The Pessary Process: Spanish-Speaking Latinas’ Experience

Abstract

Introduction

Little is known about women’s experience with conservative management of pelvic organ prolapse. We sought to understand the experiences of Spanish-speaking women who choose a pessary.

Methods

Spanish-speaking women from a urogynecologic pessary clinic were recruited for this study. Interviews were conducted and the women were asked about their pessary experience including questions involving symptom relief, pessary management, and quality of life. All interview transcripts were analyzed using the qualitative methods of Grounded Theory.

Results

Sixteen Spanish-speaking women who had been using a pessary for at least one month were enrolled in this study. Grounded theory methodology yielded several preliminary themes, in which one major concept emerged as a pessary adjustment process. In this process patients had to first decide to use a pessary, either because of physician’s recommendations or out of personal choice. Second, the patients entered an adjustment period in which they learned to adapt to the pessary, both physically and mentally. Lastly, if the patients properly adjusted to wearing a pessary they experienced relief of bothersome symptoms.

Conclusions

Our findings demonstrate that Spanish-speaking women go through a process in order to adjust to a pessary. Furthermore, the physician has a major role in not only determining a woman’s decision to use a pessary, but also whether she can adjust to wearing the pessary. This process is most successful when patients receive comprehensive management from a healthcare team of physicians and nurses who can provide individualized and continuous pessary care.

INTRODUCTION

Pelvic organ prolapse (POP) is a highly prevalent condition that significantly impairs health-related quality of life for aging women.[1,2] This burden may heavily impact women of Hispanic background, as POP has been shown to be more prevalent in this population.[3] In fact, a population-based cohort study of 2,270 women identified that Latina and Caucasian women have a 4-5 times higher risk of symptomatic pelvic prolapse compared to African-Americans.[4]

Currently, treatments for POP include pelvic floor muscle training, mechanical support with a pessary, and surgery.[5] Prior studies have revealed that pessaries are an effective form of treatment resulting in improvement of symptoms and in quality of life.[6-10] However, most research has focused on the relief of physical symptoms associated with pessary use, highlighting the need for qualitative studies that concentrate on the subjective experience of women using a pessary. Moreover, none of these investigations accounted for racial differences within the study groups and as a result it is unknown if ethnicity influences the experience of pessary use in women with POP.

Spanish-speaking Latinas constitute one of the largest growing populations in the United States.[11] These women bear a disproportionate burden of pelvic organ prolapse compared to women of other ethnicities. Despite this, little is known about perceptions and experiences of Latinas with this condition, particularly with regard to treatment choices. We sought to better understand the pessary adjustment process among Spanish-speaking Latinas and how ethnicity may influence this process.

MATERIALS AND METHODS

Patient Recruitment

IRB approval was obtained from the UCLA-Olive View Medical Center Institutional Review Board and women gave written informed consent to undergo a single interview. Women were recruited from urogynecology clinics within the Los Angeles County Healthcare system. These clinics primarily served women using pessaries and each patient was individually trained to use a pessary by a language concordant healthcare team consisting of nurses and physicians. Each patient was taught how to use the pessary and was routinely monitored by her physician. Women were included in the study if Spanish was their primary language and if they had been using a pessary for at least one month for pelvic organ prolapse (POP). We chose one month of pessary use in order to focus on women who had been through the adjustment process. Pelvic organ prolapse was confirmed by history and physical examination using the Pelvic Organ Prolapse Quantification (POPQ) system. Potential subjects were excluded if their primary language was not Spanish, if they had cognitive deficits or psychiatric conditions prohibiting effective interviewing, or if they were younger than 21 years. Patients with other pelvic floor disorders, such as urinary incontinence, were included as long as their pessary was used for primary management of POP.

After medical charts were screened, eligible patients were recruited the same day of their clinical appointment. Patients were asked to participate in a short interview session with a trained Spanish-speaking female research assistant. Patient participation was voluntary.

Patient Interviews

Patients were asked to participate in a short interview about their experience using a pessary. The interview guide was semi-structured and asked several open-ended questions, which allowed women to elaborate on their experience using a pessary (See Topical Guide: Appendix 1). Interview questions focused on demographic information, symptoms related to pessary use, pessary management, satisfaction with the pessary, and the effect of the pessary on health-related quality of life. The interviewer was a Spanish-speaking female with qualitative interviewing skills. Each interview took place in the privacy of a clinic room before the patient saw her physician and the encounter lasted approximately 15 minutes. The interviews were audio-recorded and the interviewer took extensive notes during each encounter. Audiotapes were transcribed verbatim.

Qualitative Analysis

Unlike quantitative research methods, qualitative methods allow the researcher to search for a theory implicit in the data instead of testing a hypothesis. In areas where little is known, qualitative methods allow us to explore a topic and generate, rather than test, hypotheses. All interviews were analyzed qualitatively using constructivist Grounded Theory methodology as described by Charmaz.[12] In Classic Grounded Theory works, Glaser and Strauss describe the discovery of theory as emerging from data separate from the scientific observer.[13] Constructivist Grounded Theory takes the position that the observer is a part of the world studied and the data collected.[14] According to Charmaz, Grounded Theory assumes that “any theoretical rendering offers an interpretive portrayal of the studied world.”[14] Grounded theory provides guidelines for analyzing data at several points in the research process.[12] The initial analysis involves line-by-line coding of the patient’s own words with the purpose of finding key phrases that can be grouped together to form preliminary themes.[15,16] Next, these preliminary themes are compared and aggregated to form core categories or emergent concepts. In order to reduce subjectivity, three different researchers (clinician and non-clinician) analyzed the data independently by performing line-by-line coding. Codes were then combined and categorized into preliminary themes. These preliminary themes were then compared and combined to form emerging concepts. Throughout the data process, memos, or written explorations of ideas about the data and themes, were written to assist in integrating the analyses.[15] We sought to interview approximately 15 women in order to achieve thematic saturation, in which new themes no longer occur with each additional interview.[12]

RESULTS

Sixteen Spanish-speaking women who had been using a pessary for at least one month were enrolled in this study. The range of pessary use was from one month to three years. Demographic characteristics are presented on Table 1. The mean age was 67.6 (range 47-85 years) and the majority of women in our study were of Mexican and El Salvadorian descent. Most women had little or no formal education and were Catholic. Several women were unemployed and not currently looking for employment.

Table 1.

Patient Demographics (N=16)

Characteristic	% (n)
Age, mean (range)	67.6 (47-85)
Country of Origin
Mexico	63 (10)
El Salvador	25 (4)
Guatemala	6 (1)
Nicaragua	6 (1)
Education Level
No schooling	31 (5)
Less than high school	50 (8)
Some high school	13 (2)
High school diploma	6 (1)
Religion
Catholic	44 (7)
Christian	25 (4)
None	6 (1)
Declined to state	25 (4)
Annual Income
Less than $10,000	25 (4)
$10,000-$19,999	6 (1)
$20,000-$29,999	6 (1)
Declined to state	63 (10)
Employment Status
Employed for wages	18 (3)
Self-employed	13 (2)
Out of work but not currently looking for   work	38 (6)
Homemaker	6 (1)
Declined to state	25 (4)

Grounded theory methods yielded the concept that women go through a three-stage adjustment process (Figure i).

Figure i.

The Pessary Process.

Decision-making

The first step of the adjustment process involved making the initial decision to use a pessary. There were several preliminary themes that recurred throughout the data collection process, indicating women must first make a life-changing choice to use a pessary (Table 2). This decision was either physician- or patient-driven. The first themes identified focused on patient-driven reasons for choosing a pessary. These included desperation with symptoms, as well as a fear of surgery. Bothersome symptoms drove many women to choose a pessary because they preferred rapid relief over waiting several months to obtain surgical repair. Some women stated that the decision to use a pessary was an easy choice because they “preferred to wear a foreign object than have a protruding bulge that caused irritating symptoms.” Other women were afraid to have surgery because they did not want to have anesthesia or they were concerned the surgery would not be successful.

Table 2.

Decision-Making Stage: preliminary themes and representative quotes

Preliminary Theme	Representative Patient Quotes
Pessary better than prolapse symptoms	“Pues si, el anillo es mejor que tener la vejiga colgando.” “Well yes, the ring is better than having my bladder hanging out.”
	“Me siento confortable. No tengo los problemas de cómo me sentía…de sentir la parte caída.” “I feel comfortable. I don’t have the problems of how I used to feel…of feeling my parts hanging out.”
	“Yo me siento bien. Yo mi problema era de la matriz. Lo tenía abaja. Con el disco…el disco me lo detiene.” “I feel good. My problem was due to my uterus. I had it hanging low. With the disc…the disc holds it up.”
Fear of surgery	“Pues… sentí que me convenía mejor usar el disco que me hicieran operación porque a veces hay mas complicaciones en la operación.” “Well…I felt that it benefitted me more to use the disc rather than get the operation because sometimes there are more complications with the operation.”
	“Me preguntaron que si queríamos que me operaran. Yo le dije que no. Tenia miedo.” “They asked me if I wanted them to operate me. I told them no. I was scared.”
	“Pues fíjese que ya ahorita con mi edad ya me daría miedo.” “Well look it here, right now with my age I would be scared (of surgery).”
Doctor’s recommendati on to use pessary	“Es que dijo la doctora que era la única solución.” “It’s because the doctor said that this (pessary) was the only solution.”
	“Es que la doctora me dijo no es tan necesaria la cirugía para mi.” “It’s because the doctor told me that the surgery wasn’t necessary for me.”
	“Yo les dije que prefería la cirugía pero después me dijo la doctora que la cirugía tiene muchos riesgos.” “I told them that I preferred the surgery but afterwards the doctor told me that surgery has several risks.”
Pessary as bridge to surgery	“Dijo que mientras que llegaba a la cirugía o me controlara la azúcar no podía la cirugía.” “She said that until I get to the point where I can have surgery or control my sugars I couldn’t get the surgery.”
	“Prefiero la operación que traer esto, pero o sea que mis necesidades personales acerca de los ingresos, que yo no tengo como sostenerme. Por eso quedo, no me hecho la operación.” “I prefer the operation to having this (pessary), but in terms of my personal necessities with regards to finances… I don’t have a way to provide for myself. That’s where I’m at…I haven’t been able to do the operation.”

Other themes that related to the pessary decision-making process included the strong impact of the physician’s recommendations on the patient’s choice to use a pessary. In certain instances, the physician suggested a pessary either as a temporary solution until surgery could be performed or instead of surgery. For some women, the decision to use a pessary was not their first preference, but was strongly encouraged by the physician. Women described that they wanted to have surgery, but had been advised against doing so because they were poor surgical candidates. Most commonly, patients had comorbid conditions or were older in age, which posed too many risks for surgical intervention. In one case, the patient was advised against obtaining surgery because of financial constraints that prevented her from being able to pay for the surgery.

Adjustment

The second step in the pessary process involved adjusting both mentally and physically to the pessary. The women in this study had several concerns and hesitations prior to using the pessary, but going through an adjustment period eventually allowed them to gain relief of symptoms and emotional distress (Table 3). The first two preliminary themes focused on the initial relief of fear through physically seeing the pessary, as well as listening to the physician’s explanation of how to use the pessary. Patients initially had no idea what a pessary looked like; therefore learning that the pessary was a small disc that should not be felt when properly placed, helped women feel less guarded about trying the pessary. Furthermore, women felt that the physician’s explanation of how to use the pessary relieved their hesitations prior to using it. For example, one woman stated, “The nurses and physicians explained everything. They made me feel better about deciding to use the pessary.” Through the continuous and combined care provided by nurses and physicians, patients learned to adjust to using a pessary.

Table 3.

Adjustment Stage: preliminary themes and representative quotes

Preliminary Theme	Representative Patient Quotes
Physically seeing pessary relieved initial hesitations	“Era una cosita. Me lo esenio. Como la quito. Tanto que tenia el concepto de una barría. Es que yo estaba equivocada…” “It was a tiny little thing. They showed it to me. How to take it out. All this time I had this idea that it was like a rod. Well I sure was wrong.”
Relief of fear after hearing physician’s explanation on how to use pessary	“Aquí me han dado información. Como me lo debo de ponerlo, como debo de quitarlo, y todo. Me sentí mejor.” “Here they’ve given me information. How to put it on, how to take it off, and everything. I felt better.”
	“Ella me platicó, la doctora, sobre el aparato… y pues me gustó.” “She spoke to me, the doctor, about the apparatus…and well I liked it.”
Feeling scared and strange when first using pessary	“Pues si tenia dudas porque decía yo como voy estar con esto como le voy hacer pero, pues no sabia.” “Well I did have hesitations because I said,‘how am I going to manage with this (pessary)’ but, I just didn’t know.”
	“Tenia nervios porque era algo extranjero. No sabia como se iba sentir.” “I was nervous because it was something strange. I didn’t know how it was going to feel.”
	“Si, sentía un poco de temor de yo andar con eso de adentro. Pensé que iba a sentirme mas incomoda de lo que estoy. Pero, no, me fue acostumbrando.” “I did feel a little scared of having this (pessary) inside of me…I thought I was going to feel more uncomfortable than I was already feeling. But no, I eventually got accustomed to it.”
Eventually gaining enough comfort with using pessary	“Antes venia cada mes para que me lo cambiaran, pero ya después aprendí.” “Before I came every month to have it changed, but later on I learned.”
	“Como eran los primeros días no sabia. Pero yo solo me lo ponía hasta que yo sola me acostumbre a ponerlo.” “Because it was the first few days I didn’t know how, but I would put it on by myself until finally I got accustomed to changing it myself.”
	“Cuando me puse eso pues los primeros días me daba trabajo, pero ya después ya no.” “When I put it on the first few days I had trouble, but later on I didn’t.”
Creating personal routine for pessary management	“Me dijeron que lo cambiara cada diez días verdad? Pero yo a veces lo hago cada cinco días… cada cuatro días.” “They told me to change it every ten days, but I sometimes do it every five days…every four days.”
	“Ella dijo que si podía que me lo cuitara todas las noches y en la mañana me lo pusiera. Pero ahora como ya estoy sabiendo que podía durar unos dos días …yo digo cambiarlo cada tercer día. Así me siento bien.” “She said if I could to take it out every night and in the morning to put it back in. But now that I know that I can last a few days…I say change it every three days. I feel good that way.”

The final preliminary themes that defined the adjustment phase involved trial and error with using a pessary. Women were initially scared to use the pessary and felt strange using this device for the first time. However, they soon adapted to using the pessary and became comfortable managing it themselves. One woman described how she had her pessary changed on a weekly basis by her physician because she was fearful of changing the device herself. Several patients described similar experiences, but with time these same women gained comfort with the pessary and learned to remove, clean, and replace the device. The final theme demonstrated that women eventually developed a personal routine for changing and cleaning their pessary. All the women in this study were given the same instructions on pessary management, but many women developed various personal customs that helped them gain comfort in using a pessary. It was common for some women to change and clean their pessary daily, while other women changed it once weekly.

Relief

The final step in the process, involved improvement in health-related quality of life after the patient adjusted to using the pessary. There were several themes that defined this final stage (Table 4). The initial themes focused on re-establishment of a normal life. First, the women in this study emphasized the relief they felt with no longer having to suffer with the symptoms of pelvic prolapse. Second, after using a pessary several women were able to perform daily activities that they had not previously been able to perform with the symptoms they were experiencing. One woman described that she could now clean her house, cook, and take care of her grandchildren. Lastly, many women eventually felt comfortable enough to tell their partners about using a pessary, and the majority found that their partners were very understanding and supportive. In one case, a woman’s husband initially helped her remove the pessary on a daily basis before she finally became comfortable enough removing the device herself.

Table 4.

Relief Stage: preliminary themes and representative quotes

Preliminary Theme	Representative Patient Quotes
Feeling relief of symptoms with pessary	“En cambio con este aparatito me e sentido que mi orina es mas aligera y completa…entonces estoy satisfecha con eso.” “For a change with this little apparatus I feel like my urine stream is much faster and complete…and so I’m satisfied with this.”
	“Me a sentido bien. Porque antes de que venia aquí yo sufría mucho porque me orinaba mucho en los pantalones.” “I feel good. Because before I came here I was suffering a lot because I would urinate in my pants a lot.”
	“Con el aparato no siento que tengo la pelotita esa ahí.” “With this apparatus I don’t feel the little ball that I have down there.”
Resuming normal daily activities with pessary	“Voy a la tienda, camino. Todo esta bien.” “I go to the store, I walk. Everything is good.”
	“Me siento bien. Ahora salgo y camino mas. Antes no quería. Estaba en la casa nomas.” “I feel good. Now I go out and walk more. Before I didn’t want to. I was in the house all the time.”
	“Eso a mí me ha ayudado mucho. Ya puedo hacer mis cosas. Cocino, yo lavo mi ropita, y cuido mis nietos.” “It has helped me a lot. I can do my own things. I cook, I wash my laundry, and I take care of my grandchildren.”
Partner understanding and supporting of pessary	“Pues aprendió a cambiármelo…y pues luego yo aprendí.” “Well he (husband) learned to change it for me…and later I learned.”
	“El es muy buena persona. Es muy comprensible.” “He (husband) is a good person. He is very understanding.”
	“Para el es una cosa buena. También porque no siente nada.” “For him it’s a good thing. Also because he can’t feel anything (during sex).”
Grateful and trustful of physicians and nurses	“Yo les estoy muy agradecidos aquí con que me quitaron ese mal de estar.” “I am so grateful to everyone here because they took away my illness.”
	“Les doy gracias que pues aquí ponen eso.” “I am thankful that they put this (pessary) on here.”
Willing to recommend pessary to another woman	“Que vinieran aquí y se pusieran eso.” “They should come here and put the pessary on.”
	“Que se lo pongan. Se siente bien. Nomas que aprendan. El chiste es que no tengan nervios para ponérselo.” “They should put it on. It feels fine. They just have to learn. The trick is to not be nervous to put it on.”
	“Yo creo que es muy incomodo (prolapso) y a las mujeres o quien tenga necesidad, debería usarlo…pues que lo hagan, porque es para un beneficio de uno mismo.” “I think it’s very uncomfortable (prolapse) and for women who have the necessity, they should use it…they should do it, because it’s for their own benefit.”

The final themes focused on the satisfaction felt by the women who had successfully adapted to using a pessary. It became evident that the majority of women were truly pleased with their treatment choice because they continually expressed gratitude towards the physicians and nurses who had helped them learn to use the pessary. These women were thankful for the education, support, and encouragement they received throughout the frightful process of learning to use the pessary. The Spanish-proficiency of nursing staff and physicians eliminated any language barriers that could have potentially complicated the pessary management for these women. One patient commented on how grateful she was to have a healthcare team that spoke her native language. Lastly, women demonstrated their satisfaction with the pessary when they emphasized that they would advise another woman in a similar situation to use a pessary as a primary form of treatment.

DISCUSSION

Spanish-speaking women go through a long process of adjustment when first deciding to use a pessary and this process is strongly influenced by the physician. As evidenced by the preliminary themes that emerged, a major factor in the patient’s decision-making process was the physician’s support and influence. The physician not only had a guiding hand in determining that a patient was not a suitable candidate for surgery, but also played a role in calming any fears that a woman might have about using a pessary. In addition, the influencing manner of the physician early on in the encounter helped create a trusting foundation, which allowed patients to openly discuss problems that arose in the future. The sympathetic and reassuring care provided by physicians in this study sample demonstrates how vital patient-physician trust can be to a patient’s overall satisfaction with her treatment.

Desperation with symptoms was another important factor that influenced a woman’s decision to choose a pessary. Although several women initially struggled with the idea of having a foreign object in their body, the thought of continued distress from their prolapse symptoms was enough to motivate them to try the pessary. As evidenced by Jelovsek et al., women with advanced POP are more likely to feel self-conscious, less likely to feel feminine, and have decreased overall quality of life compared to women without POP.[17] Similarly, women in our study complained of the embarrassment and humiliation they felt on a daily basis due to the severity of their symptoms. This factor alone pushed many women to try a pessary even though they struggled with the implications of using a foreign device that required routine care.

Although many women in our study were offered surgical repair of their prolapse, they often feared this treatment option and, as a result, chose a pessary. Women were afraid of surgery because of risks associated with anesthesia, their age and comorbid conditions, and the possibility of surgical complications. In a prospective study of 680 women with symptomatic prolapse, Kapoor et al. observed that two-thirds of women opted for a pessary rather than surgery as the initial treatment option.[18] Furthermore, Clemons et al. determined that age ≥65 and poor surgical risk were characteristics associated with continued pessary use after one year.[19] Our study corroborated these findings, as a substantial number of women chose a pessary because of their older age and comorbid conditions.

That women go through a life-changing adaptation process is a finding substantiated by Storey et al., in which a similar progression is described.[20] Unfortunately, some women chose a pessary because the financial burden of surgery was prohibitive. They looked at the lived experience in English-speaking Caucasian women using a pessary. Both studies demonstrate that, regardless of ethnicity, women who decide to use a pessary must learn to adapt to something foreign and challenging in order to obtain relief from their symptoms.[20] Through this experience the women in our study learned to overcome fear of the unknown and eventually gained confidence and resilience as they obtained symptomatic relief and comfort with using a pessary. Women who are unable to go through the adjustment phase, either because of physical or emotional discomfort with the pessary or inability to maintain the pessary in position, will not be able to complete the process and obtain relief, and are therefore more likely to pursue surgery.

As women continued through the ongoing learning process of using a pessary, we found that many of them eventually gained personal satisfaction, relief of symptoms, and confidence in resuming normal activities that were once impossible to perform. Storey et al. also found that once a woman achieved successful adaptation to her pessary she obtained emotional relief and regained the ability to live her life as she had intended.[20] The ability to achieve success in adapting to a pessary gives women empowerment to take control of their own health and reach a position where they can recommend a pessary and advise women faced with a similar situation.[21]

There is limited research that focuses on Spanish-speaking Latinas and their experience using a pessary, therefore we sought to identify what language or cultural barriers this population may experience that women of other ethnicities may not have. Our study found that the majority of women did not experience the language barriers we originally anticipated. The clinic provided a supportive and comforting environment in which both physicians and nurses spoke Spanish or used an interpreter when needed. Although prior data has shown that the use of a translator can create major difficulties in disclosure of medical information, we found that most women felt comfortable discussing sensitive and embarrassing health issues even if interpreters were present.[22] One reason this may have occurred is that, more often than not, nurses served as interpreters. The patients were accustomed to seeing these nurses on a regular basis for pessary management. Therefore, they trusted these nurses and could discuss personal issues in front of them without hesitation.

Although grounded theory allows for qualitative analysis of patient’s views and perceptions about their disease[23], there are still limitations present with the current study. First, the diversity of the study sample was not representative of all Latino ethnicities because the majority of our subjects were of Mexican background. Second, our study sample may not be representative of patients as a whole, as all of our patients were recruited from one hospital-based subspecialty clinic and included only Spanish-speaking women who had adapted successfully to the pessary. If surgery was not presented as an option, they may have been more likely to adapt to the pessary given that they had no other options available. Lastly, because several women wore a pessary for more than one year and there was a significant time period since going through the acceptance process, this study is subject to recall bias. Ultimately, we discovered that underserved minorities, like Caucasian women, can successfully adapt to a pessary when there is a culturally competent healthcare team present to educate, support, and provide continuous care for each patient on an individual basis.

Appendix 1. Pessary Interview Topical Guide

1. Tell me about your overall experience with a pessary?

2. Why did you get a pessary placed?

3. How long have you used a pessary?

4. Tell me about your routine for changing and cleaning your pessary?

5. Are you sexually active? If so, do you take out the pessary during intercourse?

6. How does your partner feel about your pessary?

7. What education did you receive about pessaries when first deciding to use a pessary?

8. Did you have any hesitations when first deciding to use a pessary? If so, what were these hesitations?

9. What difficulties or problems have you had with the pessary?

10.What symptoms have been relieved or worsened as a result of using a pessary?

11.Why did you choose a pessary over other treatment options such as surgery?

12.How do you feel about your quality of life since you’ve started using a pessary?

13.What advice would you give to a woman who is considering a pessary?