DAILY USED CUBE PESSARIES IN WOMENWITH PELVIC ORGAN PROLAPSE: FITTING, INFLUENCE ON PELVIC FLOORFUNCTION
E. WLAźLAK 1, J.KOCISZEWSKI 2, M. KRZYCKA 1, M. PAZDRAK 1,W. WLAźLAK 1, T. KLUZ 3, G. SURKONT1;
11st Department of Obstetrics and Gynecology, Med.Univ. of Lodz, Lodz, Poland, 2Ev.Krankenhaus, Hagen,Germany, 3Department of Obstetrics and Gynecology,Fryderyk Chopin Univ. Hosp. No1, Faculty of Med., Rzeszow Univ.,Rzeszów, Poland.
Introduction: Cube pessary isnot so popular, although there are centers where this is the mostoften used pessary to treat pelvic organ prolapse, including ourcenter. Supporters of cube pessaries point out daily use, what shouldminimize the risk of complications. They suggest that this is theonly pessary that activates pelvic floor muscles (1). The influenceof cube pessary on pelvic floor function was not studied yet. Thequality of the pelvic floor musculature and pelvic floor function maybe investigated by palpation, 2D and 4D ultrasound imaging (2,3).
Objective: The aim of the study was to check if cubepessary could be daily used by most of the patients with POP. Wewanted to analyze the influence of cube pessary on pelvic floormuscle function.
Methods: This is retrospective study ofdata obtained from 135 women who entered urogynecologic center totreat POP. From the beginning 18 were convinced to have an operativetreatment. In 14 patients fitting was unsuccessful. At the end of thesuccessful fitting four said that they need more time to choose theoption. 98 decided to try daily used cube pessary after pessaryfitting and complex information how insert and remove pessary. Allpatients had a standardized no validated interview includingevaluation of patient's evaluation of daily use of pessary, aclinical assessment using the ICS POP-Q, along with a 2D introitalpelvic floor ultrasound (transvaginal probe - PFS-TV) (2) and 2D/4Dtransperineal ultrasound (abdominal probe PFU-TA) (3) using GE KretzVoluson 730 Pro. Levator contraction strength was assessed digitally,using the Modified Oxford Grading. Levator resting tone was evaluatedusing 6-points scale. Urethral mobility was evaluated at rest, duringKegel's and on Valsalva in PFS-TV and PFU-TA. We analyzed value H -position of bladder neck (2, 3). Hiatal dimensions at rest, atKegel's and on Valsalva were measured in the plane of minimal hiataldimension during PFU-TA (3). Levator trauma was identified bytomographic ultrasound (TUI in PFU-TA) (3). On the control visit (1-3months after first visit) 99 patients were using pessary treatmentand their complex data are analyzed in the results. Perforated cubepessaries with button and knot (Dr Arabin, Germany) wereused.
Results: In 12 patients after the urogynecologicaland gynecological operations pessary fitting was unsuccessful: 3 hadshort, wide vagina, 4 had painful insertions after meshes, 2 had wideintroitus and narrow end of vagina, 3 had narrow introitus and widevagina. In 2 patients hiatus was too large even for pessary nr 5. Inone of these patients we detected one-sided levator avulsion. Meanage of 99 patients was 61,5 (28-90) years, BMI was 30 (19-48). Inmost of the patients size 2 and 3 were most suitable (n=31 and 30).Size 0 was good for 7 patients, 4 - for 6 women, 5 - for 3 patients.Best correlation of pessary size was with hiatal dimensions. Duringfirst 4 weeks in 4 patients we had to change pessary to a bigger one(1 size), in 3 patients pessary was changed to smaller one (1 size).2 women came to change the size of the pessary but they needed againjust instruction of using instead of changing the pessary. In 5patients family performed inserting and removing the pessary. Not soeasy inserting was for 7 patients, removing for 10. The rest(n=87-84) found it easy or rather easy. Inserting cube pessarylowered rest position of bladder neck in PFS-TV (distance H: 20,3 mmvs. 19,3 mm, p=0,03). During PFU-TA we also showed that cube loweredbladder neck position at area, but this was statistically notsignificant (p=0,08). Hiatal area and hiatal circumference werebigger when cube pessary was inserted (PTU-TA: 27,4 cm2 vs. 26,5 cm2,p=0,02, 21,2 cm vs. 20,8 cm, p=0,02). During PFS-TV Kegel's exerciseswere more efficient when pessary was inserted. With cube insertedchange of the value H was 3 mm versus 6 mm without pessary(p=0,0000). But changes in area and circumference of hiatus duringKegel's exercises were not statistically significant (PFU-TA).Valsalva maneuver was less efficient when cube was inserted. Changeof the H value was 7 mm versus 13 mm without pessary (PFS-TV,p=0,0001). Changes in hiatal area and circumference (PFU-TA) werealso statistically significant (-3,4 cm2 vs. - 7,6 cm2, p=0,0000 and9 mm vs. 26 mm, p=0,0000. 17 patients had uni- or bilateralavulsion.
Conclusions: Daily use of cube pessaries was welltolerated by most of the patients. The size of cube pessariescorrelated with hiatal dimensions. We did not confirm negativeinfluence of levator avulsion on successful cube pessary fitting.Post-operative changes in shape and size of vagina were the mainreasons for unsuccessful fitting. Our study suggests positiveinfluence of cube pessaries on hiatal dimension during Valsalvamaneuver.
References: 1. Int Urogynecol J (2013)24:1695-1701, 2. Neurourol Urodyn. 2015 Nov;34(8):741-6, 3.Ultrasound Obstet Gynecol. 2016 Dec;48(6):681-692.