We found that the vast majority of women (92%) with SUI without advanced pelvic organ prolapse can be successfully fitted with an incontinence pessary by trained nurse practitioners, RNs, or physical therapists. Previous hysterectomy did not result in a higher rate of unsuccessful incontinence pessary fit. Women with a longer total vaginal length were more likely to be successfully fitted but various formulas involving total vaginal length did not predict pessary size. In fact, no vaginal measurement per POPQ evaluation proved helpful in determining pessary size. Approximately two thirds of our subjects could be fitted with a no. 2, no. 3, or no. 4 incontinence ring or a 65-, 70-, or 75-mm incontinence dish. This information may be useful to the clinician for office inventory supply.
A few studies have described patient characteristics associated with continued pessary use in prolapse or prolapse and incontinent patients. Clemons et al. [10
] found that advanced age was associated with pessary continuation, but that stage III–IV prolapse and desire for surgery were associated with discontinuation. Wu et al. [11
] found that patients with both pelvic organ prolapse and stress incontinence were more likely to chose surgery, but that advanced prolapse was not associated with pessary discontinuation.
There are limited data regarding specific vaginal dimensions that may be associated with successful pessary fitting. A widened genital introitus, short vaginal length, and posterior compartment defects [10
] have been associated with unsuccessful fitting in women with pelvic organ prolapse and incontinence. In one study, it was hypothesized that women with a wider genital hiatus would be more difficult to fit successfully as incontinence pessaries are somewhat dependent on the presence of levator support to stay in place [15
]. However, when utilizing POPQ measures of the GH, there was no difference in the proportion of women that were successfully fit whether the GH measured <3 cm or >3 cm (p
There is no uniform definition for successful pessary fitting. We considered fitting to be unsuccessful if the provider could not obtain an adequate fit after at least three attempts, if the woman found the pessary painful, or if she did not plan to use the pessary after fitting. Others have considered fitting successful when the pessary was comfortable and retained during Valsalva and voiding at the initial visit [13
] or when the fit was appropriate and the woman continued to use the pessary at the 3-week follow-up visit [16
]. Whatever definition is utilized, in order to optimize pessary use in women that desire this means of treatment, early and consistent long-tem follow-up should be performed [17
While previous hysterectomy was identified in one study as a risk factor for unsuccessful fitting in women with prolapse [13
], we did not find this to be the case in our population of women without advanced prolapse. Women using pessaries to treat stress incontinence differ from women using them to treat pelvic organ prolapse. The population of women with stress incontinence is younger, is less likely to have had previous surgeries, and has a longer vaginal length and narrower genital hiatus than the population with prolapse. Accordingly, the success rate for fitting pessaries in women with SUI (92% in our study, 89% in another population of women with SUI [15
]) is generally higher than that for women with advanced prolapse (41% [16
], 73% [10
], and 90% [19
A strength of this study was that as part of a randomized non-surgical treatment trial, all patients underwent a standardized baseline evaluation, including the POPQ evaluation. An exhaustive effort was made to successfully fit and follow-up with these patients; therefore, there was minimal loss to follow-up early in the process, which is important in carefully characterizing those subjects that were fitting failures. The major limitation of this study is that the results and conclusions of our study are limited to women with SUI and no significant prolapse; a group of women with more prolapse or a wider range of POPQ values may have different results. Another limitation of this study was the lack of utilization of other patient characteristics in order to characterize those that were fitting successes or failures. The primary purpose of this study was to determine whether successful pessary fitting could be predicted by specific POPQ measures and whether these measures could also predict pessary size. As this was not the case, clearly the performance of a POPQ examination prior to pessary fitting in women with stress predominant urinary incontinence without advanced prolapse is not necessary. The vaginal measures of the POPQ exam include the sagittal axis of the vagina, but not the lateral or coronal dimensions of the vagina, and these later measures may be more important for fitting.
We conclude that incontinence pessary fitting remains an art rather than a science. Fortunately, however, it is an art that is easy to do: Most women were successfully fitted, and most did not need to try more than two pessary sizes to achieve the appropriate fit.
Given the lack of correlation with anatomic and baseline characteristics, these data suggest that incontinence pessary fitting can occur in a primary care setting by interested and experienced providers of all levels, including nurses, nurse practitioners, physical therapists, and physicians.