Causes of unsuccessful pessary fitting in women with pelvic organ prolapse

Obesity, previous reconstructive pelvic surgery, and advanced symptomatic pelvic organ prolapse (POP) are the three significant risk factors for an unsuccessful pessary fitting, according to a systematic literature review and metanalysis in the journal Neurourology and Urodynamics.

But pessary extrusion and pain/discomfort are the two most cited reasons that women stop using the devices.

“There is a lack of good data on identifying the risk factors responsible for unsuccessful pessary fitting,” said co-author Luiz Brito, MD, PhD, an assistant professor of ob/gyn at the University of Campinas in Brazil. “Some of the previous findings were controversial and were not written in a way that we could conclude about one specific factor. This review provides more evidence for considering factors for pessary use, both before and during patient counseling.”¹

The authors reviewed studies with primary outcomes that were factors associated with unsuccessful pessary fitting and discontinuation in women with POP and 21 for final analysis: 18 cohort studies, one cross‐sectional study, and two randomized controlled studies (RCTs), comprising 3,601 women total.

The overall discontinuation rate was 25.2%and ranged from 9.8% to 52.2%.

Meta‐analysis of nine studies revealed that women with advanced POP were four times more likely to discontinue use than women with stage 1/2POP. Women who had previous pelvic reconstructive surgery were nearly twice as likely to discontinue use than those who had not undergone the surgery.

In addition, each increase in body mass index (BMI) of 0.7 kg/m2 was associated with a higher risk of unsuccessful pessary fitting, although the authors did not calculate a BMI cut-off point to predict high risk.

Conversely, older age, larger total vaginal length, genital hiatus, and previous hysterectomy were not linked to discontinuation.

Of the 13 reasons given for discontinuation, pessary extrusion topped the list (385 patients, 19 studies), followed by pain/discomfort (163 patients, 19 studies) and the desire for surgical treatment (111 patients, 11 studies).

“Most of the findings were expected,” Dr. Brito told Contemporary OB/GYN. “For example, we know that obesity may increase intra-abdominal pressure, so with these findings we can hypothesize that such pressure might force pessary expulsion. Advanced POP may be related to the fact that bulging of the prolapse could exert downward pressure on the pessary. However, we thought that a larger genital hiatus would be a risk factor because a larger area would facilitate pessary expulsion.”

Based on the review, there are certain existing risk factors that clinicians can be alert for during patient counseling. “Patient motivation for pelvic reconstructive surgery may also increase the discontinuation rate due to pessary not being a definitive treatment for POP or that complications may arise like vaginal discharge and ulceration, so surgical motivation should be assessed prior to pessary insertion,” Dr. Brito said.

Yet despite these risk factors, “they may not predict the risk for unsuccessful pessary insertion on an individual basis,” he said. “Still, we can advise patients of the risk factors prior to pessary treatment.”

Because the desire for surgery and pessary extrusion are two major reasons for discontinuation, “extensive counseling is needed to optimize patient management and adherence of the pessary fitting,” Dr. Brito said. “In particular, obese patients who are motivated to use pessary should be counseled to lose weight.”

Dr. Brito reports no relevant financial disclosures.

__

Reference

1. Coelho SCA, Brito LGO, de Araujo CC, et al. Factors associated with unsuccessful pessary fitting in women with symptomatic pelvic organ prolapse: Systematic review and metanalysis. Neurourol Urodyn. 2020;39(7):1912-1921. doi:10.1001/nau.24458.