Nonsurgical Management of Stress Urinary Incontinence and Pelvic Organ Prolapse: Use of the Pessary

Isuzu Meyer

Introduction

Pelvic floor disorders, such as pelvic organ prolapse (POP), urinary, and fecal incontinence, are highly prevalent and bothersome conditions. One in 4 women report symptoms of at least one of the pelvic floor disorders in the United States.¹ The prevalence of pelvic floor disorders increases with age; 40% in women aged 60 to 79 years and 53% ages 80 years or older suffer from at least one symptomatic disorder.¹ With the rapidly growing aging population (women ages 65 years or older) predicted to double by 2050,² it is inevitable that the prevalence and burden of pelvic floor disorders will continue to increase. This chapter focuses on nonsurgical management of stress urinary incontinence (SUI) and POP with pessaries. The epidemiology, pathophysiology, and evaluation of pelvic floor disorders are discussed in separate chapters.

GENERAL PRINCIPLES

For women who desire nonsurgical management of pelvic floor disorders, pessaries can provide symptomatic relief. Of the pelvic floor disorders, pessaries are indicated for POP and urinary incontinence (specifically SUI) as they provide structural support. Particularly for SUI, pessaries have been shown to increase urethral closure pressure and reduce vaginal Q-tip angle on Valsalva.³,⁴,⁵ Additionally, the treatment of the stress component can sometimes improve urgency associated urinary incontinence symptoms.

Once determined that the patient is symptomatic and desires treatment, counseling and active patient participation in decision making is essential for treatment success. Although surgery is considered definitive management, nonsurgical options, such as pessaries, are not a “secondary” option. Patient counseling on pessaries should include the following:

Patient selection, indications, and contraindications
Establishing goals and expectations
Alternative treatment options
Proper fitting techniques (not “one-size fits all”)
Education for management and pessary care instructions

PATIENT SELECTION

It is important to determine whether the patient is a good candidate for pessary use by considering indications and contraindications of pessaries.

Indications include the following:

Symptomatic POP and/or SUI and desire treatment
Prefer nonsurgical management
A poor surgical candidate
Need to delay surgery
Pregnancy—current or the desire for future fertility, especially there is a paucity of data on the subsequent childbirth following incontinence or prolapse surgery

Contraindications include the following:

Nonadherence to pessary self-care or unable to follow up
Active infection in the pelvis
Foreign body exposure such as synthetic graft

Other Considerations

Women can choose to wear a pessary either at all times or in certain situations (during exercise, rigorous activities, etc.). Furthermore, pessaries can be used for diagnostic purposes which include the following:

To determine whether urinary retention is associated with advanced prolapse (obstructive voiding) during urodynamic evaluation

Up to 94% of women with an advanced stage cystocele had the resolution of obstructive voiding on urodynamics evaluation with pessary insertion.⁶
For surgical planning, prolapse reduction by pessary demonstrated positive predictive value of 94% and negative predictive value of 67% in predicting postoperative resolution of urinary retention in patients with cystocele.⁷
To perform a reduction stress test using pessary

Pessaries can be used to assess occult SUI or de novo SUI after prolapse surgery. However, pessary stress testing may be less predictive for occult SUI compared to using other tools, such as cotton swab, a speculum blade, or ring forceps, because a pessary may provide pelvic floor support and prevent leakage.

ESTABLISHING GOALS AND EXPECTATIONS

Patient acceptance highly depends on appropriate counseling. Based on the current literature, there is a wide range of patient acceptance and duration of pessary use, which declines over time. A prospective study of women with symptomatic POP reported 46% chose pessary compared to 53% surgery.⁸ Patient factors associated with declining pessary include younger age (younger than 65 years), lesser degree of prolapse, and concurrent urinary incontinence symptoms.⁹ Among those who elected for pessary trial, the rate of successful fitting ranges between 74% and 97%.¹⁰,¹¹,¹² Factors associated with declining pessary trial versus unsuccessful fitting can overlap (Table 16.1). There is conflicting data regarding the association between specific vaginal dimensions and successful pessary fitting. Whereas some studies demonstrated shorter vaginal length, wider introitus, and prior hysterectomy as predictors for unsuccessful fitting, others found no such association.¹³,¹⁴

TABLE 16.1 Factors Associated with Unsuccessful Fitting or Declining Pessary

PATIENT CHARACTERISTICS

Younger age (65 years or younger)

Obesity

Sexually active

Prior pelvic surgery

PELVIC FLOOR DISORDER SYMPTOMS

POP with concurrent urinary incontinence

Advanced posterior prolapse associated with incomplete bowel evacuation, needing to splint

ANATOMY

Short vaginal length (<7-8 cm)

Wide vaginal introitus (>4 fingerbreadths)

TABLE 16.2 Factors Associated with Discontinuation of Pessary after Successful Fitting

PATIENT FACTORS

Sexually active

Prior vaginal reconstructive surgery (less likely to discontinue once successfully fit)

Advanced posterior predominant prolapse

Presence of surgical scarring (difficult insertion and retention of pessary)

Inconvenience, social reasons

PESSARY FACTORS

Space filling type

Discomfort

Increased vaginal discharge

Retained pessary

Once successfully fit, those who elect not to continue with pessaries will typically do so within the first few weeks of fitting.¹⁵ Short-term continuation rate (within 6 month) ranges 60% to 92%,⁸,¹⁶,¹⁷ midterm continuation (1 to 3 years) ranges 33% to 80%⁹,¹¹,¹²,¹⁸,¹⁹,²⁰,²¹; however, the long-term use (longer than 10 years) declines to less than 15%, although very little prospective data exists.²² The wide range of continuation rates are likely due to the differences in study design (observational vs. clinical trial) as well as patient characteristics (age, prior surgery, the type[s] of pelvic floor disorders present). Factors associated with discontinuation of pessary after successful fitting are noted in Table 16.2.

In addition to symptomatic improvements achieved with pessary use, some studies have demonstrated anatomic changes (regression of prolapse) with pessary use. Reported anatomic changes include reduction in genital hiatus (4.8 ± 1.6 to 3.9 ± 1.1 cm, P < .001) after 3 months of pessary use,²³ and a decrease in prolapse stage assessed by the Pelvic Organ Prolapse Quantification system was seen in 25% of patients after 1 year of pessary use.¹⁸ Hydronephrosis can be present in up to 30% of women with prolapse.²⁴,²⁵ One study demonstrated that successful pessary use of 1 to 3 months resulted in improvement or resolution of hydronephrosis on ultrasound in 77% of women with advanced prolapse.²⁵

ALTERNATIVE TREATMENT OPTIONS

Patient counseling should include the discussion of alternative treatment options to pessaries.

Supervised Pelvic Floor Muscle Training versus Pessary

Stress urinary incontinence

A randomized controlled trial²⁶ demonstrated that women with SUI have greater symptomatic improvement with supervised pelvic floor muscle training plus pessary compared to pessary use alone during the initial 3 months (much better or very much better on the patient Global Impression of Improvement²⁷; pessary = 40% vs. combined pessary and pelvic floor muscle training = 49%, P = .006) and satisfaction (on the Patient Satisfaction Questionnaire²⁸; pessary = 63% vs. combined = 75%, P = .003); however, differences in improvement and satisfaction were no longer significant at 12 months.²⁶

Pelvic organ prolapse

Comparing pessary use versus supervised pelvic floor muscle training in a randomized controlled trial of women with prolapse beyond the hymen, no intergroup difference was noted in overall symptom severity at 24 months, measured by total Pelvic Floor Disorder Inventory-20 (PFDI-20) scores (-3.7 points, 95% confidence interval [CI] -12.8 to 5.3, via intention to treat). However, the pessary group had greater POP-specific symptomatic improvement measured by the Pelvic Oregon Prolapse Distress Inventory 6 (-3.2 points, 95% CI -6.3 to 0.0) over 24 months. Notably, the rate of successful pessary fitting was 57% in this trial.²⁹ Another randomized trial compared pelvic floor muscle training alone versus pessary plus pelvic floor muscle training in women with symptomatic stage I to III POP. At 12 months, improvement in POP symptoms (measured by the PFDI-20) and impact on quality of life (measured by the Pelvic Floor Impact Questionnaire) was shown to be greater in those with pessary use in combination with pelvic floor muscle training, compared to the pelvic floor muscle exercises alone.³⁰