The Use of a Vaginal Pessary to Decide Whether a Midurethral Sling Should be Added to Prolapse Surgery

PURPOSE: Women with pelvic organ prolapse (POP) are at risk of developing stress urinary incontinence (SUI) following prolapse surgery. Combining POP repair with anti-incontinence surgery reduces the incontinence rate but leads to overtreatment. Performing POP repair only, leads to undertreatment. Is a vaginal ring pessary a useful tool in deciding whether a midurethral sling (MUS) should be added to prolapse surgery?

MATERIALS AND METHODS: Retrospective cohort study of women with symptomatic POP, but without bothersome SUI, who underwent vaginal prolapse repair between 01/01/2008 and 31/12/2017. Preoperatively all women had a pessary inserted to detect occult SUI. If the pessary revealed bothersome SUI, a concomitant MUS was proposed. The primary outcome at follow-up was 'de novo' SUI.

RESULTS: Two hundred twenty women were included. After pessary insertion 132 (60%) women remained continent, 20 (9%) reported non-bothersome SUI and 68 (31%) had bothersome SUI. The latter were offered combined surgery. At follow-up, bothersome SUI was present in 12 (12/132, 9%) women that had been continent preoperatively and in seven (7/20, 35%) that had had non-bothersome SUI. In women who were continent with the pessary (n=132) eleven MUS procedures would have been needed to prevent one case of postoperative SUI (number needed to treat (NNT)=11). In women who had non-bothersome SUI (n=20), only three MUS procedures would have been necessary (NNT=3).

CONCLUSIONS: In women with symptomatic POP, a pessary is a useful tool in deciding whether or not to add a MUS.