Pessary Care

Follow Up and Management of Complications

Katharine O'Dell; Shanna Atnip

Disclosures

Urol Nurs. 2012;32(3):126-137, 145. 

In This Article

Areas for Future Research

As this article has illustrated, many recommendations for pessary follow up and complication management are based on expert opinion or extrapolation from research done in other areas of women's health. This emphasizes the need and opportunity for ongoing research. For example, there is a need for further research related to prolapse treatment in general. The overall comparative safety and cost-effectiveness of all prolapse treatment options, including observation, pessary, physical therapy, or surgery at each life stage, remains unclear.

Pelvic floor muscle training can also decrease symptoms, such as stress incontinence (Bø, 2004), and prolapse-related feelings of bulging and vaginal heaviness (Braekken, Majida, Engh, & Bø, 2010); however, the potential enhanced effect of pessary use in combination with regimens of pelvic muscle strengthening has not been well studied. Pessaries may be able to play a larger role in surgical outcome prediction for symptoms such as low backache that may not be improved by prolapse treatment (Heit, Culligan, Rosenquist, & Shott, 2002), and further inquiry in this area is suggested.

For pessaries in particular, the comparative costs and optimal intervals for self- and clinician-provided care options, especially as they relate to different pessary types (for example, pessaries that are retained by an intact introitus versus those that are self-retaining) are also needed. Further studies of pelvic function in the presence of pessary-support may be aided through the use of real-time ultrasound (Fox, 2009). Innovations in pessary design continue to be described (Jones & Harmanli, 2010). Advances in material and biomedical sciences may offer opportunities for clinical partnerships to develop additional alternatives for pessary shape and content, devices to aid pessary self-care, and agents to protect and rapidly heal damaged epithelium.

The role of pessaries in preventing prolapse progression is not well understood. Initial research suggests that pessary use may improve prolapse, at least temporarily, in some women (Handa & Jones, 2002). However, it is not clear whether pessaries significantly change stress or strain on pelvic support tissue, or whether some degree of pelvic tissue support can regenerate under supported conditions. In addition, while women may question whether earlier initiation of pessary use might slow or prevent symptomatic prolapse progression, there is little evidence to inform this area of decision-making.

The needs of an aging population require additional research in several areas related to pessary use. For example, there may be increasing opportunity to understand normal aging of the genitalia in very old women (over age 85) and to collect data for very long-term pessary use (20 years or more), where advancing atrophy may result either in increasing prolapse as support weakens, or decreasing pessary need as vaginal strictures and adhesions develop and activity levels decrease.

Prevention and treatment of vaginal atrophy relates both to symptom improvement and potential pessary complications. Emerging treatments, including selective estrogen receptor modulators (Bachmann, Komi, & the Ospemifene Study Group, 2010), and the estrogen precursor dehydroepiandrosterone (DHEA) (Labrie, 2010) are demonstrating efficacy in treatment of genital atrophy. Alternatives such as these may become important as non-estrogenic treatment options to improve outcomes for pessary users.

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