Pessaries for pelvic organ prolapse: evaluation of vaginal discharge and pain during pessary cleaning in an outpatient setting.

INTRODUCTION AND HYPOTHESIS: Pessary treatment for pelvic organ prolapse (POP) is effective and safe, but long-term continuation is low. Pain and vaginal discharge may play a role. This study was aimed at evaluating vaginal discharge and pain during pessary cleaning in an outpatient setting and in continuous pessary use. METHODS: Women with POP who attended the outpatient clinic for pessary cleaning between January and October 2021 were included. Primary outcome was pain during removal and reinsertion of the pessary, measured by an 11-point numeric rating scale (NRS). Secondary outcome was vaginal discharge, measured by the NRS and Patient Global Impression of Change scale (PGI-C). Multiple linear regression analysis was used to identify associated variables for pain and discharge. RESULTS: A total of 150 women were included. Mean NRS during pessary removal was 4.3 (± 2.7), with 25% of women scoring a 7 or higher. Mean NRS during reinsertion was 1.8 (± 2.0). A smaller genital hiatus and presence of vaginal atrophy or vulvar skin disease were associated with pain during pessary removal. Mean NRS for vaginal discharge was 2.5 (± 2.3). Twenty-five percent of women reported that their vaginal discharge was "(very) much worse" than before they used a pessary. Presence of vaginal erosions was associated with vaginal discharge in this study population. CONCLUSIONS: Removing a pessary in an outpatient setting is a painful procedure for many women who use a pessary continuously. Moreover, 25% of these women experience an increase in vaginal discharge while using a pessary. Future research should focus on reducing these disadvantages.

Does monthly self-management of vaginal ring pessaries reduce the rate of adverse events? A clinical audit.

Objective: To determine the rate of adverse events (AE) in women who self-manage their vaginal ring pessary on a monthly basis. We hypothesised that the AE rate would be lower compared to previously published traditional management protocols. Study design: Audit study of 75 women with pelvic organ prolapse and/or stress incontinence, who were fitted with a vaginal ring pessary during a five-year period, and who have self-managed their vaginal rings for at least two years, in a tertiary referral urogynaecology clinic. Main outcome measures: AEs included vaginal bleeding, malodorous vaginal discharge, extrusion of the device, pain/discomfort, and disorders of defaecation or de novo urinary incontinence. AEs that led to discontinuation of usage were termed "major". Results: Of the 75 women who were taught to self-manage their ring pessary, 68 were initially successful. At a median follow-up of 50.5 months [IQR 43-76 months; median 4.2 years], 36 women (52.9%) were still using their ring pessary. Five women (7.4%) had vaginal erosions and bleeding leading them to cease pessary use (four proceeded to surgery). Three minor AEs were identified (4.4%), resolving after discontinuation of ring use two weeks. Thus, the overall AE rate was 11.8% (8/68). Conclusions: In contrast to previous published AE rates of 43-56% in women having ring changes at a clinic every 4-6 months, the AE rate was 12% in the women who performed monthly self-management of vaginal ring pessaries. Such information should be made available to patients considering a vaginal ring pessary.

A pictorial overview of pubovisceral muscle avulsions on pelvic floor magnetic resonance imaging.

OBJECTIVES: Despite extensive research aimed at clarifying (failing) pelvic organ support, the complete aetiology of pelvic organ prolapse (POP) is still not fully understood. During vaginal delivery, the pelvic floor can be irreversibly traumatised, resulting in pubovisceral muscle avulsions. The aetiology of these avulsions is discussed in this pictorial overview. Normal female pelvic floor anatomy is described and variations are exemplified using magnetic resonance (MR) images. The clinical relevance of detecting pubovisceral muscle avulsions is specified. METHODS: T2-weighted MR imaging has multiplanar capabilities with high diagnostic accuracy allowing for detailed visualisation of the pelvic floor. Together with the use of a three-dimensional (3D) post-processing program, the presence and severity of pubovisceral muscle avulsions can be quantified. RESULTS: Pelvic floor MR imaging is a non-invasive method that enables adequate identification of pubovisceral muscle avulsions which are known risk factors for the development of POP. They can be scored with good to excellent inter- and intra-observer reliability. CONCLUSIONS: Radiologists and urogynaecology subspecialists should be familiar with MR imaging findings of pubovisceral muscle avulsions as this birth-related trauma is observed in over 36 % of vaginally parous women. TEACHING POINTS: • Pelvic organ prolapse (POP) is a growing problem for both patients and for our healthcare system • Pubovisceral muscle avulsions are known risk factors for pelvic organ prolapse (POP) • T2-weighted MR imaging visualises pubovisceral muscle avulsions adequately • Pubovisceral muscle avulsions are scored with good to excellent inter- and intra-observer reliability.

Correlating signs and symptoms with pubovisceral muscle avulsions on magnetic resonance imaging.

OBJECTIVE: We sought to correlate signs and symptoms of pelvic organ prolapse (POP) with pubovisceral muscle avulsions on magnetic resonance imaging (MRI). STUDY DESIGN: In this retrospective cohort study of 189 women with recurrent POP or unexplained symptoms of pelvic floor dysfunction, we reviewed T2-weighted pelvic floor MRI and categorized defects as minor or major avulsion, or as no defect present. Outcomes were correlated to quality-of-life questionnaire scores and data on obstetric and surgical history, together with POP-Quantification (POP-Q) measurements. Multivariable ordinal logistic regression analysis with manual backward elimination was applied to calculate odds ratios (ORs). RESULTS: Major pubovisceral avulsions were diagnosed in 83 (44%) women, minor avulsions in 49 (26%) women, while no defects were seen in 57 (30%) women. Women with a history of episiotomy or anterior vaginal wall reconstructive surgery had a higher OR for more severe pubovisceral muscle avulsions (adjusted OR, 3.77 and 3.29, respectively), as did women with symptoms of POP (OR, 1.01, per unit increase) or higher stage POP of the central vaginal compartment based on POP-Q measurement "C" (OR, 1.18). Women with symptoms of obstructive defecation were more likely to have no defect of the pubovisceral muscle on MRI (OR, 0.97, per unit increase). CONCLUSION: The variables episiotomy, previous anterior vaginal wall reconstructive surgery, POP-Q measurement "C," and symptoms scored with the Urogenital Distress Inventory "genital prolapse" and Defecatory Distress Inventory "obstructive defecation" subscales are correlated with pubovisceral muscle avulsions on pelvic floor MRI.

Diagnosing pubovisceral avulsions: a systematic review of the clinical relevance of a prevalent anatomical defect.

The aims of this systematic literature review were to assess whether the detection of pubovisceral avulsions using magnetic resonance (MR) imaging or perineal ultrasonography was clinically relevant in women with pelvic floor dysfunction and to evaluate the relation with anatomy, symptoms, and recurrence after surgery. We performed a systematic literature review using three bibliographical databases (PubMed, Embase, and CINAHL) as data sources. Clinical studies were included in which pubovisceral avulsions were studied in relation to pelvic organ prolapse (POP) stage, pelvic floor symptoms, and/or recurrence of POP after surgery. Ultimately, 21 studies met the inclusion criteria. POP stage and recurrence of POP after surgery were strongly associated with pubovisceral avulsions. Contradictory results were found regarding the relation between pubovisceral avulsions and urinary symptoms and symptoms of anorectal dysfunction. Pubovisceral avulsions, as diagnosed by MR imaging or perineal ultrasonography, are associated with higher stages of POP and recurrence of POP after surgery.

Zebra finches and Dutch adults exhibit the same cue weighting bias in vowel perception.

Vocal tract resonances, called formants, are the most important parameters in human speech production and perception. They encode linguistic meaning and have been shown to be perceived by a wide range of species. Songbirds are also sensitive to different formant patterns in human speech. They can categorize words differing only in their vowels based on the formant patterns independent of speaker identity in a way comparable to humans. These results indicate that speech perception mechanisms are more similar between songbirds and humans than realized before. One of the major questions regarding formant perception concerns the weighting of different formants in the speech signal ("acoustic cue weighting") and whether this process is unique to humans. Using an operant Go/NoGo design, we trained zebra finches to discriminate syllables, whose vowels differed in their first three formants. When subsequently tested with novel vowels, similar in either their first formant or their second and third formants to the familiar vowels, similarity in the higher formants was weighted much more strongly than similarity in the lower formant. Thus, zebra finches indeed exhibit a cue weighting bias. Interestingly, we also found that Dutch speakers when tested with the same paradigm exhibit the same cue weighting bias. This, together with earlier findings, supports the hypothesis that human speech evolution might have exploited general properties of the vertebrate auditory system.

Pelvic organ prolapse and collagen-associated disorders.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) and other disorders, such as varicose veins and joint hypermobility, have been associated with changes in collagen strength and metabolism. We hypothesized that these various disorders were more prevalent in both POP patients and their family members. METHODS: In this study, the prevalence of various collagen-associated disorders, including POP, was compared between POP patients (n = 110) and control patients (n = 100) and their first and second degree family members. RESULTS: POP patients reported a higher prevalence of varicose veins, joint hypermobility and rectal prolapse and were more likely to have family members with POP as compared to the control group (p < 0.01). In contrast, the family members of the POP group did not report a higher prevalence of collagen-associated disorders compared to the family members of the control group (p = 0.82). CONCLUSIONS: POP and other collagen-associated disorders may have a common aetiology, originating at the molecular level of the collagens.

The effectiveness of supportive underwear in women with pelvic organ prolapse: a pilot study.

The objective was to assess the effectiveness of supportive underwear (Pro-Portare) in women with pelvic organ prolapse. Symptomatic women with all stages of prolapse participated in the study and were followed up for 4 weeks. The effectiveness of Pro-Portare was measured by three validated disease-specific quality-of-life questionnaires, a daily diary and a questionnaire on comfort and effectiveness. Thirteen women were included in the study. No improvement on quality of life was found with the use of Pro-Portare. None of the women regarded Pro-Portare as very effective, whereas five women regarded the device as (reasonably) effective. The women's major concern was on the size, shape and hard consistency of the inlet. Two women experienced worsening of their prolapse. Pro-Portare was not effective in the alleviation of prolapse symptoms and was no final solution in any of the women.