A review of pessary for prolapse practitioner training.

Pelvic organ prolapse is a significant quality of life issue for many women. Prolapse can be managed effectively with a mechanical device called a pessary therefore many women choose this as a conservative treatment option. Despite the extent to which pessaries are used in the UK, there are no clear guidelines regarding the training required for pessary practitioners. This article reviews literature related to pessary practitioner training. METHODS: 13 publications were reviewed. RESULTS: eight themes were identified, namely 'prevalence of pessary training', 'type of pessary training', confidence in pessary care provision', 'impact on pessary care', 'skills and knowledge required to be a pessary practitioner', 'barriers', 'speciality of pessary care providers', and 'ongoing support'. CONCLUSION: at present practitioners report a lack of pessary training, which impacts on care. Effective training includes didactic learning of agreed knowledge requirements, practice of clinical skills and ongoing support.

Women's experiences of receiving care for pelvic organ prolapse: a qualitative study.

BACKGROUND: Pelvic organ prolapse is a common urogenital condition affecting 41-50% of women over the age of 40. To achieve early diagnosis and appropriate treatment, it is important that care is sensitive to and meets women's needs, throughout their patient journey. This study explored women's experiences of seeking diagnosis and treatment for prolapse and their needs and priorities for improving person-centred care. METHODS: Twenty-two women receiving prolapse care through urogynaecology services across three purposefully selected NHS UK sites took part in three focus groups and four telephone interviews. A topic guide facilitated discussions about women's experiences of prolapse, diagnosis, treatment, follow-up, interactions with healthcare professionals, overall service delivery, and ideals for future services to meet their needs. Data were analysed thematically. RESULTS: Three themes emerged relating to women's experiences of a) Evaluating what is normal b) Hobson's choice of treatment decisions, and c) The trial and error of treatment and technique. Women often delayed seeking help for their symptoms due to lack of awareness, embarrassment and stigma. When presented to GPs, their symptoms were often dismissed and unaddressed until they became more severe. Women reported receiving little or no choice in treatment decisions. Choices were often influenced by health professionals' preferences which were subtly reflected through the framing of the offer. Women's embodied knowledge of their condition and treatment was largely unheeded, resulting in decisions that were inconsistent with women's preferences and needs. Physiotherapy based interventions were reported as helping women regain control over their symptoms and life. A need for greater awareness of prolapse and physiotherapy interventions among women, GPs and consultants was identified alongside greater focus on prevention, early diagnosis and regular follow-up. Greater choice and involvement in treatment decision making was desired. CONCLUSIONS: As prolapse treatment options expand to include more conservative choices, greater awareness and education is needed among women and professionals about these as a first line treatment and preventive measure, alongside a multi-professional team approach to treatment decision making. Women presenting with prolapse symptoms need to be listened to by the health care team, offered better information about treatment choices, and supported to make a decision that is right for them.

Person-Centered Care for Patients with Pessaries.

Pelvic organ prolapse is a common condition affecting women of any age but more likely to occur in the aging woman. Prolapse has a significant impact on quality of life, sexuality, and body image. Vaginal support pessaries have been used since ancient times and are a safe and effective nonsurgical treatment option. Fitting a pessary results in immediate symptom improvement. A comprehensive evaluation for pessary fitting is time intensive but necessary. Nurse providers perform direct pessary care and have a role in caring for women with prolapse expanding access to care. Caregiver and family involvement is important for pessary care and follow-up.

Vaginal pessaries: can an educational brochure help patients to better understand their care?

AIMS AND OBJECTIVES: Pelvic organ prolapse is a common condition, with reported incidence of up to 50%. We aimed to assess whether written information, in addition to face-to-face consultation, improved happiness with information, confidence to self-manage and prolapse knowledge in women attending a pessary clinic. BACKGROUND: Little is known about the effect of adding a written information brochure on clinical outcomes of patients using pessaries. DESIGN: This prospective study used a pretest-posttest method, conducted following Ethical approval. METHODS: Between February-December 2013, all women attending Pessary Clinic were eligible for participation. A questionnaire was developed to assess happiness with information, confidence regarding self-management (using a visual analogue scale, 1-10) and prolapse knowledge (using eight multiple-choice questions). Data were collected in person at baseline prior to distribution of a patient brochure and thereafter by telephone at one week and three months. Paired analysis was conducted using the McNemar test and related samples Wilcoxon signed-rank test for VAS items with p < 0.05 significant. RESULTS: Sixty women were recruited. Fifty-eight completed all questionnaires. Improvement in happiness with information, confidence regarding self-management and knowledge scores occurred at one week (p < 0.05) and were maintained at three months (p < 0.05). Changes were unrelated to age (p > 0.05), education level (p > 0.05), first language (p > 0.05) or previous clinic visits (p > 0.05). CONCLUSION: A written information brochure, in addition to face-to-face consultation, improves happiness with information, confidence to self-manage and knowledge about pessaries compared to verbal instruction alone and helps patients better understand their care. The written brochure was equally effective in women with low education and advanced age, and occurred regardless of the number of clinic visits.

Pessary Practices of Nurse-Providers in the United States.

OBJECTIVES: Our purposes were to describe pessary-care practices and education of a sample of nurse providers in the United States and identify a cohort of high-volume providers. METHODS: An e-mail survey was sent to members of 3 related nursing professional organizations. Questions addressed general pessary care within the respondent's practice and specific pessary care choices of responding direct providers. Data were managed using REDCap electronic data capture tools. RESULTS: Of 323 respondents, 279 (86.4%) reported pessary care occurred in their office settings, 84.5% of which were urban or suburban, and 65.4% were private practices. Responders were evenly distributed through 4 regions of the United States and represented a variety of specialties. Physicians and advanced practice registered nurses provided the majority of care (up to 80%), along with registered and licensed practical nurses and medical assistants. Care routines varied, most often including 3-month-interval follow-up with speculum-assisted vaginal examinations and no routine use of vaginal products (eg, moisturizers, acidifiers, antimicrobials, or vaginal estrogens). On-the-job mentoring was the primary knowledge source (64%). Comparison of practice patterns suggested possible variation by region and certification. CONCLUSIONS: This exploratory study provides data related to the pessary-care practices of nurse providers in the United States. The range of responses emphasizes a need for evidence-based guidelines for optimal care, based on patient outcomes, satisfaction, and costs of care. Findings also illustrate a need for effective, evidence-based educational programs and clinical mentorship options with experienced providers. A cohort of expert providers was identified to continue work toward these goals.

To Pack or Not to Pack? A Randomized Trial of Vaginal Packing After Vaginal Reconstructive Surgery.

OBJECTIVE: Placement of vaginal packing after pelvic reconstructive surgery is common; however, little evidence exists to support the practice. Furthermore, patients have reported discomfort from the packs. We describe pain and satisfaction in women treated with and without vaginal packing. METHODS: This institutional review board-approved randomized-controlled trial enrolled patients undergoing vaginal hysterectomy with prolapse repairs. The primary outcome was visual analog scales (VASs) for pain on postoperative day 1. Allocation to "packing" ("P") or "no-packing" ("NP") arms occurred intraoperatively at the end of surgery. Visual analog scales regarding pain and satisfaction were completed early on postoperative day 1 before packing removal. Visual analog scale scores for pain, satisfaction, and bother attributable to packing were recorded before discharge. All packing and perineal pads were weighed to calculate a "postoperative vaginal blood loss." Perioperative data were collected from the hospital record. Our sample size estimation required 74 subjects. RESULTS: Ninety-three women were enrolled. After exclusions, 77 were randomized (P, 37; NP, 40). No differences were found in surgical information, hemoglobin levels, or narcotic use between groups. However, "postoperative vaginal blood loss" was greater in packed subjects (P < 0.001). Visual analog scale scores for pain before removal of packing (P, 41.6 vs NP, 46.3; P = 0.43] and before discharge (P, 35.0 vs NP, 40.0; P = 0.43] were not significantly different between treatment arms. Likewise, VAS scores for satisfaction before removal of packing (P, 81.0 vs NP, 90.0; P = 0.08] and before discharge (P, 90.0 vs NP, 90.5; P = 0.60] were not significantly different. Packed patients noted lower nursing verbal pain scores (P = 0.04) and used less ketorolac (P = 0.01). Bother from packing was low overall. CONCLUSIONS: Although there was no difference based on VAS, women receiving vaginal packing had lower nursing documented pain and used less ketorolac than packed women. Vaginal packing may provide benefit and can remain part of the surgical practice.

Peri-partum and pelvic floor dysfunction.

Pelvic floor muscles (PFM) are the layer of muscles that support the pelvic organs and span the bottom of the pelvis. Weakened PFM mean the internal organs are not fully supported and can lead to difficulties controlling the release of urine, faeces or flatus. Pregnancy and vaginal birth are a recognised cause of PFM weakness; however it has been shown that PFM exercises, if carried out correctly and routinely, can reduce the severity of symptoms. Midwives need to be pro-active in teaching PFM exercises and identifying women who may need to be referred on for more specialist treatment.

Sexual function in women after urinary incontinence and/or pelvic organ prolapse surgery.

AIMS AND OBJECTIVES: To determine how the sexual function is affected in women who underwent surgery for urinary incontinence and/or pelvic organ prolapse. DESIGN: The study was conducted as a descriptive and prospective research. BACKGROUND: Approximately 11·1% of the cases with pelvic organ prolapse or urinary incontinence require surgical intervention. Some authors report improved function after surgical correction of pelvic floor disorders, whereas others report deterioration of function. METHODS: The research was carried out with totally 116 patients in three groups of women who underwent surgery for urinary incontinence and/or pelvic organ prolapse. Sexual function and low urinary tract symptoms were assessed preoperatively and at six months postoperatively, with the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire 12 and Bristol Female Lower Urinary Tract Symptoms Scale. RESULTS: Prolapse/Urinary Incontinence Sexual Questionnaire-12 total scores increased significantly, and sexual function improved at postoperative six months in all groups. In the evaluation of sexual function in each group at preoperative and postoperative six months, Prolapse/Urinary Incontinence Sexual Questionnaire-12 scores of UI, and UI and POP were found to be increased significantly, while there was no change in sexual function in women in the pelvic organ prolapse surgery group at postoperative six months compared with preoperative period. CONCLUSION: As a result, it was determined that lower urinary tract symptoms were improved and sexual function of women changed positively at six months after UI and/or POP surgery. RELEVANCE TO CLINICAL PRACTICE: It is important to provide counselling on potential development of postoperative sexual function and the possibility of impairment of sexual function for women undergoing UI and/or POP surgery.

Characteristics of women with continued use of vaginal pessaries.

Vaginal pessaries have been shown to be a safe, effective treatment for pelvic organ prolapse, and in some cases, female urinary incontinence. There are limited data that predict long-term pessary use; therefore, the aim of this retrospective, exploratory study was to describe selected characteristics of women using a pessary for 12 months or longer in a nurse-run clinic.

Vaginal support pessaries: indications for use and fitting strategies.

Flexible silicone vaginal support pessaries offer a low-risk, effective option for treatment of symptoms of pelvic organ prolapse. This first article in a three-part series summarizes clinical recommendations and current evidence related to pessary indications, choice, and fitting.

Pessary care: follow up and management of complications.

Successful use of vaginal support pessaries requires provider and patient understanding of expected symptom-relief, potential complications, self-care options, and evaluation and treatment of pessary-related problems. This second article in a three-part series summarizes clinical recommendations and evidence related to pessary management.