Title: Demographic, Socioeconomic and Functional Health-Related Factors in the selection of
vaginal pessaries used for the conservative treatment of pelvic organ prolapse: a retrospective
study
Version: 3 Date: 21 Nov 2024
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
No - there are minor issues
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are minor issues
EXECUTION - Are the experiments and analyses performed with technical rigor to allow
confidence in the results?
No - there are minor issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
Probably - with minor revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: This study on the factors influencing the choice between daily
control pessaries (DCP) and long-term wear pessaries (LTP) for pelvic organ prolapse
(POP) provides valuable insights into the demographic, socio-economic, and health-related
considerations shaping patient preferences. Strengths include its practical focus, novel
exploration of under-researched variables (e.g., hand function, vision, and mobility), and
relevance to clinical decision-making. The findings are well-contextualized with historical
and contemporary literature, offering actionable guidance for healthcare providers. However,
limitations such as the retrospective design, small sample size, and occasional overemphasis
on practical recommendations detract from its generalizability. Repetitive content and missed
opportunities to deeply analyze key findings, such as educational influences and sexual activity,
weaken the narrative. Despite these issues, the study highlights critical gaps in pessary research
and underscores the importance of individualized treatment approaches, making it a valuable
contribution to POP management.
REQUESTED REVISIONS:
I recommend to take into account the following suggestions:
- Introduction: The repetition of the general risks and recurrence rates of surgical interventions
could be streamlined for conciseness.
- Introduction: Sentences like "currently, this surgery... is the most effective method" could be
clarified and referenced more explicitly to avoid ambiguity.
- Introduction: Consistency in the terminology of pessary types (e.g., "daily control pessary" and
"long-term wear pessary") should be maintained throughout the text to avoid confusion.
- Introduction: While recurrence rates for sacrocolpopexy are mentioned, it would be helpful
to provide additional comparative data for surgeries and pessary use outcomes to contextualize
the discussion.
- Introduction: Among POP, cystocele represents of the most challenging condition: the prolapse
of anterior compartment, indeed, could be treated by both prosthetic surgery and native tissue
repair. I suggest to discuss pro and cons of these two approaches.
- Introduction: The study comparing pessaries and reconstructive surgeries only mentions a
one-year follow-up. Expanding on longer-term outcomes would strengthen the argument for
conservative therapy.
- Introduction: The sentence "In most cases, it is possible to find a pessary that suits the patient"
may overstate the efficacy of pessaries without acknowledging cases where this might not be
true.
- Introduction: The hypothesis and aim of the study are somewhat abrupt at the end of the text.
Introducing these earlier or transitioning more smoothly would improve the flow.
- Introduction: While the pandemic reference is relevant, it feels tangential to the core discussion
of POP treatments and could be condensed.
- Introduction: The section lacks an explanation of why certain pessary designs (e.g., cube vs.
ring) might be preferable for specific patients, which would support the stated hypothesis.
- Introduction: While the historical context is interesting, its placement disrupts the flow of the
argument. Integrating it more smoothly into the narrative or relegating it to a sidebar/footnote
could help.
- Methods: The sample size of 115 patients is relatively small, particularly when divided into two
subgroups (73 and 42). Addressing whether this size provides sufficient power for the statistical
tests used would improve reliability.
- Methods: Information about how the sample was selected (e.g., convenience sampling, random
sampling) is missing, which may introduce selection bias.
- Methods: The methods state that data were collected through "patient questionnaires or
telephone interviews." This dual approach could introduce variability in responses due to
differing levels of clarity or understanding. Clarification on how these were standardized is
needed.
- Methods: While described as "retrospective," it is unclear whether all data were obtained from
existing medical records or if some were newly collected via the questionnaires/interviews. This
blending could affect study rigor.
- Methods: Terms such as "independence" and "physical activity" need clearer operational
definitions. For instance, how is independence measured or quantified?
- Methods: The rationale for including these specific variables as potential predictors of pessary
choice is not well explained.
- Methods: Although the mean duration of pessary use is provided, the large standard deviation
(e.g., 28.3 ± 23.6 months for LTP) suggests considerable variability. Discussing this variability
and its potential impact on results is essential.
- Methods: The options for why patients chose pessary therapy are predefined. It is unclear
whether these options were based on prior research or developed ad hoc. Additionally, an option
for open-ended responses might yield richer qualitative insights.
- Methods: While the statistical tests are mentioned, details about how assumptions (e.g.,
normality for t-tests) were tested are missing.
- Methods: The methods do not clarify whether adjustments were made for potential confounding
variables.
- Methods: Although ethics approval is noted, there is no mention of informed consent
procedures or whether patients were informed of their rights during data collection.
- Methods: The methods do not acknowledge potential limitations, such as recall bias from
questionnaires/interviews or the retrospective nature of the study.
- Methods: Typographical errors, such as "continously" instead of "continuously," should be
corrected.
- Discussion: There are instances of repetitive content, particularly regarding the advantages
of daily control pessaries (DCP) for sexually active or younger patients. Streamlining this
information would enhance readability.
- Discussion: While the discussion touches on many topics, it does not sufficiently emphasize
some of the study's most impactful findings, such as the demographic and functional differences
between DCP and LTP users.
- Discussion: References to cultural or geographical variations in pessary use (e.g., Hungarian
and French surveys) are interesting but could benefit from a more nuanced analysis of how these
differences might affect applicability in other regions.
- Discussion: Although the high recurrence rates of POP after surgery are mentioned, the
discussion could delve deeper into how pessaries might address this issue and compare to
surgical outcomes.
- Discussion: The finding that DCP users are more likely to have tertiary education is noted,
but the interpretation is superficial. Discussing how education influences body awareness,
healthcare access, or patient autonomy could strengthen this point.
- Discussion: The focus on sexual activity as a factor influencing pessary choice is prominent
but lacks depth. For example, more detail on how pessaries affect sexual function or satisfaction
could enhance the discussion. Indeed, accumulating lines of evidence already highlighted that
POP has a severe impact on quality of life and may lead to a significant impairment of
sexual functions; for this reason, a multidisciplinary approach is recommended for an accurate
management.
- Discussion: The discussion could benefit from exploring the long-term implications of pessary
use, such as quality of life or changes in patient preferences over time.
- Discussion: While practical recommendations are valuable, they occasionally overshadow the
scientific analysis, making the discussion appear more prescriptive than interpretative.
- Discussion: The complications associated with long-term pessary use, such as vaginal wall
erosion, are briefly mentioned but not explored in depth. Discussing prevention and management
strategies would be helpful.
- Discussion: The conclusions restate the findings effectively but could be more concise. A clear,
focused summary of key takeaways would enhance the section’s impact.