Introduction

Pelvic organ prolapse and stress incontinence are common conditions that affect 50% and 30% of women respectively [1, 2]. Over 70% of women with these conditions can be successfully fitted with a vaginal pessary for relief of symptoms [3]. Pessaries may be used indefinitely with regular follow-up or may be used as a temporizing measure for symptom relief while awaiting surgery.

Many patients fitted with a vaginal pessary can learn removal and reinsertion of the pessary independently. This is known as pessary self-care. The ability to perform self-care provides several advantages to patients and the health care system, including less frequent scheduled follow-up visits, the ability to follow up with primary care providers who do not have pessary care experience, and the opportunity to take more frequent brief pessary breaks. These pessary breaks can be scheduled weekly and may decrease the risk of complications such as vaginal discharge or erosions, which are common reasons for pessary discontinuation.

Previous exploratory studies on pessary use have found pessaries to be a highly acceptable treatment modality in a range of different populations [4]. Support and encouragement from members of the health care team seems to positively influence patients’ desire to pursue a pessary fitting and continue with pessary use. Given the burden of pelvic floor disorders in our aging population [5] and the high demand for pessary care in our region, we aimed to develop strategies to optimize the proportion of women doing regular pessary self-care to promote access and minimize system burden while ensuring effective, safe care. We have not encountered prior studies that explore patient and provider perspectives on what limits or encourages women to learn pessary self-care. The objective of this study was to explore the attitudes and beliefs related to pessary self-management among patients recently fitted with a pessary and providers who facilitate pessary fittings to inform strategies to promote pessary self-care.

Materials and methods

Setting and design

In this qualitative study, patients being fitted with pessaries and health care providers who regularly provide pessary care were invited to complete semi-structured interviews. Patients were invited to participate at the time of the pessary fitting appointment with either a nurse continence advisor or urogynecologist. Patients who expressed an interest in participating were contacted by phone by a member of the research team to obtain consent and for interview scheduling. Patients were eligible if they were 18 years of age or older, spoke English, and did not have significant cognitive impairment (defined as a documented diagnosis of dementia, mild cognitive impairment, traumatic brain injury, or global developmental delay). Health care provider participants (nurse continence advisors and urogynecologists) were invited to contact the research team if they were interested in participating following an announcement at a divisional meeting. There was no incentive provided for participating in the study.

Sample size was determined by data saturation, which we defined for the purposes of this study as theoretical sufficiency to generate thematic meaning to address our research question [6]. This occurred after 14 interviews.

Data collection

Interviews were completed by two medical students (PG and AE) who have experience in facilitating qualitative interviews. They had both interviewed for previous qualitative studies including pelvic floor-related subject matter (AE). Interviews were guided by a semi-structured interview guide (Supplemental file 1). The patient interviews lasted 19 min on average (range: 13 to 27 min). All interviews were recorded and transcribed by a research assistant (AvD) verbatim.

Data analysis

A constructivist approach to codebook thematic analysis was undertaken using the constant comparison method. The initial coding framework was a modification of that used by Nissen et al. [4] in their study, which was aimed at understanding the experiences of long-term pessary users in Tanzania. The coding framework was applied to the data, which was coded according to the created categories. Interviews were independently reviewed by three investigators (PG, JS, and AC) who refined the coding framework iteratively using consensus as themes emerged and converged employing methods described by Braun and Clarke [7]. We took a factual standpoint (assuming data to be accurate representations of reality), focusing on manifest content of the data (i.e., descriptions of what is said, rather than interpreting sighs, posture, laughter, etc.). When 20% of the data was coded, the coding framework was reviewed, and new categories added inductively (Table 1). NVivo 12 was used for the coding and data analysis.

Table 1 The theme “motivation” and sub-themes with participant quotes
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Results

Fourteen participants from The Ottawa Hospital were recruited for this study. Ten of 11 patients, and 4 of 8 health care providers who were approached agreed to participate. Amongst those who completed interviews, 10 participants were patients using pessaries and 4 participants were health care providers (physicians or nurses) fitting pessaries and teaching self-care. The median age of patients was 66 years (range 42 to 85). Eight patient participants had used the pessary for less than 3 months but 2 had used a pessary for more than 5 years and recently underwent re-fitting. All patients could describe their pessary, but 9 out of 10 did not know the formal name or size. All patients except one were engaged in self-care following the initial fitting.

The data were coded into basic themes within three categories: motivations, benefits, and barriers. In each category, codes were grouped into organizing themes as patterns were identified through interpretive engagement with the data [8].

Motivations for pessary self-care

The most common motivators for learning pessary self-care were ease, personal hygiene, and health care provider advice (Table 1). Patients described learning to insert and remove their pessary as a relatively simple procedure and expressed that they felt capable of performing this on their own after initial instruction.

Many patients described caring for their pessary as important for hygienic reasons. They compared learning pessary self-care to other routine hygiene activities such as changing undergarments and brushing teeth. Providers highlighted the minimization of vaginal discharge associated with regular removal and cleaning as a means of promoting patients’ perception of cleanliness. Providers felt that maintaining cleanliness was a motivator for patients.

Health care providers also played a prominent role in motivating patients to learn self-care. Health care providers described the importance of explaining the benefits of self-care, taking time to ensure patient understanding with step-by-step instructions, and providing reference pamphlets to aid in success with self-care outside of the visit. Providers described their role as normalizing self-care and strongly encouraging patients to learn self-care. Some patients also believed self-care was the standard practice and expressed that they did not feel that they were offered provider-led care. Moreover, many patients described being comfortable with the health care provider as an important facilitator for learning self-care. Patient 6 stated,

“They were very good listeners and very positive so then you feel more relaxed and confident.”

Benefits of pessary self-care

Several benefits of self-care were described by participants (Table 2). Caring for their own pessary provided patients with autonomy of care. Nine out of 10 patients felt capable of inserting and removing their device following their pessary-fitting appointment, which includes self-care education. Patient 4 explains her experience:

“When I insert it myself, it’s just more responsible–no it makes more sense, you know it’s my body, and if there is anything wrong, I’m more aware of it. I suppose that’s instead of having someone else look at it.”

Table 2 The theme “perceived benefits” and sub-themes with participant quotes
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Patients also felt that self-care fosters independence, which they greatly valued. They believed it was important to learn to manage their pessary rather than depending on health care providers. Health care providers held similar beliefs, stating that self-care gives patients more control over their body and ownership over the management of their condition.

Participants described self-care as being beneficial to their sexual relationships, as 4 out of 5 sexually active patients indicated that they were removing their pessary for intercourse. Four of the 9 patients who did self-care were not sexually active, but providers described desire for sexual activity to be a strong patient driver in engaging in self-care and reported discussing sexual activity as part of their counseling to promote self-care.

Both patients and health care providers described self-care as more convenient in terms of time dedicated to care. They specifically highlighted that self-care minimized the number of follow-up visits required. Some patients did not live near the clinic, and they highlighted the decreased number of follow-up visits as a major benefit because it minimized the requirement for travel. Several patients described engagement in self-care as a means of helping to reduce the burden on the health care system, with one commenting that the current 8-month wait time for a fitting appointment was long. They expressed a sense of duty to perform self-care to promote access to others and minimize their contribution to an overburdened system. Providers echoed this benefit and described that the default strategy at the clinic among providers at the time of the study was to teach self-care owing to a lack of appointment availability. Health care providers also noted an additional benefit that was not expressed by patients interviewed in the study: they described that pessary self-care reduces complications such as tissue irritation, erosion, laceration, bleeding, and discharge build up. The health care providers reported that they often mention this benefit to patients.

Barriers to pessary self-care

Patients and providers faced barriers to learning or teaching pessary self-care (Table 3). Some patients described physical limitations due to medical conditions such as arthritis or obesity or age-related physical changes such as decreased flexibility. Patients also described structural limitations related to the pessary itself, including difficulty grasping the pessary without a handle and challenges in bending the pessary during insertion. They expressed that their physical limitations were compounded by structural limitations to make self-care more challenging. Importantly, many patients described succeeding in self-care despite physical limitations and highlighted modifications such as the addition of a loop of dental floss or having a supportive partner assist them in performing self-care as a means of mitigating the impact of structural barriers.

Table 3 The theme “perceived barriers” and sub-themes with participant quotes
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Other patients reported facing mental barriers and these were also reported by providers when describing unsuccessful self-care teaching during pessary fittings. Some patients self-identified as lacking the mindset to learn self-care, whereas others reported believing that health care provider-led care resulted in improved health outcomes. Providers described some patients as having negative attributions toward self-care from the outset of the appointment and identified this mindset as a major barrier to consideration of self-care. Providers also described teaching self-care to patients with some medical conditions, such as dementia, as challenging and potentially futile. Finally, providers expressed that they suspected that some patients preferred frequent follow-up visits owing to the social nature of appointments, particularly in the context of limited social interactions during the COVID-19 pandemic.

Both patients and health care providers noted that negative emotions, including anxiety and fear, can pose a challenge to learning self-care. Health care providers found that it was harder to facilitate self-care in patients who did not have appropriate prior counselling or knowledge of pessaries, or who were not able to understand self-care as effectively owing to language barriers.

Time was noted as a barrier for patients and health care providers. One patient mentioned that caring for the pessary was time consuming and conflicted with her work schedule. In the clinical setting, health care providers faced time constraints when teaching self-care. Providers described the challenge of taking adequate time to counsel and coach patients to ensure capability and promote feelings of self-efficacy around self-care prior to the completion of an appointment. Providers highlighted that this was particularly challenging in clinical situations where multiple fittings were completed to find the perfect pessary fit for the patient, as these appointments often run over the scheduled time to perform the fitting alone. No patients mentioned a time limit to the appointments, but patient 8 returned twice after some vaginal irritation with her initial fitting and expressed gratitude to the nurse who found a successful pessary:

“I had an excellent nurse…This particular nurse did not give up…Now we have a pessary that works.”

Last, social taboo emerged as a barrier to self-care. Both patients and providers expressed that there is a desire among some users for secrecy around pessary use. Some patients expressed embarrassment around the requirement for pessary use. Additionally, many interviewees highlighted the lack of knowledge around the prevalence of pelvic floor disorders and pessary use as drivers of feelings of isolation and shame around pessary use. The desire for discretion was highlighted as a driver of engagement in health care provider-led care.

Discussion

This study builds on previous literature that evaluated patients’ experiences with pessary care in general by exploring patient and provider perspectives on engagement in pessary self-care. Three major themes around self-care of pessaries were identified: motivators, benefits, and barriers. The patients interviewed were generally comfortable to try to learn self-care, and they were motivated to succeed in caring for their own pessary. The major motivators were ease of self-care, personal hygiene, and health care provider advice. Participants noted several benefits to self-care, including autonomy, convenience, decreased burden on the health care system, maintenance of sexual relations, and reduced complications. Despite these advantages, barriers were identified that challenged patients’ ability to perform self-care. Physical, mental, or emotional conditions, structural issues, and social taboos posed barriers to learning pessary self-care. A lack of knowledge and limited time were factors that seemed to challenge the ability to learn self-care. Many patients expressed being able to overcome some of these barriers to engage in self-care.

Our findings contrast with those of another Canadian study that found that most women preferred regular appointments with health care providers to the option of self-care [9]. Storey et al. [9] identified psychological comfort with touching oneself as a factor in choice for provider-led care and hypothesized that this might be related to generational differences and patient age [10]. Our study, completed 13 years later, included patients with a similar median age but noted a much higher acceptability of self-care. Previous literature has noted that younger age is associated with higher rates of self-care and perhaps the distribution of patients who find self-care to be acceptable will grow as our population ages. This may suggest decreasing social taboo around pelvic floor disorders, or simply that as our population ages, generational barriers are less prevalent.

The social taboo around pelvic floor disorders was noted as a possible barrier to self-care by some, but 9 out of 10 patients expressed challenges with physical and structural limitations of maneuvering the device. Holubyeva et al. [11] noted that patients with a higher body mass index, advanced arthritis, and cognitive impairment had a lower rate of self-care in a retrospective chart review of 1,659 patients. Our study builds on this finding, noting that many health care providers felt that these factors were barriers to teaching and learning self-care, and it is not always clear whether these women are offered self-care in all settings. Half of patients interviewed expressed comfort with having their partner help them with the pessary if needed, which suggests some openness regarding disclosure of their pelvic floor disorder, and the potential for recruitment of other caregivers to aid in pessary care. Undoubtedly, willingness to participate in the current study may confer a certain level of psychological comfort in discussing pessary use, which may not reflect the mindset of nonparticipants. This potential selection bias is an important limitation of the current study.

Autonomy of care was a major sub-theme among 12 of the 14 participants in our study. Storey et al. [9] found that patients were often unable to practice self-care owing to the fear of reinserting the pessary independently. This was not a prominent finding in our study, perhaps because of the timing of interviews in relation to pessary fitting. Although some patients expressed emotional barriers such as fear and apprehension, this was in the context of having overcome the barrier.

Only health care providers expressed the socialization benefit of health care provider-led care as a potential self-care barrier. Frequent follow-ups bring forth a routine and give patients an opportunity to interact with others. Previous literature has noted that older patients describe pessary clinic visits as a social outing and as a significant part of their lives [9]. Given the increased isolation, particularly among the elderly [12, 13] with COVID-19 pandemic restrictions, we expected this theme to emerge in patient interviews. No patients identified concerns around COVID-19 social restrictions as a factor in choosing self-care or provider-care of their pessary. COVID-19 was noted to be a reason for choosing pessary for management owing to delays in operating room access. The support and encouragement from providers were positive factors in learning self-care, but perhaps the effect of pandemic-related restrictions on attitudes to care warrants further study.

Health care provider advice was a major motivation for self-care. The nurses and physicians mentioned that reduced complications were a significant benefit to pessary use and other studies have documented that patients who care for their pessary themselves experience significantly fewer adverse events including vaginal bleeding, discharge, and vaginal erosion [14]. Moreover, it was health care providers in our study who strongly considered current sexual function status in the motivation to teach self-care. Self-care is more common among sexually active patients [11], but many patients who are not sexually active perform self-care. A systematic review found that pessaries significantly improved sexual functioning and provided a better quality of life [15]. In light of this, self-care counseling by providers should focus on potential future sexual function aims rather than current level of activity.

Finally, economic analyses have demonstrated that self-care is more cost-effective [16] and, interestingly, it was our patients (rather than providers) who commented on the burden of recurrent pessary care visits on our health care system. The awareness of allowing access for other patients may be reflective of the significant quality of life impact of pelvic floor disorders. Many patients have been directly impacted by increased wait times for pessary fittings in our region during the pandemic.

One of the strengths of this qualitative analysis is the depth and detail of patient interviews, which allow for rich exploration of patient perspectives around a potentially sensitive topic. Further, individual interviews rather than focus groups may have promoted candid responses by minimizing perceptions of judgment by peers. Finally, our analysis was grounded in established theory to promote best practice in the generation of themes. Limitations of this study include the small sample size of patients, which may affect the generalizability of our findings and limit our ability to analyze subgroups. Unintentionally, 9 of the 10 patients we interviewed practiced self-care, and many had overcome barriers successfully. Self-care is the most common outcome for ongoing pessary care in our clinic among patients who have new pessary fittings. Interviewing a group of patients who preferred health care provider-led care may have revealed differing perspectives.

Conclusion

Overall, our findings suggest that there might be a wide variety of factors that influence desire and ability to learn or teach self-care. When introducing the concept of self-care, health care providers can focus on common motivators and highlight benefits such as reduced adverse complications and improved sexual function. By recognizing barriers to engagement in self-care, providers can tailor their practice to mitigate them. Future work will focus on the development of resources for patient education around pessary self-care.