Pessary fitting for pelvic organ prolapse: parameters associated with specific reasons for failure

The objective was to assess if specific reasons for unsuccessful pessary fitting have different predictive parameters.

This is a prospective observational case-control study of women with symptomatic pelvic organ prolapse (POP) choosing pessary treatment. All women underwent an interview, clinical examination, and 3D/4D transperineal ultrasound (TPUS). Groups were defined based on fitting outcome: successful, pessary dislodgment, failure to relieve POP symptoms, pain/discomfort, increased/de novo urinary incontinence, or other reasons. Clinical, demographic, and TPUS parameters were assessed in the prediction of different reasons for unsuccessful fitting and receiver operating characteristic (ROC) curves were constructed.

A total of 162 women were assessed and 130 were included. Levator hiatal area (HA) on maximum Valsalva divided by ring pessary size ("Valsalva HARP ratio") was a predictor of unsuccessful fitting (OR 3.00, 95% CI 1.15-7.81, p = 0.025) with an area under the ROC curve (AUC) of 0.62 (95% CI 0.50-0.74, p = 0.04). Predictors of pessary dislodgment were: complete avulsion (OR 24.20, 95% CI 2.46-237.84, p value 0.01) and Valsalva HARP ratio (OR 2.94, 95% CI 1.32-6.55, p value 0.01) with an area under the ROC curve (AUC) of 0.92 (95% CI 0.84-0.99, p = 0.00). No significant parameter was identified in the prediction of pain/discomfort. Solitary predominant posterior compartment POP was a predictor of failure to relieve POP symptoms (OR 20.00, 95% CI 3.48-115.02, p value 0.00; AUC 0.75, 95% CI 0.53-0.98, p = 0.03).

Complete avulsion and a small ring pessary with respect to the levator HA in Valsalva are predictors of pessary dislodgment, whereas solitary predominant posterior compartment POP is a predictor of failure to relieve POP symptoms.