Study design, materials and methods
In this qualitative study, we recruited patients with symptomatic pelvic organ prolapse (POP) fitted with a vaginal pessary as a conservative treatment for more than twelve months. This study was conducted at the urogynecology clinic public hospital. Semi-structured, one-on-one interviews were completed to data saturation. Urogynecologists and stomatherapy nurses are responsible for monitoring the conservative treatment in the outpatient clinic. Based on another qualitative study [1], eight questions were used to investigate knowledge (six questions) and practice (two questions) related to the vaginal pessary. For knowledge, questions were investigated about pelvic organ prolapse, treatment options for POP, and about pessary care. Regarding practice, women were expected to report their experience with the device and care routine. The interview transcripts were analyzed using Bardin's categorical thematic content analysis. This study was approved by the Institutional Ethics Committee.
Results
Twenty pessary users were interviewed, mostly from urban areas (n=17; 85%), without partners (n=12; 60%), retired or homemakers (n=18; 90%), less than five years of education (n=13; 65%), and independent in pessary self-care (n=16; 80%). Despite difficulties in defining POP, women demonstrated adequate understanding of risk factors, as reflected in the following statements:
"I used to work in households and lifted heavy weights. Then I noticed it wasn't normal. When I urinated and cleaned myself, I felt that bulge." (P4).
"I understood that... because I gave birth to fourteen children, due to all the force... this happened, right?" (P16).
Most participants showed the pessary as the primary conservative treatment for POP. Four interviewees depend on other people (for example, children and primary healthcare professionals) for pessary care. Nevertheless, they described self-care items: pessary removal, hygiene, fitting; application of topical estrogen; attending follow-up appointments with the healthcare team:
"I remove it every week to wash. I apply the cream." (P4).
"(...) you have to be careful when putting it on, taking it off, we have to clean it every eight days, we take it out and put it back in and I feel very well." (P6).
"The care involves using intimate soap, using gel, applying the cream three times a week like I do. And sanitize the hands, always wash the pessary when putting it on and taking it off." (P19).
All women stated that they would recommend the pessary to other women. However, some participants reported facing difficulties in using the device due to other health limitations and/ or complications associated with it:
"I have difficulty putting it on, I have a back problem, so I have to find a position, it was always very uncomfortable to put it on and take it off. Another thing, I started to have a lot of discharge, something I didn't have before, so when I started using it, I had continuous discharge, sometimes with a bad smell, sometimes not, sometimes it hurts me, I bleed a little." (P18).
Interpretation of results
Participants assisted in specialized outpatient clinics and they were using the device as a conservative therapeutic option more than year. Despite women, in general, having low knowledge regarding vaginal pessary, an adequate level of knowledge is expected in women followed by specialized professionals. The women studied had difficulty explaining the cause of the problem or citing other forms of treatment, like other investigations [1]; on the other hand, they knew how to identify factors related to the occurrence of POP. Due to the length of time the pessary was used, most were well adapted to pessary self-care, including removal, cleaning, fitting, and topical estrogen use, even if some relied on the help of others to do so. Encouraging women's independence from the health service is essential so that they can continue to use the device for longer periods. To this end, qualified professionals should use effective educational strategies to increase the patient's confidence and, when necessary, train family members or others to provide support. Independence in pessary self-care allows for autonomy, convenience, maintenance of sexual relations, and prevention of complications [2]. Similarly, other researchers showed that women experience difficulties in the practical use of the vaginal pessary, impacting treatment adherence. In this scenario, a qualified professional can assist women in experiencing positive adaptation to the pessary, including identifying strategies for each patient's particularities [3].