Pessary Uptake and Outcomes in Women Who Ultimately Had Surgery for Prolapse

Objectives: To explore patterns of pessary use in women who ultimately went on to surgical treatment of pelvic organ prolapse at our institution.

Methods: Retrospective cohort study of women who had surgery for pelvic organ prolapse over a 16-year period. Demographic characteristics, medical and surgical history, and data on treatment were collected from the medical record. Demographic characteristics were examined using Chi squared and T-test. Factors associated with pessary uptake and outcomes were explored using univariable and multivariable logistic regression.

Results: Among the 1228 patients, the mean age was 60.8 (SD 29.2), most were white (84.6%), on Medicare (48.1%) or privately insured (40.9%), and had a POP-Q stage of 2 or more (96.6%) (Table 1). One-third (406, 33.1%), initially elected for conservative management with a pessary, including 12 (3%) who chose the pessary as interim management until their surgical date. Factors associated with choosing a pessary on univariable regression include older age (OR 1.01, 95% CI 1.00-1.02), lower BMI (0.97, 0.95-0.99), public insurance (1.71, 1.33-2.21), menopausal status (3.04, 2.06-4.47), and current cancer diagnosis (1.47, 1.08-1.98). Patients who chose a pessary were less likely to be current smokers (OR 0.49, 95% CI 0.28-0.87) and sexually active (OR 0.76, 95% CI 0.59-0.97). On multivariable regression, only public insurance status remained statistically significant (aOR 1.48, 95% CI 1.07-2.05). Among women who chose a pessary, prior hysterectomy (OR 0.34, 95% CI 0.17-0.68) or prior prolapse repair (OR 0.28, 95% CI 0.13-0.60) were associated with lower odds of successful fitting whereas sexual activity was associated with higher odds of successful fitting (OR 2.39, 95% CI 1.03-5.57). On multivariable regression, patients who had a prior prolapse repair were 63% less likely to be successfully fit. Those who were sexually active were 2.8 times more likely to be successfully fit.

Conclusions: In this sample of women that ultimately pursued surgery for pelvic organ prolapse, patients with public insurance were more likely to choose a pessary. Variables associated with higher odds of successful pessary fitting were similar to previously published studies. These findings suggest sociodemographic factors and social determinants of health may influence choice of treatment for pelvic organ prolapse.

Table 1 Footnotes:
a Includes Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander and unreported.
b Includes not Hispanic and unreported.