Vaginal Pessaries for Symptomatic Pelvic Organ Prolapse: Study Identifies Risk Factors for One-Year Failure

"Risk factors for failure included a wide genital hiatus (RR: 1.25), short total vaginal length (RR: 1.30), a high GH/TVL ratio (RR: 1.27), younger age, prior prolapse surgery (RR: 1.92), and higher pre-insertion symptom scores," the researchers reported.

Female pelvic organ prolapse (POP) is common, with severity increasing with age. Vaginal pessaries, a first-line conservative treatment, provide rapid symptom relief and improve quality of life with high satisfaction rates. Compared to surgery, pessaries are reversible and offer similar symptom improvement. Factors influencing pessary choice include POP type, symptoms, patient morphology, and handling ability. Common risk factors for failure include younger age, higher BMI, prior surgeries, short vaginal length, and advanced prolapse stages. The analysis of risk factors for pessary failure remains unclear in the literature due to variations in pessary types, patient populations, and follow-up durations across studies.

To fill this knowledge gap, A.C. Pizzoferrato, Department of Obstetrics and Gynaecology, Poitiers University Hospital, Poitiers, France, and colleagues aimed to identify the risk factors for their failure within one year of insertion.

For this purpose, the researchers prospectively included women who opted for pessary fitting to manage symptomatic pelvic organ prolapse. Symptoms and quality of life were evaluated at the time of inclusion and 1 month, 6 months, and 1 year post-insertion using validated questionnaires, including PFDI-20, ICIQ-SF, PISQ-12, USP, and PFIQ-7. Patient satisfaction was measured using the PGII score, and pessary failure was defined as discontinuation of use during the study period.

The following were the key findings of the study:

• Of the 206 women included, 175 had results available at 1 year.
• At 1 year, 70 women (40.0%) experienced pessary failure, while 105 women (60.0%) continued using the pessary.
• The overall PFDI-20 symptom score and its subscores showed significant improvement as early as 1 month after pessary insertion.
• Risk factors for pessary failure included:
  • Younger age at insertion (RR per 5-year increase = 0.93).
  • History of prolapse surgery (RR = 1.92).
  • Higher PFDI-20 score before insertion (RR = 1.04).
  • Wide genital hiatus (GH) (RR = 1.25).
  • Short total vaginal length (TVL) (RR = 1.30).
  • High GH/TVL ratio (RR = 1.27).
  • Presence of a POP-Q stage ≥2 rectocele (RR = 1.51).
• At 1 year, 89.9% of users reported feeling improved or very improved.
• 85.7% expressed intent to continue pessary use for 5 years or longer.

The researchers concluded that the study highlights the vaginal pessary as an effective treatment for symptomatic pelvic organ prolapse, significantly improving patients' quality of life. However, factors like a wide genital hiatus or short vaginal length are associated with higher expulsion rates and increased risk of failure. Despite these challenges, user satisfaction remains high, with most women reporting positive outcomes in one year.

Reference: Pizzoferrato, A., Deparis, J., Levade, C., Villot, A., & Fauvet, R. (2024). Use of vaginal pessary in women with symptomatic pelvic organ prolapse: Risk factors for failure one year after insertion. European Journal of Obstetrics & Gynecology and Reproductive Biology. https://doi.org/10.1016/j.ejogrb.2024.12.054