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Archives of Gynecology and Obstetrics Mar 2023Vaginal pessaries are used as a conservative treatment for POP in women who do not want or are not candidates for surgery, or as a preliminary step to surgery. Our goals... (Observational Study)
Observational Study
INTRODUCTION AND HYPOTHESIS
Vaginal pessaries are used as a conservative treatment for POP in women who do not want or are not candidates for surgery, or as a preliminary step to surgery. Our goals are: evaluate the evolution of patients with advanced POP and repeated expulsion of the pessary, who underwent perineal suture to try to maintain the device. Describe the epidemiological characteristics of patients treated with pessaries in our environment, with or without perineal closure.
METHODS
Observational, descriptive and prospective study (October 2016-March 2021) that includes 352 women with advanced-stage POP treated with a pessary, of which 55, after repeated expulsion of the pessary, were treated with a pessary and perineal suture.
RESULTS
After pessary insertion associated with perineal closure, 26 patients (47.2%) expelled the pessary and underwent surgery, and 29 (52.8%) kept the device, avoiding surgery. Regarding the women who required perineal suture: The mean age was higher than in the group of patients who did not need this intervention (75.3 vs. 68.3 years), 94.5% had POP ≥ grade III and 100% had a perineal width > 2.5 cm.
CONCLUSIONS
Treatment with pessary and perineal closure avoids surgery in women with advanced age and repeated expulsion. Although age should not be an independent factor that limits surgical treatment or the type of intervention, it would be useful to have scales to quantify the frailty of patients, being able to standardize perineal closure in elderly and/or frail women, and in those who do not want or have contraindications for surgery.
Topics: Humans; Female; Aged; Pessaries; Prospective Studies; Pelvic Organ Prolapse; Conservative Treatment; Sutures; Treatment Outcome
PubMed: 36242614
DOI: 10.1007/s00404-022-06739-2 -
Menopause (New York, N.Y.) Feb 2021To evaluate the 5-year pessary continuation rate and identify clinical risk factors associated with discontinuation in patients with symptomatic pelvic organ prolapse... (Observational Study)
Observational Study
OBJECTIVE
To evaluate the 5-year pessary continuation rate and identify clinical risk factors associated with discontinuation in patients with symptomatic pelvic organ prolapse (POP).
METHODS
In this prospective observational study, 312 women with symptomatic POP received pessary treatment between November 2013 and July 2015 in Peking Union Medical College Hospital, China, a tertiary referral center. Patients were initially fitted with a ring pessary with support. Those who failed were fitted with a Gellhorn pessary. A successful pessary fitting was defined as a patient who was fitted and continued to use the pessary 2 weeks later. Patients with successful pessary fitting were followed for 5 years. Data analysis was performed with t tests, nonparametric tests, chi-square tests, and logistic regression.
RESULTS
In total, 265 patients (84.9%) had successful pessary fitting. After 5 years, 180 of 239 patients continued pessary use (75.3% continuation rate), with 26 lost to follow-up. The discontinuation rates decreased over time, from 8.7% at 1 year to 2.7% at 5 years. Total vaginal length < 7.5 cm (TVL, OR = 2.7, 95% CI 1.3-5.7, P = 0.007), improvement in Urinary Impact Questionnaire-7 scores < 50% at 3 months (OR = 2.1, 95% CI 1.1-4.2, P = 0.025), and incapability of self-care (OR = 2.6, 95% CI 1.3-5.1, P = 0.008) were potential discontinuation risk factors.
CONCLUSION
Three-quarters of patients with symptomatic POP had successful pessary treatment at 5-year follow-up. TVL < 7.5 cm, poor urinary symptom relief at 3 months, and incapability of self-care were potential discontinuation risk factors.
Topics: China; Female; Humans; Pelvic Organ Prolapse; Pessaries; Prospective Studies; Treatment Outcome; Vagina
PubMed: 33625108
DOI: 10.1097/GME.0000000000001751 -
Menopause (New York, N.Y.) Oct 2020To evaluate the success rate of pessary fitting and continuation rate for symptomatic pelvic organ prolapse (POP) patients with a hysterectomy and to explore potential... (Observational Study)
Observational Study
OBJECTIVE
To evaluate the success rate of pessary fitting and continuation rate for symptomatic pelvic organ prolapse (POP) patients with a hysterectomy and to explore potential predictors.
METHODS
In this prospective observational study, 119 symptomatic POP patients with a prior hysterectomy received pessary treatment between April 2015 and February 2019. A successful pessary fitting was defined as a patient who was fitted with a pessary and continued to use it 2 weeks later. Patients with successful pessary fitting were followed until February 2020. Data analysis was performed with t tests, nonparametric tests, chi-square tests, and logistic regression.
RESULTS
The success rate of pessary fitting was 63.2%. A history of POP reconstructive surgery (OR = 2.6, 95% CI 1.0-6.7, P = 0.043) and a short total vaginal length <7.3 cm, (OR = 0.5, 95% CI 0.3-0.9, P = 0.014) were potential risk factors for unsuccessful pessary fitting. A total of 78.1% of the patients continued pessary use for a median duration of 26 months. Among patients who discontinued, 75% ceased within 1 year. Older age (OR = 1.1, 95% CI 1.0-1.2, P = 0.038) and prolapse score improvement at 3 months less than 50% (OR = 2.8, 95% CI 1.1-7.2, P = 0.035) were potential risk factors for discontinuation.
CONCLUSIONS
Pessaries remain a useful approach to treat prolapse in women who had a hysterectomy. Patients with POP reconstructive surgery and total vaginal length<7.3 cm should be informed that they might have lower success rate of pessary fitting. Age and prolapse score improvement at 3 months were potential predictors for continuation.
Topics: Aged; Female; Humans; Hysterectomy; Pelvic Organ Prolapse; Pessaries; Prospective Studies; Treatment Outcome; Vagina
PubMed: 32881830
DOI: 10.1097/GME.0000000000001633 -
The Journal of Obstetrics and... Jan 2022A 37-year-old multiparous woman complained of uterine prolapse at 14 weeks of gestation. A silicone ring-shaped middle-size vaginal pessary (# 62 mm) was placed into...
A 37-year-old multiparous woman complained of uterine prolapse at 14 weeks of gestation. A silicone ring-shaped middle-size vaginal pessary (# 62 mm) was placed into the vagina to reduce prolapsed uterus. Because the cervical length became shortened at 25 weeks of gestation, we decided to start intramuscular administration of progesterone (250 mg) weekly. At 33 weeks of gestation, she complained of the vaginal pessary spontaneous falling out, so we inserted a vaginal pessary of the same size again. The uterocervical angle became acute, going from 100° to 60° after placing the vaginal pessary into the vagina. We took the vaginal pessary out at 37 weeks of gestation. The patient gave birth at 39 weeks by spontaneous vaginal delivery to a healthy baby. A vaginal pessary may help continue a pregnancy via the same mechanism as a cervical pessary, which sharpens the uterocervical angle.
Topics: Adult; Cervix Uteri; Female; Humans; Pessaries; Pregnancy; Premature Birth; Progesterone; Uterine Prolapse
PubMed: 34704307
DOI: 10.1111/jog.15079 -
Urogynecology (Philadelphia, Pa.) Dec 2022There is a lack of high-quality long-term follow-up regarding pessary treatment. Most studies are case series or retrospective with a small sample size and short-term...
IMPORTANCE
There is a lack of high-quality long-term follow-up regarding pessary treatment. Most studies are case series or retrospective with a small sample size and short-term follow-up.
OBJECTIVES
This study aimed to evaluate differences in women who continue versus discontinue pessary use and the effectiveness, quality of life, and safety associated with pessary management at 1 year.
STUDY DESIGN
This study analyzed a multicenter national registry following women for 3 years with vaginal prolapse treated with a pessary or surgery. The primary outcome of this analysis was to compare the difference in characteristics among those who continue versus discontinue pessary use at 12 months.
RESULTS
Among 1,153 participants enrolled, 376 (32.6%) opted for a pessary, and 296 (78.7%) were successfully fitted. Data were available for 240 participants (81%). At 1 year, 62% (n = 148) were still using pessaries, and 38% (n = 92) had stopped with 25% opting for surgery. Most commonly reported de novo adverse effects were urinary leakage (16%), feeling or seeing a bulge (12%), and vaginal discharge (11%). There was no difference in baseline characteristics among women who continued versus discontinued pessary use. At 12 months, subjective symptoms were similar between groups, with similar change in symptoms from baseline on most validated instruments. Those who continued to use a pessary reported worse urinary symptoms due to de novo urinary leakage ( P = 0.01).
CONCLUSIONS
At 1 year, most women successfully fitted with a pessary continued pessary use. Although there was a significant improvement in condition-specific quality of life and low rates of complications, approximately 40% of women discontinued pessary use by 12 months. We were unable to identify any baseline characteristics associated with pessary discontinuation.
Topics: Female; Humans; Pessaries; Pelvic Floor Disorders; Quality of Life; Retrospective Studies; Pelvic Organ Prolapse; Registries
PubMed: 36409637
DOI: 10.1097/SPV.0000000000001279 -
Urologia Oct 2017The use of a pessary to treat a pelvic organ prolapse (POP) is a valid non-invasive option. Severe complications are usually associated with neglected, oversized, or... (Review)
Review
INTRODUCTION
The use of a pessary to treat a pelvic organ prolapse (POP) is a valid non-invasive option. Severe complications are usually associated with neglected, oversized, or misplaced pessaries. Major complications include fistulas, bowel or bladder erosion, and hydroureteronephrosis (HUN).
MATERIALS AND METHODS
We reviewed the literature and our experience in the management of HUN in the last decade, as a consequence of pessary placement.
RESULTS
We used flow charts to take an accurate medical history of each patient. Blood and urine analyses were taken at admission to assess the potential presence of sepsis, renal failure, and urinary tract infection. Physical examination included vaginal examination. In cases of pessary presence with a concomitant increase of serum creatinine value, a possible ureteral obstruction is suspected. In order to assess the presence of HUN and its underlying causes, a computed tomography (CT) scan should be performed to assess the mechanism of urinary tract obstruction. However, in case of renal insufficiency, abdominal ultrasonography (US) could be sufficient. If HUN is detected in a patient with no signs of urosepsis, we suggest a conservative management by the removal of the pessary and catheter placement. When urosepsis is suspected, it is mandatory to administer antibiotic therapy and evaluate the HUN drainage by nephrostomy.
CONCLUSIONS
There is no uniform management of women with HUN and a concomitant pessary. For this reason, and based on the literature and our experience, we propose an original management flowchart.
Topics: Female; Humans; Hydronephrosis; Pessaries; Software Design; Ureteral Diseases
PubMed: 28967060
DOI: 10.5301/uj.5000266 -
American Journal of Obstetrics and... Aug 2022The number of twin pregnancies continues to increase worldwide as both the number of pregnancies obtained by medically assisted reproduction and age at first pregnancy... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The number of twin pregnancies continues to increase worldwide as both the number of pregnancies obtained by medically assisted reproduction and age at first pregnancy keep rising. Preterm delivery is the major complication associated with twin pregnancies. The effectiveness of preventive treatments such as progesterone or cervical cerclage for women with a short cervix is doubtful in twin pregnancies. The effectivity of cervical pessaries in preventing preterm birth and its associated morbidity and mortality is also controversial.
OBJECTIVE
We sought to investigate if the Arabin pessary reduces adverse neonatal outcomes in twin pregnancies with a short cervix.
STUDY DESIGN
This open-label, multicenter, randomized controlled trial on twin pregnancies with a cervical length of <35 mm compared pessary placement at 16+0 to 24+0 weeks' gestation with standard care alone. The primary endpoint was a composite of adverse neonatal outcomes, namely peripartum or neonatal death or significant neonatal morbidity before hospital discharge, defined as at least 1 of the following complications: bronchopulmonary dysplasia, intraventricular hemorrhage grade III to IV, periventricular leukomalacia, necrotizing enterocolitis grade II or higher, culture-proven sepsis, and retinopathy requiring treatment. A sample size of 308 pregnancies was planned to ensure 80% power to compare the proportions of women with at least 1 infant with an adverse neonatal outcome. The intention-to-treat analysis after multiple imputation of missing data, was supplemented with a secondary analysis that controlled for gestational age and cervical length, both at inclusion. The primary endpoint was also compared between randomization groups in the per-protocol population, which excluded patients with prespecified major protocol violations (mostly cervical cerclage and/or progesterone after inclusion). Secondary endpoints included preterm birth, spontaneous preterm birth, and pessary side effects.
RESULTS
In total, 315 women were randomized to either receive a pessary (n=157) or standard management (n=158). Overall, 10.8% (34 women) of participants had a missing value for the primary endpoint, mostly (79%) because of the lack of paternal consent for neonatal data collection. In the intention-to-treat analysis, the adverse neonatal outcome occurred in 16.8% of the pessary group vs in 22.5% of the control group (risk ratio, 0.69; 95% confidence interval, 0.39-1.23; P=.210). The per-protocol analysis did not show any significant difference between groups (risk ratio, 0.78; 95% confidence interval, 0.47-1.28; P=.320). The occurrence of preterm birth or spontaneous preterm birth did not differ significantly between groups. No serious side effects were associated with pessary use.
CONCLUSION
Pessary use in our study did not significantly reduce adverse neonatal outcomes in twin pregnancies with a short cervix.
Topics: Cervical Length Measurement; Cervix Uteri; Female; Humans; Infant, Newborn; Pessaries; Pregnancy; Pregnancy, Twin; Premature Birth; Progesterone
PubMed: 35123930
DOI: 10.1016/j.ajog.2022.01.038 -
BMJ Case Reports Apr 2019Vaginal pessary is a practical and effective tool for pelvic organ prolapse management. Nevertheless, serious complications can occur in neglected patients such as...
Vaginal pessary is a practical and effective tool for pelvic organ prolapse management. Nevertheless, serious complications can occur in neglected patients such as vesicovaginal and rectovaginal fistula, erosion and impaction in adjacent structures. We report a case of neglected pessary found in the uterine cavity. The patient was treated with abdominal hysterectomy with in situ doughnut pessary. Proper pessary care and regular follow-up should be emphasised among patients, caregivers and related healthcare personnel to early detect as well as to avoid complications.
Topics: Abdominal Pain; Aged; Female; Foreign-Body Migration; Humans; Hysterectomy; Pelvic Organ Prolapse; Pessaries; Time Factors; Treatment Outcome; Ultrasonography
PubMed: 30988106
DOI: 10.1136/bcr-2018-228415 -
American Journal of Obstetrics and... May 2023The American College of Obstetricians and Gynecologists recommends offering a vaginal pessary to women seeking treatment of pelvic organ prolapse. However,...
BACKGROUND
The American College of Obstetricians and Gynecologists recommends offering a vaginal pessary to women seeking treatment of pelvic organ prolapse. However, single-institution series have suggested that a sizable proportion of women fitted with a pessary will transition to surgery within the first year.
OBJECTIVE
This study aimed to estimate the proportion of female US Medicare beneficiaries with pelvic organ prolapse who undergo surgery after pessary fitting, to describe the median time to surgery from pessary fitting, and to identify factors associated with the transition from pessary to surgery.
STUDY DESIGN
The Medicare 5% Limited Data Set was queried from 2011 to 2016 for women aged ≥65 years with a diagnosis of prolapse who underwent pessary fitting. Cases with at least 3 years of follow-up in the Medicare Data Set were followed longitudinally for the primary outcome of surgery for prolapse. The cumulative incidence of prolapse surgery following index pessary fitting was calculated. Characteristics of women who underwent surgery and those who did not were compared using time-varying Cox regression analysis.
RESULTS
Among 2032 women fitted with a pessary, 608 underwent surgery within 7 years. The median time to surgery was 496 days (interquartile range, 187-1089 days). The cumulative incidence of prolapse surgery was 12.2% at 1 year and 30.9% at 7 years. After adjusting for covariates, factors significantly associated with the transition to surgery included previous prolapse surgery (adjusted hazard ratio, 1.50; 1.09-2.07) and a diagnosis of urinary incontinence at the time of pessary fitting (adjusted hazard ratio, 1.20; 0.62-0.99). Factors associated with a lower hazard of surgery included age (adjusted hazard ratio, 0.96 per year; 95% confidence interval, 0.95-0.97), dual Medicare/Medicaid eligibility (adjusted hazard ratio, 0.75; 95% confidence interval, 0.56-1.00), and pessary fitting by a nongynecologist (adjusted hazard ratio, 0.78; 95% confidence interval, 0.62-0.99).
CONCLUSION
In this population of Medicare beneficiaries, within 7 years of pessary fitting, almost one-third of women aged >65 years underwent surgery for prolapse. These results add to our current understanding of the demographics of pessary use in an older population and may aid in counseling older patients presenting for treatment of symptomatic pelvic organ prolapse.
Topics: Aged; Female; Humans; United States; Medicare; Pessaries; Pelvic Organ Prolapse; Regression Analysis; Proportional Hazards Models; Seizures
PubMed: 36627074
DOI: 10.1016/j.ajog.2023.01.006 -
JAMA May 2018
Topics: Cervical Length Measurement; Cervix Uteri; Female; Humans; Infant, Newborn; Pessaries; Pregnancy; Premature Birth
PubMed: 29715351
DOI: 10.1001/jama.2018.1482