Pelvic organ prolapse (POP) is a common gynaecological condition worldwide with
significant morbidity. Use of vaginal pessary has been recommended by multiple national
authorities such as NICE and ACOG as an effective conservative management to all patients
suffering from POP. However, the use of vaginal pessary can also associate with risks
such as increased vaginal discharge, discomfort, bleeding and ulcers. The long term
follow-up for changing pessary also exerts a significant economic cost in the healthcare
system. Self-management of vaginal pessaries helps improved patient satisfaction and
their quality of life with a much lower complication rates. Nevertheless, the attitudes
and knowledge in women about pessary use is reported to be deficient and warrant further
study.
This is a prospective cohort study aims at assessing patient's attitude towards
self-management of vaginal pessary, and identifying factors that affect patient's level
of acceptance towards self-management.
Patients who suffers from pelvic organ prolapse requiring the use of ring pessary as
treatment will be invited to join the study, with exclusion criteria.
Should patient agree to join the study, they will fill in a self-administered
questionnaire focusing on various reasons and factors that may influence patients'
attitude on the use of vaginal pessaries and also Pelvic Floor Distress Inventory (PFDI)
and Pelvic Floor Impact Questionnaire (PFIQ) at different time intervals to assess the
symptoms, severity of symptoms and their impact on a woman's activities and well-being.
Both PFDI and PFIQ are reliable, valid and condition-specific symptoms and QoL
instruments for women with pelvic floor disorders, . Chinese validated versions are
available. The epidemiological background information, any significant medical disease,
especially previous treatment and surgery for pelvic organ prolapse would be gathered
from the patient and medical records, if any. Patient will then be divided into two
intervention arms by patient's own choice: self management arms and
traditional hospital-based care arm, after counselling on the pros and cons of the above
options with written counselling material. For patients who agree to learn
self-management of vaginal pessary, per vaginal exam and staging of prolapse will be
assessed and documented using Pelvic Organ Prolapse Quantification system (POP-Q) by
gynaecologists. Pelvic floor muscles contraction and symptom of stress incontinence will
be assessed and documented. PVC ring pessary will be inserted in the recruitment session.
For those who has been stable on ring pessary without complication, a silicon ring
pessary of their size will be suggested. Participants will need to bring their own
purchased silicon ring pessary for the teaching session. For patient who has never tried
ring pessary, a PVC ring pessary will be fitted first.
For patient who does not agree to try self-management, routine clinical care with
hospital-based management will be provided as per department protocol with changing of
PVC ring pessary and follow-ups appointments.
A teaching session will be arranged for a 1-to-1 20-minute self-management education by
doctors or incontinence nurses to patient who agrees to learn self-management. Patient
will be taught on self-insertion/removal of the silicon ring pessary, and silicon ring
pessary care techniques. Returned demonstration from patient will be carried out to
ensure patient's competence in self-management. Hotline will be given to patient in case
of any difficulties in self-management of vaginal pessary.
For patients who experience difficulty in self-management either from hotline call-backs
or during 6-month follow-up session, a second teaching session will be offered to
reinforce the self-management techniques if the patient agrees to continue learning
self-management.
Follow up will be arranged in 6 months to review patient's pelvic floor disorder
symptoms, look for and document any pessary-related complications, and PFDI and PFIQ will
be repeated for quality-of-life assessment. The frequency of self replacement will also
be explored. If patient is well on self-management of ring pessary, a second 6-monthly
follow up will be arranged and again to review patient's pelvic floor disorder symptoms,
look for and document any pessary-related complications, and PFDI and PFIQ will be
repeated for quality-of-life assessment. The frequency of self-replacement will also be
explored. Patient's satisfaction will be explored using Visual Analogue Scale (VAS).
