Up to 50 per cent of women are shown to have pelvic organ prolapse, defined as a downward displacement of the uterus, bladder or bowel, after a vaginal birth (Haylen et al 2016, MacLennan et al 2000).

Pelvic organ prolapse symptoms include a feeling of vaginal bulge or heaviness, the inability to effectively empty the bladder or bowel and impaired sexual function, all of which can contribute to reduction in self-confidence.

Conservative management includes lifestyle advice, pelvic floor muscle training and vaginal support pessaries.

Of these options, pessaries have been shown to be comparable to surgery for symptom reduction and improvements in quality of life and sexual function (Lone et al 2015).

A pessary is a device that is inserted into the vagina to provide support to the vaginal walls and prolapsed organs in order to alleviate symptoms (Bugge et al 2014).

They come in different types, shapes and sizes, and the ring, Gellhorn and cube pessaries are popular choices in clinical practice.

If a pessary provides symptom relief and the patient has a preference for non-surgical management, it is possible it can be used to manage the prolapse on a long-term basis.

Unfortunately, there are inherent risks in pessary use, and studies have shown it does not take long for issues to arise. Mao et al (2019) showed 37 per cent of women who were taught self-care with weekly pessary removal developed vaginal erosion within a two-year period.

Torbey (2014) reports a case of a 75-year-old woman who developed a rectovaginal fistula within a 10-week period of being fitted with a cube pessary.

In my own clinical practice, I regularly find vaginal mucosal changes on speculum assessment in patients using pessaries. Such changes range from abrasions, excessive discharge and vaginal bleeding to decubitus ulcers.

To reduce the risks to my clients, I have established a clearly defined pathway of care, appropriate professional referrals, a clinical database and documented processes to best manage such cases.

I have closely followed the Frawley et al (2019) framework for achieving clinical competency by completing postgraduate assessment-based studies at the University of Melbourne, Curtin University, and the University of South Australia and I am currently completing my APA specialisation pathway.

These courses have helped build my knowledge base, technical skills, infection control management, clinical reasoning and understanding of pelvic floor disorders.

Although these courses have been demanding, I am committed to ensuring that I deliver the highest possible healthcare standards.

I recognised early in my career that pelvic floor physiotherapy is undertaken in a private environment, which reduces the exposure to peer review and opportunities to learn through observation.

The path I have chosen and followed is not a mandatory or professionally regulated one.

In fact, there is nothing preventing a newly graduated physiotherapist performing intimate exams, fitting a pessary or promoting themselves as a women’s health physiotherapist.

However, with as little as two hours dedicated to women’s health in undergraduate physiotherapy courses (McPherson et al 2020), there is a unique ‘registration-competency’ gap in the area of pelvic floor physiotherapy (Frawley et al 2019).

This alarming gap within our profession raises important safety and ethical questions and highlights the need for minimum standards and benchmarks for clinical practice.

Currently the APA’s position regarding pessary management is for the responsibility to be placed on the individual physiotherapist to self-reflect and determine their own competency (Physiotherapy Board of Australia 2016).

But is this really sufficient to ensure safe, ethical and effective care is delivered to our patients?

Barnsely et al (2004) clearly demonstrate that relying on clinicians’ self-assessment of clinical skills is highly flawed, as there was no correlation between health professionals’ self-assessment and external assessment of their skills.

There is also the question of what standards or benchmarks we expect physiotherapists to use for self-reflection.

Without clear guidelines, it is impossible to accurately judge our own level of skill and more importantly, where our knowledge, training and skill gaps exist.

We have seen that a lack of rigour around standards of practice leads to detrimental outcomes.

The recent issue with transvaginal mesh, where thousands of women have reported adverse events subsequent to surgical mesh implantation, should act as a warning to our profession.

In response to the adverse events, the Therapeutics Goods Administration cancelled the registration of transvaginal pelvic organ prolapse mesh devices and a Senate inquiry was called.

In 2018, the senate inquiry recommended implementation of Australian Commission on Safety and Quality in Health Care guidelines and the establishment of a mesh registry (Daly et al 2019).

Although the implications of pessary management are less severe than mesh complications, Dwyer et al (2019) have cautioned us against a similar situation arising with pessaries involving clinicians who lack sufficient training to operate in a safe and competent manner.

Without benchmarks and assessment for clinical competency, what assurance does the community have that physiotherapists are providing safe and effective pessary management?

How comfortable do we feel as a profession that there are no clearly defined minimum standards to guide competency requirements for pessary management?

Looking beyond our borders, our colleagues in the UK are leading the way in addressing the need for clinical standards and competency-based training to ensure effective pessary management.

The Chartered Society of Physiotherapists (CSP) has acknowledged the need to provide physiotherapists with agreed training standards in pessary management.

Consequently, Lough et al (2020) have recently published comprehensive guidelines that include such training requirements.

The CSP provided funding to support this work, which resulted in robust cross-disciplinary guidelines endorsed by the UK gynaecologists, nursing body and the CSP.

Let’s use this as inspiration to take positive action on a more solid, safe and sustainable position for pessary management within Australia, and to implement the highest standards of governance to ensure safety of our community.

We, as a profession, need to collaborate to develop recommendations for agreed training standards, competency-based assessment of knowledge and technical skills, mandatory data collection and reporting of adverse events for patient safety.

Email inmotion@australian.physio for references.

>>APA Continence and Women’s Health Physiotherapist Angela James MACP is a women’s, men’s and pelvic health registrar undertaking Fellowship of the Australian College of Physiotherapists by Clinical Specialisation. Angela is the founder and principal physiotherapist at Sydney Pelvic Clinic, a specialised clinic in Bondi Junction, Sydney.