Pessary Use vs Surgery Alone in Urology and Gynecology Trained Urogynecologists

Objectives: Differences in residency education may consequently lead to variations in clinical practice. We propose that such differences in training may lead to specialty-specific differences in the management of pelvic organ prolapse (POP), with urology-trained urogynecologists more inclined towards surgical interventions and gynecology-trained urogynecologists favoring non-surgical approaches such as pessaries. Given the scarcity of data in this area, this study aims to explore trends in both surgical and non-surgical treatments for POP within a Urology/Urogynecology academic practice employing physicians trained in both gynecology and urology.

Methods: Four urogynecologists—two with urology and two with gynecology backgrounds—were identified in our practice. We then identified patients seen by the 4 aforementioned physicians from January 2011-September 2022 who had POP ICD 9 and 10 codes and had CPT codes for pessary placement or prolapse surgery (Table 1). Physician training type, type of prolapse, date(s) of the procedures, and type of treatments (no intervention, pessary alone, surgery alone, or pessary and then surgery) were collected by retrospective chart review. Variables were analyzed using the t-test and chi-squared.

Results: Of 1795 patients over 12.75 years, 1579 (88%) of patients saw gynecology-trained urogynecologists and 216 (12%) saw urology-trained urogynecologists. In our cohort, gynecology-trained urogynecologists had a 92.0% rate of surgical treatment for POP, while urology-trained urogynecologists had an 85.2% rate of surgical treatment management (p=0.0010). Furthermore, gynecology-trained urogynecologists had a 10.4% rate of pessary use, while urology-trained urogynecologists had a 21.8% rate of pessary use (p < 0.0001). Of the 54 patients treated with both pessary and surgery, 47 (87.0%) had pessary first followed by subsequent surgical treatment. Of those treated with pessary followed by surgery, there was no statistically significant difference in rate by provider type (p=0.4139) (Table 2).

Conclusions: Our results indicate a statistically, but not clinically significant difference in practice by specialty training, showing that urology-trained urogynecologists may be more likely to offer pessary, a non-surgical treatment for POP, compared to gynecology-trained urogynecologists. Overall, management of POP appears similar between the two groups, indicating that training received regarding POP treatment is similar regardless of specialty orientation. Further research is needed across a wider subset of urology and gynecology-trained physicians to better quantify trends, as our study is limited to four physicians total and may reflect trends specific to individuals as opposed to specialty training. Additionally, the next step in our study is to collect and analyze demographic data to see how this influences treatment pathways.