001). In group 1 there were differences between the initial and final POP-Q scores of anterior (0.004) and apical prolapse (p = 0.005). The complication rate associated with internal pessary use was high (p = 0.044).

CONCLUSIONS

The present data suggested that external pessaries have a similar effect to internal ones for the treatment of POP and improvement of the quality of life of postmenopausal women.

The effect of the COVID-19 lockdown on women presenting with pelvic organ prolapse

PURPOSE

To determine whether there is a difference in pelvic organ prolapse (POP) stage at time of presentation after lifting coronavirus disease (COVID-19) lockdown restrictions, as compared to before the lockdown. Enhancing our understanding of how healthcare utilization for pelvic floor disorders may be affected by limited accessibility, such as the COVID-19 pandemic, could prove invaluable for similar future circumstances.

METHODS

This is a retrospective study of women with POP at their initial visit. Patients were grouped into two cohorts based on their initial presentation time: pre-COVID-19 lockdown (before March 2020) and post-COVID-19 lockdown (after December 2020). The cohorts were compared using demographic, clinical, and surgical variables. A logistic regression controlling for confounders was used to evaluate the influence of the COVID-19 lockdown on prolapse stage.

RESULTS

There were 656 (50.3%) patients in the pre-COVID-19 lockdown cohort and 648 (49.7%) in the post-COVID-19 lockdown cohort. All baseline characteristics were similar between both cohorts except for race (p = 0.015). Treatment choices differed with the post-COVID-19 lockdown cohort having a lower proportion (26.5%) opting for surgery and a higher proportion (50.5%) of patients opting for nonsurgical interventions compared to the pre-COVID-19 lockdown cohort (p = 0.0005). A higher proportion of women presented with stages I and II prolapse in the post-COVID-19 lockdown (70.4%) cohort as compared to the pre-COVID-19 lockdown (62.5%) cohort (p = 0.002).

CONCLUSIONS

Women in the post-COVID-19 lockdown cohort presented with early stage prolapse with preference for more conservative treatment options.

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.

Enhancement of Levator Ani Muscle Strength in Postpartum Women: The Impact of Pelvic Floor Muscle Training

BACKGROUND Levator ani muscle injuries during vaginal childbirth can lead to pelvic organ prolapse (POP). Pelvic floor muscle training (PFMT) is an effective conservative approach to alleviate these symptoms. This study aimed to compare outcomes with and without 3 months of PFMT in 34 women with levator ani muscle injury following vaginal delivery. MATERIAL AND METHODS In a quasi-experimental study, 34 postpartum women were divided into 2 groups: one received PFMT along with home-based materials and regular follow-ups, while the other served as the control. We measured basal tone and maximal levator ani muscle contraction using the Peritron perineometer and assessed changes after 3 months. RESULTS The basal tone and maximal contraction of the levator ani muscle significantly increased following a 3-month intervention period both in PFMT and control group (P=0.0001). The maximal contraction of the levator ani muscle after a 3-month intervention period was significantly higher in PFMT group compared with control group (36.59±1.45 vs 27.76±13.35, P=0.0001), respectively. A significant positive correlation was found between basal tone and maximal contraction (r=0.806, P=0.0001). CONCLUSIONS A 3-month PFMT program effectively increased levator ani muscle strength in postpartum women compared to those who did not undergo PFMT.

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.

Analysis of questions by patients with pelvic organ prolapse about vaginal pessaries resulting in a checklist for their physicians

OBJECTIVE

International guidelines recommend vaginal pessaries as a first-choice treatment of symptomatic pelvic organ prolapse (POP). Gynecologists rarely receive systematic training or just do not take the time to communicate with their patients. We hypothesized that we could identify key deficits and limitations of counseling before or during pessary therapy from questions directed to manufacturers with the aim to improve and promote health literacy of women with POP.

METHODS

We approached five manufacturers to provide anonymized inquiries related to pessary use. After exclusion of duplicates and questions about obstetric pessaries, 174 data sets from 145 patients remained.

RESULTS

In 19/145 patients (13.1%), a 2nd degree, and in 94/145 (64.8%), a 3rd-4th degree of POP was identified. Four patients had additional urinary incontinence. In 32/145 (22.1%), the severity of POP could not be identified. The age of patients ranged from 27 to 98 (mean = 63.7) years. Most inquiries were related to the selected pessary models or sizes (40/174; 22.9%), self-management (20/174; 11.5%), and technical aspects such as shelf life or appropriate cleaning (26/174; 14.9%). Pain or voiding dysfunction was present in 17/174 remarks (9.7%). Lifestyle questions related to the use of pessaries during sport, menstruation, or mechanical anticonception. The cube pessary was in the focus of interest followed by the sieve bowl, urethra, ring, and Gellhorn device. The list of questions was summarized as a checklist stratified according to priorities.

CONCLUSION

The checklist should help improve counseling and self-management of patients to optimize the benefit/risk ratio of conservative treatment of pelvic floor diseases.

Adherence to support pessary in the treatment of pelvic organ prolapse: a retrospective study conducted among 1,371 women

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the adherence to pessary treatment in women with pelvic organ prolapse (POP) who were found eligible for this treatment by the urogynecologist, at the first visit at the Department of Gynecology and Obstetrics, Odense University Hospital.

METHODS

Data were extracted from the women's medical records. Frequency tabulations were performed to describe the women's reasons for pessary discontinuation by age group. Binominal logistic regression analysis was conducted to investigate how women's age, POP characteristics, urogynecological history, and their pessary experience and management were associated with continued pessary use.

RESULTS

This study included 1,371 women treated with support pessary. Of these, 850 women continued pessary treatment and 521 women underwent surgical treatment. A history of hysterectomy (OR: 0.68, 95% CI: 0.51-0.90, p = 0.008), urinary incontinence (OR: 0.71, 95% CI: 0.56-0.89, p = 0.003), and previous pessary use (OR: 0.75, 95% CI: 0.56-0.99, p = 0.047) were significant factors associated with discontinuation. Further, women aged 81-99 years were significantly more likely to continue pessary treatment (OR: 1.77, 95% CI: 1.15-2.74, p = 0.009). "POP surgery," "prolapse stage," and "prolapse predominant compartment" were not associated with discontinuation. Approximately 38% of women aged 26-54 years discontinued owing to personal preference.

CONCLUSIONS

Hysterectomy, incontinence, and previous pessary use are significant predictors of pessary discontinuation. Increasing age is significantly associated with pessary continuation.

Pelvic organ prolapse: Women's experiences of Accessing Care & Recommendations for improvement

Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life.Many women with POP symptoms present initially to primary care settings. Research has shown these interactions are often unsatisfactory, with women reporting their health care professional (HCP) trivialized their symptoms or appeared to have poor knowledge about pelvic floor dysfunction (PFD).Aim The aim of this qualitative study was to explore experiences of younger women seeking treatment for POP and their recommendations for improvements.Methods Ethics approval was obtained (LS-21-01-Carroll-Ful). Women with POP were recruited from an online support group (n = 930 members). Inclusion criteria: adult women, diagnosed with POP and aware of their POP stage. Following informed consent, a demographic questionnaire, interview questions and the Central Sensitization Inventory (CSI) were forwarded. Semi-structured zoom audio-recorded interviews were conducted. Thematic analysis was undertaken; transcripts coded, and themes identified.Results Fourteen women aged 32-41, parity 1-3, with POP Grade 1-3 participated. Many women reported HCPs as dismissive or not appreciative of the impact of their condition. Others described interactions with HCPs who they felt listened, understood the impact of their POP, gave simple explanations, a positive prognosis and outlined a realistic treatment plan.Current antenatal education, post-partum care and primary HCP screening for PFD were identified by women as deficient. Many highlighted delays in accessing specialist care for POP. Women made several recommendations for improvements to the current model of care.Conclusions Increased focus on person-centred care, particularly emotional support, information and education may improve younger women's experiences when seeking care for POP.

Long-term adherence to pessary use in women with pelvic organ prolapse: A retrospective cohort study

PURPOSE OF THE RESEARCH

Vaginal pessary use is an established, non-surgical treatment option for pelvic organ prolapse. While satisfaction rates are initially high, they seem to decline over time. We aimed to determine the median duration of pessary use among our patients and to evaluate reasons for discontinuation.

METHODS

All patients who were treated with a vaginal pessary for pelvic organ prolapse between 2007 and 2022 at our institution (a maximum observation period of 15 years) were included in this retrospective cohort study. Data were collected from the in-house electronic databases and the date of pelvic floor surgery was defined as the primary endpoint. In case of no documented surgery, the date of the last follow-up visit (for patients lost to follow-up or who discontinued pessary use without subsequent surgery) or the date of final data collection (for those with presumed continued pessary use) was used as the primary endpoint. Duration of pessary use is represented by Kaplan-Meier curves. Effects of possible confounders were investigated by Cox regression models. A Cox regression model was evaluated for patients with the three most common types of pessary: ring, cube and shell. A chi-square test was performed to compare therapy adherence according to pessary type.

PRINCIPAL RESULTS

Data of 779 patients could be included in the statistical analysis. The estimated median duration of pessary use was 173 weeks (95 % CI 104-473) - approximately 3.3 years. Overall, 30 % of patients opted for surgical therapy and the majority of them did so within 4 months of initiation of pessary use (median time: 19 weeks, 95 % CI 16-26). In 5 % of cases a discontinuation of pessary use without subsequent surgery was documented and 18 % were lost to follow-up before a planned visit, thus leaving 47 % of our patients with presumed continued pessary use. Possible confounding factors for discontinuation of pessary use were tested but were found to be non-significant (body mass index, Pelvic Organ Prolapse - Quantification score, pelvic floor training, age, parity, menopausal status, nicotine consumption, incontinence or size of pessary). Reasons for discontinuation of pessary use were documented in 51 % of patients: unspecified patient wish (23 %), pessary use tiredness (10 %), general dissatisfaction with pessary therapy (7 %), unspecified reasons (5 %), pessary self-change not possible (1 %), erosion, bleeding, pain (2 %); none of the pessary types fitted (2 %).

CONCLUSIONS

According to our data, almost half of our patients with pelvic organ prolapse and pessary therapy continued pessary use until a maximum follow-up time of 15 years, whereas about one-third of patients finally opted for surgical repair (a majority of these within 4 months after pessary therapy initiation). The remaining patients were either lost to follow-up or discontinued pessary use without subsequent surgery. The stated reasons for discontinuation of pessary use were mostly non-specific, but only 1 % reported that pessary self-change was not possible. Erosion bleeding or pain was documented in only 2 % of cases as reason for discontinuation. This information helps clinicians to inform their patients with pelvic organ prolapse about expected pessary therapy success and strengthens individual counselling. Furthermore, our data indicates vaginal pessary use for pelvic organ prolapse is feasible and safe for all women and that therapy adherence can extend beyond 5 years.

Are older patients with prolapse likely to continue pessary use? A retrospective observational study

INTRODUCTION AND HYPOTHESIS

To review the outcomes and complications of vaginal prolapse management with pessaries in women aged 75 years or older, to ascertain whether pessaries are providing satisfactory long-term outcomes for older women.

METHODS

A retrospective observational study was performed on women aged 75 years or older presenting to a tertiary Urogynaecology service with vaginal prolapse who opted for management with a vaginal pessary. Demographic and clinical data were collected by reviewing clinical files. The primary outcome was the proportion of women who opted for pessary management who later required prolapse surgery. Secondary outcomes included pessary complications and risk factors for failure. Kaplan-Meier survival estimates were performed to analyse pessary failure.

RESULTS

Of the 218 women who presented with prolapse, 78% opted for pessary management, and pessary fitting was successful in 84%. Sixty-nine percent of women who opted for initial pessary management underwent surgery later, with a mean time from pessary insertion to surgery of 21.6 months. Vaginal erosions were reported in 42% of pessary users. Risk factors for pessary failure were younger age and previous history of hysterectomy or prolapse surgery.

CONCLUSIONS

Although vaginal pessary use was the preferred first-line management choice for vaginal prolapse in most older women, surgery for prolapse was ultimately required in two-thirds of those conservatively managed. As three-quarters of older women presenting with prolapse had surgery as either a primary or secondary procedure; patients need to be advised of the high chance of requiring surgery at a later stage if they opt for pessary management.

Effectiveness of exercise interventions on urinary incontinence and pelvic organ prolapse in pregnant and postpartum women: umbrella review and clinical guideline development

INTRODUCTION AND AIMS

Dysfunction related to pelvic floor muscles (PFM) is common among pregnant and postpartum women and can cause symptoms such as urinary incontinence or pelvic organ prolapse (POP). As part of developing a nationwide clinical practice guideline for nursing in Finland, the aim of this umbrella review is to summarize the existing evidence about the effectiveness of exercise interventions on urinary incontinence and POP in pregnant and postpartum women. To promote knowledge translation, recommendations for health care professionals are presented.

METHODS

We conducted an umbrella review to summarize the existing evidence. The JBI methodology for umbrella reviews was used to guide the review. The level of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, and recommendations based on the evidence were formulated by a clinical guideline working group.

RESULTS

Altogether, 9 systematic reviews, reporting findings from 89 original studies, were included. The methodological quality of the reviews was evaluated using JBI's checklist. The highest level of evidence was found for preventing the symptoms of postpartum urinary incontinence through exercise and pelvic floor muscle training (PFMT) during pregnancy. Moderate-level evidence showed that exercise and PFMT are likely to reduce the symptoms and severity of urinary incontinence, but the level of evidence was low on PFMT reducing the symptoms of POP.

CONCLUSION

We recommend encouraging and guiding pregnant and postpartum women to exercise and train PFM. We also recommend identifying pregnant and postpartum women with symptoms of PFM dysfunction and directing them to a physiotherapist or other health care professional specializing in pelvic floor function.

Effect of radiofrequency combined with magnetic stimulation on mild and moderate pelvic organ prolapse

OBJECTIVES

The efficacy of using a single electrical or magnetic stimulation for treating pelvic floor dysfunction is limited. This study aims to investigate the efficacy of radiofrequency combined with magnetic stimulation treatment for mild to moderate pelvic organ prolapse.

METHODS

Patients who completed the treatment in the Third Xiangya Hospital, Central South University were screened, and were divided into 2 groups based on different treatment plans. There were 28 patients who completed magnetic stimulation therapy (the magnetic stimulation therapy group) and 21 patients who completed radiofrequency combined with magnetic stimulation therapy (the combined treatment group). The pelvic organ prolapse quantitation (POP-Q), pelvic floor muscle strength, and pelvic floor ultrasound results were analyzed to assess the efficacy before and after the treatment in both groups, and the POP-Q results of 3 months after the treatment were used to evaluate the maintenance effect of the treatment mode.

RESULTS

The POP-Q evaluation results of Aa, Ap, and C points after the treatment in both groups were better than those before the treatment, with statistical significance (all P<0.05). The Aa point POP-Q result of the combined treatment group was better than that of the magnetic stimulation therapy group, with statistical significance (P<0.05). Pelvic floor ultrasound evaluation showed that the bladder neck position during the valsalva maneuver in the combined treatment group was higher than that in the magnetic stimulation treatment group, with statistical significance (P<0.05). The persistence effect of the combined treatment group was long better than that of the magnetic stimulation treatment group, with significant statistical significance (P<0.01).

CONCLUSIONS

The combined treatment is more effective and has a longer lasting effect than single magnetic stimulation treatment.

The usage of Gellhorn pessary in pelvic organ prolapse and in regards to success, continuity of use and effect on symptoms: a retrospective study of 2 years

INTRODUCTION

Pelvic organ prolapse (POP) is a condition involving weakened pelvic floor muscles causing organs to protrude. Conservative POP treatment comprises pelvic floor exercises and vaginal pessaries. Besides conservative care, surgery is offered. However, surgery is invasive, risky and unsuitable for those with serious medical conditions. This study aims to assess the acceptance, success and outcomes of the Gellhorn pessary for POP treatment, especially in advanced cases.

MATERIALS AND METHODS

The present study is a retrospective cohort study using hospital medical records (patient files) from October 2019 to November 2021 (for 2 years). This study was performed in Malaysian women (n=53) suffering from advanced stages of POP, in which Gellhorn pessaries of diameter (44-76mm) were inserted by trained personnel. Pelvic Floor Distress Inventory-20 (PFDI-20) and Pelvic Floor Impact Questionnaire-7 (PFIQ-7) were used to measure patients' symptoms and quality of life before and after Gellhorn pessary fitting. Patients were reassessed every three months for two years and their satisfaction scores were recorded.

RESULTS

We observed a significant difference in pre-test (pre-fitting) and post-test (three months post-fitting) scores on all three subscales and the PFIQ-7 total score. Twentyeight (52.83%) patients continued the use of Gellhorn pessary for at least 24 months, whereas 25 (47.20%) patients discontinued during this period. A retrospective analysis of the patients who discontinued Gellhorn pessary showed that 13 (24.52%) patients gave up the use of pessary for definitive surgery. It is noteworthy to mention here that only one out of the 13 patients who were awaiting surgery, chose surgery and the remaining 12 changed their mind after being fitted with the Gellhorn pessary. Seven (13.20%) patients declined reinsertion due to discomfort and voiding difficulties and refused further intervention, whereas three (5.66%) patients requested a ring pessary. Two (3.77%) patients, requested the removal of pessary due to vesicovaginal fistula and rectovaginal fistula (caused by an impacted pessary). The rate of continued use was 79.24% (42 patients) after 1st year and 52.83% (28 patients) at the end of two years.

CONCLUSION

In the current study, the Gellhorn pessary was used to treat stage 3 and 4 POP with significant symptom reduction post-fitting. More than half of the patients continued to use the pessary after 24 months of fitting. Therefore, the Gellhorn pessary can be used as a treatment strategy for stage 3 and 4 POP with reasonable acceptance in the Malaysian population.

Awareness of pelvic organ prolapse and attitude towards its treatment among Malaysian women

INTRODUCTION

The aim of this study is to determine the level of awareness of pelvic organ prolapse (POP) and factors that influence the attitude towards the treatment of POP among Malaysian women.

MATERIALS AND METHODS

This was a cross-sectional study of 400 women from registered non-government organisations (NGOs) in Malaysia who voluntarily answered questionnaires distributed through Google form via emails. Data were analysed using descriptive statistics, independent t-test and one-way ANOVA test.

RESULTS

Four hundred respondents participated in this study. The mean age was 40.42 years old (SD=12.566). The mean score for the studied population was 4.96 (SEM 0.124). Only 58 (14.5%) respondents obtained a score of eight or more, and 235 (58.8%) respondents scored between 4 and 7. The rest of 107 (26.7%) respondents scored 3 and less. There were statistically significant differences in the mean score for level of awareness between marital statuses, menopausal status, number of children and occupation. There were only 273 (68%) respondents who will seek treatment if they experience symptoms of POP. The most frequent reasons for not seeking treatment were unawareness of the availability of medical treatment for POP (69 %).

CONCLUSION

Majority of the respondents have an inadequate level of awareness on POP. Although more than half of the respondents will seek treatment if they experience symptoms of POP, concerns raised by those who chose not to seek treatment should be addressed by a more effective public awareness programme. This includes the unawareness of the availability of medical treatment and the embarrassment to see medical practitioners.

Posterior compartment prolapse and perineal descent: systematic review of available support devices

OBJECTIVE

The aim of our study is to systematically review the literature about available devices facilitating perineal support during defecation in patients with obstructive defecation syndrome (ODS) and posterior pelvic organ prolapse (POP).

METHODS

We searched for the terms "defecat/ion or ODS" and" pessar/ies or device/aid/tool/perineal/perianal/prolapse and support" in MEDLINE, PubMed and Web of Science. Data abstraction was performed according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analysis) guidelines. A two-stage inclusion was performed, selecting first on title and abstract and secondly the full text. For variables with sufficient data, a meta-analysis was performed using a random-effects model. Other variables were descriptively reported.

RESULTS

Ten studies out of 1332 were included for systematic review. The devices could be categorized into three groups: pessaries (n = 8), vaginal stent (n = 1) and external support device (n = 1). Methodology and data reporting is heterogeneous. Meta-analysis could be performed for the Colorectal-Anal Distress Inventory (CRADI-8) and Impact Questionnaire (CRAI-Q-7) in three pessary studies which showed a significant mean change. Significant improvement of stool evacuation was seen in two other pessary studies. The vaginal stent significantly decreases ODS. Subjective perception of constipation improved significantly using the posterior perineal support device.

CONCLUSION

All reviewed devices seem to improve ODS in patients with POP. There are no data on their efficacy with regard to perineal descent-associated ODS. There is a lack of comparative studies between devices. Studies are difficult to compare due to different inclusion criteria and evaluation tools.

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.

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.

Tailor-made three-dimensional printing vaginal pessary to treat pelvic organ prolapse: a pilot study

OBJECTIVE

This study aimed to apply three-dimensional (3D) printing technology to treat women with pelvic organ prolapse (POP) and to evaluate efficacy based on the improvement by quality of life (QOL) questionnaires.

METHODS

This was a pilot study at a tertiary urogynecology unit in Taiwan. Between January 2021 and June 6, 2021, participants who opted for self-management using Gellhorn pessaries to treat symptomatic POP were enrolled. For each woman, the original Gellhorn pessary was placed into the vagina to restore the prolapsed tissues and under transvaginal ultrasound guided to evaluate the gap which the Gellhorn pessary cannot cover. Otoform (an impression silicone) was used to make a model and have it hooked onto Gellhorn pessary (template). We collected templates and then applied 3D printing to customize the silicone vaginal pessary. All women completed multiple validated QOL questionnaires at baseline and at 3 and 6 months.

RESULTS

Six women completed the study. The QOL questionnaires revealed significant improvements across the board.

CONCLUSIONS

Our study demonstrates that a tailor made 3D pessary can be used for women with POP. A customized pessary can be made with the help of transvaginal ultrasound and 3D printing technology.

Patient-Specific Pessaries for Pelvic Organ Prolapse Using Three-Dimensional Printing: A Pilot Study

IMPORTANCE

Vaginal pessaries are an effective nonsurgical treatment for pelvic organ prolapse (POP) when properly fitted. However, pessary fitting and use are often unsuccessful or imperfect.

OBJECTIVE

The objective of this study was to assess the feasibility of using patient-specific pessaries fabricated from three-dimensional (3D)-printed molds to improve POP symptoms and increase overall satisfaction of pessary treatment in patients using standard vaginal pessaries.

STUDY DESIGN

Patients undergoing POP treatment with standard vaginal pessaries were enrolled in this pilot prospective study. Patient-specific pessaries were designed and fabricated for each patient using patient input, physician input, and anatomic measurements from clinical assessment. Pessary fabrication involved injection of biocompatible liquid silicone rubber into 3D-printed molds followed by a biocompatible silicone coating. Pelvic organ prolapse symptomatic distress and pessary treatment satisfaction were evaluated before and after a 3-week patient-specific pessary home trial using the validated Pelvic Organ Prolapse Distress Inventory-6 form and a visual analog scale, respectively.

RESULTS

Eight women were included in this study. Changing from standard pessary to patient-specific pessary treatment was associated with an improvement in prolapse symptoms on the Pelvic Organ Prolapse Distress Inventory-6 (median change, -3.5; interquartile range, -5 to -2.5; P = 0.02) and an increase in overall pessary satisfaction on a visual analog scale (median change, +2.0; interquartile range, +1.0 to +3.0; P = 0.02). All patients reported either an improvement or no change in pessary ease of use, comfort, and the feeling of support provided by the pessary.

CONCLUSION

Patient-specific vaginal pessaries are a promising alternative to standard pessaries for alleviating POP symptoms and improving patient satisfaction with pessary use.

Exploring the experiences of people with urogynaecology conditions in the UK: a reflexive thematic analysis and conceptual model

BACKGROUND

Urogynaecological conditions, such as pelvic organ prolapse, urinary incontinence, and urinary tract infection, can have a profound impact on people's lives. The Independent Medicines and Medical Devices Safety Review highlights missed opportunities to prevent harm when patient voices are not incorporated into healthcare policy and practice. This resonates with the Women's Health Strategy for England. The National Institute for Health and Care Research (NIHR) Policy Research Programme funded this in-depth qualitative exploration of people's experiences of living with urogynaecological conditions, and of seeking healthcare treatment, to inform health and social care improvements in the UK.

METHODS

We conducted in-depth interviews online or by telephone (April 2021-December 2021) and used reflexive thematic analysis to develop themes that cut across urogynaecological conditions.

RESULTS

We spoke to seventy-four adults aged 22-84 across a range of backgrounds and lived experiences of urogynaecological conditions, including pelvic organ prolapse, urinary incontinence and persistent or recurring urinary tract infection. Eight themes were developed: [1] I get no respite from my own body; [2] I feel confined and separated; [3] I can no longer be 'me'; [4] I am constrained by stigma, shame and silence; [5] I feel fragmented and lost in the healthcare system; [6] I need to be heard, believed, and valued; [7] I need respect as an equal partner in healthcare; and [8] (Re)connected to a more open community.

CONCLUSIONS

High quality care focuses on the whole person rather than their body parts. Openness and candour support a shared decision-making model of care. A culture of shame can have a negative impact on access to health care and recovery.

Pelvic floor dysfunction and obesity

Obesity is a growing condition within the society and more patients, who have underlying obesity, are presenting with lower urinary tract symptoms (LUTS) and pelvic floor dysfunction (PFD). The effect of obesity on general health has been well documented, and its impact on the cardiovascular, endocrine, and musculoskeletal systems has been extensively studied. There is now a growing body of evidence on the effects of obesity on the female urogenital system. It seems to influence the prevalence, presentation, assessment, management, and outcome of various types of LUTS and PFD. A holistic approach is needed to assess and manage these patients. A clear understanding of the functions of the pelvic floor and the way it can be affected by obesity is essential in providing holistic care to this group. A frank discussion about patient weight is required in the clinics handling PFD. A multimodal approach to weight loss would help improve PFD symptoms and progression. Patients with obesity should still be offered standard treatment options for all PFDs and should not be forced to lose weight as a prerequisite before starting treatment. However, they should also be made aware of the impediments that being overweight adds to their care and their expectations should be managed accordingly.

Women's attitudes towards pessary self-care: a qualitative study

INTRODUCTION AND HYPOTHESIS

Patients with vaginal pessaries can learn to care for their pessary by themselves or they can have provider-led care, which requires more frequent follow-up visits. We aimed to understand motivations for and barriers to learning self-care of a pessary to inform strategies to promote pessary self-care.

METHODS

In this qualitative study, we recruited patients recently fitted with a pessary for stress incontinence or pelvic organ prolapse, and providers who perform pessary fittings. Semi-structured, one-on-one interviews were completed to data saturation. A constructivist approach to thematic analysis using the constant comparison method was used to analyze interviews. A coding frame was created following independent review of a subset of interviews by three members of the research team and this frame was used to code interviews and develop themes through interpretive engagement with the data.

RESULTS

Ten pessary users and four health care providers (physicians and nurses) participated. Three major themes were identified: motivators, benefits, and barriers. There were several motivators for learning self-care, including care provider advice, personal hygiene, and ease of care. Benefits of learning self-care included autonomy, convenience, facilitation of sexual relations, avoidance of complications, and decreased burden on the health care system. Barriers to self-care included physical, structural, mental, and emotional barriers; lack of knowledge; lack of time; and social taboo.

CONCLUSIONS

Promotion of pessary self-care should focus on patient education about benefits and ways of mitigating common barriers while focusing on normalizing patient engagement in pessary self-care.

Adverse events associated with pessary use over one year among women attending a pessary care clinic

INTRODUCTION AND HYPOTHESIS

The primary objective was to determine the adverse event rate associated with pessary use. Secondary objectives were to determine discontinuation, patient satisfaction, and factors associated with adverse events.

METHODS

A retrospective observational study included patients attending a nurse-led pessary clinic with ≥ 1 year follow-up. Patients were fitted with a pessary by a urogynecologist and pessary care by a nurse was performed every 3-4 months. Demographic characteristics, pessary fitting, adverse events, their management and discontinuation were recorded. Pearson Chi-square and Fisher exact tests assessed the association between predetermined risk factors and pessary complications or discontinuation. Relative risk and 95% confidence intervals were computed.

RESULTS

215 women were followed for a mean (standard deviation) of 4.4 (1.9) years. Mean age was 73.8 (8.7) years. Adverse event rate was 83.7%; most commonly vaginal discharge, vaginal bleeding and erosions. Women with cardiovascular risk factors were less likely to develop pessary-related adverse events (79.7% vs. 91.9%, p = 0.03). Gellhorn and donut pessaries were more commonly associated with pessary erosions than ring with support pessaries or incontinence rings (RR 2.37 [1.67; 3.38]). Thirty-five (16.3%) women discontinued pessary use at a mean of 3.3 (1.7) years after initial fitting. Having a pessary erosion was not associated with discontinuation (p = 0.698), but recurrent erosions were (p = 0.012).

CONCLUSION

Adverse events were common among women continuing to use pessaries past 1 year, but adherence and satisfaction rates remained high after 4.4 years. Pessary type and absence of cardiovascular factors were associated with pessary-related adverse events.

Sexual function after energy-based treatments of women with urinary incontinence. A systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) affects approximately 50% of adult women worldwide and is associated with declining sexual function (SF). Energy-based devices emerged as a minimally invasive alternative treatment. Nevertheless, their effect on sexuality is uncertain. We hypothesize that the UI energy treatment can lead to sexual function improvement.

METHODS

A search was performed in PubMed, Cochrane Library, Web of Science, Embase, and Scopus for randomized clinical trials (RCTs) and nonrandomized studies of intervention, which treated incontinent women using energy, with UI and sexual function (SF) as outcomes. Severe comorbidities, pelvic organ prolapse (POP)> grade 2, and use of medication to treat UI or that affects SF were excluded. Quality assessment and meta-analysis were performed.

RESULTS

From 322 articles, 11 RCTs were included for qualitative analysis. UI symptoms improved in all studies. Regarding SF, RCT with premenopausal women showed improvement in SF in the Er:Yag group (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 and Female Sexual Function Index). A prospective study showed improvement in SF independent of the grade of SUI. RF showed benefits for SF but was not superior to pelvic floor muscle training. One nonrandomized study of intervention with a High-Intensity Focused Electromagnetic Field showed significant improvement of SF in the Golombok Rust Inventory of Sexual Satisfaction total score, a decline in pain and dissatisfaction domains. Meta-analysis with 4 RCTs and 2 nonrandomized studies found no difference between groups (0.26 (95% CI -0.67 to 1.20, and -0.74 (95% CI -3.78 to 2.30) respectively).

CONCLUSIONS

This meta-analysis did not confirm that energy equipment improved the SF of women with UI.

Patient-Reported Outcome Measures for Use in Women With Pelvic Organ Prolapse: A Systematic Review

OBJECTIVE

To describe the psychometric properties of existing patient-reported outcome measures for women with prolapse using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) framework. Additional objectives were to describe the patient-reported outcome scoring method or interpretation, methods of administration, and to compile a list of the non-English languages in which the patient-reported outcomes are reportedly validated.

DATA SOURCES

PubMed and EMBASE was searched through September 2021. Study characteristics, patient-reported outcome details, and psychometric testing data were extracted. Methodologic quality was assessed with COSMIN guidelines.

METHODS OF STUDY SELECTION

Studies reporting the validation of a patient-reported outcome in women with prolapse (or women with pelvic floor disorders that included a prolapse assessment) and reporting psychometric testing data on English-language patient-reported outcome for at least one measurement property per COSMIN and the U.S. Department of Health and Human Services definitions were included, as well as studies reporting the translation of an existing patient-reported outcome into another language, a new method of patient-reported outcome administration, or a scoring interpretation. Studies reporting only pretreatment and posttreatment scores, only content or face validity, or only findings for nonprolapse domains of the patient-reported outcome were excluded.

TABULATION, INTEGRATION, AND RESULTS

Fifty-four studies covering 32 patient-reported outcomes were included; 106 studies assessing translation into a non-English language were excluded from the formal review. The number of validation studies per patient-reported outcome (one version of one questionnaire) ranged from 1 to 11. Reliability was the most reported measurement property, and most measurement properties received an average rating of sufficient. The condition-specific patient-reported outcomes had on average more studies and reported data across more measurement properties compared with adapted and generic patient-reported outcomes.

CONCLUSION

Although measurement property data vary on patient-reported outcomes for women with prolapse, most data were of good quality. Overall, condition-specific patient-reported outcomes had more studies and reported data across more measurement properties.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021278796.

Urinary Incontinence and Pelvic Organ Prolapse in Women

BACKGROUND

Pelvic floor disorders are common, especially in pregnancy and after delivery, in the postmenopausal period, and old age, and they can significantly impact on the patient's quality of life.

METHODS

This narrative review is based on publications retrieved by a selective search of the literature, with special consideration to original articles and AWMF guidelines.

RESULTS

Pelvic floor physiotherapy (evidence level [EL] 1), the use of pessaries (EL2), and local estrogen therapy can help alleviate stress/urge urinary incontinence and other symptoms of urogenital prolapse. Physiotherapy can reduce urinary incontinence by 62% during pregnancy and by 29% 3-6 months post partum. Anticholinergic and β-sympathomimetic drugs are indicated for the treatment of an overactive bladder with or without urinary urge incontinence (EL1). For patients with stress urinary incontinence, selective serotonin-noradrenaline reuptake inhibitors can be prescribed (EL1). The tension-free tape is the current standard of surgical treatment (EL1); in an observational follow-up study, 87.2% of patients were satisfied with the outcome 17 years after surgery. Fascial reconstruction techniques are indicated for the treatment of primary pelvic organ prolapse, and mesh-based surgical procedures for recurrences and severe prolapse (EL1).

CONCLUSION

Urogynecological symptoms should be specifically asked about by physicians of all relevant specialties; if present, they should be treated conservatively at first. Structured surgical techniques with and without mesh are available for the treatment of urinary incontinence and pelvic organ prolapse. Preventive measures against pelvic floor dysfunction should be offered during pregnancy and post partum.

Are hypopressive and other exercise programs effective for the treatment of pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS

Pelvic floor muscle training (PFMT) is effective for the treatment of pelvic organ prolapse (POP), but other exercise programs have also been promoted and used. The aim of this review was to evaluate the effect of hypopressive and other exercise programs besides PFMT for POP.

METHODS

A literature search was conducted on Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro, and Scopus databases from January 1996 to 30 December 2021. Only randomized controlled trials (RCTs) were included. The keywords were combinations of "pelvic organ prolapse" or "urogenital prolapse," and "exercise therapy," "hypopressive exercise," "Kegel," "pelvic floor muscle training," "pelvic floor muscle exercises," "Pilates," "treatment," "yoga," "Tai Chi." Methodological quality was assessed using the PEDro rating scale (0-10).

RESULTS

Seven RCTs containing hypopressive exercise, yoga or breathing and hip muscle exercises in an inverted position were retrieved and analyzed. PEDro score ranged from 4 to 7. There was no additional effect of adding hypopressive exercise to PFMT, and PFMT was more effective than hypopressive exercise alone. The studies that included the term "yoga" included regular PFMT and thus can be classified as PFMT. Hip exercises in an inverted position added to PFMT vs PFMT alone showed better improvement in some secondary outcomes but not in the primary outcome, POP stage.

CONCLUSIONS

There are few RCTs assessing the effects of other exercise programs besides PFMT in the treatment of POP. To date, there is no evidence that other exercise programs are more effective than PFMT for POP.

Long-term effects and costs of pelvic floor muscle training for prolapse: trial follow-up record-linkage study

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse affects around 40% of women aged over 50 years. A multicentre parallel group randomised trial (the Pelvic Organ Prolapse PhysiotherapY (POPPY) trial) demonstrated that pelvic floor muscle training (PFMT) was effective in reducing prolapse symptoms compared with no treatment. However, insight into the long-term impact of PFMT on health outcomes and health-service utilisation is scarce.

METHODS

This study utilised linkage of Scottish administrative health records to follow-up POPPY trial participants resident in Scotland over 11 years. Mixed effects logistic regression determined the likelihood of receiving further prolapse treatment for those in the PFMT and control groups. Analyses were adjusted for age group, prolapse stage, baseline symptom severity and attitude towards surgery. A cost assessment estimated longitudinal costs to the UK National Health Service (in Scotland) of accessing further prolapse treatment for each trial group.

RESULTS

Two hundred and ninety-three women, aged 25 to 79 years, were followed up. One hundred and forty-one women (48.1%) had received further prolapse treatment: 65 (of 149; 43.6%) in the PFMT group compared with 76 (of 144; 52.8%) in the control group. PFMT was associated with a reduction in the odds of any prolapse treatment during follow-up (AOR 0.61; 95% CI 0.37 to 0.99). Total cost of secondary care was £154,544 (GBP) in the PFMT group and £172,549 (GBP) in the control group.

CONCLUSIONS

Although PFMT did not lead to significant differences in total costs for further prolapse treatment over a post-intervention period of more than 10 years, it reduced the overall long-term risk of requiring hospital-based treatment for pelvic floor disorders.

Effects of interferential current stimulation in women with pelvic organ prolapse: a prospective randomized sham-controlled study

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the effects of interferential (IF) current stimulation on pelvic floor symptoms, prolapse stages, pelvic floor muscle (PFM) strength/endurance, quality of life (QoL), sexual function, perception of subjective improvement (PSI), and satisfaction in women with pelvic organ prolapse (POP).

METHODS

The patients were randomly divided into the IF (n=13) and sham groups (n=12). Lifestyle advice was given in both groups. Active IF current was applied in the IF group and sham IF was applied in the sham group 3 days a week for 8 weeks. The following tools were used for data evaluation: pelvic floor symptom severity with the Pelvic Floor Distress Inventory-20 (PFDI-20), POP with the simplified POP-quantification system, PFM strength/endurance with a perineometer, QoL with the Prolapse Quality of Life Scale (P-QoL), and sexual function with the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Scale (PISQ-12). Evaluations were made before treatment (BT), mid-term (MT, 4th week), and after treatment (AT). PSI and satisfaction were evaluated AT with Likert-type scales.

RESULTS

In the intergroup comparison AT, a greater increase in PFM strength/endurance, P-QoL-role limitations, P-QoL-sleep/energy scores, PSI, and satisfaction level, and a decrease in cystocele stages were observed in the IF group than in the sham group (p<0.05). Further, there was a greater increase in PFM endurance in the IF group in MT (p<0.05).

CONCLUSIONS

Interferential current stimulation was effective in improving POP stage, PFM strength/endurance, and QoL in women with POP. IF current stimulation can be used as a complementary treatment method in women with POP.

Effect of Pessary vs Surgery on Patient-Reported Improvement in Patients With Symptomatic Pelvic Organ Prolapse: A Randomized Clinical Trial

IMPORTANCE

Pelvic organ prolapse is a prevalent condition among women that negatively affects their quality of life. With increasing life expectancy, the global need for cost-effective care for women with pelvic organ prolapse will continue to increase.

OBJECTIVE

To investigate whether treatment with a pessary is noninferior to surgery among patients with symptomatic pelvic organ prolapse.

DESIGN, SETTING, AND PARTICIPANTS

The PEOPLE project was a noninferiority randomized clinical trial conducted in 21 participating hospitals in the Netherlands. A total of 1605 women with symptomatic stage 2 or greater pelvic organ prolapse were requested to participate between March 2015 through November 2019; 440 gave informed consent. Final 24-month follow-up ended at June 30, 2022.

INTERVENTIONS

Two hundred eighteen participants were randomized to receive pessary treatment and 222 to surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was subjective patient-reported improvement at 24 months, measured with the Patient Global Impression of Improvement scale, a 7-point Likert scale ranging from very much better to very much worse. This scale was dichotomized as successful, defined as much better or very much better, vs nonsuccessful treatment. The noninferiority margin was set at 10 percentage points risk difference. Data of crossover between therapies and adverse events were captured.

RESULTS

Among 440 patients who were randomized (mean [SD] age, 64.7 [9.29] years), 173 (79.3%) in the pessary group and 162 (73.3%) in the surgery group completed the trial at 24 months. In the population, analyzed as randomized, subjective improvement was reported by 132 of 173 (76.3%) in the pessary group vs 132 of 162 (81.5%) in the surgery group (risk difference, -6.1% [1-sided 95% CI, -12.7 to ∞]; P value for noninferiority, .16). The per-protocol analysis showed a similar result for subjective improvement with 52 of 74 (70.3%) in the pessary group vs 125 of 150 (83.3%) in the surgery group (risk difference, -13.1% [1-sided 95% CI, -23.0 to ∞]; P value for noninferiority, .69). Crossover from pessary to surgery occurred among 118 of 218 (54.1%) participants. The most common adverse event among pessary users was discomfort (42.7%) vs urinary tract infection (9%) following surgery.

CONCLUSIONS AND RELEVANCE

Among patients with symptomatic pelvic organ prolapse, an initial strategy of pessary therapy, compared with surgery, did not meet criteria for noninferiority with regard to patient-reported improvement at 24 months. Interpretation is limited by loss to follow-up and the large amount of participant crossover from pessary therapy to surgery.

TRIAL REGISTRATION

Netherlands Trial Register Identifier: NTR4883.

Natural history of lower urinary tract symptoms in treatment-seeking women with pelvic organ prolapse; the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN)

BACKGROUND

The association of pelvic organ prolapse with overactive bladder and other lower urinary tract symptoms, and the natural history of those symptoms are not well characterized. Previous cross-sectional studies demonstrated conflicting relationships between prolapse and lower urinary tract symptoms.

OBJECTIVE

This study primarily aimed to determine the baseline association between lower urinary tract symptoms and prolapse and to assess longitudinal differences in symptoms over 12 months in women with and without prolapse. Secondary aims were to explore associations between lower urinary tract symptoms and prolapse treatment. We hypothesized that: (1) prolapse is associated with the presence of lower urinary tract symptoms, (2) lower urinary tract symptoms are stable over time in patients with and without prolapse, and (3) prolapse treatment is associated with lower urinary tract symptom improvement.

STUDY DESIGN

Women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study with adequate 12-month follow-up data were included. Prolapse and lower urinary tract symptom treatment during follow-up was guided by standard of care. Outcome measures included the Lower Urinary Tract Symptoms Tool total severity score (in addition to overactive bladder, obstructive, and stress urinary incontinence subscales) and Urogenital Distress Inventory-6 Short Form. Prolapse (yes or no) was defined primarily when Pelvic Organ Prolapse Quantification System points Ba, C or Bp were >0 (beyond the hymen). Mixed-effects models with random effects for patient slopes and intercepts were fitted for each lower urinary tract symptom outcome and prolapse predictor, adjusted for other covariates. The study had >90% power to detect differences as small as 0.4 standard deviation for less prevalent group comparisons (eg, prolapse vs not).

RESULTS

A total of 371 women were analyzed, including 313 (84%) with no prolapse and 58 (16%) with prolapse. Women with prolapse were older (64.6±8.8 vs 55.3±14.1 years; P<.001) and more likely to have prolapse surgery (28% vs 1%; P<.001) and pessary treatment (26% vs 4%; P<.001) during the study. Average baseline Lower Urinary Tract Symptoms Tool total severity scores were lower (fewer symptoms) for participants with prolapse compared with those without (38.9±14.0 vs 43.2±14.0; P=.036), but there were no differences in average scores between prolapse groups for other scales. For all urinary outcomes, average scores were significantly lower (improved) at 3 and 12 months compared with baseline (all P<.05). In mixed-effects models, there were no statistically significant interactions between pelvic organ prolapse measurement and visit and time-dependent prolapse treatment groups (P>.05 for all regression interaction coefficients). The Lower Urinary Tract Symptoms Tool obstructive severity score had a statistically significant positive association with Pelvic Organ Prolapse Quantification System Ba, Bp, and point of maximum vaginal descent. The Lower Urinary Tract Symptoms Tool total severity scale had a statistically significant negative association with Pelvic Organ Prolapse Quantification System Ba and point of maximum vaginal descent. No other associations between prolapse and lower urinary tract symptoms were significant (P>.05 for all regression coefficients). Symptom differences between prolapse groups were small: all regression coefficients (interpretable as additive percentage change in each score) were between -5 and 5 (standard deviation of outcomes ranged from 14.0-32.4).

CONCLUSION

Among treatment-seeking women with urinary symptoms, obstructive symptoms were positively associated with prolapse, and overall lower urinary tract symptom severity was negatively associated with prolapse. Lower Urinary Tract Symptoms Tool scores improved over 12 months regardless of prolapse status, including in those with treated prolapse, untreated prolapse, and without prolapse.

International Urogynecology Consultation: Patient Reported Outcome Measures (PROs) use in the evaluation of patients with pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Patient-reported outcome measure instruments include patient-reported outcomes (PROs) and patient-reported goals (PRGs), which allow practitioners to measure symptoms and determine outcomes of treatment that matter to patients.

METHODS

This is a structured review completed by the International Urogynecology Consultation (IUC), sponsored by the International Urogynecological Association (IUGA). The aim of this working group was to evaluate and synthesize the existing evidence for PROs and PRGs in the initial clinical work-up/evaluation and research arena for patients with pelvic organ prolapse (POP).

RESULTS

The initial search generated 3589 non-duplicated studies. After abstract review by 4 authors, 211 full texts were assessed for eligibility by 2 writing group members, and 199 studies were reviewed in detail. Any disagreements on abstract or full-text articles were resolved by a third reviewer or during video meetings as a group. The list of POP PROs and information on PRGs was developed from these articles. Tables were generated to describe the validation of each PRO and to provide currently available, validated translations.

CONCLUSIONS

All patients presenting for POP should be evaluated for vaginal, bladder, bowel and sexual symptoms including their goals for symptom treatment. This screening can be facilitated by a validated PRO; however, most PROs provide more information than needed to provide clinical care and were designed for research purposes.

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.

Effect of electroacupuncture on symptoms of female pelvic organ prolapse (stage II-III) (EAPOP study): protocol of a randomised controlled trial

INTRODUCTION

Pelvic organ prolapse (POP) is downward descent of pelvic organs, which causes symptoms of the lower genital, urinary and gastrointestinal tracts, and undermines women's daily activities and quality of life. Although studies indicated that electroacupuncture (EA) may be effective in improving the POP symptoms, evidences were not robust. Therefore, this study aims to conduct a randomised controlled trial (RCT) to evaluate the efficacy and safety of electroacupuncture on relieving symptoms of a POP stage II and III among women.

METHODS AND ANALYSIS

A two-arm, multicentre, patient-blind RCT will be conducted to compare EA with sham electroacupuncture (SEA) for treating symptoms of POP stage II and III among women in six tertiary hospitals in China. One hundred and sixty eligible women will be assigned with a 1:1 ratio to have received either EA or SEA for 24 times in 12 weeks and followed-up for 24 weeks. The primary outcome will be the change on the total score of the Pelvic Floor Distress Inventory-short form 20 at week 12 from baseline, and will be analysed by t-test or multiple regression model. Intention-to-treat analysis will be performed for all outcomes, and a p value of less than 0.05 (two-sided testing) will be considered as statistical significance.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Medical Ethical Committee of Guang'ammen Hospital (No. 2019-249-KY-01). Patients will be informed about the details of the study and asked to sign consent form before enrolment. The results of this study are expected to be written and published on peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04589715.

Treatment of Pelvic Organ Prolapse by the Downregulation of the Expression of Mitofusin 2 in Uterosacral Ligament Tissue via Mesenchymal Stem Cells

Background: The relationship between pelvic organ prolapse (POP), an aging-related disease, and the senescence-related protein mitofusin 2 (Mfn2) has rarely been studied. The aim of the present study was to explore the therapeutic effects of the downregulation of Mfn2 expression by stem cells on POP through animal experiments. Methods: First, a rat POP model was constructed by ovariectomy and traction. The rats in the non-pelvic organ prolapse (NPOP) and POP groups were divided into four groups for negative controls (N1−N4, N1: NPOP-normal saline; N2: NPOP-untransfected stem cells; N3: NPOP-short hairpin negative control (NPOP-sh-NC); N4: NPOP-short hairpin-Mfn2 (NPOP-sh-Mfn2)), and four groups for prolapse (P1−P4, P1: POP-normal saline; P2: POP-untransfected stem cells; P3: POP-sh-NC; P4: POP-sh-Mfn2), respectively. Stem cells were then cultured and isolated. The expression of Mfn2 was inhibited by lentivirus transfection, and the stem cells were injected into the uterosacral ligament of the rats in each group. The expression levels of Mfn2 and procollagen 1A1/1A2/3A1 in the uterosacral ligaments of the rats were observed at 0, 7, 14, and 21 days after injection. Results: Compared to the rats in the NPOP group, the POP rats had significant prolapse. The Mfn2 expression in the uterosacral ligaments of the POP rats was significantly increased (p < 0.05, all), and the expression of procollagen 1A1/1A2/3A1 was significantly decreased (p < 0.001, all). The POP rat model maintained the same trend after 21 days (without stem cell injection). At day 14, compared to the rats in the N1 group, the Mfn2 expression in the uterosacral ligament of the rats in the N4 group was significantly decreased (p < 0.05, all), and the expression of procollagens was significantly increased (p < 0.05, all). Similarly, compared to the rats in the P1 group, the Mfn2 expression in the uterosacral ligament of the rats in the P4 group was significantly decreased (p < 0.05, all), and the expression of procollagens was significantly increased (p < 0.05, all). Similarly, on day 21, the Mfn2 mRNA and protein expression in the uterosacral ligament of the POP and NPOP rats was significantly decreased (p < 0.05, all), and the expression of procollagens was significantly increased (p < 0.05, all) in the rats in the sh-Mfn2 group (N4, P4) compared to the rats in the saline group (N1, P1). Conclusions: The downregulation of Mfn2 expression by stem cells decreased the expression of Mfn2 and increased the expression of procollagen1A1/1A2/3A1 in the uterosacral ligament of the POP rats; this effect was significant 14−21 days after the injection. Thus, Mfn2 may be a new target for POP control.

The effect of pelvic floor muscle training for women with pelvic organ prolapse: a meta-analysis

INTRODUCTION AND HYPOTHESIS

This study was aimed at evaluating the effect of pelvic floor muscle training (PFMT) as a conservative treatment for patients with pelvic organ prolapse (POP).

METHODS

A comprehensive search to identify eligible randomized controlled trial (RCT) studies was conducted using electronic databases including PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase up to 10 June 2021. Results were presented as risk ratio (RR), the weighted mean difference (WMD), with 95% confidence interval (95% CI) using the random effects model. Outcome variables were pooled using Review Manager version 5.3.

RESULTS

Thirteen studies were included. Our results demonstrated that women who received PFMT intervention had a greater improvement than controls in prolapse symptom score (POP-SS; mean difference [MD] -1.66, 95% CI -2.36 to -0.97, p < 0.00001] and POP stages (risk ration [RR] 1.51, 95% CI 1.14-2.01, p = 0.004). The number of participants who felt better after PFMT was higher (RR 1.98, 95% CI 1.21-3.24, p = 0.006). Subgroup analysis showed that the symptoms of prolapse and the degree of prolapse were improved significantly in the short term, but there was no significant difference in the long-term effect. In addition, there was no significant difference in the impact of PFMT on the elderly and the quality of life. More RCTs are needed to evaluate the effect of PFMT on the elderly and whether the quality of life can be improved.

CONCLUSIONS

We found that PFMT can improve subjective symptoms and objective POP severity. More research is needed on the long-term effect.

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

INTRODUCTION

Pelvic organ prolapse (POP) can be managed with a pessary; however, regular follow-up may deter women from pessary management due to the inconvenience of frequent appointments, as well as preventing pessary users from autonomous decision-making. Pessary self-management, whereby the woman removes and inserts her own pessary may be a solution to these issues. However, there remains a number of uncertainties regarding the potential benefits and risks of pessary self-management. This scoping review aims to map available evidence about the subject of pessary self-management for POP to identify knowledge gaps providing the basis for future research.

METHODS AND ANALYSIS

The scoping review will be conducted using the Joanna Briggs Institute scoping review methodology and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A search of Medline, CINAHL, Embase and PsycInfo will be undertaken to identify relevant articles which meet the eligibility criteria using the search terms 'pessary' and 'self-management' or 'self-care'. A hand search of the reference list of non-original research identified during the search but excluded, will be conducted for additional publications which meet the inclusion and exclusion criteria. Data relevant to the topic of pessary self-management will be extracted and critical appraisal of all included publications undertaken.

ETHICS AND DISSEMINATION

No ethical or Health Research Authority approval is required to undertake the scoping review. However, it has been registered with The Open Science Framework (DOI 10.17605/OSF.IO/DNGCP). The findings will inform future research exploring pessary self-management and be disseminated via both a presentation at a national conference and publications in peer reviewed journals.

Role of Fibroblasts and Myofibroblasts on the Pathogenesis and Treatment of Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a multifactorial connective tissue disorder caused by damage to the supportive structures of the pelvic floor, leading to the descent of pelvic organs in the vagina. In women with POP, fibroblast function is disturbed or altered, which causes impaired collagen metabolism that affects the mechanical properties of the tissue. Ideal surgical repair, either native tissue repair or POP surgery using an implant, aims to create a functional pelvic floor that is load-bearing, activating fibroblasts to regulate collagen metabolism without creating fibrotic tissue. Fibroblast function plays a crucial role in the pathophysiology of POP by directly affecting the connective tissue quality. On the other hand, fibroblasts determine the success of the POP treatment, as the fibroblast-to-(myo)fibroblast transition is the key event during wound healing and tissue repair. In this review, we aim to resolve the question of “cause and result” for the fibroblasts in the development and treatment of POP. This review may contribute to preventing the development and progress of anatomical abnormalities involved in POP and to optimizing surgical outcomes.

Evaluation and Management of Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a common clinical entity that can have a significant impact on a patient's quality of life secondary to symptoms of pelvic pressure, vaginal bulge, urinary and bowel dysfunction, or sexual dysfunction. It is highly prevalent, with roughly 13% of women undergoing surgery for prolapse in their lifetime. Vaginal prolapse is diagnosed by history and physical examination. Additional testing may be indicated for evaluation of bowel and bladder symptoms. On examination, prolapse can represent descent of the anterior vaginal wall, vaginal apex (cervix/uterus or vaginal cuff scar after hysterectomy), or posterior vaginal wall, although it represents a combination of these in many cases. Treatment options for POP include observation, pelvic floor physical therapy, pessary use, and surgery. In patients with asymptomatic POP, observation is typically used. In those not desiring or medically unfit for surgery, pessaries are an effective nonsurgical option. When it is indicated, surgery can be performed through transvaginal, laparoscopic/robotic, or open approaches, using either the patient's own tissue or mesh augmentation. Deciding between these is based on the compartments involved, extent of prolapse, medical and surgical comorbidities, differences in durability and risk between operations, and shared decision-making with the patient. Here, we review pertinent clinical considerations in the evaluation and management of POP.

Case series: Vaginal pessary for pelvic organ prolapse and its association with vaginal cancer

Vaginal pessaries have long been used in the management of pelvic organ prolapse as an alternative option for surgery. Vaginal cancer is a very rare form of gynaecological malignancy, and its association with vaginal ring pessaries has yet to be clearly established. We examined the cases of vaginal cancers in a tertiary state hospital for the last three years and found four cases of vaginal cancers, in which three of these cases were associated with a long history of using vaginal ring pessary for pelvic organ prolapse. Two of them had defaulted follow- up and presented with a vaginal mass and vaginal bleeding. These two cases did not have evidence of distant metastases, one of them underwent surgical removal of the tumour and radiotherapy, whilst the other case was initially given neoadjuvant chemotherapy, but the patient died prior to her planned surgery. The third patient declined further investigation and treatment after she was diagnosed with vaginal cancer. In conclusion, such potential serious long term complication from vaginal pessary should be informed prior to its insertion, it is also imperative to ensure compliance to regular follow- up for patients on vaginal pessaries, and to biopsy any suspicious chronic vaginal ulcers.

A predictive model of choosing pessary type for women with symptomatic pelvic organ prolapse

OBJECTIVE

To investigate clinical factors including translabial ultrasound parameters, which are predictive for choosing pessary type (Ring or Gellhorn) in the fitting trial, and to establish a predictive model.

METHODS

A retrospective study was conducted on symptomatic women with pelvic organ prolapse (POP) at the Pelvic Floor Disease Diagnosis and Treatment Center (Liaoning Province, China) between May 2018 and December 2020 who were successfully fitted with pessaries. This retrospective study was supplemented with a prospective cohort study on women seeking pessary for first-line treatment of POP at the above tertiary center between December 2020 and April 2021 for validation. Enrolled participants were grouped by their fitted type of pessary. Demographic and clinical parameters between groups, including pelvic organ prolapse quantification and translabial ultrasound, were analyzed using logistic regression. A receiver operating characteristic curve was calculated using predictive values obtained by regression as the predictor for choosing pessary type in the pessary fitting trial.

RESULTS

The 181 participants included in the retrospective analysis were randomly divided into the "Development" and "Validation" datasets. In the "Development" set, multivariable logistic regression analyses showed that a younger age (odds ratio [OR]: 0.950; 95% confidence interval [CI]: 0.908-0.995; P = 0.026), a larger hiatal circumference on Valsalva (OR: 1.348; 95% CI: 1.103-1.647; P = 0.004), and a higher POP-Q stage (OR: 2.963; 95% CI: 1.210-7.255; P = 0.017) were independent predictors for successful fitting with the Gellhorn pessary. The predictive model was P = exp(Z)/[1 + exp(Z)], Z = -0.051 × Age (y) + 0.298 × hiatal circumference on Valsalva (cm) + 1.086 × pelvic organ prolapse stage (2, 3, or 4) - 5.490. The area under the receiver operating characteristic curves (AUC) was 0.776 (P < 0.001) and 0.705 (P < 0.001) based on the "Development" dataset and "Validation" datasets, respectively. The AUC was 0.815 (P < 0.001) based on the prospective cohort validation.

CONCLUSIONS

For severe POP, women with younger age and larger hiatal circumference, Gellhorn pessaries should be their first choice instead of ring ones in pessary fitting trials.

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.