A tailored flexible vaginal pessary treatment for pelvic organ prolapse in older women

Objectives To present a flexible protocol of vaginal pessaries for older women with significant pelvic organ prolapse (POP). Design A prospective cohort study of 140 consecutive older women (aged ≥65 years) with significant POP treated with individually fitted vaginal pessaries. After initial insertion, each patient was invited for a first evaluation after 1 month and subsequent follow-ups at increasing intervals of 1 month. During each examination, the pessary was removed and the vagina was inspected for infection, bleeding, or erosions. All patients were advised to use a vaginal estrogen cream twice a week. Setting The study was conducted during 2020 in the urogynecology clinic of a tertiary medical center. Participants The study cohort included 140 consecutive older women with significant and symptomatic POP treated with vaginal pessaries. Main outcome Primary outcomes included time intervals between follow-up visits, pessary-associated complications, need to change the pessary, need to remove the pessary temporarily, and whether the patients eventually underwent POP surgery. Results The mean age of the patients at the time of pessary fitting was 76.7 ± 9.2 years (range 65-100 years). Mean interval between follow-up examinations was 3.3 ± 1.1 months (range 1-6 months). Most patients (83.6%) used a ring pessary with support, but only a small number of patients were able to maintain the pessary by themselves. Of the 140 patients, five (3.6%) patients only eventually underwent POP surgery, and in 11 (7.9%) patients, the vaginal pessary had to be removed for 2-4 weeks because of significant vaginal discharge or superficial erosions. Additionally, 12 (8.6%) patients developed stress urinary incontinence following pessary insertion. Conclusions Customized management with vaginal pessary for symptomatic POP in older women is effective and safe, and is a suitable therapeutic alternative for older women who are unable or unwilling to undergo reconstructive pelvic surgery.