What are the considerations for pessary use in a patient with pelvic organ prolapse?

Pessary Considerations for Pelvic Organ Prolapse

Critical Context Clarification

The evidence provided addresses cervical pessaries for preterm birth prevention in pregnancy, NOT pessaries for pelvic organ prolapse management. These are entirely different clinical scenarios with different pessary types, indications, and evidence bases. I will answer based on the limited pelvic organ prolapse evidence available and general medical knowledge.

Primary Recommendation for Pelvic Organ Prolapse

Pessary therapy should be offered as first-line treatment for symptomatic pelvic organ prolapse in patients who prefer non-surgical management, are not surgical candidates, or decline surgery. 1

Patient Selection and Assessment

Indications for Pessary Use

• Symptomatic pelvic organ prolapse (vaginal bulge, pelvic pressure, or protrusion) where the degree of patient bother warrants intervention 1
• Patient preference for non-surgical management over definitive surgical repair 1
• Patients who are poor surgical candidates due to medical comorbidities 2, 3
• Women who have not completed childbearing 3
• Patients awaiting surgery who need interim symptom relief 4

Pre-Fitting Evaluation

• Evaluate the degree of patient bother from prolapse symptoms, as treatment decisions should align with symptom impact on quality of life 1
• Perform physical examination to assess prolapse stage (≥stage 2 typically warrants treatment) 5
• Assess for anterior compartment (cystocele/urethrocele), apical (uterine/vaginal), and posterior compartment (rectocele) involvement 6
• Rule out contraindications including active pelvic infection, vaginal bleeding of unknown etiology, or severe vaginal erosions 4

Pessary Selection and Fitting

Evidence-Based Approach

• Trial and error, expert opinion, and clinical experience remain the best guides for pessary selection, as evidence for specific selection criteria is incomplete 2
• Ring and Gellhorn pessaries are the most commonly used types for pelvic organ prolapse 5
• Successful fitting rates are high: most patients with prolapse can be successfully fitted and experience excellent symptom relief 4

Novel Considerations

• Newer collapsible pessary designs demonstrate significantly lower pain scores with insertion and removal (mean difference 9.91 mm for insertion, 11.23 mm for removal on visual analog scale) compared to standard non-collapsible pessaries 5

Expected Outcomes and Efficacy

Symptom Relief

• Patient satisfaction is high with pessary use for pelvic organ prolapse management 7, 2
• Pessaries are effective in alleviating prolapse symptoms, though long-term follow-up data in published literature is often limited 7
• Improvement in disease-specific quality of life measures (Pelvic Floor Impact Questionnaire-7 scores improved from 32.23 to 16.86, P=.019) 5

Safety Profile

• Pessary use is minimally invasive and appears to be safe for pelvic organ prolapse treatment 7
• Major complications occur only when pessaries are neglected; with proper follow-up, serious adverse events are rare 4

Management and Follow-Up

Common Side Effects

• Minor complications include vaginal discharge, odor, and vaginal erosions, which can usually be successfully treated 4
• Increased vaginal discharge is nearly universal but manageable 6
• Approximately 14% of patients may require pessary repositioning 6

Ongoing Care

• Regular follow-up is essential to prevent major complications from neglected pessaries 4
• Patients can be taught to manage the pessary themselves for either short- or long-term relief 2
• Long-term pessary use is a safe and effective option when properly managed 3

Critical Pitfalls to Avoid

• Do not neglect regular follow-up: all major complications are associated with neglected pessaries 4
• Do not assume all patients can self-manage: insertion and removal pose challenges for many patients, particularly with traditional non-collapsible designs 3
• Do not use pessaries in patients with active pelvic infection or unexplained vaginal bleeding 4
• Recognize that comparison data with surgical treatment is rare and not assessed in randomized controlled trials 7

Limitations of Current Evidence

The evidence base for pessary use in pelvic organ prolapse has significant gaps: follow-up periods are often short, use of validated urogynaecological questionnaires is limited, and high-quality comparative effectiveness research with surgery is lacking 7. Despite these limitations, clinical experience and available data support pessary use as an effective, low-risk treatment option with high patient satisfaction 2, 3.