My colleague Jane was performing an incontinence assessment on Mrs H, a housebound woman in her seventies who was having urinary incontinence. During the course of the assessment Mrs H told Jane that she had a prolapsed uterus. When Jane offered to speak with Mrs H's GP about it, Mrs H replied that her GP had said the only thing that could be done was surgery.
Jane knew that a prolapsed uterus could also be managed with a pessary, although she did not know much more than that. She contacted the GP, who said that Mrs H was not a good candidate for surgery. When Jane asked about a pessary, the GP replied that she did not know how to fit them, and neither did the practice nurse. Jane contacted the local bladder and bowel service, but there was no one there who was able to fit Mrs H with a pessary. Eventually Jane discovered that there was a clinical nurse specialist, working within the gynaecology department of a nearby hospital, who fitted patients with pessaries. Jane arranged for Mrs H to have an outpatient appointment with the clinical nurse specialist, including arranging hospital transport and a relative to accompany Mrs H. Mrs H was eventually fitted for a pessary, with advice on managing it and a follow-up appointment. The pessary did not fully reverse Mrs H's incontinence, but it did make it more manageable. It also improved Mrs H's quality of life and helped her feel more comfortable.
As Jane said, ‘All that fuss and hard work, just to get one patient fitted with a pessary, which is just a small piece of plastic.’
Pelvic organ prolapse
This is sometimes called a prolapsed womb or prolapsed vagina. It is when the vaginal walls, vaginal vault, uterus or any combination of these prolapse and move down the vagina. It can also affect the bladder and/or bowel, causing incontinence in either or both (Dwyer et al, 2019). The risk factors for pelvic organ prolapse (POP) are:
- Pregnancy and childbirth
- Ageing and the menopause
- Lifestyle and exercise
- Constipation
- Smoking
- Obesity
- Continuous heavy lifting/strenuous exercise in the gym
- Genetic collagen deficiency disorders (such as Marfan syndrome or Ehlers-Danlos syndrome) (Rantell, 2019).
However, the greatest risks are being post-menopausal and having given birth. It affects 12-20% of women who have given birth, compared with 1-2% of women who have not (Fisher and Glenn, 2000).
POP is defined in three stages:
- First stage, where the cervix descends into the vagina
- Second stage, where the cervix protrudes through the vulva and starts to protrude outside the vagina
- Third stage, where the whole of the uterus is outside the vulva and is visible (Fisher and Glenn, 2000).
The first symptoms that patients present with are urinary incontinence and/or a feeling of ‘fullness’ or discomfort in their vagina. Further symptoms can be a ‘heaviness’ in the vagina, difficulty opening their bowels, urinary and/or faecal incontinence, they may even have frequent urinary tract infections and painful sexual intercourse (James and Jenner, 2002). The majority of patients with POP will first present in primary care with these symptoms. Unfortunately, all of these can be dismissed as a ‘normal’ part of ageing.
Managing pelvic organ prolapse
Rantell (2019) recommended three stages of treatment: first, do nothing. Second, conservative management, including lifestyle changes, pelvic floor exercises and the use of pessaries. Third, surgery.
Although the medical model would be to jump straight to surgery, conservative management should always be considered first. They may not be as quick to resolve the issue as surgery, but conservative approaches are much more cost-effective and will allow a patient to retain much more control of their own care.
The National Institute for Health and Care Excellence (NICE)(2019) guideline recommends that patients lose weight (if their BMI is over 30 kg/m2), minimise heavy lifting and prevent or manage constipation. These might sound small changes but they can have a big impact on a woman's life.
Pelvic floor muscle training
The NICE guideline recommends that patients receive a supervised programme of pelvic floor muscle training for at least 16 weeks. They can improve the strength and tone of the pelvic floor muscles, giving more control over the group of muscles that control urinary flow (Hanzaree and Steggall 2010). However, these are complex exercises and cannot simply be learnt from a leaflet handed to a patient, they need a trained practitioner to teach them (Hanzaree and Steggall, 2010). This is a therapeutic treatment, not a quick panacea.
Pessaries
A vaginal pessary is a device that is inserted into the vagina to provide structural/physical support to the prolapsing parts of the vagina/uterus (Rantell, 2019). The most common type of pessary is the ring/donut pessary (James and Jenner, 2002), which fits inside the vagina and lifts the uterus back up. Dywer et al (2019) identified 26 different styles of pessaries and, given this variety, recommended that patients need to be assessed and examined by a trained practitioner. The different styles of pessaries are designed for different degrees of prolapse but also to support different lifestyles—some are not suitable for women who are sexually active, some pessaries can be self-managed, while others need to be removed and re-inserted by a trained practitioner (Dwyer et al, 2019).
NICE (2019) recommends that a pessary is used with a patient with symptomatic pelvic organ prolapse. Dywer et al (2019) also recommends that women have access to a variety of pessaries to be able to match the pessary to the patient's lifestyle. Therefore, a patient should not just be offered the most popular style. Fitting a woman with a pessary is not the end of their care, they will need a regular 6-monthly review to ensure that there are no complications from the pessary they are using (NICE, 2019) and also because a woman's health or lifestyle may have changed and the pessary may no longer be effective.
Dywer et al (2019) argued that a pessary is an equal management option to surgery and therefore should be presented to patients as such, not just as a stop-gap before a patient can have surgery. A pessary does not come without its own complications (including vaginal discharge, bleeding, difficulty removing pessary or pessary expulsion (NICE, 2019)), but they are not as severe as the complications of surgery: pain, risk of infection, time out of a person's life, and the financial cost to the NHS of surgery. Not all patients will be suitable for a pessary, as is the case for most other conservative options for various healthcare conditions, but why shouldn't patients be offered it first?
The problem with pessaries
Pessary assessment, selection and fitting is a specialist clinical skill. It cannot be learnt from just watching a YouTube video or reading one practice review article. Unfortunately, the practitioners who posses these skills are not widely available to patients. Dywer et al (2019), in their literature review, found a lack of adequate, standardised training, which impacts on a clinician's confidence and knowledge. In one study, they found that 75% of South African gynaecologists had no formal training in pessary selection and insertion.
The majority of patients with POP seek medical advice in primary care. Rantell (2019) found there is a lack of health professionals, in primary care who are trained and confident in pessary fitting and long-term management. Therefore, if a patient wants a pessary they will have to be referred to a urogynaecology service. This can be a lengthy process, with a wait to be initially seen, and can be resource heavy for the patient: they have to travel to the urogynaecology service and the appointment may fill half a day with travel and waiting to be seen.
Why aren't there more nurses trained and experienced in fitting and managing pessaries? This service can improve patients' lives, cut down on the need for costly surgery and save the NHS resources. It could also be easily provided in primary care, close to the patients who need it, therefore saving the patients time and money too.
How many nurses know about pessaries, let alone how to access them? I had never heard of them, throughout my nursing career, until I came to work in the community and looked after a patient with one (although the care I provided did not relate to it). A colleague, who had previously worked in gynaecology, told me what they actually were.
Conclusion
Incontinence can severely affect a person's quality of life, not least the shame and embarrassment of having it, and yet for some women this can be managed by the correct insertion of a plastic pessary. A pessary can also prevent the need for surgery, with all its costs to the patient and the NHS. Even if a nurse isn't competent in fitting them, shouldn't they be promoting them to suitable patients? Unfortunately, the biggest barrier to patients accessing pessaries is the lack of suitably trained and competent practitioners who can fit and manage them, especially in primary care.