The Success Rate of Hong Kong Chinese Women with Pelvic Organ Prolapse in Pessary Self-Management: a Multi-Centered Prospective Study

Abstract

Introduction and Hypothesis

The objective was to determine the success rate of pessary self-management (PSM) and identify influencing factors among the Hong Kong Chinese population with pelvic organ prolapse (POP).

Methods

A prospective study was conducted from November 2023 to April 2024 across three local tertiary hospitals. A total of 165 Chinese women with POP using a ring pessary were enrolled. Exclusion criteria included dependency, limited dexterity, and cognitive impairment. Participants received a standardized one-to-one PSM teaching session. Success was defined as continuing PSM at the 1-year follow-up. Statistical analysis identified factors associated with success.

Results

The PSM success rate was 86.7% (143 out of 165). The successful group was significantly younger (mean 68.7 vs 73.9 years, p = 0.011), had higher education levels (p = 0.023), with lower parity (median 2 vs 3, p = 0.048), and less advanced stages of POP (88% stages 1–2 vs 54.5%, p < 0.001). Contrary to initial hypotheses, successful PSM was associated with the use of a larger pessary (69.8 mm vs 66.6 mm, p = 0.047).

Conclusions

PSM is a highly viable and successful strategy for Chinese women, with a success rate comparable with Western populations. Key factors for success include younger age, higher education, milder prolapse, and the use of a larger pessary. These findings support the early introduction of PSM to suitable patients to enhance patient empowerment and optimize conservative POP management.

Introduction

Pelvic organ prolapse (POP) is a common gynecological condition worldwide with significant morbidity. The lifetime risk of a woman requiring surgical intervention for POP is 11–19% [1, 2]. The prevalence of all stages of POP is even higher, ranging from 31 to 41% [3, 4]. Vaginal pessary has been shown to relieve the symptoms of POP and improve the quality of life of women [5, 6]. As an effective conservative management option, the use of a vaginal pessary is recommended by national authorities such as the National Institute for Health and Care Excellence (NICE) for all women with POP [7]. Up to 92% of women can be successfully fitted with a pessary [7–9]. However, pessary use is not without risk; 5–56% of women experience complications such as increased vaginal discharge, discomfort, bleeding, and ulceration [10, 11]. Furthermore, the need for long-term follow-up for pessary changes every 3–6 months imposes a significant economic cost on health care systems.

Pessary self-management (PSM) has been reported to improve care for women with POP, enhancing their satisfaction and quality of life. PSM is associated with a substantially lower complication rate than hospital-based management [12]. This approach empowers women to remove, clean, and reinsert the ring pessary according to their lifestyle and habits, thereby reducing the risk of vaginal discharge from bacterial colonization and vaginal ulceration from prolonged pressure on the vaginal mucosa. Nonetheless, much of the evidence on PSM is derived from English-speaking populations. Owing to cultural differences, results from white populations may not be applicable to the Asian population, where fear of self-digitation and higher rates of sexual dysfunction in elderly women are profound in the locality [13]. Our prior pilot study found that over 56% of local Chinese women with POP are willing to learn self-management [14], but to our knowledge the actual success rate has not yet been studied.

This study is aimed at assessing the success rate of PSM among women with POP who require a vaginal pessary for treatment, and to identify factors that affect women’s success rate and compliance with PSM.

Materials and Methods

This study was approved by Central IRB of The Hong Kong Hospital Authority (Central IRB Ref. No.: KC/KE-23–0126/ER-1). Women with POP requiring a ring pessary for treatment were recruited from three local tertiary hospitals, Kwong Wah Hospital, Prince of Wales Hospital and Alice Ho Miu Ling Nethersole Hospital. Exclusion criteria included women who were dependent in their daily living; had limited dexterity owing to medical conditions such as Parkinsonism or stroke; pregnant; living with a cognitive deficit preventing informed consent or self-management; under 18 years of age; declining PSM; or of non-Chinese ethnicity.

The benefits and risks of self-management were explained by an investigator using a written information pamphlet detailing the study design. Written consent was obtained from all participants. Women were assured that participation was entirely voluntary, and that refusal would not affect their medical care.

Epidemiological background, significant medical history, current sexual status, and previous POP treatments or surgeries were collected from women and their medical records. A gynecologist assessed and documented vaginal examination findings and stage of prolapse using the Pelvic Organ Prolapse Quantification system. A polyvinyl chloride ring pessary was inserted at the recruitment session. For women who retained the pessary without complications, a silicone ring pessary of the appropriate size was provided at a subsequent teaching session.

A one-to-one, 20-min teaching session was arranged 4–8 weeks later, during which an investigator educated patients on self-insertion, removal, and care of the silicone ring pessary. A returned demonstration from the women was performed to ensure competence and confidence. Women were instructed to remove, clean, and reinsert the pessary according to their need and it should be performed at least once a month. A hotline number was provided for any difficulties or discomfort related to self-management. For women experiencing difficulties, either reported via the hotline or identified at the 6-month follow-up, a second teaching session was offered to reinforce techniques, provided that the women agreed to continue learning.

A urogynecological follow-up clinic was arranged at 6 months to review pelvic floor symptoms and check for any pessary-related complications. The gynecologist would review the skill of women performing self-replacement. If the woman was managing well with PSM, a second 6-month follow-up was scheduled to repeat the assessment. For women who did not perform PSM well, a second teaching session would be offered if they were still keen to have PSM.

Successful PSM was defined as continuing self-management at the second 6-month follow-up (i.e., 1 year after initial teaching). Failed PSM was defined as either failing initial learning or discontinuing self-management at any point during the 1-year study period.

For sample-size calculation, we assumed a 90% success rate as this group of women were highly motivated as they agreed to learn PSM to begin with, and this was the result reported previously by other studies [15, 16]. The absolute precision was 5% with a 95% level of significance. The target sample size was 139. The drop-out rate was assumed to be 10% and we assumed that 60% of eligible women would agree to learn PSM; thus, a total of 275 patients would be needed.

Statistical analysis was performed using SPSS (Windows version). Normally distributed variables were analyzed using Student’s t test, non-normally distributed variables using the Mann–Whitney U test, and categorical variables using Fisher's exact test. A p value of < 0.05 was considered statistically significant.

Results

From November 2023 to April 2024, a total of 328 women were invited and agreed to participate in the study, 165 patients (58.9%) agreed to learn PSM (Table 1). All women had completed the study with a 0% drop-out rate. The mean age was 69.4 ± 8.4 years and median parity was 2. In all, 60% of recruited women had stage I–II POP whereas 40% of women had stage III–IV POP. In the 165 women who agreed to learn PSM, 146 (88.5%) managed to self-insert and self-remove the silicon ring pessary after the first teaching session. Four women (2.4%) required a second teaching session to consolidate their skills and all together 150 women (90%) reached a successful learning outcome in the initial learning phase (first and second teaching sessions).

Table 1.

Demographics and characteristics of all participants and the data on the successful or failed pessary self-management groups

		All, N = 165	Successful PSM, n = 143 (86.7%)	Failed PSM, n = 22 (13.3%)	p value
Age (years), n (SD)		69.4 (8.4)	68.7 (9.2)	73.9 (6.9)	0.011
Sexual status, n (%)
Active		27 (16.4)	23 (16.1)	4 (18.2)	0.076
Inactive		138 (83.6)	120 (83.9)	18 (81.8)
Parity, (median), n (SD)		2 (1.2)	2.3 (1.1)	3 (1.4)	0.048
Body weight (kg), n (SD)		58.2 (8.8)	58.6 (8.4)	56.1(9.9)	0.213
BMI (kg/m2), n (SD)		24.6 (3.5)	24.6 (3.1)	24.5 (4)	0.85
Education, n (%)
Nil		10 (6.1)	6 (4.2)	4 (18.2)	0.026
Primary		90 (55)	76 (53.1)	13 (59.1)
Secondary		61 (37)	57 (40.1)	4 (18.2)
Tertiary		4 (2.4)	4 (2.8)	1 (4.5)
Education, n (%)
Primary or below		99 (60)	82 (57.3)	17 (77.3)	0.023
Secondary or above		66 (40)	61 (42.7)	5 (22.7)
Duration of ring pessary use (years), n (SD)		3.5 (3.7)	3.4 (3.6)	4.3 (4)	0.286
POP stage, n (%)
Stage 1–2		138 (83.6)	126 (88.1)	12 (54.5)	< 0.001
Stage 3–4		27 (16.4)	17 (11.9)	10 (45.5)
Total vaginal length (cm), n (SD)		7.1 (0.6)	7.1 (0.6)	6.9 (0.6)	0.108
Genital hiatus (cm), n (SD)		2.5 (0.9)	2.5 (0.9)	2.6 (1.0)	0.565
Compartment of POP prolapsed, n (%)
Apical		164 (99.4)	142 (99.3)	22 (100)	1
Anterior		150 (90.1)	129 (90.2)	21 (95.5)	0.695
Posterior		121 (73.3)	101 (70.6)	20 (90.9)	0.067
Ring pessary size (mm), n (SD)		68.8	69.8	66.59	0.047
Complication, n (%)
Bleeding		30 (18.2)	27 (18.9)	3 (13.6)	0.768
Vaginal pain		16 (9.7)	13 (9.1)	3 (13.6)	0.451
Dislodgement		15 (9.1)	14 (9.8)	1 (4.5)	0.695
Vaginal discharge		29 (17.6)	24 (16.8)	5 (22.7)	0.547

POP pelvic organ prolapse

At 1-year follow-up, 143 women (86.7%) continued performing PSM without difficulty. Among the 7 patients who stopped PSM despite initial successful learning, most of them described fear of failed insertion after removal, reluctance with regard to self-digitation, and finding the process of PSM too troublesome, refusing to continue. The failure rate by 1 year was 13.3% (22 out of 165), including the 7 women who initially succeeded in learning in the first teaching session, but then did not continue/declined to do PSM for various reasons, and the other 15 who failed to perform it physically in the initial teaching and refused to learn in the second teaching session. The successful PSM group was statistically significantly younger (68.7 ± 9.2 vs 73.9 ± 6.9 years, p value 0.011), had a higher education level, lower parity (median 2 vs 3), lower POP stages, and used a larger ring pessary size (mean pessary diameter 69.8 mm vs 66.6 mm, p value 0.047). Regarding pessary-related complications, the complication rates in both success and failure groups are similar, with no statistical significance. The rates of vaginal discharge were 16.8% in the success group and 22.7% in the failure group. Fourteen women (9.8%) from the successful PSM group suffered from pessary dislodgement during the study period between 1–3 times. All of them successfully self-reinserted the pessary without problems, whereas one woman from the failure group had her pessary reinserted by the gynecologist at her next follow-up.

Discussion

This is a prospective study in the Hong Kong Chinese population studying the PSM success rate. This prospective study demonstrates that pessary self-management (PSM) is a highly successful and feasible option for Chinese women with POP who agreed to learn self-replacement, with a remarkable 86.7% success rate at 1 year. This finding is particularly significant as it aligns with the high success rates reported in Western cohorts (92% in a Dutch study [15], 85.8% in a UK study [16]), effectively challenging the preconception that cultural reservations regarding self-digitation would be a major barrier to implementation in this population. A previous report from another Asian country, Thailand, reported a high initial success rate in PSM up to 88.6% [17]. The complication rate of vaginal discharge in our cohort is comparable with previously reported local data (4.5 to 36.5%) [5, 18, 19]. The rate of vaginal bleeding during pessary use was reported to be 6.8 to 56.3% [5, 18–20], both locally and internationally; our data in both groups (successful group 18.9% vs failed group 13.6%) concur with the previously reported values.

Our analysis identified several key patient-specific factors predictive of PSM success. The significant association with younger age (68.7 vs 73.9 years, p = 0.01) likely reflects advantages in manual dexterity, cognitive adaptation to new skills, and overall physical condition. This is complemented by the finding that a higher education level (p = 0.023) was a significant factor, which may contribute to a better understanding of the long-term benefits of PSM, thereby fostering greater motivation and compliance.

The data further revealed that the severity of prolapse is a critical determinant. Women with early-stage POP (stages I–II) had a significantly higher success rate (88%) than those with advanced stages (stages III–IV, 45.5%, p < 0.001). Advanced prolapse presents a mechanical challenge; a larger prolapsed mass beyond the introitus can be difficult to manage during self-insertion, as women may unintentionally bear down, exacerbating the protrusion. A previous Dutch study had found no correlation between stage of POP and success rate [15], whereas other studies in white women have not discussed the relationship between success rate and stage of POP [10, 11, 16].

A counterintuitive but crucial finding was the advantage of a larger pessary size (69.8 mm vs 66.6 mm, p = 0.047). Contrary to the initial hypothesis that a smaller device would be easier to handle, our clinical experience during teaching sessions revealed that smaller pessaries are often more difficult to grasp and compress securely, leading to slippage and significant frustration of the women. Even when inserted, their removal was often challenging, necessitating aids such as a suture tied to the pessary before insertion.

The positive finding of younger age associated with higher success rate encourages the early promotion, early education, and early empowerment with PSM in women suffering from POP. Our study confirms the high success rate in PSM learning by women suffering from POP reported by prior studies, despite significant ethnic and cultural differences.

Most of our recruited women were living close to the hospitals owing to the geographical characteristic of Hong Kong being a small city that is densely populated, and the clinical services offered by all hospitals are highly affordable, at approximately US$10 per clinic visit. Furthermore, women were provided with the pessary free of charge. Women were not blamed for not being able to learn the skills. All these factors contributed to a high follow-up rate and there was 0% drop out during the study period.

Strength(s) of the Study

This is the first, to the best of our knowledge, multicentered prospective study in a Chinese population on the topic. It fills a significant evidence gap by providing robust, prospective data on PSM success in a population where cultural factors were previously thought to be a barrier. This makes the findings highly relevant and novel for Asian health care settings. A 100% follow-up rate with zero dropouts is an exceptional strength. It eliminates attrition bias and ensures that the results (86.7% success rate) are a true reflection of the experience of the cohort, greatly increasing the internal validity and reliability of the findings.

The use of a standardized one-to-one teaching session, a clear definition of “success” (continuing at 1 year), and a structured follow-up pathway (with a hotline and option for re-teaching) ensures consistency in the intervention and outcome measurement across three different hospitals.

Limitations of the Study

Participants were self-selected (58.9% of invited women agreed). These women were likely more motivated, confident, and potentially healthier than the general population with POP using pessaries. Therefore, the 86.7% success rate may represent a “best-case scenario” and might be lower if all eligible women were mandated to learn PSM. The findings are specific to Hong Kong Chinese women. Generalizability to other Chinese subgroups (e.g., mainland China, other diasporas) or other Asian ethnicities may be limited owing to cultural, educational, and health care system differences.

The high success rate in PSM reported in this study in women who agreed to learn PSM, suggests that the main barrier in promoting PSM to all women with POP lies in the initial phase, the initial motivation, and willingness to learn. For women who showed high motivation and willingness, the overall success rate is high, up to almost 90% in 1 year. In order to motivate and raise willingness in PSM, early patient education and early introduction of the PSM concept are vital. Measures including PSM introduction videos being played in patient waiting rooms in general gynecology outpatient clinics would be feasible PSM promotion. Incorporating PSM introduction and offering PSM as a first-line management during initial patient contact in their first POP diagnosis help to prepare the women for possible future PSM and may potentially increase willingness and improve motivation.

Conclusion

This study confirms that PSM is a highly successful strategy for Hong Kong Chinese women, with an 86.7% success rate at 1 year. Key factors for success include younger age, higher education, and earlier-stage prolapse. Contrary to initial assumptions, the use of a larger pessary size was also associated with higher success, likely because of easier handling. These findings support the early introduction of PSM to suitable patients to enhance patient empowerment and reduce the long-term health care burden of clinic-based management.

Authors’ Contributions

S.C.H.L.: project development, data collection and management, data analysis, manuscript writing; W.L.C.: data collection, data analysis; W.T.C.: data collection; R.Y.K.C.: data collection, manuscript editing; S.S.C.C.: project development, data collection, manuscript editing.

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethical Approval

This study was approved by the Central IRB of Hospital Authority (Central IRB Ref. No.: KC/KE-23–0126/ER-1).

Conflicts of interest

None.