Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse

Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse Tarinee Manchana This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3411931/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Jan, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted 5 You are reading this latest preprint version Abstract Purpose To evaluate long-term continuation rates, adverse events of ring pessary use at a minimum of 5 years follow-up, and factors associated with discontinuation in symptomatic pelvic organ prolapse (POP) Methods Women with symptomatic POP who were treated with vaginal ring pessary and had successful fittings were included. Adverse events and reasons for discontinuation of pessary use were recorded. Patients who were lost to follow-up were defined as discontinued. Results During 12 year-period, 239 of 329 POP patients(72.6%) had successful fittings with ring pessary. The mean age was 67.8 ± 8.9 years(range 27–86) and 70% of patients had advanced stage. The cumulative probability of continued ring pessary use was 84.1%,64.4%,49.3%,and 33.5%, at 1,3,5,and 10 years, respectively. Most common reason for discontinuation was frequent expulsion(21.6%), followed by vaginal erosion(16.5%), no prolapse improvement(12.4%), and inability or inconvenience to do self-care(9.3%). However, 9 patients(9.3%) had improvement of prolapse and were able to discontinue pessary insertion. Age above 70 years, wide genital hiatus, and incapability of self-care are independent factors associated with long-term discontinuation. Adverse events occurred in 23.4% of patients,18.8% of them had vaginal erosion,11.7% vaginal discharge/infection, and 18.4% de novo SUI. However, no statistical significance existed between those who continued and discontinued pessary use due to these adverse events. Conclusion Ring pessary is an effective treatment in symptomatic POP, with acceptable long-term continuation rates and minor adverse events. Self-care of pessary is very important aiming to minimize adverse events. Advanced age, wide introitus and incapability of self-care were associated factors for long-term discontinuation. Adverse events Continuation Discontinuation Long-term Pelvic organ prolapse Ring pessary Figures Figure 1 Figure 2 A take-home message Ring pessary is an effective treatment in women with symptomatic POP. It has acceptable long-term continuation rate and minor adverse events. Introduction Pelvic organ prolapse (POP) is a prevalent pelvic floor disorder that has affected more than half of women that are older than 50 years of age [ 1 ]. It tends to become more common as women’s life expectancy age increases. Treatment options for symptomatic POP include conservative treatment with pelvic floor muscle training, vaginal pessary, and surgery. However, pelvic floor muscle training is effective in POP patients who are not advanced stage and are asymptomatic or have mild symptoms. In the past, surgery was accepted as a mainstay treatment for POP. The lifetime risk of POP surgery was 13% by the age of 80 years. The risk significantly increased until ages above 70 years [ 2 ]. Generally, most women with POP are elderly with various medical comorbidities. Therefore, surgical options should be carefully considered for these women. Vaginal pessary is a non-surgical treatment for POP and should be offered as the first line of treatment for symptomatic POP regardless of age or prolapse severity [ 3 , 4 ]. It is effective, has acceptable morbidity and can improve quality of life in women with symptomatic POP [ 4 , 5 ]. Successful pessary fitting has been reported to be over 85%, but the continuation rates decreases over time. Several studies showed that the continuation rates at 1 year ranged between 50% and 80% [ 4 – 6 ]. Although there is no consensus about the definition of long-term use, it is generally defined as continued use of longer than one year [ 6 , 7 ]. Some studies reported the 5-year continuation rates decreased to 50% [ 6 , 8 ]. Information about long-term continuation rates and adverse events over 5 years is limited. It has been reported to vary depending on different types of pessaries, stage of POP, and pessary caring protocol. Although there are many types of pessaries, ring pessary is the most common, easiest insertion, and removal. Our previous study reported acceptable short-term continuation rates and adverse events at one year [ 9 ]. This study aims to evaluate the long-term continuation rates of ring pessary use at a minimum of 5 years follow-up, adverse events, and also evaluate the factors associated with discontinuation. Materials and Methods A retrospective study was conducted in women with symptomatic POP who treated with vaginal pessary at Gynecology Clinic, King Chulalongkorn Memorial Hospital between January 2007 and December 2018. After approval by Institutional Review Board, Faculty of Medicine, Chulalongkorn University, the medical records of these patients were reviewed. Symptomatic patients were defined as ones who had prolapse symptoms such as feeling a bulge or pressure in the vagina, or lump protruding out of the vagina. Patients who were fitted with ring pessary by principal investigator were included. The patients who failed ring pessary fitting or temporally used pessary while awaiting surgery were excluded. The patients who continued to wear ring pessary for longer than 2 weeks were classified as successful fitting. All patients were advised to do self-care of their pessaries (remove at night and reinsert in the morning) at least once a week, and topical estrogen was prescribed 1 to 2 times per week in all menopausal women. Appointments every 3 months were scheduled for patients who were unable to manage the pessary by themselves or their caregivers, otherwise they had appointments yearly. Demographic data, menopausal status, medical comorbidities, previous pelvic surgery, lower urinary tract symptoms and sexual activity were all recorded. POP was staged according to Pelvic Organ Prolapse Quantification (POP-Q) system. Adverse events such as malodorous vaginal discharge, vaginal bleeding, vaginal erosion, and new onset of urinary incontinence were recorded. Patients who were lost to the follow-up were defined as discontinuation. Descriptive statistics were used for demographic data. The Kaplan-Meier curve was used to generate the cumulative probability of continued pessary use. Patients who discontinued pessary use, lost to follow-up were censored. Univariate and multivariate logistic regression analysis were used to identify the factors associated with discontinuation. Statistical analyses were performed with SPSS for Windows (version 28.0). P values less than 0.05 were considered statistically significant. Results During a study period, 329 patients with symptomatic POP agreed to try ring pessary insertion. Among them, 239 patients (72.6%) had successfully fittings and were included in this study. Flow diagram of the ring pessary use during 5-year period was showed in Fig. 1 . Mean age was 67.8 ± 8.9 years (range 27–86), the mean parity was 3.5 ± 2.1 (range 0–12), and mean BMI was 24.5 ± 3.4 kg/m 2 (range 14.6–33.7). Most patients were in menopause and none received hormone treatment. One hundred and eighty-four patients (77%) had medical comorbidities such as diabetes mellitus, hypertension, dyslipidemia, and coronary heart disease. Only 30 patients (12.6%) were sexually active, and they remove the pessaries during sexual intercourse. Previous hysterectomy was reported in 27 patients (11.3%) (24 abdominal hysterectomy and 3 vaginal hysterectomies). Fifteen patients (6.3%) had previous pelvic reconstructive surgery such as colporrhaphy with or without mesh augmentation, culdoplasty, sacrospinous ligament fixation. Prior ring pessary insertion, the voiding difficulty was reported in 142 patients (59.4%), frequency of urination 25.9%, nocturia 46%, urgency/urgency urinary incontinence (UUI) 53.6%, stress urinary incontinence (SUI) 41%. The most common POP-Q stage was stage 3 (47.3%), followed by stage 2 (29.7%) and stage 4 (23.0%). Forty-eight patients (20.1%) requested surgery with median duration of ring pessary use of 18.5 months (range 1-136; IQR 9,48.5). The most common reason for surgery was frequent expulsion in 20 patients (41.7%). The other reasons included vaginal erosion (10 patients; 20.8%), no prolapse improvement (10 patients; 20.8%), pessary as a burden, and fear of not being able to have surgery when they are older (8 patients; 16.7%). Most of them (26 patients; 54.2%) performed vaginal hysterectomy with colporrhaphy, 14 patients (29.1%) had colpocleisis, 6 patients (12.5%) had colporrhaphy, and 2 patients (4.2%) had translevator ventral rectopexy. Among 26 patients who performed vaginal hysterectomy, 4 patients had concomitant midurethral sling procedures. Fifty-eight patients (24.3%) lost to follow-up. The median follow-up time was 56 months (range 1-182; IQR 19,99). At the study endpoint, 84 patients (35.1%) continued using ring pessary. The cumulative probability of continued ring pessary use was 84.1%, 64.4%, 49.3%, and 33.5% at 1, 3, 5, and 10 years, respectively (Fig. 2 ). The median duration of ring pessary use in patients who discontinued before study completion was 31 months (range 1-136; IQR 13,57). Among patients who discontinued ring pessary use, 74.8% (116/155) stopped treatment before 5 years. The most common reason for discontinuation besides lost to follow-up was frequent expulsion (21 patients: 21.6%). The other reasons were vaginal erosion with bleeding (16 patients: 16.5%), no improvement of prolapse (12 patients: 12.4%), inability or inconvenience to do self-care (9 patients: 9.3%), desire to leave the prolapse due to not bothersome (15 patients: 15.5%), death (10 patients: 10.3%), other reasons (pregnancy, hip fracture, colon cancer and myelodysplatic syndrome) (5 patients: 5.2%). However, 9 patients (9.3%) had improvement of prolapse and were able to discontinue pessary insertion. Age above 70 years, wide genital hiatus of more than 6 centimeters, and incapability of self-care were independent factors associated with long-term discontinuation of ring pessary use. (Table 1 , 2 ) Table 1. Factor associated with discontinuation of ring pessary use at 5 years Factors Total N=239 Continuation N=123 Discontinuation N=116 p value Mean age + SD 67.8 + 8.9 66.2 + 7.8 69.5 + 9.7 0.005 Age > 70 years 110 (46.0%) 45 (33.3%) 65 (52.9%) 0.003 Mean BMI + SD 24.5 + 3.4 24.9 + 3.1 24.1 + 3.6 0.07 Prior hysterectomy 27 (11.3%) 14 (11.4%) 13 (11.2%) 1.00 Prior pelvic reconstructive surgery 15 (6.3%) 10 (8.1%) 5 (4.3%) 0.29 Advanced stage 166 (69.5%) 82 (66.7%) 84 (72.4%) 0.40 Short vaginal length 6 cm 47 (19.7%) 17 ( 13.8 %) 30 (25.9%) 0.02 De novo stress urinary incontinence 26 (10.9%) 18 (14.6%) 8 (6.9%) 0.06 Incapability of self-care 27 (11.3%) 8 (6.5%) 19 (16.4%) 0.02 Table 2 Univariate and multivariate regression analysis for factors ascociated with discontinuation of ring pessary use Univariate Multivariate OR (95%CI) p value OR (95%CI) p value Age > 70 years 2.21 (1.32–3.71) 0.003 2.15 (1.26–3.66) 0.005 Wide introitus > 6 cm 2.21 (1.14–4.26) 0.02 2.07 (1.05–4.07) 0.04 Incapability of self-care 2.82 (1.18–6.71) 0.02 2.64 (1.08–6.43) 0.03 Of the 239 patients, only 27 patients (11.3%) could not manage the pessary by themselves or with their caregivers. Any adverse events were reported in 56 patients (23.4%) and the details are shown in Table 3 . Vaginal erosions occurred in 45 patients (18.8%). The mean age of patients who had vaginal erosion was 69.9 ± 8.0 years, and the median duration of pessary use before the occurrence of erosion was 22 months (range 3-126; IQR 9,42). This event was treated with topical estrogen and temporary pessary removal. Vaginal discharge or infection occurred in 28 patients (11.7%). It was treated with oral metronidazole at 500 mg twice daily for 7 days. Of those patients who followed self-care protocol, only 11.7% and 3.1% of them complained of vaginal bleeding and discharge, respectively. Of 141 patients who had no pre-existing SUI, 26 patients (18.4%) developed new-onset or de novo SUI. All patients reported mild symptom without interfering with quality of life and no patients discontinued pessary use due to this symptom. De novo UUI occurred in 19 patients (14%) of 136 patients without pre-existing UUI. There was no statistical significance between those who continued or discontinued pessary use due to these adverse events. There were no serious adverse events such as genital tract fistula, embedding into intraabdominal organs, or vaginal cancer. Table 3 Adverse events at the study end point Events Total N = 239 Continuation N = 84 Discontinuation N = 155 p value Vaginal discharge 28 (11.7%) 9 (10.7%) 19 (12.3%) 0.84 Vaginal erosion/bleeding 45 (18.8%) 15 (17.9%) 30 (19.4%) 0.86 De novo SUI 26 (10.9%) 13 (15.5%) 13 (8.4%) 0.13 De novo UUI 19 (7.9%) 10 (11.9%) 9 (5.8%) 0.13 Discussion Conservative treatment with vaginal pessary should be attempted as the first-line therapy for POP. It is considered minimally invasive, easy to use, minimal side effects, and has low cost. Generally, there are 2 types of pessaries: support and space occupying. Support pessary usually recommended for an early stage with sufficient perineal support, but space occupying pessary is used for the advanced stage with less perineal support and wide genital hiatus [ 10 ]. Although, ring pessary is a support pessary, it can be inserted successfully in any stage of POP. Ring pessary is used most often and seems to be easiest to use [ 11 ]. Our previous study reported that 70% of patients who had successful fitting with ring pessary, presented at an advanced stage. Vaginal length shorter than 6 cm and vaginal introitus wider than 4 fingerbreadths were the only significant risk factors for unsuccessful fitting [ 9 ]. Continuation rates of pessary use at 1 year has been reported at a range between 50–80% [ 12 ]. This rate is consistent with our previous study and the recent study, which reported a continuation rates of 84–85% [ 5 ]. Limited data of continuation rates at 5 years or longer has been published. To date, there are two prospective studies which reported 5-year continuation rates of 75–86% [ 13 , 14 ]. Study by Lone et al. reported a very high continuation rates at 5 years (86%) [ 13 ]. Most patients in Lone’s study had early stage POP (70%); this contrasts with our study, which 70% of patients had the advanced stage. Another prospective study included 97% of patients with advanced stage reported 75% continuation rates at 5 years. However, these studies had pessary fitting with ring pessary and Gellhorn. A Gellhorn pessary is a space occupying pessary reported to have significantly longer use than any other type of pessary [ 7 ]. This might explain the higher continuation rates. Furthermore, they excluded patients who lost to follow up. If these patients were defined as the discontinuation group, the 5-year continuation rates would decrease to 68% [ 14 ]. This result shows that the ring pessary is not much inferior to the Gellhorn pessary in long-term use. To the best of our knowledge, there is only one retrospective study that has reported a long-term continuation rates focused only ring pessary. The study of Sarma et al. reported only 14% of patients continued to use ring pessary at the median follow-up time of 7 years [ 15 ]. However, majority of patients had urinary incontinence concomitant with any degree of prolapse. Incontinence pessary (Introl bladder neck support device) was more commonly used than traditional ring pessary (Portex). A high rate of discontinuation was observed within 1.4 years due to more than half of patients experiencing any adverse events such as vaginal bleeding, vaginal discharge, extrusion of the device, pain, constipation, and worsening urinary incontinence. They reported that 46.8% of patients complained of vaginal bleeding and 25.5% of vaginal discharge. Self-care protocol is important in order to minimize adverse events [ 16 ]. The proportion of patients who followed self-care protocol was not mentioned in this study. In contrast, the self-care protocol was successful in 80% of our patients, thus only 11.7% and 6.1% of patients complained of vaginal bleeding and vaginal discharge in our study. As a result, the continuation rates was reported to be higher in our study, at 5 years was 49.2% and 10 years was 33.4%. Age as a risk factor for long-term discontinuation remains uncertain. Some studies reported that older women are more likely to continue vaginal pessary [ 7 , 8 , 17 – 19 ]. However, women who are older than 70 years had a significantly higher discontinuation rates in our study. The definition of long-term pessary use is different. Those studies used only one year as a definition of long-term use, but our study used 5 years. The median duration of pessary use before discontinuation in our study was 31 months, and three quarters of them stopped treatment before five years. Therefore, one year as a cut-off point might be inadequate. Acceptance for pessary use in old women during the first few years might be obvious. However, it usually decreases after a longer follow up time. Most patients in our study who discontinued and requested surgery felt that the self-care protocol was a burden and feared not being able to have surgery when they were older. Ma et al. reported that age is not a significant factor associated with pessary discontinuation, but a vagina shorter than 7.5 cm, poor urinary symptom relief at 3 months and incapability of self-care were potential discontinuation risk factors at the 5-year follow-up [ 14 ]. However, advanced age, wide genital hiatus, and incapability of self-care were independent factors for discontinuation in our study. Different cultural aspects, healthcare system, financial and educational aspects may influence acceptance and adherence to treatment. The rate of long-term adverse events was reported inconsistently between 12% and 56% [ 6 , 13 – 15 ]. Ma et al. reported the complication rate of 23.4% with weekly pessary care. [ 14 ] This finding is consistent with our study that most patients can manage pessaries by themselves. Vaginal erosion was the most common adverse event in our study, occurring in 18.8% of patients. Advanced age and vaginal atrophy have been reported as risk factors for vaginal erosion [ 6 ]. Although the rate of vaginal erosion in our study seems to be high, it was similar to the results from previous studies with long follow-up time [ 6 , 14 ] Previous studies including ours reported that the median duration before the occurrence of vaginal erosion was 2 years [ 6 ]. However, these adverse events usually resolved conservatively with topical estrogen and temporary pessary removal. No serious adverse events such as genital tract fistula, embedding into intraabdominal organs, or vaginal cancer were found in our study. Adverse events can be minimized with adequate follow-up and self-care protocol. The limitations of our study are retrospective design, high lost to follow-up rate, and only ring pessary was used. However, an acceptable 5-year continuation rates of 49.3% was reported. Major strength of this study is long follow-up time, and the long-term continuation rates was reported at 5 and 10 years. To our best knowledge, this is the first study that reported a 10-year continuation rates focused only ring pessary use. One-third of our patients remained using ring pessary at 10 years. One-fourth of them discontinued use due to non-pessary related reasons. Death occurred in 10% of patients and 5% of them developed other medical conditions that required pessary removal. Interestingly, up to 10% of them had prolapse improvement and were able to discontinue pessary use. Handa et al. reported that 20% of women demonstrate improvement of the POP stage and none had worsening prolapse during pessary use. Recovery of overstretching of the pelvic floor by pessary support results in improvement of levator ani function and muscular strength. This might explain prolapse improvement with long term pessary use more than one year [ 20 ]. In conclusion, ring pessary is an effective treatment in POP irrespective of POP stage, with acceptable long-term continuation rates and minor adverse events. A self-care protocol is an important strategy to minimize adverse events. Advanced age, wide introitus and incapability of self-care were associated factors for long-term discontinuation. Declarations The author declare that no funds, grants, or other support were received during the preparation of this manuscript. The author have no relevant financial or non-financial interests to disclose. The author contributed to the study conception and design. Material preparation, data collection, analysis and manuscript writing were performed by Tarinee Manchana. This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Faculty of Medicine, Chulalongkorn University (Date May 27, 2023/No. 0280/66). Author Contribution Manchana T: Project development, data collection, data analysis and manuscript writing References Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol 183:277-285. https://doi.org/10.1067/mob.2000.107583 Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M (2014) Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. 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Int Urogynecol J Pelvic Floor Dysfunct 13:349-351. https://doi.org/10.1007/s001920200078 Cite Share Download PDF Status: Published Journal Publication published 08 Jan, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted Editorial decision: Accept as is 07 Nov, 2023 Reviewers invited by journal 13 Oct, 2023 Editor invited by journal 05 Oct, 2023 Editor assigned by journal 05 Oct, 2023 First submitted to journal 04 Oct, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3411931","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":240023472,"identity":"8637b207-5958-4ed7-88c3-bdafab0432f3","order_by":0,"name":"Tarinee Manchana","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYBAC+wNgCkQyHwMz2dgJaGFjgGthS2NgSABSzMRr4TEDa2EgrIU78XNBzR15c/Yz3x58/LFNno+ZgfHDxxx8Wng3S8849sxwZ0/udsMZCbcN25gZmCVnbsOrZYM0b8Nhxg0HcrdJ8yTcZgRqYWPmxa9l82+gFvsN5988A2mxJ0bLNpAtiRtu5LCBtCQSpcWa59jh5A03nplJzki7ndzGzNhMyC+bb/PUHLbdcD75mcQHm9u289ubD374iEcLg/wDDCHGBjzqR8EoGAWjYBQQAwD8wUy97hrpWAAAAABJRU5ErkJggg==","orcid":"","institution":"Faculty of Medicine, Chulalongkorn University","correspondingAuthor":true,"prefix":"","firstName":"Tarinee","middleName":"","lastName":"Manchana","suffix":""}],"badges":[],"createdAt":"2023-10-05 03:13:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3411931/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3411931/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00404-023-07299-9","type":"published","date":"2024-01-08T15:00:47+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44790387,"identity":"37deb08e-46cf-42dc-bbd7-8007dbce0e2f","added_by":"auto","created_at":"2023-10-17 14:38:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37751,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram showing the ring pessary use within 5 years in women with symptomatic pelvic organ prolapse (POP) with the reasons for discontinuation.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3411931/v1/8edd06a49410aec3a2da4403.png"},{"id":44789223,"identity":"e990fa7f-18f8-4d08-b629-4fcf6021fd33","added_by":"auto","created_at":"2023-10-17 14:30:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":53676,"visible":true,"origin":"","legend":"\u003cp\u003eCumulative probability of ring pessary use in symptomatic pelvic organ prolapse patients.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3411931/v1/a7bb689f522e8477a030add5.png"},{"id":49628495,"identity":"3b778f6d-05c7-448d-8891-e590216d76ad","added_by":"auto","created_at":"2024-01-15 15:06:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":289591,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3411931/v1/1255ee81-d9ed-4c01-ae10-b218358c8f90.pdf"}],"financialInterests":"","formattedTitle":"Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse","fulltext":[{"header":"A take-home message","content":"\u003cp\u003eRing pessary is an effective treatment in women with symptomatic POP. It has acceptable long-term continuation rate and minor adverse events.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003ePelvic organ prolapse (POP) is a prevalent pelvic floor disorder that has affected more than half of women that are older than 50 years of age [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It tends to become more common as women\u0026rsquo;s life expectancy age increases. Treatment options for symptomatic POP include conservative treatment with pelvic floor muscle training, vaginal pessary, and surgery. However, pelvic floor muscle training is effective in POP patients who are not advanced stage and are asymptomatic or have mild symptoms. In the past, surgery was accepted as a mainstay treatment for POP. The lifetime risk of POP surgery was 13% by the age of 80 years. The risk significantly increased until ages above 70 years [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Generally, most women with POP are elderly with various medical comorbidities. Therefore, surgical options should be carefully considered for these women.\u003c/p\u003e \u003cp\u003eVaginal pessary is a non-surgical treatment for POP and should be offered as the first line of treatment for symptomatic POP regardless of age or prolapse severity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is effective, has acceptable morbidity and can improve quality of life in women with symptomatic POP [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Successful pessary fitting has been reported to be over 85%, but the continuation rates decreases over time. Several studies showed that the continuation rates at 1 year ranged between 50% and 80% [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although there is no consensus about the definition of long-term use, it is generally defined as continued use of longer than one year [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Some studies reported the 5-year continuation rates decreased to 50% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Information about long-term continuation rates and adverse events over 5 years is limited. It has been reported to vary depending on different types of pessaries, stage of POP, and pessary caring protocol. Although there are many types of pessaries, ring pessary is the most common, easiest insertion, and removal. Our previous study reported acceptable short-term continuation rates and adverse events at one year [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This study aims to evaluate the long-term continuation rates of ring pessary use at a minimum of 5 years follow-up, adverse events, and also evaluate the factors associated with discontinuation.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA retrospective study was conducted in women with symptomatic POP who treated with vaginal pessary at Gynecology Clinic, King Chulalongkorn Memorial Hospital between January 2007 and December 2018. After approval by Institutional Review Board, Faculty of Medicine, Chulalongkorn University, the medical records of these patients were reviewed. Symptomatic patients were defined as ones who had prolapse symptoms such as feeling a bulge or pressure in the vagina, or lump protruding out of the vagina. Patients who were fitted with ring pessary by principal investigator were included. The patients who failed ring pessary fitting or temporally used pessary while awaiting surgery were excluded. The patients who continued to wear ring pessary for longer than 2 weeks were classified as successful fitting. All patients were advised to do self-care of their pessaries (remove at night and reinsert in the morning) at least once a week, and topical estrogen was prescribed 1 to 2 times per week in all menopausal women. Appointments every 3 months were scheduled for patients who were unable to manage the pessary by themselves or their caregivers, otherwise they had appointments yearly. Demographic data, menopausal status, medical comorbidities, previous pelvic surgery, lower urinary tract symptoms and sexual activity were all recorded. POP was staged according to Pelvic Organ Prolapse Quantification (POP-Q) system. Adverse events such as malodorous vaginal discharge, vaginal bleeding, vaginal erosion, and new onset of urinary incontinence were recorded. Patients who were lost to the follow-up were defined as discontinuation.\u003c/p\u003e \u003cp\u003eDescriptive statistics were used for demographic data. The Kaplan-Meier curve was used to generate the cumulative probability of continued pessary use. Patients who discontinued pessary use, lost to follow-up were censored. Univariate and multivariate logistic regression analysis were used to identify the factors associated with discontinuation. Statistical analyses were performed with SPSS for Windows (version 28.0). P values less than 0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring a study period, 329 patients with symptomatic POP agreed to try ring pessary insertion. Among them, 239 patients (72.6%) had successfully fittings and were included in this study. Flow diagram of the ring pessary use during 5-year period was showed in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Mean age was 67.8\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;8.9 years (range 27\u0026ndash;86), the mean parity was 3.5\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.1 (range 0\u0026ndash;12), and mean BMI was 24.5\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;3.4 kg/m\u003csup\u003e2\u003c/sup\u003e (range 14.6\u0026ndash;33.7). Most patients were in menopause and none received hormone treatment. One hundred and eighty-four patients (77%) had medical comorbidities such as diabetes mellitus, hypertension, dyslipidemia, and coronary heart disease. Only 30 patients (12.6%) were sexually active, and they remove the pessaries during sexual intercourse. Previous hysterectomy was reported in 27 patients (11.3%) (24 abdominal hysterectomy and 3 vaginal hysterectomies). Fifteen patients (6.3%) had previous pelvic reconstructive surgery such as colporrhaphy with or without mesh augmentation, culdoplasty, sacrospinous ligament fixation. Prior ring pessary insertion, the voiding difficulty was reported in 142 patients (59.4%), frequency of urination 25.9%, nocturia 46%, urgency/urgency urinary incontinence (UUI) 53.6%, stress urinary incontinence (SUI) 41%. The most common POP-Q stage was stage 3 (47.3%), followed by stage 2 (29.7%) and stage 4 (23.0%).\u003c/p\u003e\n\u003cp\u003eForty-eight patients (20.1%) requested surgery with median duration of ring pessary use of 18.5 months (range 1-136; IQR 9,48.5). The most common reason for surgery was frequent expulsion in 20 patients (41.7%). The other reasons included vaginal erosion (10 patients; 20.8%), no prolapse improvement (10 patients; 20.8%), pessary as a burden, and fear of not being able to have surgery when they are older (8 patients; 16.7%). Most of them (26 patients; 54.2%) performed vaginal hysterectomy with colporrhaphy, 14 patients (29.1%) had colpocleisis, 6 patients (12.5%) had colporrhaphy, and 2 patients (4.2%) had translevator ventral rectopexy. Among 26 patients who performed vaginal hysterectomy, 4 patients had concomitant midurethral sling procedures.\u003c/p\u003e\n\u003cp\u003eFifty-eight patients (24.3%) lost to follow-up. The median follow-up time was 56 months (range 1-182; IQR 19,99). At the study endpoint, 84 patients (35.1%) continued using ring pessary. The cumulative probability of continued ring pessary use was 84.1%, 64.4%, 49.3%, and 33.5% at 1, 3, 5, and 10 years, respectively (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The median duration of ring pessary use in patients who discontinued before study completion was 31 months (range 1-136; IQR 13,57). Among patients who discontinued ring pessary use, 74.8% (116/155) stopped treatment before 5 years. The most common reason for discontinuation besides lost to follow-up was frequent expulsion (21 patients: 21.6%). The other reasons were vaginal erosion with bleeding (16 patients: 16.5%), no improvement of prolapse (12 patients: 12.4%), inability or inconvenience to do self-care (9 patients: 9.3%), desire to leave the prolapse due to not bothersome (15 patients: 15.5%), death (10 patients: 10.3%), other reasons (pregnancy, hip fracture, colon cancer and myelodysplatic syndrome) (5 patients: 5.2%). However, 9 patients (9.3%) had improvement of prolapse and were able to discontinue pessary insertion. Age above 70 years, wide genital hiatus of more than 6 centimeters, and incapability of self-care were independent factors associated with long-term discontinuation of ring pessary use. (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e,\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eTable 1. Factor associated with discontinuation of ring pessary use at 5 years\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable style=\"width:469.3pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:43.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eFactors\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border:solid black 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt;height:43.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eTotal\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eN=239\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border:solid black 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt;height:43.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eContinuation\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eN=123\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border:solid black 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt;height:43.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eDiscontinuation\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eN=116\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border:solid black 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt;height:43.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003ep\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003evalue\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eMean age \u003cu\u003e+\u003c/u\u003e SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e67.8 \u003cu\u003e+\u003c/u\u003e 8.9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e66.2 \u003cu\u003e+\u003c/u\u003e 7.8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e69.5 \u003cu\u003e+\u003c/u\u003e 9.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.005\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:22.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eAge \u0026gt; 70 years\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e110 (46.0%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e45 (33.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e65 (52.9%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.003\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eMean BMI \u003cu\u003e+\u003c/u\u003e SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e24.5 \u003cu\u003e+\u003c/u\u003e 3.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e24.9 \u003cu\u003e+\u003c/u\u003e 3.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e24.1 \u003cu\u003e+\u003c/u\u003e 3.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e0.07\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003ePrior hysterectomy\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e27 (11.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e14 (11.4%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e13 (11.2%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e1.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:30.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003ePrior pelvic reconstructive surgery\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:30.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e15 (6.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:30.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e10 (8.1%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:30.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e5 (4.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:30.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e0.29\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eAdvanced stage\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e166 (69.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e82\u003c/span\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;(66.7%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e84\u003c/span\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;(72.4%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e0.40\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:22.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eShort vaginal length \u0026lt; 6 cm\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e3 (1.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e1 (0.8%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e2 (1.7%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.2pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e0.61\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eWide introitus \u0026gt; 6 cm\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e47 (19.7%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e17 (\u003c/span\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e13.8\u003c/span\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e30 (25.9%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.02\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:28.7pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eDe novo stress urinary incontinence\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:28.7pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e26 (10.9%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:28.7pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e18 (14.6%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:28.7pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e8 (6.9%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:28.7pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e0.06\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:133.55pt;border:solid black 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003eIncapability of self-care\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e27 (11.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.45pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e8 (6.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:92.5pt;border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:black;'\u003e19 (16.4%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:58.3pt;border-top:none;border-left:none;border-bottom: solid black 1.0pt;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:23.25pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:.5in;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;margin:0in;text-align:center;'\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.02\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUnivariate and multivariate regression analysis for factors ascociated with discontinuation of ring pessary use\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUnivariate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMultivariate\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR (95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR (95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;70 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.21 (1.32\u0026ndash;3.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.15 (1.26\u0026ndash;3.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWide introitus\u0026thinsp;\u0026gt;\u0026thinsp;6 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.21 (1.14\u0026ndash;4.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.07 (1.05\u0026ndash;4.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncapability of self-care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.82 (1.18\u0026ndash;6.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.64 (1.08\u0026ndash;6.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eOf the 239 patients, only 27 patients (11.3%) could not manage the pessary by themselves or with their caregivers. Any adverse events were reported in 56 patients (23.4%) and the details are shown in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. Vaginal erosions occurred in 45 patients (18.8%). The mean age of patients who had vaginal erosion was 69.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0 years, and the median duration of pessary use before the occurrence of erosion was 22 months (range 3-126; IQR 9,42). This event was treated with topical estrogen and temporary pessary removal. Vaginal discharge or infection occurred in 28 patients (11.7%). It was treated with oral metronidazole at 500 mg twice daily for 7 days. Of those patients who followed self-care protocol, only 11.7% and 3.1% of them complained of vaginal bleeding and discharge, respectively. Of 141 patients who had no pre-existing SUI, 26 patients (18.4%) developed new-onset or de novo SUI. All patients reported mild symptom without interfering with quality of life and no patients discontinued pessary use due to this symptom. De novo UUI occurred in 19 patients (14%) of 136 patients without pre-existing UUI. There was no statistical significance between those who continued or discontinued pessary use due to these adverse events. There were no serious adverse events such as genital tract fistula, embedding into intraabdominal organs, or vaginal cancer.\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAdverse events at the study end point\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;239\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eContinuation\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;84\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDiscontinuation\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;155\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVaginal discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28 (11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9 (10.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19 (12.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVaginal erosion/bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15 (17.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30 (19.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDe novo SUI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26 (10.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13 (15.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13 (8.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDe novo UUI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19 (7.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10 (11.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9 (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eConservative treatment with vaginal pessary should be attempted as the first-line therapy for POP. It is considered minimally invasive, easy to use, minimal side effects, and has low cost. Generally, there are 2 types of pessaries: support and space occupying. Support pessary usually recommended for an early stage with sufficient perineal support, but space occupying pessary is used for the advanced stage with less perineal support and wide genital hiatus [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Although, ring pessary is a support pessary, it can be inserted successfully in any stage of POP. Ring pessary is used most often and seems to be easiest to use [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Our previous study reported that 70% of patients who had successful fitting with ring pessary, presented at an advanced stage. Vaginal length shorter than 6 cm and vaginal introitus wider than 4 fingerbreadths were the only significant risk factors for unsuccessful fitting [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Continuation rates of pessary use at 1 year has been reported at a range between 50\u0026ndash;80% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This rate is consistent with our previous study and the recent study, which reported a continuation rates of 84\u0026ndash;85% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Limited data of continuation rates at 5 years or longer has been published. To date, there are two prospective studies which reported 5-year continuation rates of 75\u0026ndash;86% [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Study by Lone et al. reported a very high continuation rates at 5 years (86%) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Most patients in Lone\u0026rsquo;s study had early stage POP (70%); this contrasts with our study, which 70% of patients had the advanced stage. Another prospective study included 97% of patients with advanced stage reported 75% continuation rates at 5 years. However, these studies had pessary fitting with ring pessary and Gellhorn. A Gellhorn pessary is a space occupying pessary reported to have significantly longer use than any other type of pessary [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This might explain the higher continuation rates. Furthermore, they excluded patients who lost to follow up. If these patients were defined as the discontinuation group, the 5-year continuation rates would decrease to 68% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This result shows that the ring pessary is not much inferior to the Gellhorn pessary in long-term use.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, there is only one retrospective study that has reported a long-term continuation rates focused only ring pessary. The study of Sarma et al. reported only 14% of patients continued to use ring pessary at the median follow-up time of 7 years [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, majority of patients had urinary incontinence concomitant with any degree of prolapse. Incontinence pessary (Introl bladder neck support device) was more commonly used than traditional ring pessary (Portex). A high rate of discontinuation was observed within 1.4 years due to more than half of patients experiencing any adverse events such as vaginal bleeding, vaginal discharge, extrusion of the device, pain, constipation, and worsening urinary incontinence. They reported that 46.8% of patients complained of vaginal bleeding and 25.5% of vaginal discharge. Self-care protocol is important in order to minimize adverse events [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The proportion of patients who followed self-care protocol was not mentioned in this study. In contrast, the self-care protocol was successful in 80% of our patients, thus only 11.7% and 6.1% of patients complained of vaginal bleeding and vaginal discharge in our study. As a result, the continuation rates was reported to be higher in our study, at 5 years was 49.2% and 10 years was 33.4%.\u003c/p\u003e \u003cp\u003eAge as a risk factor for long-term discontinuation remains uncertain. Some studies reported that older women are more likely to continue vaginal pessary [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, women who are older than 70 years had a significantly higher discontinuation rates in our study. The definition of long-term pessary use is different. Those studies used only one year as a definition of long-term use, but our study used 5 years. The median duration of pessary use before discontinuation in our study was 31 months, and three quarters of them stopped treatment before five years. Therefore, one year as a cut-off point might be inadequate. Acceptance for pessary use in old women during the first few years might be obvious. However, it usually decreases after a longer follow up time. Most patients in our study who discontinued and requested surgery felt that the self-care protocol was a burden and feared not being able to have surgery when they were older. Ma et al. reported that age is not a significant factor associated with pessary discontinuation, but a vagina shorter than 7.5 cm, poor urinary symptom relief at 3 months and incapability of self-care were potential discontinuation risk factors at the 5-year follow-up [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, advanced age, wide genital hiatus, and incapability of self-care were independent factors for discontinuation in our study. Different cultural aspects, healthcare system, financial and educational aspects may influence acceptance and adherence to treatment.\u003c/p\u003e \u003cp\u003eThe rate of long-term adverse events was reported inconsistently between 12% and 56% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Ma et al. reported the complication rate of 23.4% with weekly pessary care. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] This finding is consistent with our study that most patients can manage pessaries by themselves. Vaginal erosion was the most common adverse event in our study, occurring in 18.8% of patients. Advanced age and vaginal atrophy have been reported as risk factors for vaginal erosion [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although the rate of vaginal erosion in our study seems to be high, it was similar to the results from previous studies with long follow-up time [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Previous studies including ours reported that the median duration before the occurrence of vaginal erosion was 2 years [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, these adverse events usually resolved conservatively with topical estrogen and temporary pessary removal. No serious adverse events such as genital tract fistula, embedding into intraabdominal organs, or vaginal cancer were found in our study. Adverse events can be minimized with adequate follow-up and self-care protocol.\u003c/p\u003e \u003cp\u003eThe limitations of our study are retrospective design, high lost to follow-up rate, and only ring pessary was used. However, an acceptable 5-year continuation rates of 49.3% was reported. Major strength of this study is long follow-up time, and the long-term continuation rates was reported at 5 and 10 years. To our best knowledge, this is the first study that reported a 10-year continuation rates focused only ring pessary use. One-third of our patients remained using ring pessary at 10 years. One-fourth of them discontinued use due to non-pessary related reasons. Death occurred in 10% of patients and 5% of them developed other medical conditions that required pessary removal. Interestingly, up to 10% of them had prolapse improvement and were able to discontinue pessary use. Handa et al. reported that 20% of women demonstrate improvement of the POP stage and none had worsening prolapse during pessary use. Recovery of overstretching of the pelvic floor by pessary support results in improvement of levator ani function and muscular strength. This might explain prolapse improvement with long term pessary use more than one year [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn conclusion, ring pessary is an effective treatment in POP irrespective of POP stage, with acceptable long-term continuation rates and minor adverse events. A self-care protocol is an important strategy to minimize adverse events. Advanced age, wide introitus and incapability of self-care were associated factors for long-term discontinuation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003eThe author declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/li\u003e\n \u003cli\u003eThe author have no relevant financial or non-financial interests to disclose.\u003c/li\u003e\n \u003cli\u003eThe author contributed to the study conception and design. Material preparation, data collection, analysis and manuscript writing were performed by Tarinee Manchana.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Faculty of Medicine, Chulalongkorn University (Date May 27, 2023/No. 0280/66).\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eManchana T: Project development, data collection, data analysis and manuscript writing\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSwift SE (2000) The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol 183:277-285. https://doi.org/10.1067/mob.2000.107583\u003c/li\u003e\n\u003cli\u003eWu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M (2014) Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol 123:1201-1206. https://doi.org/10.1097/AOG.0000000000000057\u003c/li\u003e\n\u003cli\u003eAtnip SD (2009) Pessary use and management for pelvic organ prolapse. Obstet Gynecol Clin North Am 36:541-563. https://doi.org/10.1016/j.ogc.2009.08.010\u003c/li\u003e\n\u003cli\u003eKo PC, Lo TS, Tseng LH, Lin YH, Liang CC, Lee SJ (2011) Use of a pessary in treatment of pelvic organ prolapse: quality of life, compliance, and failure at 1-year follow-up. J Minim Invasive Gynecol 18:68-74. https://doi.org/10.1016/j.jmig.2010.09.006\u003c/li\u003e\n\u003cli\u003eManchana T, Bunyavejchevin S (2012) Impact on quality of life after ring pessary use for pelvic organ prolapse. Int Urogynecol J 23:873-877. https://doi.org/10.1007/s00192-011-1634-6\u003c/li\u003e\n\u003cli\u003eRamsay S, Tu le M, Tannenbaum C (2016) Natural history of pessary use in women aged 65 - 74 versus 75 years and older with pelvic organ prolapse: a 12-year study. Int Urogynecol J 27:1201-1207. https://doi.org/10.1007/s00192-016-2970-3\u003c/li\u003e\n\u003cli\u003eWolff B, Williams K, Winkler A, Lind L, Shalom D (2017) Pessary types and discontinuation rates in patients with advanced pelvic organ prolapse. Int Urogynecol J 28:993-997. https://doi.org/10.1007/s00192-016-3228-9\u003c/li\u003e\n\u003cli\u003eChien CW, Lo TS, Tseng LH, Lin YH, Hsieh WC, Lee SJ (2020) Long-term Outcomes of Self-Management Gellhorn Pessary for Symptomatic Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg 26:e47-e53. https://doi.org/10.1097/SPV.0000000000000770\u003c/li\u003e\n\u003cli\u003eManchana T (2011) Ring pessary for all pelvic organ prolapse. Arch Gynecol Obstet 284:391-395. https://doi.org/10.1007/s00404-010-1675-y\u003c/li\u003e\n\u003cli\u003eWeber AM, Richter HE (2005) Pelvic organ prolapse. Obstet Gynecol 106:615-634. https://doi.org/10.1097/01.AOG.0000175832.13266.bb\u003c/li\u003e\n\u003cli\u003ePott-Grinstein E, Newcomer JR (2001) Gynecologists\u0026apos; patterns of prescribing pessaries. J Reprod Med 46:205-208.\u003c/li\u003e\n\u003cli\u003eLamers BH, Broekman BM, Milani AL (2011) Pessary treatment for pelvic organ prolapse and health-related quality of life: a review. Int Urogynecol J 22:637-644. https://doi.org/10.1007/s00192-011-1390-7\u003c/li\u003e\n\u003cli\u003eLone F, Thakar R, Sultan AH, Karamalis G (2011) A 5-year prospective study of vaginal pessary use for pelvic organ prolapse. Int J Gynaecol Obstet 114:56-59. https://doi.org/10.1016/j.ijgo.2011.02.006\u003c/li\u003e\n\u003cli\u003eMa C, Zhou Y, Kang J, Zhang Y, Ma Y, Wang Y, et al (2021) Vaginal pessary treatment in women with symptomatic pelvic organ prolapse: a long-term prospective study. Menopause 28:538-545. https://doi.org/10.1097/GME.0000000000001751\u003c/li\u003e\n\u003cli\u003eSarma S, Ying T, Moore KH (2009) Long-term vaginal ring pessary use: discontinuation rates and adverse events. BJOG 116:1715-1721. https://doi.org/10.1111/j.1471-0528.2009.02380.x\u003c/li\u003e\n\u003cli\u003eViera AJ, Larkins-Pettigrew M (2000) Practical use of the pessary. Am Fam Physician 61:2719-2726.\u003c/li\u003e\n\u003cli\u003eClemons JL, Aguilar VC, Sokol ER, Jackson ND, Myers DL (2004) Patient characteristics that are associated with continued pessary use versus surgery after 1 year. Am J Obstet Gynecol 191:159-164. https://doi.org/10.1016/j.ajog.2004.04.048\u003c/li\u003e\n\u003cli\u003eFriedman S, Sandhu KS, Wang C, Mikhail MS, Banks E (2010) Factors influencing long-term pessary use. Int Urogynecol J 21:673-678. https://doi.org/10.1007/s00192-009-1080-x\u003c/li\u003e\n\u003cli\u003eNiigaki DI, Silva RSP, Bortolini MAT, Fitz FF, Castro RA (2022) Predictors for long-term adherence to vaginal pessary in pelvic organ prolapse: a prospective study. Int Urogynecol J 33:3237-3246. https://doi.org/10.1007/s00192-022-05133-5\u003c/li\u003e\n\u003cli\u003eHanda VL, Jones M (2002) Do pessaries prevent the progression of pelvic organ prolapse? Int Urogynecol J Pelvic Floor Dysfunct 13:349-351. https://doi.org/10.1007/s001920200078\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Adverse events, Continuation, Discontinuation, Long-term, Pelvic organ prolapse, Ring pessary","lastPublishedDoi":"10.21203/rs.3.rs-3411931/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3411931/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo evaluate long-term continuation rates, adverse events of ring pessary use at a minimum of 5 years follow-up, and factors associated with discontinuation in symptomatic pelvic organ prolapse (POP)\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWomen with symptomatic POP who were treated with vaginal ring pessary and had successful fittings were included. Adverse events and reasons for discontinuation of pessary use were recorded. Patients who were lost to follow-up were defined as discontinued.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDuring 12 year-period, 239 of 329 POP patients(72.6%) had successful fittings with ring pessary. The mean age was 67.8\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;8.9 years(range 27\u0026ndash;86) and 70% of patients had advanced stage. The cumulative probability of continued ring pessary use was 84.1%,64.4%,49.3%,and 33.5%, at 1,3,5,and 10 years, respectively. Most common reason for discontinuation was frequent expulsion(21.6%), followed by vaginal erosion(16.5%), no prolapse improvement(12.4%), and inability or inconvenience to do self-care(9.3%). However, 9 patients(9.3%) had improvement of prolapse and were able to discontinue pessary insertion. Age above 70 years, wide genital hiatus, and incapability of self-care are independent factors associated with long-term discontinuation. Adverse events occurred in 23.4% of patients,18.8% of them had vaginal erosion,11.7% vaginal discharge/infection, and 18.4% de novo SUI. However, no statistical significance existed between those who continued and discontinued pessary use due to these adverse events.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eRing pessary is an effective treatment in symptomatic POP, with acceptable long-term continuation rates and minor adverse events. Self-care of pessary is very important aiming to minimize adverse events. Advanced age, wide introitus and incapability of self-care were associated factors for long-term discontinuation.\u003c/p\u003e","manuscriptTitle":"Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-17 14:30:46","doi":"10.21203/rs.3.rs-3411931/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept as is","date":"2023-11-07T15:44:52+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-10-13T20:23:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Archives of Gynecology and Obstetrics","date":"2023-10-05T17:46:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-10-05T14:38:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2023-10-04T23:13:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"54e1b3af-2ea5-45c3-9b6d-859cdec66a9d","owner":[],"postedDate":"October 17th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-01-15T15:02:52+00:00","versionOfRecord":{"articleIdentity":"rs-3411931","link":"https://doi.org/10.1007/s00404-023-07299-9","journal":{"identity":"archives-of-gynecology-and-obstetrics","isVorOnly":false,"title":"Archives of Gynecology and Obstetrics"},"publishedOn":"2024-01-08 15:00:47","publishedOnDateReadable":"January 8th, 2024"},"versionCreatedAt":"2023-10-17 14:30:46","video":"","vorDoi":"10.1007/s00404-023-07299-9","vorDoiUrl":"https://doi.org/10.1007/s00404-023-07299-9","workflowStages":[]},"version":"v1","identity":"rs-3411931","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3411931","identity":"rs-3411931","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}