Moving On: How Many Women Opt for Surgery After Pessary Use for Prolapse?

OBJECTIVE: Our primary objective was to evaluate the proportion of women who underwent surgery after successful pessary fitting for pelvic organ prolapse (POP). Our secondary objectives were to assess when surgery occurs and to evaluate factors associated with choosing surgery as compared to continuing with a pessary. METHODS: Our study population included women successfully fitted with a pessary for POP 1/1/12 and 12/31/16. We excluded non-English-speaking women and those who used pessary only as a bridge until surgery. We evaluated events occurring after a successful fitting, including whether women (1) continued pessary use, (2) underwent surgery, or (3) discontinued pessary without surgery. Our primary outcome was the proportion of women who opted for surgery after a successful pessary fitting for POP. We also assessed the median time to surgery and compared women who underwent surgery with those who continued with a pessary to assess variables associated with surgery. RESULTS: Of the 444 women with POP who were successfully fitted with a pessary and met inclusion criteria, 137 (31%) ultimately underwent surgery. The median time to surgery was 10 months (interquartile range, 4-18), with 59% having surgery within 1 year, and 89% within 2 years. In a logistic regression analysis controlling for age in decades, advanced POP stage, and Charlson Comorbidity Index, younger age remained significantly associated with surgery (odds ratio, 0.77, 95% confidence interval, 0.62-0.95; P = 0.02). CONCLUSIONS: Among women successfully fitted with a pessary for POP, one third ultimately underwent surgery, with approximately 60% of these women undergoing surgery within the first year and 90% within 2 years.

Defecatory dysfunction and other clinical variables are predictors of pessary discontinuation.

INTRODUCTION AND HYPOTHESIS: Pessaries provide first-line therapy for women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The primary hypothesis was that defecatory dysfunction was associated with pessary discontinuation. METHODS: This was a retrospective cohort study of all women undergoing first pessary placement at one academic center from April 2014 to January 2017. Defecatory dysfunction was defined as the presence of constipation, rectal straining, rectal splinting, and/or incomplete defecation. Pessary discontinuation was defined as <1 year of pessary use and not using one at the most recent visit. Descriptive statistics; Person's chi-square, Fisher's exact, and Student's t test, and multivariate logistic regression analysis were used where appropriate. RESULTS: Charts of 1092 women were reviewed and 1071 were included. Mean age was 62 ± 15 years, mean body mass index (BMI) 28 ± 6 kg/m2, and mean parity 2 ± 1; 68% were Caucasian, 73% were menopausal, and 41% were sexually active. Reason for pessary use included POP (46%), SUI (24%), or both (30%). Overall pessary discontinuation rate was 77%; overall rate of defecatory dysfunction was 45%. In a logistic regression model, defecatory dysfunction in the form of incomplete defecation remained significantly associated with pessary discontinuation [odds ratio (OR) 3.29, 95% confidence interval (CI) 1.43-7.52]. Absence of bulge symptoms (OR 2.18, 95% CI 1.22-3.90), and younger age (OR 1.02, 95% CI 1.02-1.05) also remained significantly associated with pessary discontinuation. CONCLUSIONS: Pessary discontinuation was common, and defecatory dysfunction in the form of incomplete defecation had the strongest association with discontinuation. Understanding predictive factors of pessary discontinuation may help guide clinicians and patients when choosing treatment options for pelvic floor dysfunction.

Neonatal outcomes and their relationship to maternal buprenorphine dose during pregnancy.

BACKGROUND: Buprenorphine pharmacotherapy for opioid-dependent pregnant women is associated with maternal and neonatal outcomes superior to untreated opioid dependence. However, the literature is inconsistent regarding the possible existence of a dose-response relationship between maternal buprenorphine dose and neonatal clinical outcomes. METHODS: The present secondary analysis study (1) examined the relationship between maternal buprenorphine dose at delivery and neonatal abstinence syndrome (NAS) peak score, estimated gestational age at delivery, Apgar scores at 1 and 5 min, neonatal head circumference, length, and weight at birth, amount of morphine needed to treat NAS, duration of NAS treatment, and duration of neonatal hospital stay and (2) compared neonates who required pharmacotherapy for NAS to neonates who did not require such pharmacotherapy on these same outcomes, in 58 opioid-dependent pregnant women receiving buprenorphine as participants in a randomized clinical trial. RESULTS: (1) Analyses failed to provide evidence of a relationship between maternal buprenorphine dose at delivery and any of the 10 outcomes (all p-values>.48) and (2) significant mean differences between the untreated (n=31) and treated (n=27) for NAS groups were found for duration of neonatal hospital stay and NAS peak score (both p-values<.001). CONCLUSIONS: (1) Findings failed to support the existence of a dose-response relationship between maternal buprenorphine dose at delivery and any of 10 neonatal clinical outcomes, including NAS severity and (2) that infants treated for NAS had a higher mean NAS peak score and, spent a longer time in the hospital than did the group not treated for NAS is unsurprising.