Ring Pessary Sizer: a pilot study to objectively measure size of a ring pessary required by a patient
© Springer-Verlag 2007
Received: 24 October 2007
Accepted: 30 November 2007
Published: 4 January 2008
Ring pessaries are frequently used to relieve the symptoms of utero–vaginal prolapse. So far, the assessment of the size of a ring pessary required by a patient has been subjective. We have developed an instrument, called a ‘Ring Pessary Sizer’, which could objectively estimate the size of ring required by a patient. This article details a prospective study of 37 patients who were using ring pessary without any problems for whom the Ring Pessary Sizer was able to correctly estimate within one size of the ring in 31 (84%) cases. A Ring Pessary Sizer would make the choice of the size of a ring pessary more objective for a clinician and less inconvenient for a patient. This will also have numerous cost saving benefits.
The aim of this pilot study was to explore the potential of the Ring Pessary Sizer (RPS) in measurement of a ring required by the patient.
The main objective of this study was to assess the extent of agreement between the size currently used and that suggested by RPS.
Bland-Altman analyses of the findings were performed using StatsDirect statistical software (http://www.statsdirect.com/).
The results of this study demonstrate the usefulness of RPS in determining the size of a ring pessary required by a patient. The RPS had been most accurate in determining ring sizes between 59 and 80 mm (<59 mm ring size was overestimated three sizes and >80 mm size it was underestimated two sizes). A possible explanation for this could be the changes in pelvic floor muscles in patients requiring smaller (<59 mm) or lager size (>80 mm) rings. Therefore, while making an assessment for a pessary size for a patient, the softness of the connective tissue of the paravaginal area and the laxity of the pelvic floor muscles should also be considered before determining a ring size.
Neither assessor (NSQ, FA) experienced difficulty in the use of RPS and obtaining readings for a ring pessary size. The possibility of personal bias in the study to determine the ring pessary size by the RPS is extremely low as it is not easy to correctly determine the ring pessary size by just looking at it after it was removed from the patient.
Ring pessaries are commonly used in gynaecology out-patient settings. A study has showed that 86% of gynaecologists and 98% of urogynaecologists use them . The main indications for the use of ring pessary are the symptoms of utero–vaginal prolapse and urinary symptoms. Vaginal pessaries are the only currently available nonsurgical intervention for managing women with a prolapse. Conservative management is advised for patients who are not fit for surgery or do not want surgery. In a prospective study of 100 consecutive women with symptomatic pelvic organ prolapse fitted with a pessary, 73 women retained the pessary 2 weeks later. After 2 months, 92% of these women were satisfied with the pessary; virtually all symptoms of prolapse and 50% of urinary symptoms had resolved, although occult stress incontinence was unmasked in 21% of the women .
Ring pessaries are relatively inexpensive items, the average cost of a ring pessary is £1.20. However, the RPS is cheaper than the cost of a single ring pessary. The subjective method of finding an appropriate size of ring pessary may be uncomfortable for patient and causes wastage of unused opened rings. Although, ‘falling out’ of ring pessaries is not only due to incorrect measurement of ring size but may also be due to laxity of pelvic floor muscle . However, a RPS adds a degree of objectivity in determining a ring size for a patient. Ill-fitted rings often fall out and patients have to be seen as outpatients again, causing inconvenience to patients and putting an unnecessary burden on the running of clinics. The cost of trying various sizes of ring pessaries on the emotional well-being of patients is immeasurable.
The use of the RPS may not be necessary for a trained gynaecologist to determine the size of ring required by the patient. However, in larger hospitals where there is a trend to refer this procedure to ‘ring clinics’, availability of the RPS would be extremely useful. The ‘ring clinics’ are usually run by nurse practitioners who may be relatively inexperienced in digitally determining the size of a ring accurately. Although, a gynaecologist specifying the size of a ring pessary may initially make referral to ‘ring clinics’. It is a well-known phenomenon that the size of a ring pessary may change with age .
The use of a RPS to determine the size of ring pessary required by a patient is a straightforward procedure. We feel that the learning curve for nurses/nurse practitioners who have experience in performing Cusco’s speculum examination to use the Ring Pessary Sizer would be steep and that supervision by a gynaecologist in the first five cases may be required.
We intend to perform a larger, randomised controlled study in the future to either have the ring pessaries fitted using digital assessment or by the Ring Pessary Sizer with follow-up which would include time to fit, number of wasted ring pessaries, and requirement for subsequent re-fittings.
We feel that introduction of the RPS to gynaecology outpatients will assist the clinician and improve the outcome of this procedure for a patient. This in itself will prove beneficial and cost effective to Health Trusts throughout the United Kingdom.
The study had North East Wales Local Research Ethics Committee approval (06/Wno03/41). The authors are very grateful to the nursing staff of the gynaecology outpatients. We are also thankful to all the consultants in the Department of Obstetrics and Gynaecology at the hospital for giving permission to recruit their patients into the trial and to Andy Vail for his help in the statistical analysis.
Disclosure of interests
NSQ is the inventor and holds the UK patent for the Ring Pessary Sizer.
- Rock JA, Thompson JD (1997) Telinde’s operative gynaecology. Lippincott-Raven, Philadelphia, PA, pp 1077–1085Google Scholar
- Oslen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL (1997) Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 89:501–506View ArticleGoogle Scholar
- Weber AM, Richter HE (2005) Pelvic organ prolapse. Obstet Gynecol 106:615–634PubMedGoogle Scholar
- Bash KL (2000) Review of vaginal pessaries. Obstet Gynecol Surv 7:455–460View ArticleGoogle Scholar
- Cundiff GW, Weidner AC, Visco AG, Bump RC, Addison WA (2000) A survey of pessary use by members of American Urogynecologic Society. Obstet Gynecol 95:931–935PubMedView ArticleGoogle Scholar
- Clemon JL, Aguilar VC, Tillingghast TA, Jackson ND, Myers DL (2004) Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse. Am J Obstet Gynecol 190:1025–1029View ArticleGoogle Scholar
- Doshani A, Teo REC, Mayne CJ, Tincello DG (2007) Uterine prolapse. Br Med J 335:819–823View ArticleGoogle Scholar
- Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancy JOL, Klarskov P, Shull BL, Smith ARB (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175:10–17PubMedView ArticleGoogle Scholar