Objective
We sought to evaluate whether use of a vaginal pessary would change body image, bother symptoms, and quality of life in women with pelvic organ prolapse.
Study Design
Women presenting for pessary insertion completed the short forms of Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire, and Body Image Scale. After successful pessary insertion and use for at least 3 months, subjects completed the surveys again. Scores were compared with a paired t test.
Results
A total of 75 subjects were enrolled and follow-up responses were available for 54 subjects for analysis. Body Image Scale scores showed a significant decrease (6.1–3.4; P < .001), indicating an improvement in these women’s perception of themselves, as did Pelvic Floor Distress Inventory-20 scores (81.34–45.83; P < .001) and Pelvic Floor Impact Questionnaire scores (50.32–17.98; P = .003).
Conclusion
The use of a pessary for 3 months reduces bother symptoms and improves both quality of life and perception of body image in women.
Vaginal pessaries can be used as a first-line treatment for symptomatic prolapse, but their use has been declining due to advances in surgery. Currently, they are predominantly used for those who are poor surgical candidates. There are few prospective studies evaluating how vaginal pessaries impact bother symptoms related to prolapse in women. These studies have demonstrated an improvement in prolapse and even urinary symptoms over a short-term follow-up.
Self-perception of body image is reduced in women with advanced pelvic organ prolapse (POP). Body image is an important part of a woman’s well-being that should be taken into consideration with treatment for pelvic floor disorders. Aesthetic and plastic surgery improves depression and satisfaction with body image. Additionally, surgery for symptomatic POP can improve body image and depressive symptoms in women. The aim of this study was to evaluate whether the use of vaginal pessary improves bother symptoms, quality of life, and body image in women using a vaginal pessary for symptoms of prolapse.
Materials and Methods
Institutional review board approval was obtained prior to the initiation of this study, and all subjects signed informed consent for participation. Eligible subjects comprised women, aged ≥18 years, presenting for vaginal pessary fitting from February 2008–April 2009, inclusive, who could understand the written materials and provide informed consent. In our hospital-based urogynecology practice, all women presenting for evaluation and treatment of symptomatic prolapse are offered a pessary for initial management. Women are fitted for a pessary based on the size of prolapse, pelvimetry, manual dexterity, and comfort level to remove and insert the pessary on their own. The types of pessaries that were used in this study were the ring pessary, ring pessary with support, and Gellhorn pessary. Demographic information, medical comorbidities, and stage of prolapse based on the POP quantification system were collected.
Subjects completed Body Image Scale (BIS) prior to being fitted for the vaginal pessary. The BIS consists of 9 items about how the subjects feel about their appearance and changes as a result of their condition ( Figure ). It has been used in women with cancer and was found to be valid and reliable; it evaluates a woman’s self-perception of her appearance, attractiveness, and body satisfaction. It was subsequently adapted for use in a trial of women undergoing hysterectomy for benign indications and shown to be reliable and valid in this population. It also has been used in a study of body image in women with pelvic floor disorders. Responses to each question were 1 of the following: “not at all,” “a little,” “quite a bit,” or “very much,” with corresponding scores being 0, 1, 2, or 3, respectively. The range of scores is from 0–27, with lower scores representing a better body image. Similar to the study by Jelovsek and Barber, we eliminated 1 question regarding “appearance of the scar” since it is not applicable to women with a vaginal pessary. The questions demonstrated good internal consistency (Cronbach α = 0.91) but no assessment of test-retest reliability.
Based on a prior trial using the BIS, our sample size calculation was based on finding a difference of 4.4 U on the BIS from pretreatment to posttreatment. Assuming SD of 10.0, a sample size of 43 would have 80% power to detect a difference in means of 4.4, using a paired t test with a .05 2-sided significance level. Given an anticipated compliance rate of >96%, and allowing for postenrollment exclusions of up to 10%, we planned to enroll 50 subjects to achieve a cohort of at least 43 with 3-month follow-up data.
Statistical evaluations used a paired t test to compare scores on the body image questionnaire, short forms of the Pelvic Floor Distress Inventory (PFDI)-20 and Pelvic Floor Impact Questionnaire (PFIQ), and the prolapse subscale of the PFIQ (POP Impact Questionnaire-7) before and after treatment for all subjects. Both the PFDI-20 and PFIQ are validated for use in women with prolapse. The internal consistency of the BIS was evaluated using Cronbach α. Statistical analyses were conducted using software (SPSS, v 14.0; SPSS, Inc, Chicago, IL) at the .05 significance level such that all results yielding P < .05 were deemed statistically significant.
Results
A total of 75 subjects were enrolled. Of these, 21 (28%) were considered postenrollment losses: 5 could not be fitted for a pessary and desired surgery, 6 were not comfortable with the pessary or thought that the pessary did not relieve their symptoms, and 10 could not be contacted for follow-up. Fifty-four subjects completed 3-month questionnaires for analysis. The mean age (±SD) of subjects was 62.5 ± 14.7 years; mean BMI was 26.6 ± 5.0. Subjects who did not have 3-month follow-up were younger, and a larger percentage was more likely to report prior prolapse surgery and depression. Demographics of both those with and without follow-up are listed in Table 1 .
| Demographic | Subjects included (n = 54) | Subjects excluded a (n = 21) | P value |
|---|---|---|---|
| Age, y (mean, SD) | 65.2 ± 12.8 | 53.8 ± 15.2 | .002 b |
| BMI (mean, SD) | 26.4 ± 5.2 | 26.9 ± 4.6 | .670 |
| Vaginal parity, median (range) | 2 (0–7) | 2 (0–4) | |
| Prior prolapse surgery, n (%) | 10 (18.5) | 9 (42.9) | .040 b |
| Menopausal, % | 81.5 | 66.7 | .221 |
| Stage prolapse, n (%) | .334 | ||
| 1 | 1 (1.9) | 2 (9.5) | |
| 2 | 20 (37.0) | 9 (42.9) | |
| 3 | 31 (57.4) | 10 (47.6) | |
| 4 | 2 (3.7) | 0 (0) | |
| Medical comorbidities, n (%) | |||
| Hypertension | 26 (48.1) | 6 (20.7) | .018 b |
| Diabetes | 4 (7.4) | 2 (6.9) | .932 |
| Depression | 1 (1.9) | 4 (13.8) | .048 b |
| Smoking (past or current) | 21 (38.9) | 7 (33.3) | .792 |
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