How A Pessary Changed My Life
How A Pessary Changed My Life A recent prospective clinical trial, as published in Investigative and Clinical Urology in March 2022, has shed light on the effectiveness of both pessary use and surgery in managing pelvic organ prolapse symptoms. Interestingly, the study revealed that patients perceived surgical outcomes as more significant compared to pessary use.
A Unique Study Approach
The uniqueness of this study, according to senior author Dr. John A. Occhino, M.D., M.S., a specialist in Female Pelvic Medicine and Reconstructive Surgery at Mayo Clinic’s Minnesota campus, lies in its design. Each participant was involved in comparing their experiences with one treatment modality against the other. This self-controlled approach allowed for a direct comparison between pessary use and surgery. Despite having fewer participants than some other studies, this design was deemed valid and contributed to the study’s overall quality, as explained by the study’s first author, Dr. Brian J. Linder, M.D., also specializing in Female Pelvic Medicine and Reconstructive Surgery at Mayo Clinic’s Minnesota campus.
Patient-Driven Intervention
All participants in the study were driven by self-identified symptoms of prolapse that bothered them. Dr. Occhino notes that these therapeutic objectives can be somewhat subjective. After consulting with their physicians, participants were given the option to choose between observation, pessary use, or surgery. Following this decision, they were invited to participate in the study. Instead of randomizing participants to either pessary use or surgery, which can be challenging due to patients’ preference for personal choice, each participant underwent both therapies. Surgery was scheduled between seven and 30 days after the initial consultation, with participants wearing a pessary before surgery.
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Vaginal Colporrhaphy and Sacrocolpopexy
The study utilized the Patient Global Index of Improvement to assess how prolapse symptoms affected participants’ daily lives at different stages: baseline, after pessary use, and three months post-surgery (for those who underwent surgery). This approach allowed for the measurement of recovery and a return to normal activities. Out of the 61 participants, 40 underwent both treatments and directly compared pessary use and surgery. Among these, 33 preferred surgical outcomes, five experienced similar results with both therapies, and two found greater symptom improvement with a pessary. The improvements measured included reductions in pressure, bulge sensations, and heaviness, as determined by a validated questionnaire.
Key Points to Consider
Dr. Occhino and Dr. Linder highlight several noteworthy aspects of the study:
- Participant Demographics: The geographical location of the study (Upper Midwest) resulted in a predominantly white participant population.
- Patient Choice: All participants decided on surgery before enrolling in the study.
- Pessary Preference: Approximately 19% of participants opted to continue using a pessary after trying the device, finding it effective in managing their symptoms.
- Outcome Assessment: Participants’ outcomes three months post-surgery were based on surveys rather than physical examinations.
The reasons behind the preference for surgical outcomes remain unclear and warrant further research, according to Dr. Occhino. Dr. Linder suggests that future research could explore anatomical correction using imaging after pessary use and surgery.
Both physicians emphasize that patients bothered by prolapse symptoms can find relief through either pessary use or surgery. The advantage of a pessary lies in its nonsurgical and risk-free nature, but it is not a permanent solution. Dr. Linder echoes this sentiment, emphasizing that there is no wrong answer; patients should choose the treatment that aligns with their preferences and needs. Many patients are eligible for multiple treatment options, and the primary goal is symptom improvement, regardless of whether it involves surgery.
Goals in Treating Pelvic Organ Prolapse
Current trends in pelvic organ prolapse therapy focus on assessing subjective surgical outcomes in addition to anatomical assessment. Ideally, improvement should encompass both symptomatic relief and anatomical correction. Anatomical assessment alone may label even minor instances of prolapse recurrence as treatment failures, despite patients feeling satisfied.
Satisfaction with a pessary is highly personal, and some participants in the study chose to continue using it instead of opting for surgery. This study supports the practice of using a pessary as a diagnostic trial to demonstrate potential improvements achievable with surgery.
Prolapse intervention goals include alleviating pressure, bulge sensations, and achieving anatomical correction. Patients with overactive bladders may experience symptom improvement through prolapse surgery or may require additional therapy. Pain relief is not typically a goal in prolapse treatment, as the condition is not commonly associated with pain; if pain is present, it likely indicates another issue.
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Benefits of Referral to Specialized Clinics
Dr. Occhino suggests that surgeons with expertise in prolapse surgery can effectively treat patients locally. However, if such expertise is not available locally, referring patients to a Female Pelvic Medicine and Reconstructive Surgery (FPMRS)-certified surgeon is advisable. This approach ensures not only that patients receive treatment from a highly experienced practitioner but also provides access to a clinic designed specifically for prolapse treatment.
Specialized clinics offer a wider range of pessary options to better suit individual anatomies, addressing common issues such as pessary falling out. Additionally, specialized clinics can devote more time to assessing patients’ urinary and sexual function and considering various treatment options. This comprehensive assessment is invaluable to patients with prolapse symptoms.
Mayo Clinic’s specialty FPMRS clinic offers convenient one-day visits for prolapse, encompassing all necessary tests and physician appointments for nonlocal patients. While physician referrals to specialized clinics are beneficial for building subspecialist relationships and providing medical documentation, patients can also self-refer.
Ultimately, seeking evaluation should be driven by bothersome symptoms. The approach taken is “if it ain’t broke, don’t fix it,” allowing patients and physicians to make informed decisions based on the severity of symptoms.
