How Can We Ensure Competency Standards In Pessary Management for POP?
Pessaries are being increasingly utilised as a component of the biopsychosocial non-surgical management of Pelvic Organ Prolapse (POP), in addition to pelvic floor muscle training, lifestyle changes and topical oestrogen. It is vital that these treatments are provided effectively and safely following evidence based and competency assessed standards.
Once the domain of gynaecologists and some GPs, pessaries are being increasingly provided by pelvic health physiotherapists.
This article, written in conjunction with Specialist Pelvic Health Physiotherapist Dr Patricia Neumann explores recommendations, treatment options and competency standards for the use of pessaries as part of POP management.
Why Consider A Pessary For POP?
Pessaries are particularly helpful for those not wanting to pursue surgery, have not finished their childbearing, are unfit for surgery, or want to be able to participate in higher levels of exercise. Pessaries have been shown to be suitable and safe in both older and younger populations1.
There is level 1 evidence that supports pessary self-management, reducing the risk of complications and the need for specialist visits without compromising quality of life2,3. This facilitates increased engagement in sport and exercise and if required an increased ability to care for family and participate in heavy physical work.
A recent study4 found that physiotherapists in private practice are seeing younger women (<40) and providing them with the option of a pessary. This is helping to reduce POP symptoms and encouraging women to re-engage with physical activity which in turn leads to improved management of other health conditions such as mental health and bone mineral density.
A Competency Framework For Physiotherapists Fitting Pessaries
In 2018, the Australian Commission on Safety and Quality in Healthcare (ACSQHC)5 published treatment options of POP, which included the fitting of a vaginal pessary. They stated that a physiotherapist with a “special interest” in the pelvic floor can provide these treatments - but is a special interest enough?
There is Level 1 evidence for pelvic floor muscle training (PFMT) as first line therapy to improve both the symptoms and anatomical stage of POP6 when delivered by a physiotherapist who has had specific post-graduate training in managing pelvic floor dysfunction.
The physiotherapist should be able to manage bladder, bowel, sexual and pain issues and provide trauma-informed care6, which requires much more than an ‘interest’ but rather further professional development, training and qualifications.
Specialist Pelvic Health Physiotherapist Dr Patricia Neumann commenced running a professional certificate at the University of South Australia in advanced POP management in 2018. The course aims to provides specific training in pessary management so that other health care professionals are competent to provide evidence-based, best-practice care. In 2021 Dr Neumann also published an E-Delphi study outlining the development of a multinational, multidisciplinary competency framework for physiotherapy training in pessary management7. Despite this, there are still no professional standards around the training needed for physiotherapists to manage pessaries.4
What You Should Expect From A Physiotherapist Competent In Pessary Management
Starting with a patient-centred approach and competence in all areas of pelvic health, you can expect at least the following for pessary management:
- Clear understanding of indications for pessary fitting, contra-indications and precautions.
- Collaboration with the patient’s GP or gynaecologist, to address the medical issues which include8:
- Confirming the diagnosis of prolapse and excluding a pelvic mass.
- Prescribing topical oestrogen as indicated for vaginal atrophy.
- Providing medical follow-up for complications e.g bleeding, signs of infection etc.
- Providing annual medical review, discussing goals and surgical options.
- Advanced skills in assessing the pelvic floor muscles, connective tissue support and prolapse for stage and compartment.
- Knowledge regarding pessary choices including different types, not just ring pessaries, as these are likely to fail with a levator avulsion. In this case, space-occupying pessaries may be indicated (Cube and Gellhorn)2.
- Skills in fitting and removing the different types of pessaries, teaching self-management.
- Knowledge of possible complications, when to escalate care and best practice infection control.
- Data management and protocols ensuring regular follow-up and contingency plans for urgent problems.
- Interprofessional collaboration and governance.
A Call To Action
We encourage all health practitioners to be aware of the evidence-based guidelines and the need for physiotherapists fitting pessaries to adopt the recommended competency standards.
Susannah van der Venne, team leader at WMHP completed the UniSA professional certificate in 2021. She, alongside Shan Morrison, Specialist Pelvic Health Physiotherapist, oversee our pessary training, competency and documentation, through regular professional development sessions, expanding our team’s University of Melbourne post graduate training in pelvic health physiotherapy.
References
1Bø et al (2023) Evidence-based Physical Therapy -Bridging Science and Physical Therapy 3rd Edition. Elsevier.
2Nemeth et al (2023). Self-management of vaginal cube pessaries may be a game changer for pelvic organ prolapse treatment: a long-term follow-up study. International Urogynecology Journal, 34(4), 921-927.
3Hagen et al (2023). Clinical effectiveness of vaginal pessary self-management vs clinic-based care for pelvic organ prolapse (TOPSY): a randomised controlled superiority trial. EClinicalMedicine, 66.
4McEvoy K, Griffin R, Harris M, Moger H, Wright O, Nurkic I, Thompson J, Das R, Neumann P, (2023) Pessary management practices for pelvic organ prolapse among Australian health care practitioners: a cross‑sectional study, International Urogynecology Journal, https://doi.org/10.1007/s00192-023-05540-2
5 Australian Commission on Safety and Quality in Healthcare Pelvic Organ Prolapse. 2018; https://www.safetyandquality.gov.au/publications-and-resources/resource-library/treatment-options-pelvic-organ-prolapse-pop
6Incontinence (ICI) 7th Edition 2023 available at: https://www.ics.org/education
7Neumann, P. B., Radi, N., Gerdis, T. L., Tonkin, C., Wright, C., Chalmers, K. J., & Nurkic, I. (2022). Development of a multinational, multidisciplinary competency framework for physiotherapy training in pessary management: an E-Delphi study. International Urogynecology Journal, 33(2), 253-265.
8UK Pessary Guideline (2021) available at: https://www.ukcs.uk.net/UK-Pessary-Guideline-2021
