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The Cochrane Database of Systematic... Jul 2023Pelvic organ prolapse (POP) is the descent of a woman's uterus, bladder, or rectum into the vagina. It affects 50% of women over 50 years old who have given birth to at... (Review)
Review
BACKGROUND
Pelvic organ prolapse (POP) is the descent of a woman's uterus, bladder, or rectum into the vagina. It affects 50% of women over 50 years old who have given birth to at least one child, and recognised risk factors are older age, higher number of births, and higher body mass index. This review assesses the effects of oestrogen therapy, alone or in combination with other treatments, on POP in postmenopausal women.
OBJECTIVES
To assess the benefits and harms of local and systemic oestrogen therapy in the management of pelvic organ prolapse symptoms in postmenopausal women, and to summarise the principal findings of relevant economic evaluations.
SEARCH METHODS
We searched the Cochrane Incontinence Specialised Register (up to 20 June 2022), which includes CENTRAL, MEDLINE, two trials registers, and handsearching of journals and conference proceedings. We also checked the reference lists of relevant articles for additional studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs), quasi-RCTs, multi-arm RCTs, and cross-over RCTs that evaluated the effects of oestrogen therapy (alone or in combination with other treatments) versus placebo, no treatment, or other interventions in postmenopausal women with any grade of POP.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data from the included trials using prespecified outcome measures and a piloted extraction form. The same review authors independently assessed the risk of bias of eligible trials using Cochrane's risk of bias tool. Had data allowed, we would have created summary of findings tables for our main outcome measures and assessed the certainty of the evidence using GRADE.
MAIN RESULTS
We identified 14 studies including a total of 1002 women. In general, studies were at high risk of bias in terms of blinding of participants and personnel, and there were also some concerns about selective reporting. Owing to insufficient data for the outcomes of interest, we were unable to perform our planned subgroup analyses (systemic versus topical oestrogen, parous versus nulliparous women, women with versus without a uterus). No studies assessed the effects of oestrogen therapy alone versus no treatment, placebo, pelvic floor muscle training, devices such as vaginal pessaries, or surgery. However, we did identify three studies that assessed oestrogen therapy in conjunction with vaginal pessaries versus vaginal pessaries alone and 11 studies that assessed oestrogen therapy in conjunction with surgery versus surgery alone.
AUTHORS' CONCLUSIONS
There was insufficient evidence from RCTs to draw any solid conclusions on the benefits or harms of oestrogen therapy for managing POP symptoms in postmenopausal women. Topical oestrogen in conjunction with pessaries was associated with fewer adverse vaginal events compared with pessaries alone, and topical oestrogen in conjunction with surgery was associated with reduced postoperative urinary tract infections compared with surgery alone; however, these findings should be interpreted with caution, as the studies that contributed data varied substantially in their design. There is a need for larger studies on the effectiveness and cost-effectiveness of oestrogen therapy, used alone or in conjunction with pelvic floor muscle training, vaginal pessaries, or surgery, for the management of POP. These studies should measure outcomes in the medium and long term.
Topics: Female; Humans; Middle Aged; Estrogens; Pelvis; Pessaries; Postmenopause; Urinary Bladder
PubMed: 37431855
DOI: 10.1002/14651858.CD014592.pub2 -
European Journal of Obstetrics,... Apr 2020To identify the knowledge, attitudes and practice of women and healthcare professionals in relation to pessary use for POP. (Review)
Review
OBJECTIVE
To identify the knowledge, attitudes and practice of women and healthcare professionals in relation to pessary use for POP.
METHOD
This systematic review was carried out in agreement with PRISMA recommendations. PubMed/MEDLINE, SCOPUS, Virtual Health Library, Web of Science, CAPES Periodicals and CINAHL databases were searched for studies without date or language limitations. Search strategies were developed for identifying studies examining knowledge, attitudes and practice toward vaginal pessaries use. Two reviewers independently screened titles and abstracts to identify eligible studies. Data extraction was performed independently in duplicate into a standardized form. Quality of included studies was assessed using the Joanna Briggs Institute quality assessment tool. The protocol was registered with the PROSPERO International prospective register of systematic reviews [CRD42018114236].
RESULTS
Fourteen studies were included. Knowledge and practice were the main domains investigated among patients and professionals, respectively. The results demonstrated poor patient knowledge; however, in urogynecologic patients, knowledge was better. Previous consultation with a Female Pelvic Medicine and Reconstructive Surgery specialist (p = .001) and a higher level of education (p = .006) were associated with improved knowledge of pessary use. Fear of vaginal discharge, irritation, bleeding, and pain were factors that supported the decision not to use a pessary. Previous consultation with a generalist gynecologist (p = .03)and a lower level of education (p = .03) predicted aversion to pessary use. Providers demonstrated adequate knowledge and recommended pessary in 86.4% to 98.0% of cases. Having specialist and pessary management training were some factors that influenced a better attitude towards pessaries among health professionals.
CONCLUSION
The knowledge, attitudes and practice of women and health care providers about pessary use are seldom investigated. Developing a psychometrically valid instrument for assessment of knowledge, attitudes and practice is desirable to examine the complex interactions between these three constructs, expose barriers to pessary care, and develop targeted educational interventions.
Topics: Female; Health Knowledge, Attitudes, Practice; Humans; Pelvic Organ Prolapse; Pessaries
PubMed: 32113060
DOI: 10.1016/j.ejogrb.2020.02.016 -
The Journal of Maternal-fetal &... Jan 2022To evaluate the effectiveness of cervical pessary in preventing preterm birth (PTB) and improving perinatal outcomes among singleton and twin pregnancies. (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To evaluate the effectiveness of cervical pessary in preventing preterm birth (PTB) and improving perinatal outcomes among singleton and twin pregnancies.
METHODS
Electronic databases were systematically searched from their inception until 14 March 2019. Randomized clinical trials comparing the effectiveness of cervical pessary placement with expectant management were included. The primary outcome was the incidence of PTB <34 weeks.
RESULTS
Thirteen studies were included, involving eight studies about singleton and six studies about twin pregnancies. For singleton pregnancies with short cervical length, cervical pessary, comparing with expectant treatment, seemed have no effectiveness in preventing PTB <34 weeks (relative risk, 95% confidence interval, 0.73, 0.42-1.28), <37 weeks (0.69, 0.43-1.09), and <28 weeks (0.79, 0.42-1.48); while for twin pregnancies with short cervical length, cervical pessary also did not reduce the risk of PTB <34 weeks (0.81, 0.49-1.35), <37 weeks (0.93, 0.83-1.05), and <28 weeks (0.72, 0.38-1.38). However, cervical pessary seemed have the effectiveness of reducing the risk of spontaneous PTB <28 weeks (0.50, 0.25-0.99) and low birth weight (<1500 g) (0.68, 0.50-0.94) among twin pregnancies with short cervical length. In addition, cervical pessary increased the rate of vaginal discharge and did not improve perinatal outcomes among both singleton and twin pregnancies.
CONCLUSIONS
Comparing with the expectant treatment, the effectiveness of cervical pessary for reducing the risk of PTB remains uncertain. Additional trials are warranted to further evaluate the effectiveness of cervical pessary.
Topics: Cervix Uteri; Female; Humans; Infant, Low Birth Weight; Infant, Newborn; Pessaries; Pregnancy; Pregnancy, Twin; Premature Birth
PubMed: 31948303
DOI: 10.1080/14767058.2020.1712705 -
Journal of Clinical Medicine Dec 2022Introduction: Quality of life (QoL) improvement is one of the main outcomes in the management of pelvic organ prolapse as a chronic illness in women. This systematic... (Review)
Review
Introduction: Quality of life (QoL) improvement is one of the main outcomes in the management of pelvic organ prolapse as a chronic illness in women. This systematic review aimed to investigate the impact of surgical or pessary treatment for pelvic organ prolapse (POP) on quality of life. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was applied. Electronic databases, including PubMed, Scopus, and Web of Science, were searched for original articles that evaluated the QoL before and after surgical interventions or pessary in pelvic organ prolapse from 1 January 2012 until 30 June 2022 with a combination of proper keywords. Included studies were categorized based on interventions, and they were tabulated to summarize the results. Results: Overall, 587 citations were retrieved. Of these, 76 articles were found eligible for final review. Overall, three categories of intervention were identified: vaginal surgeries (47 studies), abdominal surgeries (18 studies), and pessary intervention (11 studies). Almost all interventions were associated with improved quality of life. The results of the meta-analysis showed a significant association between the employment of surgical approach techniques (including vaginal and abdominal surgeries) and the quality of life (Pelvic Floor Distress Inventory (PFDI) (MD: −48.08, 95% CI: −62.34 to −33.77, p-value < 0.01), Pelvic Floor Impact Questionnaire (PFIQ) (MD: −33.41, 95% CI: −43.48 to −23.34, p < 0.01)) and sexual activity of patients with pelvic organ prolapse (Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) (MD: 4.84, 95% CI: 1.75 to 7.92, p < 0.01)). Furthermore, narrative synthesis for studies investigating the effect of the pessary approach showed a positive association between the use of this instrument and improvement in the quality of life and sexual activity. Conclusions: The results of our study revealed a significant improvement in the women’s quality of life following abdominal and vaginal reconstructive surgery. The use of pessary was also associated with increased patient quality of life.
PubMed: 36498740
DOI: 10.3390/jcm11237166 -
Archives of Gynecology and Obstetrics Jun 2024There is no evidence about the efficacy of self-care of vaginal pessary in women with symptomatic pelvic organ prolapse (POP). The aim of this systematic review and... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
There is no evidence about the efficacy of self-care of vaginal pessary in women with symptomatic pelvic organ prolapse (POP). The aim of this systematic review and meta-analysis is to assess the adherence to pessary treatment among women who engage in self-management of their pessary.
METHODS
We performed a systematic review and meta-analysis, according to PRISMA 2020 guidelines, and selected seven publications for inclusion in the analysis.
RESULTS
Pooled continuation rate of self-cared vaginal pessary was the 76% (95%CI: 66-85%) with a I-test of 93.3% (p < 0.001). Pooled conversion to POP surgery was the 12% (95%CI: 1-23%) with a I-test of 96% (p < 0.001). Continuation rate was not statistically different between women who were treated by self-care and non-self-care management of vaginal pessary (RR 1.11, 95%CI 0.96-1.27; p = 0.15), with a related I-test of 37% (p = 0.21).
CONCLUSION
Self-care vaginal pessary management presented a high continuation rate in women affected by pelvic organ prolapse at a long follow-up. The rate of conversion to surgical management of POP was low. No significant difference in continuation rate were highlighted between women who adopted the self-care or the clinical-based management of pessary.
Topics: Humans; Pelvic Organ Prolapse; Pessaries; Female; Self Care; Patient Compliance; Treatment Outcome
PubMed: 38634900
DOI: 10.1007/s00404-024-07506-1 -
International Urogynecology Journal Feb 2022Pelvic organ prolapse (POP) is common and associated with sexual dysfunction. Vaginal pessaries are an effective treatment for POP, but their impact on sexual function... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION AND HYPOTHESIS
Pelvic organ prolapse (POP) is common and associated with sexual dysfunction. Vaginal pessaries are an effective treatment for POP, but their impact on sexual function is not well established. The aim of this systematic review and meta-analysis was to establish the impact of vaginal pessaries used for POP on female sexual function.
METHODS
Systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. A comprehensive search was conducted across Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, CINAHL, ClinicalTrials.gov , The WHO International Clinical Trials Registry Platform, ProQuest Dissertations & Theses, Open Grey and Scopus Citation Database. Randomised controlled trials and cohort studies that assessed sexual function in women pre- and post-pessary treatment for POP were included, assessed for risk of bias and their results synthesised.
RESULTS
A total of 1,945 titles and abstracts were screened, 104 full-text articles were assessed for eligibility, 14 studies were included in the narrative analysis and 7 studies were included in the meta-analysis. The results suggest that, in sexually active women, there is no evidence of a deterioration in sexual function and some evidence of an improvement.
DISCUSSION
This review offers reassurance that in sexually active women who successfully use a pessary for treatment of their prolapse, there is no deterioration in sexual function. There is some evidence of an improvement in sexual function, but given the clinical heterogeneity in the studies included, caution should be taken in generalising these findings.
Topics: Female; Humans; Pelvic Organ Prolapse; Pessaries; Sexual Dysfunction, Physiological; Treatment Outcome
PubMed: 34982188
DOI: 10.1007/s00192-021-05059-4 -
International Urogynecology Journal Jul 2022To clarify which parameters are associated with unsuccessful pessary fitting for pelvic organ prolapse (POP) at up to 3 months follow-up. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To clarify which parameters are associated with unsuccessful pessary fitting for pelvic organ prolapse (POP) at up to 3 months follow-up.
METHODS
Embase, PubMed and Cochrane CENTRAL library were searched in May 2020. Inclusion criteria were: (1) pessary fitting attempted in women with symptomatic POP; (2) pessary fitting success among the study outcomes with a maximal follow-up of 3 months; (3) baseline parameters compared between successful and unsuccessful group. A meta-analysis was performed using the random effects model.
MAIN RESULTS
Twenty-four studies were included in the meta-analysis. Parameters associated with unsuccessful pessary fitting were: age (OR 0.70, 95% CI 0.56-0.86); BMI (OR 1.35, 95% CI 1.08-1.70); menopause (OR 0.65 95% CI 0.47-0.88); de novo stress urinary incontinence (OR 5.59, 95% CI 2.24-13.99); prior surgery, i.e. hysterectomy (OR 1.88, 95% CI 1.48-2.40), POP surgery (OR 2.13, 95% CI 1.34-3.38), pelvic surgery (OR 1.81, 05% CI 1.01-3.26) and incontinence surgery (OR 1.87, 95% CI 1.08-3.25); Colorectal-Anal Distress Inventory-8 scores (OR 1.92, 95% CI 1.22-3.02); solitary predominant posterior compartment POP (OR 1.59, 95% CI 1.08-2.35); total vaginal length (OR 0.56, 95% CI 0.32-0.97); wide introitus (OR 4.85, 95% CI 1.60-14.68); levator ani avulsion (OR 2.47, 95% CI 1.35-4.53) and hiatal area on maximum Valsalva (OR 1.89, 95% CI 1.27-2.80).
CONCLUSION
During counselling for pessary treatment a higher risk of failure due to the aforementioned parameters should be discussed and modifiable parameters should be addressed. More research is needed on the association between anatomical parameters and specific reasons for unsuccessful pessary fitting.
Topics: Female; Humans; Pelvic Floor; Pelvic Organ Prolapse; Pessaries; Urinary Incontinence, Stress; Vagina
PubMed: 35037973
DOI: 10.1007/s00192-021-05015-2 -
BMJ Open Jul 2022Pelvic organ prolapse (POP) can be effectively managed using a pessary. A scoping review found that pessary self-management appears to benefit women with no increased... (Review)
Review
INTRODUCTION
Pelvic organ prolapse (POP) can be effectively managed using a pessary. A scoping review found that pessary self-management appears to benefit women with no increased risk. Despite this, many are unwilling to self-manage their pessary. At present, there is a lack of understanding about what affects willingness to self-manage a pessary. However, there may be relevant, transferable findings from other literature about barriers to the self-management of other chronic conditions. Therefore, this systematic review aims to identify, appraise and synthesise the findings of published qualitative research exploring the barriers and facilitators to self-management of chronic conditions reported by women.
METHODS AND ANALYSIS
The systematic review will be conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a guide for the systematic review of qualitative data. A search of MEDLINE, CINAHL, Embase and PsycInfo will be undertaken to identify relevant articles that meet the eligibility criteria using the search terms 'Women', 'Woman' 'Female,' 'Chronic', 'Long-term', 'Disease', 'Illness', 'Condition' 'Health,' 'Self-management,' 'Qualitative,' 'Barrier' and 'Facilitator'. 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. Studies published before 2005 and those not available in English will be excluded. Data relevant to the topic 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 systematic review. The systematic review findings will be disseminated by publication. The findings will also inform subsequent exploratory work regarding pessary self-management.
PROSPERO REGISTRATION NUMBER
CRD42022327643.
Topics: Chronic Disease; Female; Humans; Qualitative Research; Research Design; Self-Management
PubMed: 35858726
DOI: 10.1136/bmjopen-2022-061655 -
American Journal of Obstetrics and... Jul 2020Randomized controlled trials that have assessed the efficacy of cervical pessary to prevent preterm birth in asymptomatic high-risk women have reported conflicting... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Randomized controlled trials that have assessed the efficacy of cervical pessary to prevent preterm birth in asymptomatic high-risk women have reported conflicting results.
OBJECTIVE
To evaluate the efficacy and safety of cervical pessary to prevent preterm birth and adverse perinatal outcomes in asymptomatic high-risk women.
DATA SOURCES
MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS (from their inception to October 31, 2019), Cochrane databases, Google Scholar, bibliographies, and conference proceedings.
STUDY ELIGIBILITY CRITERIA
Randomized controlled trials that compared cervical pessary with standard care (no pessary) or alternative interventions in asymptomatic women at high risk for preterm birth.
STUDY APPRAISAL AND SYNTHESIS METHODS
The systematic review was conducted according to the Cochrane Handbook guidelines. The primary outcome was spontaneous preterm birth <34 weeks of gestation. Secondary outcomes included adverse pregnancy, maternal, and perinatal outcomes. Pooled relative risks with 95% confidence intervals were calculated. Quality of evidence was assessed using the GRADE methodology.
RESULTS
Twelve studies (4687 women and 7167 fetuses/infants) met the inclusion criteria: 8 evaluated pessary vs no pessary in women with a short cervix, 2 assessed pessary vs no pessary in unselected multiple gestations, and 2 compared pessary vs vaginal progesterone in women with a short cervix. There were no significant differences between the pessary and no pessary groups in the risk of spontaneous preterm birth <34 weeks of gestation among singleton gestations with a cervical length ≤25 mm (relative risk, 0.80; 95% confidence interval, 0.43-1.49; 6 trials, 1982 women; low-quality evidence), unselected twin gestations (relative risk, 1.05; 95% confidence interval, 0.79-1.41; 1 trial, 1177 women; moderate-quality evidence), twin gestations with a cervical length <38 mm (relative risk, 0.75; 95% confidence interval, 0.41-1.36; 3 trials, 1128 women; low-quality evidence), and twin gestations with a cervical length ≤25 mm (relative risk; 0.72, 95% confidence interval, 0.25-2.06; 2 trials, 348 women; low-quality evidence). Overall, no significant differences were observed between the pessary and no pessary groups in preterm birth <37, <32, and <28 weeks of gestation, and most adverse pregnancy, maternal, and perinatal outcomes (low- to moderate-quality evidence for most outcomes). There were no significant differences in the risk of spontaneous preterm birth <34 weeks of gestation between pessary and vaginal progesterone in singleton gestations with a cervical length ≤25 mm (relative risk, 0.99; 95% confidence interval, 0.54-1.83; 1 trial, 246 women; low-quality evidence) and twin gestations with a cervical length <38 mm (relative risk, 0.73; 95% confidence interval, 0.46-1.18; 1 trial, 297 women; very low-quality evidence). Vaginal discharge was significantly more frequent in the pessary group than in the no pessary and vaginal progesterone groups (relative risks, ∼2.20; high-quality evidence).
CONCLUSION
Current evidence does not support the use of cervical pessary to prevent preterm birth or to improve perinatal outcomes in singleton or twin gestations with a short cervix and in unselected twin gestations.
Topics: Asymptomatic Diseases; Cervix Uteri; Female; Humans; Pessaries; Pregnancy; Premature Birth; Randomized Controlled Trials as Topic; Risk Assessment
PubMed: 32027880
DOI: 10.1016/j.ajog.2019.12.266 -
Journal of Personalized Medicine Jun 2023Forty percent of women will experience prolapse in their lifetime. Vaginal pessaries are considered the first line of treatment in selected patients. Major complications... (Review)
Review
BACKGROUND
Forty percent of women will experience prolapse in their lifetime. Vaginal pessaries are considered the first line of treatment in selected patients. Major complications of vaginal pessaries rarely occur.
METHODS
PubMed and Embase were searched from 1961 to 2022 for major complications of vaginal pessaries using Medical Subject Headings (MeSH) and free-text terms. The keywords were pessary or pessaries and: vaginal discharge, incontinence, entrapment, urinary infections, fistula, complications, and vaginal infection. The exclusion criteria were other languages than English, pregnancy, complications without a prior history of pessary placement, pessaries unregistered for clinical practice (herbal pessaries), or male patients. The extracted data included symptoms, findings upon examination, infection, type of complication, extragenital symptoms, and treatment.
RESULTS
We identified 1874 abstracts and full text articles; 54 were assessed for eligibility and 49 met the inclusion criteria. These 49 studies included data from 66 patients with pessary complications amenable to surgical correction. Clavien-Dindo classification was used to grade the complications. Most patients presented with vaginal symptoms such as bleeding, discharge, or ulceration. The most frequent complications were pessary incarceration and fistulas. Surgical treatment included removal of the pessary under local or general anesthesia, fistula repair, hysterectomy and vaginal repair, and the management of bleeding.
CONCLUSIONS
Pessaries are a reasonable and durable treatment for pelvic organ prolapse. Complications are rare. Routine follow-ups are necessary. The ideal patient candidate must be able to remove and reintroduce their pessary on a regular basis; if not, this must be performed by a healthcare worker at regular intervals.
PubMed: 37511669
DOI: 10.3390/jpm13071056