Pelvic organ prolapse is defined as the downward displacement of the uterus and/or different vaginal compartments as well as the bladder or bowel (Haylen et al, 2016). Prolapse is a debilitating condition that can cause bowel and bladder symptoms as well as affecting sexual function, quality of life and body image (Haylen et al, 2016). In the UK, the lifetime risk of a woman requiring a procedure to treat prolapse is 10% (Abdel-Fattah et al, 2011). As some women are not bothered by prolapse and others either do not seek treatment or opt for conservative management, the true prevalence of the condition is unknown (Abdel-Fattah et al, 2011). Women seeking prolapse treatment are likely to be offered surgical or conservative management. Conservative management options include lifestyle advice, pelvic floor muscle retraining, support underwear, oestrogen therapy and pessaries (Dwyer and Kearney, 2018). Of conservative management options, pessaries have been demonstrated to be comparable to prolapse surgery for quality of life, urinary symptoms, vaginal symptoms and sexual function (Lone et al, 2015).
A pessary is a mechanical device inserted into the vagina to provide physical support to the vaginal walls and prolapsed organs (Bugge et al, 2013). A wide range of pessaries are available (Figure 1). Currently there is a lack of rigorous evidence or resulting guidelines determining the best pessary to use. Therefore, clinical decisions are made based on anecdotal evidence and experience (Atnip, 2009). Continual follow-up is required while the pessary remains in situ. At each appointment the pessary must be removed and vaginal tissue examined to ensure that it remains intact and healthy (Atnip, 2009). The ideal frequency of pessary follow-up has not been determined, but ranges between 3 months and 12 months (Gorti et al, 2009).
At present there is a lack of information about who provides pessary care (Hooper et al, 2017). Care has traditionally been provided by doctors. However, as advanced nursing roles have developed in the UK, pessary care appears to have gradually become a role that nurses participate in and often lead. A lack of guidelines related to pessary care mean that pessary practitioners are largely dependent on professional experience or literature provided by pessary manufacturers rather than evidence (Atnip, 2009; International Centre for Allied Health Evidence, 2012). The lack of policy or guidance related to pessary practitioner training is an issue of concern for both health professionals and service users. This was confirmed during a recent James Lind Alliance project on pessary use for prolapse priority setting (Lough et al, 2018), where practitioner training was highlighted as a research priority.
The current enforced ‘pause’ in the use of vaginal mesh in the UK has brought renewed focus on the regulation of medical devices. Although medical device regulation is complex, the Medicines and Healthcare products Regulatory Agency (MHRA) states that health professionals require training in the safe and effective use of medical devices, that training must be documented and regular updates must be provided to ensure maintenance of professional ability (MHRA, 2015). A further result of the ‘pause’ may also be increased demand for less invasive management options for urinary incontinence and prolapse such as pessaries. Therefore, the need for a better understanding of standards related to insertion of a pessary as a long-term medical device are paramount in the current climate of urogynaecology.
This review explores and summarises current literature regarding pessary practitioner training, including the impact of training on skill, knowledge and competence, as well as the different methods of pessary training.
Literature review
The literature search was performed using the following databases: AHMED, MEDLINE including in-process and other non-indexed citations, BNI, CINAHL, and EMBASE. Search terms used were: ‘pessary’, ‘confidence’, ‘training’, ‘prolapse’, ‘healthcare professional’ and ‘competency’. Synonyms were used where appropriate. Papers were excluded if they were not relevant to pessary practitioner training, were not published in English, were duplicates, or were non-original research such as review articles. No date parameters were set. Abstracts were included if a full article was not accessible. A hand search of reference lists from papers reviewed revealed further relevant publications for inclusion.
Search results
Seventy-four publications were identified during the initial search (Figure 2). A further 13 publications were identified during hand-searching. Following review, 74 articles were excluded. The identified literature also included a large number of non-original research review articles offering opinions or guidance regarding conservative management of prolapse. These were excluded, but references were searched for relevant publications not already identified. This left 13 articles.
The study samples included doctors, nurses and other health professionals (Table 1). There was a combination of both observational and interventional methodological approaches. Studies were conducted in the USA, Canada, Australia, South Africa and the UK. Following repeated reviews of each paper, it was evident that there were a number of emerging themes related to pessary training.
| Authors | Year of publication | Country | Health professional | Description |
|---|---|---|---|---|
| Pott-Grinstein and Newcomer | 2001 | USA | Doctors | Questionnaire sent to 2000 gynaecologists drawn randomly from American College of Obstetricians and Gynaecologists Responses from 947 participants |
| Abdool | 2011 | South Africa | Doctors | Self-administered questionnaire distributed to 420 gynaecologists Responses from 133 participants |
| Schneider and Monga | 2005 | USA | Doctors | Questionnaire survey of all 28 obstetrics and gynaecology residents* 1998–2002 |
| Christakis et al | 2017 | Canada | Doctors | Questionnaire sent out to obstetricians, gynaecologists and urologists Responses from 340–301 obstetricians and gynaecologists and 39 urologists |
| Kassis et al | 2014 | USA | Doctors | Electronic questionnaire sent to obstetric and gynaecology residents Responses from 222 of 481 |
| Minassian et al | 2004 | Canada | Doctors | Questionnaire among residents completing urogynaecology training |
| O'Dell et al | 2016 | USA | Nurses | Questionnaire sent to members of 3 nursing organisations 279 respondents, 216 being providers of pessary care |
| Bugge et al | 2013 | UK | Nurses, physiotherapists and doctors | Questionnaire among relevant professionals Responses from 678 |
| Wilson et al | 2015 | Australia | Nurses | Prospective cohort study of women presenting to a rural nurse-led pessary clinic |
| Hooper et al | 2017 | USA | Nurses | Modified Delphi method |
| Kandadai et al | 2016 | USA | Doctors | Electronic questionnaire sent to all obstetric and gynaecology residents Responses from 478 |
| Escobar et al | 2017 | USA | Doctors | Pilot randomised controlled trial Conference abstract |
| Neumann et al | 2015 | Australia | Nurses, physiotherapists and doctors | Prospective questionnaire study to evaluate pessary training course |
Themes identified
The findings of each study were summarised and recurring themes identified. These are ‘prevalence of pessary training’, ‘type of pessary training’, confidence in pessary care provision’, ‘impact on pessary care’, ‘skills and knowledge required to be a pessary practitioner’, ‘barriers’, ‘specialty of pessary care providers’, and ‘ongoing support’.
Prevalence of pessary training
As there are no guidelines specifying the training requirements for a pessary practitioner, measurement of this relies on self-reported data. Between 8% and 70% of doctors reported receiving training to provide pessary care (Pott-Grinstein and Newcomer, 2001; Abdool, 2011; Kassis et al, 2014; Kandadai et al, 2016). Of these, many appeared dissatisfied with the training received, with over half of respondents in one study describing the training as minimal (Pott-Grinstein and Newcomer, 2001) and 75% of surveyed South African gynaecologists stating the need for a formal training programme (Abdool, 2011). Despite 80% of obstetrics and gynaecology residents in one study reporting that they had received no training or minimal training in pessary fitting, 33% had been responsible for independently providing pessary care (Kassis et al, 2014). Respondents in other studies reported receiving training related to prolapse, vaginal examination and history taking, but not pessary management (Minassian et al, 2004; Kandadai et al, 2016). When training was compared between different health professionals who provide pessary care, 15% reported no previous pessary training (Bugge et al, 2013). There was no significant difference between the prevalence of training among responding doctors, nurses and physiotherapists (Bugge et al, 2013).
Type of pessary training
When exploring the different methods of pessary training, the majority appears to be delivered through supervision and observation within clinical practice. A survey of nurse practitioners in the USA found that 46% of respondents were trained through mentorship from a doctor and 19% from a nurse in clinical practice (O'Dell et al, 2016). Other sources of knowledge much less frequently cited were national workshops, professional journals, industry resources and academic institutions (O'Dell et al, 2016). Of 478 obstetrics and gynaecology residents who responded to a questionnaire exploring knowledge and comfort of pessary use in US hospitals, 52% reported receiving formal didactic training regarding pessary fitting and management, while 74% reported receiving this training informally (Kandadai et al, 2016). Learning through clinical supervision from a dedicated mentor was unanimously agreed to be the best method of pessary training by nurses participating in a four-round modified Delphi technique survey (Hooper et al, 2017).
Only two studies evaluated pessary training delivered as an intervention. Escobar et al (2017) randomised junior doctors between two groups, both of whom received one session of didactic training. The intervention group also received practical training with a pelvic model and practised inserting and removing pessaries. The doctors completed a test to assess their knowledge immediately before and after training. Pessary knowledge increased for both groups. Although the study found there was no difference in test results between groups immediately following training, 6 months later knowledge levels in the control group decreased whereas there was a small increase in knowledge for the intervention group. Although not significant, this suggests practical clinical skills training may improve retention of pessary management knowledge over time. Trainees in the intervention group also had greater satisfaction with the training than those who received didactic training alone. The clinical impact of the increased knowledge and satisfaction is not known; however, as with other clinical skills, one would assume that experience, confidence and understanding will benefit patient care (McGaghie et al, 2011).
Female volunteers assisted in another study (Neumann et al, 2015). However, whether these women had prolapse or had previously been fitted with a pessary is not clear. Under the supervision of experienced pessary practitioners, trainees practised insertion, fitting and removal of a pessary on each woman. Unlike the study by Escobar et al (2017), there was no comparison between the outcome of training provided with and without practical experience. Therefore the importance of the practical component of training is not clear. There are logistical issues to providing practical training of clinical skills in pessary care. The costs associated with simulation models, as used by Escobar et al (2017), may be prohibitive in certain settings. However, Neumann et al (2015) acknowledged the difficulty in accessing a sufficient number of women willing to volunteer to have a pessary fitted during training. An alternative they suggested is supervised clinical practice in an established pessary clinic.
Confidence in pessary care provision
Confidence providing pessary care was a recurring theme. It has been suggested that relying on clinician self-assessment of their confidence performing clinical skills is flawed with both trainee doctors and nurses perceiving their ability to be higher than it is (Barnsley et al, 2004; Baxter and Norman, 2011). Despite this, six publications asked respondents to report their confidence or comfort levels performing pessary care. Two studies of obstetrics and gynaecology residents highlighted that despite independently providing pessary care, many had poor comfort and confidence levels; in one study, 49% reported being ‘not at all comfortable’ or ‘not very comfortable’ fitting pessaries (Kassis et al, 2014). In the other, less than half of all respondents felt their training prepared them for pessary fitting and only 59% felt prepared for pessary management (Kandadai et al, 2016). Despite this, 75% of respondents within this study expected to be comfortable providing pessary care after graduation (Kandadai et al, 2016).
The expectation of confidence providing pessary care after graduation was demonstrated in a study of residents, who despite feeling least confident providing pessary care compared with other clinical skills, experienced the greatest increase in confidence following graduation (Schneider and Monga, 2005). Furthermore, after completing a urogynaecology rotation of between 4 and 12 weeks and fitting a mean of 9 pessaries, 91% of obstetrics and gynaecology residents felt confident providing pessary care (Minassian et al, 2004). Although 94% reported receiving formal training in physical examination and history taking, the publication did not detail the level of pessary training received by respondents. Therefore the clinical experience gained fitting pessaries during the rotation, despite the lack of formal pessary training, may account for the high level of confidence reported. There is further evidence to support the suggestion that clinical experience providing pessary care correlates with practitioner confidence. Neumann et al (2015) found that training gave participants from various professions the confidence to provide advice to women about the role of pessaries in prolapse management. However, even after receiving formal training, a small number of course trainees lacked confidence, particularly with regard to fitting pessaries such as the Gellhorn pessary, which were used less frequently in clinical practice.
There were also differences identified between respondents' comfort levels based on specialty training; 86% of obstetrics and gynaecology doctors surveyed by Christakis et al (2017) reported being moderately or very comfortable fitting and removing pessaries, compared with 13% of urologists. Whether this relates to difference in training or subsequent clinical practice is not clear. However, it does suggest that, as with other clinical skills, it may be necessary to regulate those who provide pessary care. Understanding the factors that increase confidence levels for pessary practitioners facilitates the development of future pessary training. It appears that in addition to receiving didactic training, clinical experience during independent and supervised practice are necessary to ensure a confident pessary practitioner (Kandadai et al, 2016).
Impact on pessary care
No studies explored patient perspectives regarding the impact of pessary training on care. Therefore the impact of training on quality of care is unknown. Two aspects of pessary care influenced by training were patient access to pessary management and the range of pessaries offered.
Pessary management should be presented to women as an equally viable management option to surgery (Abdool et al, 2011; Lone et al, 2015). Despite this only 25% of doctors attending a local obstetrics and gynaecology meeting in South Africa offered pessary management to their patients (Abdool et al, 2011). In other publications, between 57% and 69% of patients were offered pessaries as a primary treatment option (Velzel et al, 2015; Jiang et al, 2017). One possible reason for fewer doctors offering pessary management in this study is that only 8% reported receiving formal pessary training. Therefore, they may not have been aware of the effectiveness of pessaries in prolapse management or had the confidence to provide a treatment of which they have limited knowledge and skill.
Having access to a variety of pessaries is essential as pessaries must fit within the patient's lifestyle. Some pessaries are not suitable for sexually active women, some are self-managed and others are not. Furthermore, depending on the patient's anatomy and type of prolapse, some pessaries may be more successful than others. In one study where only 70% of respondents had pessary training, and of these 50% described it as minimal, there was a high percentage (76-93%) of pessary practitioners who were unfamiliar with and therefore did not fit 5 of 11 pessaries (Pott-Grinstein and Newcomer, 2001). Among obstetrics and gynaecology residents, despite only 20% reporting prior pessary training, 74% were able to recognise a ring pessary and 86% were able to recognise a Gellhorn pessary (Kassis et al, 2014). These are two of the most frequently used pessaries in clinical practice and respondents were not asked to identify a wider range of pessaries as with Pott-Grinstein and Newcomer's study. Conversely while Bugge et al (2013) acknowledged significant differences between the types of pessaries offered by practitioners depending on their profession, this did not appear to be influenced by pessary training.
Pessary training is likely to impact on availability of pessary care as those who have no experience with pessaries are unlikely to offer this as an option. However, the relationship between pessary training and the range of pessaries used is unclear. It is logical to assume that if practitioners have knowledge and experience with a variety of pessaries, they will understand when to use them to improve patient outcomes. Whether other factors such as the financial implications of ordering a wide range of pessaries also affect the pessaries offered to patients is not clear. Fitting kits consisting of a range of pessary types and sizes to be inserted for a short period of time to assess pessary fit then removed and autoclaved to facilitate use for multiple patients were advocated by O'Dell et al (2012) as a cost-effective method of determining which pessary to use. However, easy access to an autoclave is necessary, which may prohibit use of these in some clinical settings (O'Dell et al, 2012). It is unclear whether this is the reason that pessary fitting in the UK tends to follow a trial and error approach with wastage of incorrectly sized pessaries rather than use of a fitting kit (Qureshi et al, 2008).
Therefore further research is required to explore how pessary practitioners decide the optimum pessary to use with each patient and whether use of technology such as a fitting kit could be practically used more widely in the UK.
Skills and knowledge required to be a pessary practitioner
A recurring theme was the skills and knowledge required to be a pessary practitioner. There was agreement that practitioners needed to be knowledgeable in female pelvic anatomy, the range of pessaries available and the clinical characteristics and lifestyle factors that make a pessary suitable for a specific patient (Neumann et al, 2015; Wilson et al, 2015; Hooper et al, 2017). In addition, Neumann et al (2015) included pessary fitting, follow-up, self-management, pessary complications and different methods of prolapse management as part of their training. Having an understanding of different methods of prolapse management is essential for pessary practitioners as patients may require advice and guidance regarding alternative treatment options. Clinical skill performing vaginal examination was also deemed necessary (Neumann et al, 2015; Wilson et al, 2015). The majority of nurse participants in one study felt that, in addition to knowledge of female anatomy, to be competent providing pessary care, trainees required supervision fitting 20 of each type of pessary (Hooper et al, 2017).
Barriers
Obstetrics and gynaecology residents reported various obstacles to developing urogynaecology skills including pessary care, such as time limitations, a lack of training opportunities, insufficient patient population to practice on and a lack of recognition and remuneration for undertaking additional training (Christakis et al, 2017). After completing pessary training, health professionals were asked to report barriers that had prevented 71% of them from providing independent pessary care 6 months later (Neumann et al, 2015). Many encountered logistical issues such as time constraints, concerns about resource requirements, a lack of medical support and a lack of pessaries or room availability. Additionally, some respondents reported a lack of demand for a pessary service in their population. Following training, 5% of trainees felt lacking in confidence and this was their main barrier to providing pessary care. This highlights that a one-off training session may not be sufficient to equip health professionals with the skills and knowledge required to work autonomously.
Understanding the barriers to providing pessary care that health professionals report may highlight methods to overcome them. As with all education, adequate time is required to enable trainees to learn and retain skills and knowledge. It appears that practitioners would value formal training as well as the opportunity to practise their newly attained clinical skills.
Specialty of pessary care providers
Eight studies had a sample population solely consisting of doctors, three solely of nurses and two a combination of doctors, nurses and physiotherapists. This may represent the proportions of pessary practitioners in each profession. Doctors and nurses in advanced roles were identified as those most likely to provide pessary care (O'Dell et al, 2016). Other pessary practitioners included medical or nursing assistants, practice nurses, registered nurses and physician assistants (O'Dell et al, 2016). Neumann et al (2015) suggested that physiotherapists already possess the clinical skills to perform vaginal examination, assess prolapse and provide other conservative management options for prolapse and therefore could be trained to provide pessary care. The majority of trainees included in the study were physiotherapists (81%). It is possible that there was such a high ratio of physiotherapists to other professionals on this course as it was advertised through an Australian physiotherapy organisation. Following the course, one of the main barriers to independently providing pessary care, reported by 6% of physiotherapists, was that it was not perceived to fit within their role. Interestingly this was not a barrier reported by nurses. However, it is worth noting that only a small number of the trainees had actually started to fit pessaries when contacted for follow up, therefore only a few were able to state which barriers they had encountered, if any. In the same study 3% of respondents, made up of physiotherapists and a nurse, found that there was a lack of a policy to support pessary care to be delivered by those other than doctors in their environment (Neumann et al, 2015). There is no published research exploring pessary service-users' preferences about the profession of their pessary practitioner; however, this would be an important consideration before delegating the role to those other than doctors who have traditionally performed this role.
Therefore, it seems that the perception is not that pessary care is solely a role for doctors, but that there may be resistance to or barriers preventing those other than doctors and nurses from providing pessary care, despite receiving formal, standardised pessary training.
Ongoing support
The importance of ongoing support following pessary training was highlighted in two publications. Following pessary tuition from an expert, trainees spent five half days working in a tertiary pelvic floor clinic at a local hospital (Wilson et al, 2015). This enabled practitioners to develop clinical skills under the supervision of an experienced colleague despite not having this support in their own work setting. Wilson et al also advocated longer-term support for clinicians through mentorship and regular professional development. The authors suggested that where this is not locally available, it should instead be offered remotely using video or teleconferences or meetings at annual events such as conferences. In recognition of the lack of confidence that new trainees reported following training, Neumann et al (2015) suggested that ongoing mentorship may address this. It is suggested that local staff experienced in pessary care could become qualified pessary mentors to provide clinical supervision and ongoing training.
Discussion
It is clear that, at present, many pessary practitioners acknowledge a lack of training and feel this should be addressed. It appears that a combination of didactic and practical training is best to ensure a confident and competent practitioner who retains knowledge over time. Ongoing support is also necessary to ensure trainees become confident and translate pessary training into clinical practice. There is a broad consensus regarding the knowledge and skills required to be an effective pessary practitioner and these do not seem to differ depending on the profession of the pessary practitioner. Neumann et al (2015) demonstrated that pessary practitioner training across professions is possible and effective. However, further research is required exploring the clinical impact of pessary practitioner training with a particular focus on patient outcome and patient perspective as this is lacking at present.
Limitations
There are a number of methodological limitations. The studies took place over 5 different countries and 4 continents. As healthcare systems, health professional roles and training vary significantly between countries, the generalisability of findings is questionable. A further issue is that many of the studies had a sample population of only one profession, often doctors. Again, as training and roles vary greatly between different health professions, the generalisability of findings regarding training experience, barriers to training and confidence are likely to differ depending on the study population. Only Bugge et al (2013) and Neumann et al (2015) attempted to reduce this potential for bias by recruiting pessary practitioners regardless of their profession. A further possibility of selection bias is that five studies identified potential participants through membership of professional organisations of which they believed pessary practitioners would be members. This assumption means that the experience and opinions of pessary practitioners who are not members of professional organisations are not represented. Of the two studies that evaluated pessary training as an intervention, both were delivered from only one centre therefore the transferability of these findings to other settings is also not clear.
Conclusion
Pessary practitioners' dissatisfaction with current training was a consistent theme in the literature. A lack of adequate, standardised training appears to impact on clinician confidence and knowledge, as well as equitable access to evidence-based pessary care. A current high-profile issue in urogynaecology is that of mesh complications. A criticism of vaginal mesh procedures is that some were performed by surgeons who lacked sufficient training to operate safely and competently. Although the implications of a poorly managed pessary are much less severe than mesh complications, comparisons can be made as both involve insertion of a long-term medical device. Therefore professionals must learn from the current situation with mesh: to protect themselves as practitioners, to protect the availability of pessaries as a treatment option, and, most importantly, to protect patients.