Pessary Placement for Voiding Dysfunction Due to Pelvic Organ Prolapse

Objectives: Literature surrounding conservative management of voiding dysfunction (VD) due to pelvic organ prolapse (POP) is limited. Previous studies are restricted to patients with anterior predominant vaginal wall prolapse and lack long-term follow up data. The objective of this study is to evaluate the efficacy of POP reduction with a pessary for the management of VD.

Methods: This is a retrospective case series of adult women who underwent a pessary fitting for POP and VD between January 2016 to December 2022 at two tertiary care centers. VD was defined as patient report of obstructive voiding symptoms and postvoid residual (PVR) >150 mL prior to pessary fitting. Obstructive voiding symptoms were determined by positive response on the Pelvic Floor Disability Index to difficultly emptying bladder, sensation of incomplete bladder emptying, pain or discomfort in the lower abdomen/pelvis, and/or need to manually push on the vagina to urinate. Exclusion criteria included: neurologic conditions potentially contributing to VD, failed pessary fitting at index visit, lack of follow up after pessary fitting, or no documented repeat PVR after pessary fitting. Patient demographics, clinical characteristics, and outcomes were abstracted from the chart.

Results: 61 patients underwent successful pessary fitting for VD in the setting of POP at two large academic institutions. Median age was 75 years old (35-89) and BMI 26.5 kg/m2 (18-46). Majority of patients were white (61%), postmenopausal (93%), not currently sexually active (56%), and had Medicare or Medicaid insurance coverage (79%). Approximately one third of patients had a prior hysterectomy. Patient reports of “difficult bladder emptying” and “sensation of incomplete bladder emptying” were the most reported symptoms of obstructive voiding. Advanced staged prolapse (prolapse ≥ stage 3) was documented for 84% of patients with anterior predominance in 50%. Median genital hiatus was 4 cm (1-9) and PVR prior to pessary fitting was 263 mL (150-810). Ring with support was the most common pessary utilized (77%). VD resolved in 60 out of 61 patients (98%). One patient continued to have elevated PVRs after pessary placement. Median repeat PVR after pessary placement was 50 mL (0-250). Patients utilized a pessary for a median of 13.5 months (1-125), and 15 patients progressed onto surgical management of POP (25%). 4 patients experienced vaginal erosions, 8 reported

Conclusions: Pessary placement resolved VD due to POP in 98% of patients. Clinicians can offer pessary placement as a nonsurgical management option for patients with VD due to POP. This is the first study to evaluate the efficacy of pessary placement for VD due to POP with long term outcomes.