Pessaries for pelvic organ prolapse: Is there enough evidence?

Dear Editor,

There is evidence for the high incidence of use of pessaries by the gynecologists for the treatment of pelvic organ prolapse. Studies have shown that almost 77-87% of the gynecologists use pessaries as a first line treatment for pelvic organ prolapse.[1,2,3] Despite the widespread use of pessaries in the treatment of pelvic organ prolapse, this is not based on sound scientific evidence. Even though, pessaries support the vaginal walls and thus, the pelvic organs and help alleviate the symptoms of pressure on the bowel and bladder, these symptoms have not translated into clinically meaningful results.[4] A Cochrane systematic review and meta-analysis was conducted to assess the effects of pessaries on patients’ perceived symptoms, satisfaction with treatment, grade of prolapse, quality-of-life and the incidence of complications.[4] The review identified only one randomized controlled trial, which too was associated with methodological flaws. The authors concluded that there is insufficient evidence on the subject and highlighted the need for large randomized controlled trials to show the effects of pessaries. The continued use of pessaries for pelvic organ prolapse without any scientific evidence is alarming. In addition to its lack of benefit, pessaries are also associated with significant adverse effects. The involuntary expulsion of device, discomfort due to the pessaries, vaginal bleeding, infection and dislike due to the regular changing of pessaries are known adverse effects of pessaries.[1] Therefore, the use of pessaries should be seriously re-evaluated. There is an urgent need for large scale, randomized controlled trials to conclusively report the efficacy and adverse effects of these devices. The lack of rigorous evidence on the subject also warrants that the use of these devices be kept at the lowest possible until conclusive data can be generated. It also remains to be seen whether the continued use of pessaries by the Gynecologists despite the lack of evidence represents a lack of awareness or is a result of patient preference. Whatever the case, the current use of pessaries as a first line treatment of pelvic organ prolapse is unjustified, except in a select few cases and should be stopped.