Improving Resident Comfort and Competency with Pessary Use: A Quality Improvement Study

Objectives: Urinary incontinence and pelvic organ prolapse are common conditions among females. As the population continues to age, the frequency of pelvic floor disorders (PFDs) are expected to increase. Vaginal pessaries are an important non-surgical option for the management of PFDs and it is estimated that up to 90% of women can be successfully fitted with a pessary. Given the prevalence of PFDs, it is important that general gynecologists are comfortable fitting and managing pessaries to maximize access to this important treatment option. However, generalists reported lower rates of use when compared to urogynecologists, likely stemming from infrequent training during residency. Interventions such as increased experience with pessary fitting and receiving formal “pessary specific” didactics would improve residency competency of pessary management. Unfortunately, effective formal instructional programs are lacking in many residency programs. The primary objective of this study was to assess residents’ competency and comfort regarding pessary fittings and management before and after implementation of an instructional didactic and comprehensive simulation. The secondary objective was to examine if the implementation of the intervention increases scores on a written knowledge test.

Methods: In this quality improvement initiative, a board-certified urogynecologist provided a pessary fitting and management lecture followed by a simulation. The lecture topics included general pessary types, indications, fittings and follow up care. A anonymous pre- and post-intervention questionnaires were completed by each resident to assess experience, comfort, and knowledge of pessaries.

Results: Twenty residents participated in the study with a 100% response rate to the questionnaires. The mean age of respondents was 28 (+ 1.75). Training levels were distributed evenly (PGY1, 62.5%; PGY2, 50%; PGY3, 70%; PGY4, 62.5%). 80% of residents had experienced patients with prolapse and/or stress incontinence during resident continuity clinic, however only 5% endorsed a formal pessary didactic (although 55% endorsed informal learning). Out of all residents surveyed, 0% felt that the residency program adequately prepared them for pessary fitting prior to the intervention. Only 5% felt that they would be comfortable with pessary fitting/management at graduation. Following the simulation, 75% “agreed” or “strongly agreed” with the previous statement. 100% of residents “agreed” or “strongly agreed” that the instructional session improved their confidence in caring for patients with pessaries. Post-intervention, knowledge assessment improved across all training years.

Conclusions: Despite training at a large academic center with an accredited urogynecology fellowship and multiple board-certified urogynecologists, residents had low knowledge and comfort regarding pessaries. Implementation of universal pessary-specific didactic with accompanying simulation improved resident-reported skills, confidence and competency.