Conservative management of voiding dysfunction due to pelvic organ prolapse

Objectives:
Literature is limited regarding conservative management of voiding dysfunction (VD) due to pelvic organ prolapse (POP). The objective of this study is to evaluate the efficacy of utilizing a pessary for the management of VD in the setting of POP.


Methods:
This is a retrospective cohort study of patients who reported VD in the setting of POP and underwent pessary fitting between January 2016 to December 2022 at a tertiary care center. The primary objective was to assess the efficacy of conservative management of VD due to POP. Secondary objectives included identifying factors associated with improved VD. Women who were >18 years old who reported VD symptoms in the setting of POP were included if they underwent a pessary fitting. VD was defined as a response of “moderately” or “greatly bothered” by obstructive voiding symptoms on the Pelvic Floor Disability Index (PFDI). Degree of POP was determined on physical exam using the POPQ system. Patients with neurologic conditions potentially contributing to urinary retention were excluded. A retrospective chart review was performed of all patients who met inclusion criteria. Patient demographics, clinical characteristics and outcomes were recorded. Improved VD was defined as patients that reported improved voiding symptoms at office follow up after pessary fitting. Patients who reported no improvement or unknown improvement due to lack of follow up or documentation were determined to have no or unknown VD improvement. Group comparisons were performed as appropriate.


Results:
70 patients with POP and symptoms of VD underwent a pessary fitting. Median age was 70 years old (38-89) with a BMI of 26.8 kg/m2 (18-48). Majority of women were postmenopausal (87%) and no longer sexually active (66%). Sensation of incomplete bladder emptying was the most reported obstructive voiding symptom on PFDI (84%) followed by difficult bladder emptying (66%). Stage II (41%) and III (51%) POP were most noted on exam with anterior predominance (80%). Median postvoid residual (PVR) at the time of pessary fitting was 100 cc (5-810). 96% were successfully fitted with a pessary. 54% of women reported improved voiding symptoms at follow up after pessary fitting. 4% reported no improvement while 37% had unknown improvement. Median repeat PVR after pessary fitting was 55 cc (10-250). 27% women progressed onto surgical management. Women who reported improved VD after pessary fitting were more likely to be older (71.2 vs 63.6, p=0.01) with advanced POP (Stage III/IV POP 73.7% vs 37.5%, p=0.01) and a higher initial PVR (220 cc vs 119.8 cc, p< 0.001).


Conclusions:
Conservative management with a pessary is an effective treatment for managing women with VD symptoms in the setting of POP. This is one of the first studies to evaluate efficacy of conservative management in improving VD symptoms and POP.