The Use of a Vaginal Pessary to Decide Whether a Mid Urethral Sling should be Added to Prolapse Surgery

Women with pelvic organ prolapse are at risk for stress urinary incontinence after prolapse surgery. Combining pelvic organ prolapse repair with anti-incontinence surgery reduces the incontinence rate but leads to overtreatment. Performing only pelvic organ prolapse repair leads to under treatment. Is a vaginal ring pessary a useful tool when deciding whether a mid urethral sling should be added to prolapse surgery?

We performed a retrospective cohort study in women with symptomatic pelvic organ prolapse but without bothersome stress urinary incontinence who underwent vaginal prolapse repair between January 1, 2008 and December 31, 2017. Preoperatively a pessary was inserted in all women to detect occult stress urinary incontinence. If the pessary revealed bothersome stress urinary incontinence, a concomitant mid urethral sling was proposed. The primary outcome at followup was de novo stress urinary incontinence.

Included in study were 220 women. After pessary insertion 132 women (60%) remained continent, 20 (9%) reported nonbothersome stress urinary incontinence and 68 (31%) had bothersome stress urinary incontinence. The latter group was offered combined surgery. At followup bothersome stress urinary incontinence was present in 12 of the 132 women (9%) who had been continent preoperatively and in 7 of the 20 (35%) who had had nonbothersome stress urinary incontinence. In 132 women who were continent with the pessary a total of 11 mid urethral sling procedures would have been needed to prevent postoperative stress urinary incontinence in 1 (number needed to treat was 11). In the 20 women who had nonbothersome stress urinary incontinence only 3 mid urethral sling procedures would have been necessary (number needed to treat was 3).

In women with symptomatic pelvic organ prolapse a pessary is a useful tool when deciding whether to add a mid urethral sling.