International Urogynecology Journal

, Volume 24, Issue 6, pp 1017–1024

Vaginal pessaries for pelvic organ prolapse and urinary incontinence: a multiprofessional survey of practice

Authors

    • School of Nursing, Midwifery and HealthUniversity of Stirling
  • Suzanne Hagen
    • NMAHP Research UnitGlasgow Caledonian University
  • Ranee Thakar
    • Croydon University Hospital
Original Article

DOI: 10.1007/s00192-012-1985-7

Cite this article as:
Bugge, C., Hagen, S. & Thakar, R. Int Urogynecol J (2013) 24: 1017. doi:10.1007/s00192-012-1985-7

Abstract

Introduction and hypothesis

Vaginal pessaries may offer symptomatic improvement for women with pelvic organ prolapse (POP) or urinary incontinence (UI). This study aimed to investigate multidisciplinary perspectives on vaginal pessary use in clinical practice and to understand the service organisation of vaginal pessary care for women with these conditions.

Methods

A pretested, anonymous survey was e-mailed to members of the Royal College of Obstetrics and Gynaecology, the Association for Continence Advice and the Association of Chartered Physiotherapists in Women’s Health in the UK.

Results

A total of 678 respondents, from medical, nursing and physiotherapy professions, consented to survey participation and provided useable data (response rate 20.7 %). Doctors were significantly more likely to report involvement in pessary care than nurses or physiotherapists. Respondents were optimistic about the success of pessary treatment; however, a lower proportion reported using pessaries for UI than for prolapse. The majority of respondents used ring pessaries and shelf pessaries, most recipients were older women, and commonly an indication for fitting a pessary was that the woman was unfit for surgery. More than 15 % of respondents providing pessary care had not received training. Follow-up services for women with pessaries varied considerably.

Conclusions

The variation in pessary care delivery and organisation requires further study in order to maximise efficiency and effectiveness. The development of nurse- or physiotherapist-led models of care may be appropriate, but the effectiveness of such models requires testing. Furthermore, to potentially improve outcomes of pessary care, a greater understanding of the availability, content and process of training may be warranted.

Keywords

IncontinencePessaryProlapseService deliverySurveyMultidisciplinary

Introduction

Pelvic organ prolapse (POP) and urinary incontinence (UI) are common conditions in women [1, 2] that can lead to distress. Conservative management that includes pelvic floor muscle training and use of vaginal pessaries are the first-line treatment [3, 4]. Two Cochrane reviews suggest that there is not enough evidence of pessary effectiveness as treatment for either POP [5] or UI [6]. However, studies suggest that women with prolapse experience symptomatic relief on using pessaries [710]. One study even suggested that the use of pessaries in women with prolapse may offer therapeutic benefit in improvement of prolapse stage [11]. Successful pessary fitting for UI has been reported [12, 13], with some evidence of continued use at 6 months [14].

Three surveys of professional practice in relation to vaginal pessaries have been undertaken [1517]; one in the UK [15] and two in the USA [16, 17]. All three surveys focus on doctors who practice in gynaecology, and all suggest a high usage of pessaries, from 87 % to 98 % of survey respondents. However, in a recent multicentre feasibility trial, recruitment proved to be challenging, and one of the reasons given was that gynaecologists were not fitting high numbers of pessaries [18]. One potential explanation may be that although high proportions of gynaecologists use pessaries in their practice, they do not use them often, an explanation that would be supported by Pott-Grinstein and Newcomer [16], who reported that respondents fitted a mean of 2.4 pessaries a month.

There is minimal data on delivery and organisation of pessary services. The studies that do report such data identify inconsistency in pessary care within and across studies [12, 15, 16]. For example, one study reported that gynaecologists tended to provide pessary services themselves [16], whereas another described a nurse-led service [12]. There is some suggestion that 6-monthly review of women fitted with a pessary may be a common aftercare pattern [15], but others report a shorter (12-weekly) follow-up period [16]. Therefore, there is an outstanding need to comprehensively understand current pessary practice and delivery and organisation of pessary services. This study aimed to address this knowledge gap and specifically to describe the proportion of nurses, physiotherapists and gynaecologists using pessaries for treating POP or UI in the UK; what types of pessaries they use; how they organise follow-up services; and what follow-up care they provided.

Materials and methods

The study was an on-line, anonymous, survey of existing professional groups of nurses, physiotherapists and gynaecologists who have an interest in women’s health and/or continence problems. The sample was captured through the main professional organisation for each group involved, namely: the Association for Continence Advice (ACA, predominately nursing membership, n = 121); Association of Chartered Physiotherapists in Women’s Health (ACPWH, predominately physiotherapy membership, n = 238); and Royal College of Obstetricians and Gynaecologists (RCOG, predominately obstetricians and gynaecologists, n = 2923). In each case, members who indicated to their organisation a willingness to receive contact from outside agencies were sent an e-mail containing introductory information and a link to the survey. Where possible, the e-mail was sent directly from the organisation to the members (ACA/ACPWH), and where not possible (RCOG), the e-mail address list (no names or details) was provided to the researchers, who distributed the e-mails and then permanently deleted the list. The e-mail and front page of the survey provided information to each participant regarding the study. Confirmation was obtained from the West of Scotland Research Ethics Committee that ethical approval for the research was not required. However, ethical conduct in undertaking research was maintained. Participants were required to indicate their consent to participate before answering questions in the survey. One reminder was sent by e-mail, which again contained the link to the survey.

The questionnaire was developed specifically for the survey (Electronic supplementary material). It was piloted with four clinicians from across nursing, physiotherapy and gynaecology. Some minor amendments were made. In line with Cochrane guidance on electronic surveys [19], the questionnaire was kept short, was presented on a white background and the word “survey” was not used in the e-mail subject line. The pilot study suggested it would take approximately 10 min to complete the questionnaire. Questionnaire items focussed upon the respondent’s own clinical practice, the use/non-use of pessaries for POP or UI, indications for use for POP or UI, types of pessary used, aftercare and service organisation.

Initial analysis utilised descriptive statistics to describe respondents, use of pessaries or not, types of pessaries used, aftercare and service delivery characteristics. Subsequently relational statistics were used to explore relationships between variables. Statistical tests used were determined by the variable type and their distribution (chi-square tests were used for categorical variables, with Fisher’s exact test used for 2 × 2 tables; independent samples t tests were used to compare groups where the independent variable was continuous). The analysis plan was determined prior to analysis. To allow for multiple testing and increased risk of type I error, a significance level of 1 % was used throughout.

Results

A total of 696 participants opened the survey, eight did not consent and ten provided no useable data, leaving a total sample of 678 (20.7 % response rate); 555 (19.0 %) from RCOG and 123 (34.3 %) from ACA/ACPWH. The ACA/ACPWH responses could not be separated because they were sent from one list manager who had responsibility for both groups. Of the 678 respondents, 22.3 % (n = 151) were not involved in pessary care; most fitted and provided aftercare for women with pessaries (73.9 % n = 501), with a small proportion either fitting or providing aftercare (3.8 %, n = 26). The ACA/ACPWH respondents were significantly less likely to be involved in pessary care, with only 10.6 % (n = 13) indicating their involvement compared with 92.6 % (n = 514) of RCOG members (chi-square = 402.5 df = 2 p < 0.001). The reasons given for non-involvement in pessary care are displayed in Table 1. We hypothesised that those who did not have pessary fitting as part of their role would also be those who reported not having the skills; however, we found no statistical association between variables.
Table 1

Reasons given for noninvolvement in pessary care

 

RCOG (n = 39)

ACA/ACPWH (n = 109)

Totals (n = 148)a

Obstetric-only practice

16 (41.0 %)

0

16 (10.8 %)

Not part of professional role

13 (33.3 %)

66 (60.1 %)

79 (53.4 %)

Do not have the skills

0

83 (76.1 %)

83 (56.1 %)

Not necessary for the women I treat

5 (12.8 %)

3 (2.7 %)

8 (5.4 %)

Not appropriate for the women I treat

3 (7.7 %)

2 (1.8 %)

5 (3.4 %)

Do not think pessaries are an effective treatment for POP

0

0

0

Do not think pessaries are an effective treatment for UI

0

3 (2.7 %)

3 (2.0 %)

Other reasons

13 (33.3 %)

12 (11.0 %)

25 (16.9 %)

RCOG Royal College of Obstetricians and Gynaecologists, ACA Association for Continence Advice, ACPWH Association of Chartered Physiotherapists in Women’s Health

a Not all respondents answered all questions; percent calculated based on numbers responding

The 527 respondents involved in pessary care were directed to complete the remainder of the survey. Their mean age was 46.1 years [standard deviation (SD) 9.4], 52.4 % (n = 276) were women and they were qualified for an average of 21.8 years (SD 9.7). Most were doctors (96.8 % n = 487), 1.8 % were nurses (n = 9) and 1.4 % (n = 7) were physiotherapists. Most worked in district general hospitals (DGH, 63.6 %, n = 321), with 30.3 % (n = 156) in university hospitals and 5.5 % (n = 28) in other areas, including general practice, community hospitals and private consulting rooms. A sizeable minority of those involved in pessary care indicated that they had no training in pessary use (15.2 %, n = 77).

The median number of pessaries fitted in 1 month was five [interquartile range (IQR) 2.5:8; range 0–50). Only six people indicated they fitted >20 pessaries a month; the five who gave details of their professional background were all doctors. Respondents fitted an average of 2.88 (SD 1.35) different types of pessary, with ring pessaries and shelf pessaries being the main types fitted (Fig. 1). Shelf pessaries were significantly more likely to be fitted by doctors (87.1 % fitting) than nurses or physiotherapists (36.4 % fitting) (Fisher’s exact test, p < 0.001) and tended to be used more by those who had been qualified for less time [confidence interval (CI) 3.38–8.31; t = 4.661; 20.9/26.7 years; p < 0.001]. Male health professionals tended to use donut pessaries more than female professionals (chi-square statistic = 7.265, df = 1, 20.4 % male, 11.9 % female, p < 0.01). Other than those already stated, there were no further significant associations between the professional group of the person fitting the pessary, the length of time qualified or the health professional’s gender and type of pessary fitted. There was an association between a participant’s age and the length of time they were qualified; as length of time qualified is the more meaningful, the result relating to this clinical variable is the one presented. There were no associations between type of pessary used and whether the respondent had received pessary training.
https://static-content.springer.com/image/art%3A10.1007%2Fs00192-012-1985-7/MediaObjects/192_2012_1985_Fig1_HTML.gif
Fig. 1

Pessaries fitted at all and pessaries fitted most commonly

Respondents were asked to indicate which one pessary type they used most commonly. The ring pessary was used most commonly, followed by shelf pessaries (Fig. 1). Nurses and physiotherapists only ever indicated ring or shelf pessaries as the one they most commonly used. Whereas these two types were also mainly indicated as most commonly used by doctors, a small number also stated a Gellhorn pessary or another type as most commonly used. Silicone pessaries were used by 43.8 % (n = 217), latex by 5.1 % (n = 25), 26.3 % (n = 130) used both and 24.8 % (n = 123) did not know the type of material. Of the 527 respondents involved in pessary care, 519 answered the question about whether or not they fitted pessaries for POP: all indicated that they did. A considerably lower proportion of these respondents indicated that they fitted pessaries for UI (55.7 %, n = 286). Of those who did not fit pessaries for UI, 35.2 % (n = 80) indicated it was because they thought pessaries were an ineffective treatment for incontinence. Other reasons given were: a pessary could make UI worse, other treatments were better for UI than pessaries or they would refer onto someone else to fit the pessary for UI. The vast majority of participants who fitted pessaries for both indications more commonly did so for POP (99.2 %, n = 502) than for UI (0.8 %, n = 4). Table 2 outlines the circumstances under which a health professional reported fitting a pessary for POP or UI.
Table 2

Reported circumstances for fitting a pessary for women with pelvic organ prolapse or for women with urinary incontinence

 

Prolapse (n = 515)

Urinary incontinence (n = 281)

When a woman is unfit for surgery

98.8 % (509)

79.0 % (222)

When a woman is pregnant

62.5 % (322)

31.3 % (88)

When a woman is in the postpartum period

52.4 % (270)

31.0 % (87)

When a woman plans to have more children

59.8 % (308)

31.3 % (88)

When a woman is not sexually active

41.0 % (211)

21.0 % (59)

When a woman requests a pessary as treatment

95.0 % (489)

66.9 % (188)

When a referral to fit a pessary is received from another health professional

56.7 % (292)

33.1 % (93)

When it is an adjunct to pelvic floor muscle training

33.0 % (170)

42.0 % (118)

When it is part of preoperative evaluation

54.2 % (279)

57.7 % (162)

When all other treatment options are exhausted

43.1 % (222)

31.7 % (89)

For other reasons

6.6 % (34)

8.2 % (23)

Female health professionals were more likely than their male counterparts to fit pessaries as an adjunct to pelvic floor muscle training (PFMT) for POP (25.4 % male vs 38.5 % female, chi-square statistic = 9.52, df = 1, p < 0.01). There were no significant differences between respondent’s professional group or whether they had had pessary training and circumstances for fitting a pessary for POP. There were no significant associations between professional group, training, gender, time qualified and circumstances given for fitting a pessary for women with UI. Pessaries were fitted far more commonly in older women: 87.6 % (n = 462) of respondents indicated they most commonly fitted pessaries in women in the age category ≥60 years. No respondent indicated they most commonly fitted pessaries in women <40 years. There were no significant associations between training or gender and the age category of women to whom pessaries were fitted. Respondents were generally optimistic about initial fitting success and longer-term success (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs00192-012-1985-7/MediaObjects/192_2012_1985_Fig2_HTML.gif
Fig. 2

Respondents perceptions of proportions of women who will have successful fitting and long-term pessary success

Respondents involved in pessary care saw a median of five women a month for pessary aftercare (IQR 2:8; range 0–40), and only eight respondents saw >20 women a month for aftercare—seven of whom were doctors and one a nurse. There was considerable variance in responses about the organisation and content of pessary follow-up care (Table 3). In terms of health-care delivery at follow-up appointment, a significant association suggested that health professionals qualified for longer (28.7 years, SD 11.7) were less likely to ask a woman at a follow-up appointment about her experiences of having a pessary than those qualified for less time (21.5 years SD 9.5) (95 % CI 2.98–11.61, t = 3.32, p < 0.001). There were no significant associations between professional groups, where a professional worked or gender and health-care delivery at follow-up appointments. PFMT in addition to a pessary was significantly more likely to be recommended following fitting by those with pessary training than without (51.6 % vs 34.3 %, respectively; chi-square statistic 7.17, df = 1, p < 0.01) and by female than by male health professionals (54.9 % vs 40.9 %, respectively; chi-square statistic 9.04, df = 1, p < 0.01). There were no significant associations between professional group and the recommendations made at follow-up after pessary fitting.
Table 3

Features of follow-up care

Follow up care (n responses)

Responses

Percent (number)

Review appointments arranged (n = 502)

Yes

97.4 (489)

No

2.6 (13)

Frequency of follow up care (n = 508)

Monthly

0.2 (1)

3 monthly

11.2 (57)

6 monthly

85.0 (432)

Annually

3.5 (18)

Care offered at follow up appointments (n = 510)

Woman asked about pessary experience

94.9 (484)

Woman’s vaginal tissue is examined

94.5 (482)

Pessary is cleaned

25.5 (130)

Same pessary re-inserted

19.2 (98)

New pessary fitted

90.4 (461)

Woman’s bladder is scanned

0.2 (1)

Other

5.7 (29)

Recommended care following fitting (n = 475)

Self-care

17.7 (84)

Removal for sexual intercourse

10.5 (50)

Routine systemic oestrogens

0.2 (1)

Routine local oestrogens

20.0 (95)

Local oestrogens for specific problems

71.2 (338)

Practice pelvic floor muscle training

49.3 (234)

Other

8.0 (38)

Who was responsible for pessary fitting at respondent’s place of work (n = 508)

Gynaecologist

98.2 (499)

Nurse

32.3 (164)

Physiotherapist

2.2 (11)

GP

21.7 (110)

Other

1.8 (9)

Who was responsible for pessary aftercare at respondent’s place of work (n = 507)

Gynaecologist

85.2 (432)

Nurse

45.6 (231)

Physiotherapist

3.0 (15)

GP

44.8 (227)

Patient (self care)

4.1 (21)

Other

2.2 (11)

Dedicated pessary service (n = 508)

Yes

28.7 (146)

No

71.3 (362)

Who leads dedicated pessary service (n = 146)

Consultant

24.0 (35)

Nurse

74.0 (108)

Physiotherapist

1.4 (2)

Other

0.7 (1)

Discussion

This survey is the first to include non-medical professionals’ perspectives on service delivery and organisation of pessary care. However, it appears that pessary care is predominantly undertaken by medical staff, with very few nurses or physiotherapists in the women’s health field reporting that they had a role in pessary care. Commonly, respondents who were ACA/ACPWH members reported not undertaking pessary care because they did not have the necessary skills. Of those who did provide pessary care, 15 % reported that they did not have training. Respondents were optimistic about the success of fitting and longer-term pessary use, and there was a high level of consistency in the types of pessary used, with ring pessaries and shelf pessaries used most commonly. Although the majority of respondents were involved in pessary care, responses indicated that frequency was commonly five women seen a month for fitting and/or five women seen for follow-up; these women were most likely >60 years. Furthermore, the pattern of follow-up care and advice was extremely variable.

Most previous surveys relating to pessary use focussed on POP only or offered only minimal data separating POP and UI. In our survey, we noted considerable difference in the proportions of respondents providing pessary care for women with POP (100 %) and those with UI (55.7 %). There was some similarity in reasons given for use for both conditions, with a woman being unfit for surgery being the most common indication in both cases.

As this is the first survey reported in the literature to include non-medics, we offer a perspective that suggests service delivery in the UK may be heavily centred on medical practice, with some small pockets of nursing or physiotherapy delivered care. This is in keeping with Pott-Grinstein and Newcomers’ survey [16] in which 74 % of US-based gynaecologists report seeing patients themselves but differs from reports of nurse-led clinics in Canada [12]. Hanson [12] raised the possibility of up-skilling nurses to fit pessaries. Given that positive outcomes are reported for nurse-led clinics in urogynaecology more generally [20], it might be possible to reorganise service delivery such that a specialist nurse or physiotherapist takes the lead on pessary fitting and aftercare within a service. However, the clinical governance of such a service would require robust evaluation.

In our study, 15 % of those involved in pessary care had no training in that procedure. We did not specify training type in the questionnaire, and therefore, training could have been “on the job” or formal. Training was associated with a greater likelihood of asking a woman about her experience and about giving her advice to undertake PFMT, but not with other features of service delivery. Although lack of training is previously reported [16], lack of association with other features of service delivery is perhaps surprising. One may hypothesise that those with training may use pessaries differently than those who are untrained, but we found this was not the case. Pessary fitting is a skill that requires expertise and practice [21]. Given the relatively low number of women seen each month and the presence of a significant proportion of health professionals without training, further research could focus on understanding the optimal skill and training levels required to deliver effective pessary care.

As with a previous survey [17], the ring pessary was the type most commonly used. This was also one type that has previously been associated with high success rates [12, 22]. In our survey, medical doctors in particular also commonly used the shelf pessary, which was not commonly identified in other surveys. What is perhaps surprising is that, given the wide variety of pessaries on the market, such a limited variety are used, particularly given Gorti et al.’s [15] finding that 78 % of UK-based consultants tailor the pessary used to the defect identified. Possible explanations for this lack of varied use could lie in a requirement for more training to gain greater confidence, the financial implications of introduction of newer, costlier devices such as the Gellhorn and Cube pessaries or in a general reluctance by some clinicians to use pessaries except in cases when there is no other option. Ring pessaries and shelf pessaries have been used for a long time in the UK. It is only in recent years that other kinds, e.g. Gellhorn and Cube, have been introduced into practice; hence the use varies nationally between hospitals and users.

Our contemporary findings suggest that currently practising health professionals who fit and manage pessaries may be more optimistic about success rates (Fig. 2) than the rates quoted within papers published 15–20 years ago (Sulak reported an average length of pessary use of 16 months [23], and Wu et al. [22] reported that of those who use pessaries for >1 month, 66 % will continue for 1 year and 53 % for 3 years). Our findings, as with those of others, suggest a tendency towards greater use for older women (Hanson et al., mean age 63 years [12]; Manchana and Bunyavejchevin, mean age 66.7 years [9]; Cundiff et al., mean age 61 years [7]; Lone et al., median age 70 years [24]). Thus, although health professionals may be more positive in their beliefs about the success rates and long-term use of pessaries than suggested in earlier studies, the women who receive pessaries still tend to be older. This may suggest that conservative treatment options are missed for younger women or that younger women reject pessaries as an option [25], which requires further investigation, particularly if reports of therapeutic benefit are corroborated [11].

Most respondents involved in pessary care reported a 6-month follow-up period, although, as with previous studies, there was still variability in response [15]. Other studies report no major complications in the use of a protocol that follows a 3-monthly review for the first year and 6 monthly thereafter [22]. Complications due to pessary usage have been described mainly in case reports [26, 27] and are mainly due to neglect, i.e. inadequate monitoring/periodical inspections [28]. Of interest, only 17.7 % of respondents advised women to manage their pessary themselves; this is in contrast to the findings of Pott-Grinstein and Newcomer [16] and contradicts the recommendations of Hanson [12]. Self-care is a central tenant of much contemporary health-care policy; however, it is possible that health professionals feel that they do not have the time to teach women the required skills or that women reject self-care as an option. There was a tendency for health professionals to replace pessaries at follow-up rather than to wash and reinsert the same pessary, the latter being a model advocated elsewhere [21]. The evidence for or against pessary reuse is minimal. Although pessaries are reused in other health-care systems [21, 22], the usual practice in the UK is to insert a new one. Further evidence of effectiveness and acceptability would be beneficial to practice. Overall, there was a variance in the services offered and advice given to women at follow-up that would suggest more evidence is needed to reveal aspects of care that are best and most effective practice.

Our survey provides data on both POP and UI. It suggests that pessaries are used to treat POP much more commonly than UI. Although Cochrane reviews for UI [6] and POP [5] each report a lack of evidence of effectiveness, there is perhaps a greater body of evidence overall supporting the symptomatic benefits for POP [79] than there is for UI. However, Hanson’s observational study [12] notes successful fit (of at least 1 month) for 64 % of women with stress UI, 67 % for mixed UI and 64 % for urgency UI. Our findings suggest that there is a lack of professional consensus about pessary use in practice and that as a consequence women, unless unfit for surgery, may be less likely to be offered a pessary as a treatment option for UI.

These data provide previously unavailable evidence that pessary care in the UK seems to be mainly in the domain of medical staff. This knowledge perhaps enables us to consider the alternative service organisation possibilities in keeping with the recent Health and Social Care Act 2012 [29]. A robust randomised clinical trial of a nurse-/physiotherapy-led services compared with standard care would allow assessment of effectiveness and cost effectiveness. Furthermore, it is clear that pessary services are focussed on older women. The reasons for this could usefully be explored, using a qualitative research design with younger women, to gain their views on pessary treatment for POP or UI. and perhaps a complimentary study with clinicians to explore why they tend to use pessaries more with older women, as well as their views on training needs and alternative forms of service organisation.

The main limitation of the findings rests within the low response rate. However, our number of respondents from RCOG is similar to the number of respondents who used pessaries in practice in Gorti et al.’s UK survey [15]. Although we know the survey was sent to 3,282 e-mail addresses, the true denominator is likely to be considerably lower than this. The RCOG list has members for whom the survey would not be relevant, principally those practising obstetrics only, and a number who were retired. There was likely to be overlap on the lists, particularly the ACA and ACPWH lists. Thus, the appropriate response rate would be higher. Our respondents were all based in the UK or Irish Republic. Consequently, the findings may be less applicable in other health-care systems. The low proportion of nurses and physiotherapists involved in pessary care is surprising. One potential explanation is that the professional organisations we chose to survey do not, in fact, have memberships that include nurses and physiotherapists who provide pessary care. However, ACA and ACPWH are core organisations for those involved in urogynaecological care, so that explanation may be unlikely. Overall, we received responses from a diverse group of professionals who provide pessary care. Given our respondents were positive about the initial and long-term success of pessaries, it may be that the survey has greater representation from enthusiasts and that the findings may thus represent a more optimistic view that generally prevails.

Conclusion

Health professionals were generally optimistic about the success of pessaries. Many who offer pessary care have no training for the role, and many who do not offer pessary care indicate it is because they do not have the skills/training. Thus, to potentially improve services and outcomes, we may want to ensure that a greater proportion of those who are, or could be, involved in pessary care have appropriate training. The variance in service delivery and organisation requires further evaluation to rationalise services. It may be that there are opportunities to develop services for women by adopting nurse- or physiotherapist-led models. However, the effectiveness of the model requires testing.

Acknowledgments

We acknowledge the contribution of those who responded to the questionnaire.

Conflicts of interest

None.

Supplementary material

192_2012_1985_MOESM1_ESM.pdf (292 kb)
ESM 1(PDF 291 kb)

Copyright information

© The International Urogynecological Association 2012