Analysing the support mechanisms of the vaginal ring pessary on supine and upright MRI

Vaginal pessaries have been used for millennia to alleviate symptoms of pelvic organ prolapse (POP). Despite their long-standing use, the success rate of pessary treatment is approximately 60%, and the underlying mechanisms of support are not well understood. This study aims to investigate three previously proposed hypotheses regarding the support mechanisms of pessaries, utilizing supine and upright magnetic resonance imaging (MRI): (1) support by bony structures, (2) support by levator ani muscles (LAM), and (3) the uterus keeping the pessary in place by acting as a lever. Thirty POP patients, with a successful pessary fit for more than 3 months, underwent MRI scans in both upright and supine position. The position of the pelvic bony structures, LAM, uterus, and pessary were analysed by placing corresponding points on these structures and comparing the differences between supine and upright. Also, the angle of the pessary with the horizontal plane of the pelvic inclination corrections system was analysed. Principal component analysis was applied to evaluate how the positions of the LAM and the pessary changed between the two positions. The lowest point of the pessary descends below the lowest point of the bony structures in upright position, disproving the first hypothesis. The pessary significantly descends towards the LAM from supine to upright, but does not drop below it, strengthening the second hypothesis. The pessary angle is below 90° in upright position, the uterus is positioned in the pessary centre and remains constant from supine to upright, strengthening the third hypothesis.