A review: patient questions about use of vaginal ring pessaries for prolapse

The authors of this article are to be commended for summarizing the questions raised by patients about the use of a variety of vaginal ring pessaries (1). As the authors point out, vaginal pessaries are recommended as first line management for treatment of symptomatic prolapse by National Institute for Health and Care Excellence (NICE) [2019], International Urogynecological Association (IUGA) [2023] and other gynaecological associations in Germany [2014], Canada [2021] and France [2022] (1). Therefore, it is disconcerting to note that these questions were directed at the manufacturers of the vaginal pessaries, suggesting that such patients may not have received sufficient information from their care providers. However, the authors wrote to five manufacturers in different countries, but only one manufacturer provided details. There were 174 inquiries from 145 patients, of whom 86% were from Germany. Hence the results may not be internationally representative.

More than 65% of women who approached the manufacturers for information were using the cube pessary. The remaining devices (Sieve bowl pessary, Urethral pessary) are quite uncommon devices in Commonwealth countries, so again this report appears to be mainly applicable to Germany/Europe. Indeed, only 4% of patients needing information were using a ring pessary (which is very widely used in Britain/USA/Australia).

As regards cube pessaries, researchers from Austria recently evaluated 174 patients who were fitted with cube pessary and followed by phone/on line for 5 years (2). Continued use of the cube occurred in 82% of patients, but 15% had mild side effects such as vaginal discharge. Pizzoferrato et al. [2022] administered an electronic questionnaire to members of eight learned societies in France (respondents were 70% doctors, 20% physiotherapists) (3). The most common pessaries employed were vaginal ring (64%) and cube pessary (57%). McEvoy et al. [2023] from Australia surveyed gynaecologists (n=132), nurses (n=25) general practitioners (n=23) and physiotherapists (n=291); of these 90% selected a vaginal ring, 5% selected cube pessaries and 3% used Gellhorn pessaries. Hence the use of cube pessaries varies considerably between countries (4).

The authors indicate that the majority of questions directed at the manufacturer were related to ’selected pessary models or sizes’, as well as self-management and cleaning/shelf life. This is not surprising, as the cube pessary must be removed and washed daily, owing to the strong suction created by the four-sided perforated device. Other pessaries (e.g., ring, Schaatz, ring with support Gellhorn) can be left in situ for 4–6 months, with one recent report indicating that leaving such ring devices in situ for up to 9 months does not increase adverse events (5).

The majority of publications from the last 5–10 years give increasing attention to the notion that patients should be educated about self-management. Patients are shown how to self insert and remove the device, wash the ring pessary in hot soapy water at least every month, with gynaecology checkups only required annually. A recent 5-year audit of 75 women who were trained to self manage vaginal ring pessaries showed that 91% of patients were able to learn the technique. Of these, 53% continued to self-manage for a median of 4.2 years, with adverse events (largely minor) occurring in 11.8% (6). This was considerably lower than the 58% risk of adverse events recorded over 14 years from the same department, in patients who had their ring changed by a clinician every 4–6 months (7).

The authors cite a publication from 2001 (Pott-Grinstein et al.) (8) from the USA, indicating that 86% of providers had received minimal formal training in the use of such pessaries. However, in the last 20 years, gynaecological and urogynaecological societies have frequently provided a variety of workshops, educational symposia and presentation of original data regarding efficacy and safety of vaginal pessaries at their annual conferences, so this situation has changed.

For example, Pizzoferrato et al. [2022] found that 69% of providers said that they were comfortable with pessary fitting and follow-up (3). Nemeth et al. [2023] found that 43% of nurses and 65% of general practitioners felt that they needed additional training (2). McEvoy et al. found that 83% of specialists were trained within their fellowship program, nurses and general practitioners (GPs) predominantly learnt through mentoring/on the job training, and physiotherapists received training through professional development courses (4). Only 2% of their respondents reported having had no formal training in pessary management.

Regardless of these improvements in training for pessary use, the authors’ checklist recommended for health care providers given in this publication are a timely reminder of what patients need to know. For example, all pessaries are a foreign body, thus increased discharge is to be expected, although the vaginal microbiome seldom changes. Postmenopausal women should coat the cube pessary with oestrogen cream twice weekly (or apply digitally for other rings). Devices should be cleaned after menstruation, and if the pessary evokes pain or difficult micturition/defecation then re-sizing should be considered.

As the population becomes increasingly aged, and with the withdrawal of vaginal mesh for prolapse surgery, vaginal ring pessaries are likely to become increasingly popular. Health care providers need to be mindful of the need to educate patients fully prior to inserting any vaginal pessary.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine. The article has undergone external peer review.

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-23-52/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-23-52/coif). The author has no conflicts of interest to declare.

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References

1. Wagner JR, Fink T, Arabin B. Analysis of questions by patients with pelvic organ prolapse about vaginal pessaries resulting in a checklist for their physicians. Arch Gynecol Obstet 2024;309:329-37. [Crossref] [PubMed]
2. Nemeth Z, Kolumban S, Schmidt R, et al. Self-management of vaginal cube pessaries may be a game changer for pelvic organ prolapse treatment: a long-term follow-up study. Int Urogynecol J 2023;34:921-7. [Crossref] [PubMed]
3. Pizzoferrato AC, Nyangoh-Timoh K, Martin-Lasnel M, et al. Vaginal Pessary for Pelvic Organ Prolapse: A French Multidisciplinary Survey. J Womens Health (Larchmt) 2022;31:870-7. [Crossref] [PubMed]
4. McEvoy K, Griffin R, Harris M, et al. Pessary management practices for pelvic organ prolapse among Australian health care practitioners: a cross-sectional study. Int Urogynecol J 2023;34:2519-27. [Crossref] [PubMed]
5. Thys SD, Hakvoort RA, Asseler J, et al. Effect of pessary cleaning and optimal time interval for follow-up: a prospective cohort study. Int Urogynecol J 2020;31:1567-74. [Crossref] [PubMed]
6. Moore KH, Lammers K, Allen W, et al. Does monthly self-management of vaginal ring pessaries reduce the rate of adverse events? A clinical audit. Eur J Obstet Gynecol Reprod Biol X 2022;16:100164. [Crossref] [PubMed]
7. Sarma S, Ying T, Moore KH. Long-term vaginal ring pessary use: discontinuation rates and adverse events. BJOG 2009;116:1715-21. [Crossref] [PubMed]
8. Pott-Grinstein E, Newcomer JR. Gynecologists' patterns of prescribing pessaries. J Reprod Med 2001;46:205-8. [PubMed]