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Easing the pressure

Easing the pressure
20 October 2015

Bringing a ring pessary service from secondary care into primary care has made a huge difference to the patients of Oldham

Bringing a ring pessary service from secondary care into primary care has made a huge difference to the patients of Oldham

Genital prolapse or pelvic organ prolapse is defined as the descent of the pelvic organs in to the vagina. It occurs when the pelvic muscles and connective tissues weaken. It is often asymptomatic and diagnosed during clinical examination as an incidental finding.
The exact prevalence is unknown as many women with prolapse do not consult the doctor. In the United Kingdom, prolapse accounts for 20% of women who are on the waiting list for major gynaecological surgery.

Forty per cent of participants in the women’s health initiative (WHI) trial in the United States had some degree of prolapse. Of the 27,342 women enrolled in the study, uterine prolapse was seen in 14% of women.

The Oxford Family Planning Association study followed women in the age group 25 to 39 years and found the hospital admission with prolapse was 20.4 per 10,000 annually and the incidence of surgery for prolapse was 16.2 per 10,000 annually.

Risk factors
The most common risk factors are increasing age, obesity, high parity, and pregnancy, conditions that raise the intra abdominal pressures like heavy lifting, constipation, manual work and chronic obstructive pulmonary disease (COPD). Caucasians are at greater risk as compared to Asians, Africans and Americans. Menopause due to oestrogen deficiency also increases the risk.

Other less common causes are congenitally short vagina, multiple or large babies and previous pelvic surgery such as hysterectomy, bladder repair or colposuspension and pelvic tumours.

Stages of prolapse

  • Stage 0: No prolapse.
  • Stage one: The most distal portion of the prolapse is greater than 1cm above the level of the hymen (within the vagina).
  • Stage two: The most distal portion of the prolapse is less than or equal to 1cm proximal or distal to the hymen (descent to the introitus).
  • Stage three: The most distal portion of the prolapse is greater than 1cm below the hymen but protrudes no further than 2cm less than the total length of the vagina.
  • Stage four: The full length of the prolapse bulges out of the vagina.


  • Anterior compartment
  • Urethrocele (prolapse of urethra).
  • Cystocele (prolapse of bladder).
  • Cystourethrocele (prolapse of bladder and urethra).
  • Cystourethrocele (prolapse of bladder and urethra).
  • Middle compartment.                
  • Uterine or vault descent.
  • Enterocele (herniation of pouch of Douglas).      
  • Posterior compartment.
  • Rectocele (prolapse of rectum).

The most common type of prolapse is cystocele, followed by uterine and then rectocele.

Conservative management must be offered to all patients by a primary care physician. Watchful waiting is most appropriate if prolapse is stage one. These women must be examined every four-six months to look for development of new symptoms or signs for the rest of their lives.

Weight management advice should be given to all women if body mass index (BMI) is greater than 30. High fibre diet to avoid constipation and straining, avoiding heavy lifting and pelvic floor exercises can all aid the management of mild prolapse.

Pelvic floor exercises (PFE) must always be encouraged postpartum during postnatal examination. PFE can prevent the progression of prolapse and alleviate mild symptoms of prolapse. They are not useful in stage three or stage four prolapse.

If the prolapse is related to menopause hormone replacement therapy (HRT) might be beneficial and can be tried for short period if no contraindications.

Vaginal pessaries have an established role in those who are not keen on the surgery, are medically unfit for surgery and those waiting for the surgery. The most commonly used are ring and shelf pessaries.

Complications related to pessary use are uncommon; the most common ones are vaginal infections, ulcerations, erosions or cystitis.

Urgent referral to secondary care
Patients with complete procidentia, vaginal ulceration or urinary retention should be referred to secondary care as specialist input is needed for their management.

Oldham pessary service
One of the key measures of NHS Oldham’s quality, innovation, productivity and prevention (QIPP) programme is the aim to minimise hospital follow up appointments and treat patients more cost-effectively wherever possible. The resulting key performance indicators (KPIs) applied to provider contracts to reduce variation in follow up activity levels led to the local acute trust’s (Pennine Acute – Royal Oldham Hospital) re-thinking its follow up processes.

One consequence has been the local acute trust’s decision to discharge (rather than arrange follow-ups) for patients requiring regular pessary changes – a service that can and should be delivered in a primary care setting.

However, without primary care services in situ to meet demand, patients faced the prospect of seeking a GP referral each time they required their pessary changing, and the clinical commissioning group (CCG) faced a big bill of first appointments as opposed to follow-ups (more than double the cost).

Oldham commissions gynaecology outpatient services from the Greater Manchester clinical assessment service (GMCATS) – a Care UK service provided from mobile units at multiple locations across Greater Manchester.

However, as referral exclusion criteria apply to this service (BMI, co-morbidities, etc), it cannot treat everyone requiring this service.

Taking into account the following strategic priorities:

  • Patient’s choice.
  • Care closer to home.
  • Primary care capacity and capabilities.

Oldham CCG supported an intention to move towards asking GPs who could provide this service.

Being a GP with a special interest (GPwSI) my practice took this opportunity and have been providing the pessary change and new pessary insertion for prolapse patients since October 2012.

Service outline
Patients are referred via choose and book. Choose and book is a national electronic referral service and gives patients a choice of date of appointment, place and time of the appointment. Leaflets explaining the most commonly asked questions are posted to the patient with the appointment:

  • What is a ring pessary?
  • Why do I need one?
  • What happens during the appointment?
  • Side effects of pessary.
  • Will it affect my sexual life?
  • How often would it need replacing?
  • Name of the GP and telephone number.

The dedicated ring pessary clinic is held on a Wednesday in my health centre and three-four patients are seen every week.

At the time of consultation, consent is taken. Blood pressure, BMI and urine is checked by the nurse. The nurse enquires smoking history, alcohol consumption and list of medication.

All necessary policies and procedures are in place – infection control, consent policy, patient leaflet and satisfaction survey.
After a pelvic examination a suitable size pessary is inserted. Patient is sent home with the advice leaflet and a letter goes to the GP the next day.

Attendance figures
From October 2012-September 2013 it was very slow to start with:

  • Total referrals: 43 (no referrals in October 2012 and November 2012).
  • Pessary fitted: 39
  • Pessary not needed: 4
  • Referral to hospital: 0
  • Vaginal infections picked up: 8

The figures from October 2013-October 2014:

  • Total referrals: 108. Actual attendance 107 (one did not attend (DNA))  
  • Pessary fitted: 97
  • Did not attend: 1
  • Pessary not needed: 7 (and one DNA)
  • Referral to hospital: 2
  • Vaginal infections picked up: 16

The clinical governance framework audit process is the responsibility of my practice manager. The team meets monthly to make sure the service delivers KPIs.
Performance indicators are achieved at a rate of 98-100% (see Table 1 for a difference in hospital and general practice costs).

Taking in to account the cost of pessary, speculums, nurse and reception staff payments, the practice has not made much profit but has delivered the main aim – to ensure the cost effective care for female patients in the settings of their choice so that women do not have to take time off from work and do not have to pay heavy car park fees.

This service provision is sustainable because it utilises the skills of a primary care clinician. This model can be replicated anywhere because patients would like to be seen in an environment most appropriate to their needs.

The practice was one of the four finalists in the Medical Defence Union Group Scheme and GP enterprising Award in July 2014.

The practice won second prize in the Primary Care Women Health Forum (PCWHF) in August 2013: promoting best practices for women in primary care.

The service has brought smiles to Oldham CCG, primary care and secondary care colleagues and the practice team.

Dr Anita Sharma (pictured above), GP and clinical director vascular care and prescribing, Oldham CCG.

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