What are the indications and treatment options for vaginal pessary (vaginal ring or support device) placement in women with pelvic organ prolapse or stress urinary incontinence?

Vaginal Pessary Placement in Women

Primary Indications

Vaginal pessaries are indicated for women with symptomatic pelvic organ prolapse and/or stress urinary incontinence who prefer non-surgical management, are awaiting surgery, or are not surgical candidates. 1, 2

Specific Clinical Scenarios for Pessary Use

• Symptomatic pelvic organ prolapse with complaints of vaginal bulge, pelvic pressure, or associated urinary/bowel dysfunction 3, 4, 1
• Stress urinary incontinence as a non-surgical treatment option 1, 5
• Patient preference for non-surgical management over operative intervention 1, 2
• Medical comorbidities making surgery high-risk or contraindicated 3, 4
• Pregnancy-related conditions including cervical insufficiency or incarcerated uterus 1
• Bridge therapy while awaiting definitive surgical treatment 1

Treatment Outcomes and Effectiveness

Success Rates

• Most women (approximately 60-80%) can be successfully fitted with a pessary and experience excellent symptom relief with high satisfaction rates 1, 2
• Pessary plus pelvic floor muscle training (PFMT) is superior to PFMT alone, with 2.15 times more women reporting symptom improvement (RR 2.15,95% CI 1.58-2.94) 2
• Prolapse-specific quality of life improves significantly when pessaries are combined with PFMT compared to PFMT alone (median POPIQ score: 0.3 vs 8.9, P=0.02) 2

Comparative Effectiveness

• Pessaries versus no treatment: uncertain benefit for symptom improvement based on limited evidence 2
• Pessaries versus PFMT alone: uncertain if there is a difference in symptom improvement (MD -9.60,95% CI -22.53 to 3.33) 2
• Pessary plus PFMT versus PFMT alone: this combination approach is the most effective non-surgical strategy 2

Complications and Adverse Events

Common Minor Complications

• Vaginal discharge and odor are the most frequent complaints 1, 2
• Vaginal erosions or irritation occur but are usually successfully treated 1, 2
• Increased urinary incontinence may develop in some patients 2
• Abnormal vaginal bleeding occurs slightly more often with pessaries (RR 2.18,95% CI 0.69-6.91) 2

Risk Profile

• Major complications occur only when pessaries are neglected and not properly maintained 1
• Pessaries increase adverse event risk 75-fold compared to PFMT alone (RR 75.25,95% CI 4.70-1205.45), though most events are minor 2
• De novo voiding difficulty may occur but evidence is uncertain (RR 1.32,95% CI 0.54-3.19) 2

Clinical Management Algorithm

Initial Assessment

• Confirm prolapse on physical examination showing descent of anterior vaginal wall, vaginal apex (cervix/uterus or vaginal cuff), posterior vaginal wall, or combinations 3, 4
• Document specific symptoms: vaginal bulge sensation, pelvic pressure, urinary dysfunction, bowel symptoms, or sexual difficulties 3, 4
• Assess patient goals and preferences regarding surgical versus non-surgical management 3, 4

Treatment Selection

For asymptomatic prolapse: observation is appropriate 3, 4

For symptomatic prolapse with patient preferring non-surgical approach:

• Offer pessary fitting as first-line therapy 1, 2
• Combine pessary with PFMT for optimal outcomes rather than pessary alone 2

For stress urinary incontinence:

• Pessaries are a valid non-surgical option for women declining surgery 1, 5
• Note that surgical options (synthetic midurethral slings, autologous fascial slings, Burch colposuspension) have higher cure rates (66-84%) for definitive treatment 6, 7

Pessary Fitting and Follow-up

• Proper fit determined by trial is essential for effectiveness 5
• Type of pessary depends on direction and grade of the prolapsing organ 5
• Most commonly used pessaries are made from polyvinyl-chloride, polythene, silicone, or latex 2
• Regular follow-up and maintenance are mandatory to prevent major complications 1

Critical Pitfalls to Avoid

• Neglecting pessary maintenance leads to all major complications - establish clear follow-up protocols 1
• Failing to combine pessary with PFMT misses the opportunity for superior outcomes compared to either therapy alone 2
• Not counseling about surgical alternatives - patients should understand that surgical options (particularly synthetic midurethral slings with 84% cure rates or autologous fascial slings with 66% success at 5 years) offer higher cure rates for stress incontinence 6, 7
• Assuming all patients can be fitted - while most women can be successfully fitted, some anatomical variations may preclude pessary use 1, 2