Pessary Management of Incontinence
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, Portland, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: Two-thirds of patients with genuine stress incontinence with minimal pelvic organ prolapse can be successfully fitted with an incontinence pessary or dish.
Source: Nager CW, et al. Incontinence pessaries: Size, POPQ measures, and successful fitting. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:1023-1028.
In this multicenter trial, patients with documented stress urinary incontinence (SUI) with a pelvic organ prolapse quantification (POPQ) score < 2 were randomized to groups that received an incontinence pessary or an incontinence pessary along with behavioral therapy. Ninety-two percent of the 235 patients were successfully fitted with an incontinence pessary or dish. A history of hysterectomy, the genital hiatus, and the genital hiatus/total vaginal length ratio did not predict unsuccessful fitting. No specific POPQ measurement was helpful in determining incontinence pessary size.
This is a publication from the Pelvic Floor Disorders Network with involvement of excellent investigators from the United States. Just as the subspecialty of uro-gynecology (a.k.a., female pelvic medicine and reconstructive surgery) is becoming established, the authors sought to bring some standardization to the art of pessary fitting. If the size of the pessary can be predicted using standard measures, then an office could more easily target which pessaries to have in stock and available to patients. It would also aid the novice in fitting pessaries, an experience that is not extensively found during residency training in many locations.
Of clinical relevance for the busy practitioner, during the study, successful fitting of the incontinence ring or dish was accomplished by trained nurse practitioners, RNs, or physical therapists. Two-thirds of the patients were successfully fitted with a No. 2, No. 3, or No. 4 incontinence ring or a 65-, 70-, or 75-mm dish.
The authors note that a weakness of the study is that the patients had minimal prolapse and all had SUI. Patients with more prolapse or with different POPQ measures may well fare differently. A strength, however, is that it was shown that pessaries can be successfully fitted by interested providers other than just physicians. Because no specific POPQ measurements guided the fitting of the pessary, the authors conclude that the state of the art is just that ... fitting an incontinence pessary remains an art.
This certainly opens our eyes to another aspect of conservative management of incontinence. I wonder how "lost" this lost art is, i.e., how many readers are actively using pessaries in their practice. Can a patient who is considering surgical and nonsurgical options for incontinence be considered fully informed if a pessary has not been mentioned? Even though pessary use is not extensive in our practice, we certainly do have them available. The Milex web site is the best place to go to look for these supplies. Was this an unsolicited advertisement for them? Not really. Consider it more of a helpful office management cost-efficiency tip.