NEW YORK (Reuters Health) – Researchers in Hong Kong have identified possible risks for vaginal pessary dislodgment, suggesting nonetheless that the device be offered to patients with prolapse. But some U.S. gynecologists question the risks.
Dr. Rachel Cheung of Prince of Wales Hospital, in Shatin, and colleagues recruited 1,002 women referred to the hospital’s urogynecology clinic for symptomatic organ prolapse from January 2010 to June 2015. A total of 779 had a vaginal pessary inserted at their first consultation; 528 (mean age, 65) who returned for one-year follow-up were included in the analysis.
As reported online November 11 in Maturitas, the pessary was dislodged in 177 (33.5%) within the year and 351 (66.5%) had been able to retain the pessary.
On multivariate analysis, factors significantly associated with pessary dislodgement were stage III or IV prolapse (odds ratio, 1.76), prolapse predominant at the apical compartment (OR, 2.14) and larger genital hiatus (OR, 1.63). Age, body-mass index, previous hysterectomy, and short vagina were not associated with dislodgment.
Of 145 women with stage III/IV prolapse, 69 (47.6%) retained the pessary for one year.
The authors conclude that a vaginal pessary should be offered despite the stage of prolapse.
Three U.S. gynecologists weighed in on the findings in emails to Reuters Health. All agreed that a pessary should be offered, but they had different perspectives on the potential risks.
Dr. Kimberly Ferrante of NYU Langone Health in New York City said, “In looking at the methods, there are a few things that stand out. First is that the authors only used a ring-shaped pessary. Many times women with a larger genital hiatus need a different type of pessary (for example, a gellhorn or a donut or a cube).”
Using “only one type of pessary, and one we know may not work as well in women with more advanced prolapse or with a widened hiatus, limits the generalizability or the real-world application of this study,” she noted.
“Another difference is the decision to place the pessary and leave it in place for four to six months unless there was dislodgement,” she said. “General practice is to teach patients how to remove the pessary and replace it themselves, and while there is no data about how often to remove, clean and replace it, I typically ask patients to do this at least once a week, and many do it nightly.”
If patients don’t want to or can’t remove it, she added, “we typically see them every three months for cleaning and replacement to prevent vaginal erosions.”
“Of the 1,000 women who were seen in the clinic, 779 had a vaginal pessary placed,” Dr. Ferrante continued. “It is definitely not my experience that 80% of women who come in with no prior treatment for prolapse choose a pessary at their first consultation. Many women choose not to treat the prolapse once they are reassured it is not dangerous, and a significant proportion will choose surgery even though they are offered a pessary.”
“What this study helps us with is counseling women on who might be more likely to fail a pessary so they have realistic expectations,” she concluded.
Dr. Charles Ascher-Walsh, Director of Gynecology at Icahn School of Medicine at Mount Sinai in New York City also noted that a pessary “should never be in place longer than three months at a time,” and that patients remove it themselves or return to the office every three months to have it removed.
The study findings on pessary dislodgment “are not surprising,” he added. “Most urogynecologists are aware that while (certain) patients may be less likely to retain a pessary, they should still always be given the option to try it.”
Dr. Catherine Matthews, codirector of Women’s Pelvic Health Services at Wake Forest Baptist Health in Winston-Salem, North Carolina said, “I challenge the finding of apical prolapse being associated with pessary failure. My clinical observation is that distal posterior vaginal wall prolapse is the most likely compartment to fail pessary management. I would certainly offer a pessary to women with advanced apical prolapse.”
“We strongly endorse offering a trial of vaginal pessary to all women as a nonsurgical alternative,” she said. “Certainly, advanced prolapse (stage III or IV) is not a contraindication for pessary trial.”
Dr. Cheung did not respond to a request for comment.
SOURCE: http://bit.ly/2iQIRMF
Maturitas 2017.
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