Vaginal Pessary Use for Pelvic Organ Prolapse in Ghana

Objectives: Pessaries are a cost-effective, low-risk conservative treatment option for pelvic organ prolapse (POP). Low- and lower-middle income countries (LMICs) are under-represented in the literature as most POP studies are of women in North America and Europe. There is little known about pessary use in Ghana, a large LMIC in West Africa. Our objective is to assess the acceptability of pessaries for POP management among patients presenting to a urogynecology clinic at a tertiary hospital in Ghana.

Methods: We performed a retrospective study of routinely collected clinical data from January 2019 to September 2021. A single Urogynecology fellowship-trained gynecologist performed physical exams and documented clinical information such as Pelvic Organ Prolapse Quantifications (POP-Q) staging. For patients with POP concerns, pelvic floor physical therapy was offered as first line treatment, then a pessary if physical therapy was not acceptable or failed, and then surgery if pessary management was not acceptable or failed. Following initial pessary fitting, patients returned in two weeks for a recheck. If satisfied at that time and were able to perform home self-care, patients only returned on an as needed basis, otherwise returned every three months if unable to perform home self-care. Patient demographic and clinical characteristics, including POP-Q staging, pessary size, and pessary complications were recorded and collected in a de-identified database.

Results: Of the total 405 patients evaluated in the urogynecology clinic, 297 patients (73%) presented with POP symptoms (Table 1). Of those with POP symptoms, 189 patients (64%) had documented POP-Q staging: 8 patients (3%) with Stage 1, 59 patients (20%) with Stage 2, 96 patients (32%) with Stage 3, and 26 patients (9%) with Stage 4 POP (Table 1). As a result of limited pessary supply, 91 patients were provided the option of using a pessary for management of POP. A large majority of the patients (86 of 91, 95%) chose to use a pessary, out of which 82 were fitted due to supply constraints. Of the 82 patients, 78 (95%) were successfully fitted in the office. All 78 patients (100%) reported symptomatic POP improvement, and 59 (75.6%) started pessary self-care at home. Ten patients (13%) stopped using pessaries over the study period, citing reasons such as “tired of pessary” and “had surgery”. Self-reported pessary complications over the study period included vaginal erosions (16, 21%) and ulcerations (8, 10%), pain with insertion (6, 8%), and urinary difficulty (3, 4%).

Conclusions: In this retrospective study of patients evaluated in a urogynecology clinic in Ghana, an overwhelming majority of patients with symptomatic POP accepted treatment with a vaginal pessary with high rates of patient satisfaction. Given the limited supply of pessaries, these descriptive data support the need for further research and additional resources for a sustainable pessary supply in Ghana.