Jun 22

Pelvic Organ Prolapse and the Sexy Pessary Posse




Display of every type of modern vaginal pessary for pelvic organ prolapse

Ladies, it's all about choice

Pelvic organ prolapse is a condition where the organs around the vagina are out of place – bladders drop (called cystocele), rectums bulge forward and sometimes out of the vaginal opening (rectocele), and/or the uterus drops down, literally falling out of the vagina turning everything inside out when its severe (uterine prolapse).  When prolapse is so bad that things are bulging out between the vaginal labia (yup, it happens) most women are uncomfortable to want to do something about it.
With severe prolapse, whatever the prolapsing part(s), and it’s usually more than one thing out of place, there are 2 choices – reconstructive surgery, or a vaginal prosthesis called a pessary.  A pessary is a vaginal widget that holds things up where they need to be when it’s inside. They come in all shapes and sizes – the easiest pessaries are ring-shaped. They’re easy because women can remove and insert them easily and reliably without assistance. Ring pessaries are sort of like contraceptive diaphragms in terms of insertion and removal. But sometimes, due to weak, thin Kegel muscles or uterine prolapse so severe that it pushes the rings out, sturdier pessaries, such as Gellhorns, donuts and Gehrungs, are the only ones that stay in.

Some women don’t like pessaries – or can’t find any that fit comfortably. They usually opt for prolapse surgery that puts all the organs back into position. The surgery can be complicated and, as with all surgeries, results can be less than perfect, making pessaries a viable option for women who are poor surgical candidates or simply don’t want to undergo extensive soft-tissue reconstructive surgery.

These British researchers undertook the task of looking at whether or not either treatment choice, surgery or pessary, affected sexual quality of life.  In data published in the March 2011 issue of the International Urogynecology Journal, they  found some interesting trends – women choosing surgery were younger, and at first glance seemed to have better sexual quality of life than their pessary using sisters, but when the statistician removed age differences, the sexual quality of life was the same between the two groups. Interestingly, 31 women who started with pessary didn’t like it and switched to surgery. Not much is said about them as the study design excluded data of patients who switched groups after the initial choice of treatment.

Here’s the study summary written for the June 2011 literature review for Journal of Sexual Medicine:

Abdool Z, Thakar R, Sultan AH, Oliver RS

Prospective evaluation of outcomes of vaginal pessaries versus surgery in women with symptomatic pelvic organ prolapse.

Int Urogynecol J (2011)22:273-78.

A prospective, non-randomized design compared women with prolapse opting for pessary management vs reconstructive surgery of pelvic organ prolapse, using baseline  and 1 year quality of life data, including but not limited to sexual function (Sheffield Pelvic Organ Prolapse Quality of Life questionnaire-SPS-Q).

Women referred to the Urogynaecology unit of Mayday University Hospital in Surrey, England were evaluated and counseled regarding prolapse management.  Each completed the SPS-Q, a 13 item quality of life assessment tool addressing impact of prolapse on bladder, bowel and sexual function using four-point ordinal response scales (never, occasionally, most of the time, all of the time), validated and sensitive to changes in clinical status. Women choosing pessary were first fitted for ring pessaries; the most user-friendly. If rings did not work, gellhorn or donut pessaries were fitted for sexually inactive women, and cubes fitted for sexually active women, as cubes are easily removed for sexual activity.

Patients were excluded if they underwent incontinence surgery or switched from pessary to surgery (N=89) either due to use of pessary as interval measure in preparation for surgery (N=58), or because pessary was too problematic, prompting a change of heart in favor of prolapse surgery (N=31).

554 women entered the trial, 359 with pessary and 195 choosing surgery. Women excluded from final analysis numbered 195 in the pessary group and 88 in the surgery group.  The final analysis was carried out on women completing questionnaire at 1 year who either underwent surgery as first option or were still using pessary at 1 year, 46% of the pessary group and 55% of the surgical patients.

Mean age was higher in the pessary group (68 vs 60 yrs). Other demographic measures were equivalent. At 1 year there was statistically significant improvement in sexual function in both pessary and surgery patients, in addition to similar improvement in bladder, bowel and prolapse symptoms. Frequency of intercourse was better in the surgical group (54% vs 46% p=0.028), however this sexual frequency difference faded when controlling for age.

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.


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