AUGS Position Statement: Vaginal Pessary Use and Management for Pelvic Organ Prolapse

ABSTRACT

Over the past 50 years, pessary use has increased in popularity and has become an essential pelvic organ prolapse (POP) management tool. However, evidence is lacking to define care standardization, including pessary fitting, routine maintenance, and management of pessary-related complications. This clinical consensus statement (CCS) on vaginal pessary use and management for POP reflects statements drafted by content experts from the American Urogynecologic Society and Society of Urologic Nurses and Associates. The purpose of this CCS is to identify areas of expert consensus and nonconsensus regarding pessary fitting, follow-up, and management of pessary complications to improve the safety and quality of care where evidence is currently limited. The American Urogynecologic Society and Society of Urologic Nurses and Associates' vaginal pessary for POP writing group used a modified Delphi process to assess statements that were evaluated for consensus after a structured literature search. A total of 31 statements were assessed and divided into 3 categories: (1) fitting and follow-up, (2) complications, and 3) quality of life. Of the 31 statements that were assessed, all statements reached consensus after 2 rounds of the Delphi survey. This CCS document hopefully serves as a first step toward standardization of pessary care, but the writing group acknowledges that improved research will grow the base of knowledge and evidence providing clinicians a foundation to manage pessary care effectively and confidently.

WHY THIS MATTERS

• At present, guidance for pessary management has fallen to pessary manufacturers and the opinion of expert clinicians, leading to significant variation in recommendations for care.

• The purpose of this clinical consensus statement is to identify areas of expert consensus and nonconsensus regarding pessary fitting, follow-up, and management of pessary complications to improve the safety and quality of care where evidence is currently limited.

• The recommendations, developed by the writing group, may support these efforts by providing consistent care guidelines and statements on pessary fitting and management, while highlighting areas for further research for current practitioners or those new to the use of pessaries.

Vaginal support pessaries are considered first-line treatment in the nonsurgical management of women with pelvic organ prolapse (POP),1 given that pessaries have been demonstrated to improve quality of life (QoL) by reducing bothersome POP symptoms associated with pelvic floor disorders.2–9 Despite their common use, a recent Cochrane review demonstrated only 4 high-quality articles of their efficacy. 10 Physicians and advanced practice providers in various specialties in the United States fit and manage pessaries. The American Urogynecologic Society (AUGS) and the Society of Urologic Nurses and Associates (SUNA) recommend that expert guidance and insight into pessary practices should be used when the quality and quantity of high-level evidence are insufficient to develop multidisciplinary clinical guidance documents. To improve quality of care, clinical consensus statements (CCSs) are used as a bridge to summarize experts' views on care that requires interpretation and value judgment. Authors of CCSs use explicit methodology to draft experts' opinions to identify areas of agreement and disagreement regarding care in situations where high-level evidence is limited.11 Although pessaries may be used for other indications such as stress urinary incontinence or preterm labor, the scope of this CCS is limited to pessaries used for the treatment of prolapse. A panel of experts in pessary care from both the AUGS and SUNA membership was convened by the AUGS Publications Committee to draft a CCS regarding use and management of vaginal pessaries for POP. This panel of experts is referred to in this document as “the writing group.” The purpose of this CCS is to identify areas of expert consensus and nonconsensus regarding pessary fitting, follow-up, and management of pessary complications to improve the safety and quality of care where evidence is currently limited.

The vaginal pessary is a minimally invasive, cost-effective device that positively impacts the health of women worldwide. Once fitted correctly, a pessary enhances QoL, improves self-esteem, and restores the daily function of women suffering from POP. However, improved guidance in pessary care is needed. Although there are good data on quality-of-life improvement with pessary use, the data on pessary fitting and management are of low quality. The goal of this document is to provide guidance for health care providers in caring for women who choose a pessary to manage their prolapse symptoms. The writing group acknowledges that the risk of unintentional bias may exist in our recommendations, given the lack of quality pessary research from which to draw conclusions. Higher quality research will grow the base of knowledge and evidence providing clinicians a foundation to manage this care effectively and confidently. Increased knowledge may enable educators to develop concise educational protocols for future clinicians specializing in female pelvic medicine. This education may directly translate to improvements in patient care, starting with the initial fitting procedure, to surveillance, and, finally, management of complications. Achieving greater patient satisfaction and improved outcomes will advance the art and the science of the pessary.

REFERENCES

1. Alas AN, Bresee C, Eilber K, et al. Measuring the quality of care provided to women with pelvic organ prolapse. Am J Obstet Gynecol 2015;212(4):471.e1–471.e9. doi:10.1016/j.ajog.2014.10.1105.

2. Patel M, Mellen C, O'Sullivan DM, et al. Impact of pessary use on prolapse symptoms, quality of life, and body image. Am J Obstet Gynecol 2010;202(5):499.e1–499.e4. doi:10.1016/j.ajog. 2010.01.019.

3. Panman CM, Wiegersma M, Kollen BJ, et al. Effectiveness and cost-effectiveness of pessary treatment compared with pelvic floor muscle training in older women with pelvic organ prolapse: 2-year follow-up of a randomized controlled trial in primary care. Menopause 2016;23(12):1307–1318. doi:10.1097/GME.0000000000000706.

4. Ai F-F, Mao M, Zhang Y, et al. Effect of generalized anxiety disorders on the success of pessary treatment for pelvic organ prolapse. Int Urogynecol J 2018;29(8):1147–1153. doi:10.1007/s00192- 018-3562-1.

5. Mao M, Ai F, Zhang Y, et al. Changes in the symptoms and quality of life of women with symptomatic pelvic organ prolapse fitted with a ring with support pessary. Maturitas 2018;117:51–56. doi:10.1016/j.maturitas. 2018.09.003.

6. Cheung RY, Lee JH, Lee LL, et al. Vaginal pessary in women with symptomatic pelvic organ prolapse: a randomized controlled trial. Obstet Gynecol 2016;128(1):73–80. doi:10.1097/AOG. 0000000000001489.

7. Chan SS, Cheung RY, Lai BP, et al. Responsiveness of the pelvic floor distress inventory and pelvic floor impact questionnaire in women undergoing treatment for pelvic floor disorders. Int Urogynecol J 2013; 24(2):213–221. doi:10.1007/s00192-012-1827-7.

8. Barber MD, Walters MD, Cundiff GW, PESSRI Trial Group. Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery and pessary treatment for pelvic organ prolapse. Am J Obstet Gynecol 2006;194(5):1492–1498. doi:10.1016/j.ajog. 2006.01.076.

9. Shayo BC, Masenga GG, Rasch V. Vaginal pessaries in the management of symptomatic pelvic organ prolapse in rural Kilimanjaro, Tanzania: a pre-post interventional study. Int Urogynecol J 2019;30(8): 1313–1321. doi:10.1007/s00192-018-3748-6.

10. Bugge C, Adams EJ, Gopinath D, et al. Pessaries (mechanical devices) for managing pelvic organ prolapse in women. Cochrane Database Syst Rev 2020;11:CD004010. doi:10.1002/14651858. CD004010.pub4.

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