Pelvic Organ Prolapse(POP) is known to be debilitating to women. We are seeing approximately 10% proceeding to surgical management. Vaginal pessaries are well established as first line treatment for managing POP. The TOPSY study demonstrated comparable improvement in Quality of Life(QoL) and fewer complications with self-management of pessaries. The TOPSY study also demonstrated economical gain from self-management in comparison to clinic-based care. This review aims to observe our populations experience of self-management.

A retrospective analysis of prospectively collected data of patients undergoing self-management of pessaries between January 2022-June 2024. Data was collected from electronic case notes including demographics, type and stage of prolapse and pessary, as well as any complications and patient satisfaction.

206 patients undergoing self-management were identified over this time period. 

Demographic data showed 81%(n=169) to be over 50yrs (mean age 62yrs), with a mean BMI of (mean 27). 43%(n=89) were managed for multicompartment prolapse.  98% (n=202) used either cube (42%;n=88) or a form of ring pessary (55%;n=114). In women with a cystocele(n=53), 51% used a cube pessary and 47% ring pessary. Women with Rectocele(n=28)  were given cube pessary preferably (61%) compared to 39% using a form of ring pessary  
Out of all patients 23% (n=47) experienced complications:  ulceration (19%), bleeding (5%), worsening urinary symptoms (4%). 40%(n=19) of those with complication experienced discomfort and 50%(n=10) of those with discomfort led to discontinuation of use. 

62%(n=129) were satisfied and continued with self-management with only 5% (n=11) continuing pessaries but not self-managing. 18% of patients overall stopped using pessaries altogether and distribution of these appeared similar comparing cube to ring pessary with 33% and 31% respectively (p-value = 0.76).  Other patients used different pessaries or had no follow up data available. 

Cube pessaries had the highest complication rate (39%) with only 64% continuing to use them. 17 women trialled initially with cube switched to ring pessary. Of those 76% were now satisfied and the remainder have  discontinued pessary use altogether. 

Of those women that discontinued pessary usage (n=57), 21%(n=12) opted for surgery and 12%(n=7) were lost to follow up.  

Following successful self-management, 68%(n=85) were discharged with patient-initiated follow-up. Others had plans for follow up ranging from 3-12 months or did not have documented outcomes other than ongoing self management. Of the original cohort, 60%(n=125) were still self-managing.Of women who continue to self-manage in the longer term i.e. more than 6 months 97% (n=121) were deemed satisfied overall with self-management.

Self-management with pessaries appears to be improving quality of life for 97% of patients regarding satisfaction with few proceeding to surgery. Discontinuation is  high with a number of those accounted for by complications such as discomfort, ulceration or not returning for follow up. Based on documentation, numerous patients undergoing change to type of pessary, are subsequently satisfied. 

One limitation is that it was unclear how many patients were reliably using oestrogen cream and this may be helpful to reduce dissatisfaction, discomfort or complications. 

Self-management of pessaries is deemed more economical based on the TOPSY study. Looking at high satisfaction rates, this data may benefit both services and patients with more patient freedom in relation to number of hospital attendances and ability to initiate their own follow-up. Given lower cost of ring pessaries and little difference in discontinuation rates, it may be advisable to offer to trial ring pessaries before trialling a more specialist type.

It can be concluded that low complication rates and high satisfaction are associated with self-management. This data plus longer-term follow up data would be useful to share experience while also counselling about options.

Clinical effectiveness of vaginal pessary self-management vs clinic-based care for pelvic organ prolapse (TOPSY): a randomised controlled superiority trial Hagen, Suzanne et al. eClinicalMedicine, Volume 66, 102326