This study focuses directly on patients’ perspectives and explores their expectations from pessary use in the treatment of POP. Our findings suggest that while pessaries are a common tool used in treating POP, much work remains to be done in improving patient experiences associated with its use. In our survey, a majority of participants reported difficulty with pessary cleaning and management (95%). This can be addressed by enhanced education on maintenance of pessary by care providers, which, as demonstrated by Murray et al., can be as simple as providing a brochure explaining about the pessaries and how they work [8]. Furthermore, providing the same education to all patients can help target the discrepancy between older patients and sexual health knowledge, as how a pessary is fitted and education received may impact pessary usage. One study proposed an association between pessary management and generational attitudes surrounding sexual health, where younger women may be more familiar with using a pessary due to their willingness to learn about it, whilst older women may be less likely to self-manage due to personal attitudes towards sexual health they may have had growing up [9]. Other explanations may be attributed to increased comorbidities with age, leading to a perception of, or actual increased difficulty; however, a causal link between the two has not been established [9, 10]. This link may also explain why a considerable fraction of participants contemplated discontinuation, despite acknowledging major benefits such as reduced bulging and increased ability to exercise. Our survey also explains why despite the difficulties associated with pessary use, respondents are able to appreciate the benefits and would recommend this option to others. It may have been worth exploring what participants’ expectations from using a pessary were, especially given the rate of symptom improvement was only partial for a large portion of participants. Though this was not analysed in this study, this may be worth examining in future studies.

Other variables, such as poor fitting and pessary expulsion also contribute to higher rates of pessary discontinuation [2]. One review found variable pessary fitting success rates ranging from 41 to 96% due to a multitude of reasons, most notably being the anatomical parameters associated with reduced pessary success [6]. A shorter total vaginal length, wider introitus, levator ani abnormalities and larger hiatal area all contributed to an unsuccessful pessary fitting [6]. Though patient-specific anatomy was not addressed in our study, it may provide an explanation for why 40% of participants considered discontinuing pessary use. Ultimately, though there are different types of pessaries, women with specific anatomy may benefit from different pessary types that may not be covered by the common pessary types. As a result, the research on pelvic anatomy and pessary success rates is limited, but these findings suggest that exploring this relationship could potentially reduce rates of pessary failure.

One important component of our study that distinguishes our study from other research was the exploration of factors that could help improve continued pessary use; the majority of participants felt that ideal characteristics of a pessary included easy insertion and removal, side effect relief and reduced displacement/friction. Though one study by Jones & Harmanli noted that difficulty with pessary insertion and removal was a limiting factor in the more widespread use of pessaries, they did not consider other reasons that were explored in this study. For example, side effect relief and reduced displacement/friction were features that over half of our participants cited as ideal characteristics of pessaries [11]. These factors tend to be issues associated with maintaining pessary use over time, as opposed to the initial fitting and removal. Furthermore, over half of respondents felt that an applicator would help with pessary insertion, – something not explored in previous studies. Altogether, our findings provide additional information for means of pessary development to reduce the risk of discontinuation.

A key observation was that the longevity of respondent pessary use was poor. We know that prolapse is a chronic condition and can worsen with time but our survey found that by 1 year, pessary use drops to less than half and only one third are actually still using a pessary after 2 years. This is a high rate of patients that may either go on to have further treatment or choose to have further POP symptoms than manage with a pessary. Additionally, there is a striking difference in responses to those that would consider stopping currently using a pessary (42%) but also recommend a pessary to others (95%). Clearly there is value in having a satisfactory experience long term with pessary usage.

The combination of high discontinuation rates with adverse effects such as pelvic pain and urine leakage highlights the importance of educating patients on what to expect when wearing a pessary. In one study, participants reported vaginal discharge, pelvic discomfort and occult stress incontinence as some of the most common complications [12]. The authors noted that issues typically only occur in patients with poor follow-up care, thus making regular follow-up care a necessity for patients who manage pessaries themselves [12]. Another study found symptomatic relief for urinary and prolapse symptoms in participants using a ring with support pessary but had minimal improvement on bowel symptoms. In this study, the authors hypothesized that this could be attributed to the weak relationship between posterior compartment prolapse (i.e., rectocele) and bowel dysfunction symptoms [13]. Together, these findings emphasize the need for improved support and education on what patients can expect when wearing a pessary. It also suggests that further development into more user-friendly pessary designs may be able address the challenges observed. For example, as noted earlier, the use of an applicator – similar to that of a tampon applicator – to help with fitting, and the development a new customized pessary – alternative to the current types available – to aid in symptom relief, reduced friction, and increased autonomy for patients may be avenues worth exploring. Ultimately, these areas are opportunities to enhance the overall experience and adherence to pessary therapy for POP.

Our study had some limitations. First, our questions did not come from a previously validated questionnaire. Whilst the questionnaire was designed based on previous research on this topic with the help of physicians specializing in urogynecology, the fact that it had never been used before made it difficult to ascertain the questionnaire’s reliability and validity [2, 14]. Another limitation is that we recruited participants from social media sites and pelvic floor clinics; hence, patients who presented to other primary clinics, or other health care providers who fit pessaries would have been excluded. Patients who may not have any form of social media were not included in this study which introduces a recruitment bias into our study. Moreover, the largely older age demographic of participants meant that using online questionnaires was a less effective means of data collection. Had we collected more data in-person, there may have been a more accurate representation of the average pessary user, making the results overall more reliable. Another limitation with respect to participant demographics was that our sample was predominantly Caucasian. These findings are not what we would expect on a national scale, given that Canada’s population is only 67% Caucasian, not over 90% 15. The sample demographics being different may have an impact on personal preferences as well participants’ personal experiences with pessaries. Perhaps advertising our study in online groups for people of colour struggling with POP may have increased recruitment, as well as advertisement in other large cities such as Toronto or Vancouver, both of which have a considerably larger proportion of racialized and ethnic groups compared to Saskatoon and Montreal [15]. Lastly, our small sample size limits generalizability to a larger population. Implementing a large-scale version of our survey with diversified recruitment patterns would also help improve external validity and ensure accurate results.

Despite these limitations, there are many strengths associated with this research study. Whilst there are many papers examining the factors associated with pessary success, studies focusing on the patient’s perspective on what makes a good pessary is sparse. The few studies available in this area do not consider what patients regard as the most important characteristics of a pessary. Moreover, other studies have examined the anatomical parameters associated with successful pessary fitting but not focused on the patient experience [6, 14]. This is the first study that examines factors associated with a successful pessary fitting by explicitly asking about patient preferences. Our study also has a large degree of clinical relevance, given that the questions mainly centered around each participants’ diagnosis, symptoms and highlighted their treatment expectations for a pessary. The results from this survey are very promising in further guiding pessary education, management and development of better pessary care. Further research into this area can help inform prescribers on which patient would be a good candidate for pessary use and how to improve their experience, therefore improving their efficacy and increasing adherence.