Conservative treatment with vaginal pessary should be attempted as the first-line therapy for POP. It is considered minimally invasive, easy to use, minimal side effects, and has low cost. Generally, there are 2 types of pessaries: support and space occupying. Support pessary usually recommended for an early stage with sufficient perineal support, but space occupying pessary is used for the advanced stage with less perineal support and wide genital hiatus [10]. Although, ring pessary is a support pessary, it can be inserted successfully in any stage of POP. Ring pessary is used most often and seems to be easiest to use [11]. Our previous study reported that 70% of patients who had successful fitting with ring pessary, presented at an advanced stage. Vaginal length shorter than 6 cm and vaginal introitus wider than 4 fingerbreadths were the only significant risk factors for unsuccessful fitting [9]. Continuation rates of pessary use at 1 year has been reported at a range between 50–80% [12]. This rate is consistent with our previous study and the recent study, which reported a continuation rates of 84–85% [5]. Limited data of continuation rates at 5 years or longer has been published. To date, there are two prospective studies which reported 5-year continuation rates of 75–86% [13, 14]. Study by Lone et al. reported a very high continuation rates at 5 years (86%) [13]. Most patients in Lone’s study had early stage POP (70%); this contrasts with our study, which 70% of patients had the advanced stage. Another prospective study included 97% of patients with advanced stage reported 75% continuation rates at 5 years. However, these studies had pessary fitting with ring pessary and Gellhorn. A Gellhorn pessary is a space occupying pessary reported to have significantly longer use than any other type of pessary [7]. This might explain the higher continuation rates. Furthermore, they excluded patients who lost to follow up. If these patients were defined as the discontinuation group, the 5-year continuation rates would decrease to 68% [14]. This result shows that the ring pessary is not much inferior to the Gellhorn pessary in long-term use.
To the best of our knowledge, there is only one retrospective study that has reported a long-term continuation rates focused only ring pessary. The study of Sarma et al. reported only 14% of patients continued to use ring pessary at the median follow-up time of 7 years [15]. However, majority of patients had urinary incontinence concomitant with any degree of prolapse. Incontinence pessary (Introl bladder neck support device) was more commonly used than traditional ring pessary (Portex). A high rate of discontinuation was observed within 1.4 years due to more than half of patients experiencing any adverse events such as vaginal bleeding, vaginal discharge, extrusion of the device, pain, constipation, and worsening urinary incontinence. They reported that 46.8% of patients complained of vaginal bleeding and 25.5% of vaginal discharge. Self-care protocol is important in order to minimize adverse events [16]. The proportion of patients who followed self-care protocol was not mentioned in this study. In contrast, the self-care protocol was successful in 80% of our patients, thus only 11.7% and 6.1% of patients complained of vaginal bleeding and vaginal discharge in our study. As a result, the continuation rates was reported to be higher in our study, at 5 years was 49.2% and 10 years was 33.4%.
Age as a risk factor for long-term discontinuation remains uncertain. Some studies reported that older women are more likely to continue vaginal pessary [7, 8, 17–19]. However, women who are older than 70 years had a significantly higher discontinuation rates in our study. The definition of long-term pessary use is different. Those studies used only one year as a definition of long-term use, but our study used 5 years. The median duration of pessary use before discontinuation in our study was 31 months, and three quarters of them stopped treatment before five years. Therefore, one year as a cut-off point might be inadequate. Acceptance for pessary use in old women during the first few years might be obvious. However, it usually decreases after a longer follow up time. Most patients in our study who discontinued and requested surgery felt that the self-care protocol was a burden and feared not being able to have surgery when they were older. Ma et al. reported that age is not a significant factor associated with pessary discontinuation, but a vagina shorter than 7.5 cm, poor urinary symptom relief at 3 months and incapability of self-care were potential discontinuation risk factors at the 5-year follow-up [14]. However, advanced age, wide genital hiatus, and incapability of self-care were independent factors for discontinuation in our study. Different cultural aspects, healthcare system, financial and educational aspects may influence acceptance and adherence to treatment.
The rate of long-term adverse events was reported inconsistently between 12% and 56% [6, 13–15]. Ma et al. reported the complication rate of 23.4% with weekly pessary care. [14] This finding is consistent with our study that most patients can manage pessaries by themselves. Vaginal erosion was the most common adverse event in our study, occurring in 18.8% of patients. Advanced age and vaginal atrophy have been reported as risk factors for vaginal erosion [6]. Although the rate of vaginal erosion in our study seems to be high, it was similar to the results from previous studies with long follow-up time [6, 14] Previous studies including ours reported that the median duration before the occurrence of vaginal erosion was 2 years [6]. However, these adverse events usually resolved conservatively with topical estrogen and temporary pessary removal. No serious adverse events such as genital tract fistula, embedding into intraabdominal organs, or vaginal cancer were found in our study. Adverse events can be minimized with adequate follow-up and self-care protocol.
The limitations of our study are retrospective design, high lost to follow-up rate, and only ring pessary was used. However, an acceptable 5-year continuation rates of 49.3% was reported. Major strength of this study is long follow-up time, and the long-term continuation rates was reported at 5 and 10 years. To our best knowledge, this is the first study that reported a 10-year continuation rates focused only ring pessary use. One-third of our patients remained using ring pessary at 10 years. One-fourth of them discontinued use due to non-pessary related reasons. Death occurred in 10% of patients and 5% of them developed other medical conditions that required pessary removal. Interestingly, up to 10% of them had prolapse improvement and were able to discontinue pessary use. Handa et al. reported that 20% of women demonstrate improvement of the POP stage and none had worsening prolapse during pessary use. Recovery of overstretching of the pelvic floor by pessary support results in improvement of levator ani function and muscular strength. This might explain prolapse improvement with long term pessary use more than one year [20].
In conclusion, ring pessary is an effective treatment in POP irrespective of POP stage, with acceptable long-term continuation rates and minor adverse events. A self-care protocol is an important strategy to minimize adverse events. Advanced age, wide introitus and incapability of self-care were associated factors for long-term discontinuation.