Parameters associated with unsuccessful pessary fitting for pelvic organ prolapse up to three months follow-up: a systematic review and meta-analysis

Abstract

Objectives: To clarify which parameters are associated with unsuccessful pessary fitting for pelvic organ prolapse (POP) at up to 3 months follow-up.

Methods: Embase, PubMed and Cochrane CENTRAL library were searched in May 2020. Inclusion criteria were: (1) pessary fitting attempted in women with symptomatic POP; (2) pessary fitting success among the study outcomes with a maximal follow-up of 3 months; (3) baseline parameters compared between successful and unsuccessful group. A meta-analysis was performed using the random effects model.

Main results: Twenty-four studies were included in the meta-analysis. Parameters associated with unsuccessful pessary fitting were: age (OR 0.70, 95% CI 0.56-0.86); BMI (OR 1.35, 95% CI 1.08-1.70); menopause (OR 0.65 95% CI 0.47-0.88); de novo stress urinary incontinence (OR 5.59, 95% CI 2.24-13.99); prior surgery, i.e. hysterectomy (OR 1.88, 95% CI 1.48-2.40), POP surgery (OR 2.13, 95% CI 1.34-3.38), pelvic surgery (OR 1.81, 05% CI 1.01-3.26) and incontinence surgery (OR 1.87, 95% CI 1.08-3.25); Colorectal-Anal Distress Inventory-8 scores (OR 1.92, 95% CI 1.22-3.02); solitary predominant posterior compartment POP (OR 1.59, 95% CI 1.08-2.35); total vaginal length (OR 0.56, 95% CI 0.32-0.97); wide introitus (OR 4.85, 95% CI 1.60-14.68); levator ani avulsion (OR 2.47, 95% CI 1.35-4.53) and hiatal area on maximum Valsalva (OR 1.89, 95% CI 1.27-2.80).

Conclusion: During counselling for pessary treatment a higher risk of failure due to the aforementioned parameters should be discussed and modifiable parameters should be addressed. More research is needed on the association between anatomical parameters and specific reasons for unsuccessful pessary fitting.

Keywords: Patients’ characteristics; Pelvic organ prolapse; Pessary fitting; Predictive factors; Predictive parameters; Vaginal pessaries.

Fig. 1

Records identification, inclusions and exclusions with reasons

Fig. 2

Forest plots of the significant parameters (results of the meta-analysis excluding imputed data)

Fig. 3

Forest plot for the association of age with successful pessary fitting up to 3-month follow-up (N = 2901)

Fig. 4

Forest plot for the association of BMI with unsuccessful pessary fitting up to 3-month follow-up (N = 2244)

Fig. 5

Forest plot for the association of menopausal status with successful pessary fitting up to 3-month follow-up (N = 1338)

Fig. 6

Forest plot for the association of Stress urinary incontinence (SUI) (i.e. pre-existing or de novo SUI) with unsuccessful pessary fitting up to 3-month follow-up (N = 1065)

Fig. 7

Forest plot for the association of prior hysterectomy with unsuccessful pessary fitting up to 3-month follow-up (N = 3431)

Fig. 8

Forest plot for the association of prior prolapse surgery with unsuccessful pessary fitting up to 3-month follow-up (N = 2330)

Fig. 9

Forest plot for the association of prior pelvic surgery with unsuccessful pessary fitting up to 3-month follow-up (N = 230)

Fig. 10

Forest plot for the association of prior incontinence surgery with unsuccessful pessary fitting up to 3-month follow-up (N = 497)

Fig. 11

Forest plot for the association of “CRADI-8” (i.e. Colorectal-Anal Distress Inventory-8) scores with unsuccessful pessary fitting up to 3-month follow-up (N = 401)

Fig. 12

Forest plot for the association of TVL (i.e. total vaginal length) with successful pessary fitting up to 3-month follow-up (N = 1135)

Fig. 13

Forest plot for the association of wide introitus (i.e. ≥ 4 fingerbreadths) with unsuccessful pessary fitting up to 3-month follow-up (N = 200)

Fig. 14

Forest plot for the association of levator ani muscle avulsion with unsuccessful pessary fitting up to 3-month follow-up (N = 339)