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abstract

161 - PREDICTORS OF RING PESSARY SUCCESS

161

PREDICTORS OF RING PESSARY SUCCESS

S. PIXTON, J. CAUDWELL- HALL, F. TUREL,H. DIETZ;
Sydney Med. Sch. Nepean, Sydney, Australia.

Introduction: Pelvic Organprolapse (POP) is a common chronic health issue for women across theglobe[1]. Pessary rings have been identified as a safe, effective andaffordable treatment option for conservative management of pelvicorgan prolapse [2]. However, in some women it seems impossible to fita pessary large enough to be retained during times of increasedintra-abdominal pressure. It is generally accepted that pessaries areless likely to be successful in women who have had a hysterectomy orprevious POP surgery [3]. To date there is little data on objectiveanatomical findings as predictors of successful pessarymanagement.
Objective: To determine associations betweenfindings on history, examination and functional pelvic floor anatomy(as determined by translabial ultrasound, TLUS) and the successfuluse of ring pessaries.
Methods: This is a retrospectiveanalysis of women with symptomatic prolapse who presented to atertiary urogynaecological unit between November 2013 and November2015. All underwent an assessment including a standardized interviewand clinical examination using the POP-Q. 4D TLUS was performed afterbladder emptying in the supine position. Women with symptomaticprolapse were offered management with a ring pessary. Those whoagreed had a ring inserted that day and were followed up 3 monthsafter insertion. Successful trial of pessary (successful fitting) wasdefined as continued pessary use for at least 3 months. TLUS data wasanalysed retrospectively, blinded to clinical data, using proprietarysoftware. Statistical analysis was performed using logisticregression to assess the relationship between pelvic floor parameterson examination and imaging with successful pessary use. Multivariateanalysis was used to control for potential confounders.
Results:Between 11/13 and 11/15, 176 women presented with a symptomaticprolapse, of which 128 (72%) were offered a pessary. The other 48either elected for immediate surgical management, had only minorclinical findings, or had medical contraindications to pessary use.Of those offered a pessary, 39 declined and 89 (70%) accepted, havinga ring inserted the same day. Of those, 3 were lost to follow up and2 had incomplete data sets, leaving 84 for analysis.
42/84 (50%)were still using a pessary at the 3 month follow up and were deemedto have had a successful trial of pessary management.

Table1: Demographic predictors of Pessary success


Success(n=42)

Failure(n=42)

OR(CI)

P

Age(mean, SD)

62.6(12.8)

58.9(14.1)

0.98(0.95- 1.01)

0.2

Parity(mean, SD)

2.8(1.2)

3.1(1.5)

1.17(0.86- 1.6)

0.3

Menopausal(%)

35(83%)

26(62%)

0.33(0.12- 0.9)

0.031

Smoker(%)

4(10%)

7(17%)

1.9(0.5- 7.0)

0.3

Prev.hysterectomy (%)

7(16.7)

15(36)

2.78(0.99- 7.77)

0.051

Prev.prolapse surgery (%)

8(19)

15(36)

2.36(0.87- 6.4)

0.091


Table 1 shows demographicpredictors. Premenopausal women and those with prior hysterectomywere more likely to fail pessary management, and this was confirmedon multivariate analysis (P= 0.031 and P= 0.009 respectively). Onclinical examination there were three significant predictors ofpessary ring success: higher measurements for Bp, Gh+Pb and Pb(p=0.027, P= 0.013 and 0.021 respectively), see Table 2, but onlyGh+Pb remained statistically significant on multivariate logisticregression (P= 0.049).

Table2: Examination findings as predictors of pessary success


Success(n=42)

Failure(n=42)

OR(CI)

P

BMI

27.8(5)

29.5(6)

1.05(0.97- 1.14)

0.2

Ba(mean, SD)

0.85(1.8)

0.7(1.8)

0.91(0.72- 1.17)

0.5

C(mean, SD)

-1.6(4)

-1.8(3.3)

0.98(0.87- 1.1)

0.8

Bp(mean,SD)

-1.1(1.4)

-0.4(1.6)

1.42(1.04- 1.93)

0.027

Gh(mean,SD)

4.9(1.4)

5.5(1.5)

1.37(0.98- 1.91)

0.07

Pb(mean,SD)

3.2(0.8)

3.6(0.8)

2(1.1- 3.7)

0.021

Gh+Pb(mean,SD)

8.1(1.9)

9.1(1.6)

1.45(1.1- 1.9)

0.013

TVL(mean,SD)

8.4(1.4)

8.5(1.3)

1.02(0.74- 1.41)

0.9

Avulsionon palpation, n (%)

14(33%)

17(40.5)

1.36(0.56- 3.31)

0.5


Predictors on ultrasound similarlyincluded posterior compartment descent and hiatal area on Valsalva(Table 3). However, on multivariate analysis these measures did notremain significant. No significant association was found betweenavulsion and pessary success (OR=1.625, CI 0.682-3.872, p=0.273),although avulsion was more common in the failure group (50% vs 38%).

Table3: Imaging predictors of pessary success


Success(n=42)

Failure(n=42)

OR(CI)

P

Hiatalarea on Valsalva (cm2; mean ( SD))

33.7(8.5)

38.7(9.9)

1.05(1-1.1)

0.049

BND(mm; mean (SD))

35.2(14.5)

36.6(13.8)

1.02(0.68- 3.87)

0.3

Avulsion(n, %)

16(38%)

21(50%)

1.63(0.68- 3.87)

0.3

Cystocele(mm (SD))

-24.5(17.7)

-20.1(15.2)

1.02(0.99- 1.02)

0.2

Urerinedescent (mm(SD))

-11.5(19)

-14.7(20)

0.99(0.96- 1.02)

0.6

Rectaldescent (mm (SD))

(-9.5(14.6)

-17(12.2)

0.96(0.92- 0.99)

0.035


Conclusions: Successfulpessary use seems less likely in premenopausal women, those afterhysterectomy and in those with an enlarged hiatus as evidenced byhigher Gh+Pb measurements. However, these predictors are weak. Hencering pessary management may be offered to all women presenting withsymptomatic prolapse, provided there are no contraindications. Thisalso seems true for those with a highly abnormal pelvic floor, suchas women affected by levator avulsion and/ or severe ballooning. Thelatter is particularly reassuring as those women are likely to failsurgical management.
References: 1.) Am J Obstet Gynecol(2006) 108(1), 93-99.
2.) Am J Obstet Gynecol (2004) 190,345-350
3.) Am J Obstet Gynecol (2005) 193, 89-94