This study aims to evaluate the follow-up of women with symptomatic pelvic organ prolapse (POP) undergoing conservative treatment using the ring-type vaginal pessary.

A prospective cohort study of women with symptomatic pelvic organ prolapse (POP) and a POP-Q stage 2 or higher was performed between December 2013 and November 2019. We conducted this study at referred to a public tertiary y urogynaecology unit. These patients included in the study used ring pessaries with or without support for fitting.  Pessary vaginal was offered as initial treatment for symptomatic POP. Demographic and obstetric data, pelvic organ prolapse stage, size of pessary used, and factors associated with pessary follow-up were evaluated. The mean time of use of the pessary and the rate of discontinuation of conservative treatment were calculated. We used the Mann‐Whitney test to compare continuous variables and the χ2 test to compare categorical variables between groups. Candidate independent variables were those with p< 0.05 in the univariate analysis. We used IBM SPSS for Windows, version 22.0.

A total of 170 women with symptomatic POP (stages II, III, and IV) fitted with a ring pessary. Of these women, 124 (72.9%) were successfully using it at 4 weeks (Figure 1). The median age was 67.1 years (range 36-98 years), 51% (n=51/100) without a partner, 94.3% (n=133/141) menopausal, and the median parity was 4.9 (range 0-22).  Only 39/164 patients (23.8%) were sexually active. Long-term use was found in 56.5% (n=70/170) of these patients, with an average use pessary time of 27.5±20.0 months in the continued use group and 11.4±14.7 months in the discontinued use group. An average of attempts adjusted to the pessary until a successful initial adaptation of 2.6 ± 1.435 (range 1-8) in the continued use group and 2.13 ± 1.642 (range 1 - 5) in the discontinued group. In relation to the teaching-learning process, we found the median of nursing consultations to stay independent pessary care (fit, clean, and removal):  2.6±1.435 (range 1-8) in the continued use group and 4.64±1.77 (range 2-7) in the discontinued use group. Two main moments were observed for the occurrence of the interruption of conservative treatment: in the initial weeks and around 12 months of pessary use. After cessation, 12 (9.7%) chose surgical intervention (Figure 2). Factors associated with longer use were without a sexual partner (p = 0.05) and menopause (p=0.023).

The continued pessary use has shown improvement in the symptoms of prolapse, urinary and intestinal. In the analyzed literature, we found varying rates of long-term use, ranging from 14% - 98% for more than 12 months [1-2]. Similarly, other researchers showed that the interruption of pessary use occurred, in most cases, in up to 12 months. For women who are successful pessary fitting at four weeks, the majority of women continue to use them for up to five years [2]. Among the factors associated with the continuous use of the pessary, researches point to age over 65 years, sexually active women, stage III-IV posterior vaginal wall prolapse, desire for surgery, TVL ≥ 7,5 cm, discomfort, urinary incontinence, and bleeding/ulcerations as the main predictors for discontinued use pessary [1-2]. Nevertheless, there are records that younger women prefer surgical treatment and older women, conservative therapy [2]. The mean time of pessary use was 1.4 years (ranging from 0.1 to 11 years). These data are similar to those found in this study, in which we can see that most women give up after a few weeks of use or after a year. By the way, these researchers found women who kept using the pessary for more than a decade. Another study identifies that the median duration of pessary use was 39.5 months (range 17-64.5 months) [3].

A ring with or without support pessary can be used successfully to relieve the symptoms of prolapse, more than half of the women have continued to use the conservative treatment over the years. No sexual partner and menopause were associated with longer pessary use.

Ko Po-Chun, Lo TS, Tseng LH, Lin YH, Liang CC, Lee SJ. Use of a pessary in treatment of pelvic organ prolapse: quality of life, compliance, and failure at 1-year follow-up. J Minim Invasive Gynecol. 2011;18(1):68-74. https://doi.org/10.1016/j.jmig.2010.09.006
Lone F, Thakar R, Sultan AH, Karamalis G. A 5-year prospective study of vaginal pessary use for pelvic organ prolapse. Int J of Gynecol Obst. 2011;114(1):56-59.
Boyd, Sarah S., et al. Pelvic Organ Prolapse Severity and Genital Hiatus Size With Long-Term Pessary Use. Female Pelvic Med Reconstr Surg. 2021; 27(2): e360-e362. doi: 10.1097/SPV.0000000000000937.