Physiotherapy pessary providers in Australia: results of a multidisciplinary survey of practice

Geographical distribution

Physiotherapists were located widely around the continent but most densely around the eastern and southern coasts (Fig. 1).

Table 1 details the distribution of physiotherapists across the regions in Australia, according to their Modified Monash Model (MMM) category. Sixty-six per cent worked in metropolitan areas, 19% in regional areas, 25% in rural towns, and 1% in remote communities. None worked in very remote communities.

Physiotherapists delivered pessary care across all Australian states and territories. Details of the distribution per state and territory are provided in Table 2.

Over half of the 321 respondents to the question (n = 179, 56%) indicated that women travelled a long distance to see them for PM.

Clinical setting

Table 3 describes the clinical settings (public or private practice) in which physiotherapy respondents (n = 303) worked. Multiple responses were allowed to the survey questions about clinical settings, allowing for the fact that physiotherapists could work in more than one setting. Thirty physiotherapists (1%) reported working across both settings. Fifty-nine responses were recorded from physiotherapists working in the public system, and 291 from those in private practice. Another four worked in private hospital settings.

Of the 291 physiotherapists in a private practice setting, 153 (53%) provided pessary care with other pessary providers, while 89 (31%) reported working in a single-discipline physiotherapy practice with only one pessary provider. A further 51 (18%) were the only pessary provider in a multidisciplinary practice.

Table 4 provides further details of the shared-care arrangements of the physiotherapy respondents with doctors and nurses. Of the 205 private practitioner respondents in private practice, 57 (28%) stated that they did not have a shared-care arrangement with other health care providers. Others reported shared-care arrangements with medical and nursing pessary professionals.

Experience and training

Physiotherapy pessary providers had been practising in their profession for a mean of 16.8 [range: 2–45] years. The majority (n = 216, 67%) had more than 10 years’ experience as a physiotherapist, while 26 (8%) had been practising for less than 5 years.

Physiotherapists had a mean of 4.2 [range: 0.5–15] years’ experience in managing pessaries. While 12 (4%) had >10 years’ experience in PM and 81 (25%) had 6–10 years’ experience, the majority (n = 229, 71%) had ≤5 years’ experience. Seventy-three (23%) reported less than 1 year’s experience in PM. Fig. 2 shows the distribution of physiotherapists and their experience in PM per state/territory.

Fig. 2.

Physiotherapists’ experience in pessary management per state quota.

Physiotherapists reported completing various types of training methods in PM. With more than one response allowed, of the 300 respondents to this questions, 244 (81%) reported completing 1–2 day professional development courses, 161 (53%) reported receiving training via mentoring or on-the-job training, and 91 (30%) had a specific university-based qualification in PM. Forty respondents (13%) had completed both professional development training and had a postgraduate qualification in PM. Seven (2%) stated that they had received only on-the-job training or mentoring.

Of all 324 respondents, there were 26 (8%) with <5 years’ experience as a physiotherapist. Of these, 20 (6%) reported their highest level of PM training was via a professional development course, 4 (1%) had no mentoring or support, 8 (3%) reported being the sole pessary provider in a private practice, and 12 (4%) reported having no workplace competency standard.

Physiotherapists were asked whether their workplace required demonstration of their competence in PM, with 174 (57.4%) responding ‘No’ and 129 (42.6%) responding ‘Yes’. By contrast, 100% of four physiotherapists working in public health service pessary clinics were required to demonstrate their competence.

Mentoring

Approximately one-third (n = 105, 35%) of physiotherapy respondents stated that they received no mentoring or support in PM. 119 (40%) respondents reported providing mentoring or support to others. Amongst the small group of 12 physiotherapists with the most PM experience (>10 years), 10 (83%) were providing mentoring or support to others. Of the 154 physiotherapy respondents with 3 or less years’ pessary management experience, 28 (18%) provided mentoring or support to others. Nine (12%) of the 73 physiotherapists with the least experience in PM (1 year or less) reported mentoring others.

Most physiotherapists (n = 244, 81%) stated that they wanted further training, particularly those in rural and remote areas. Over two thirds (n = 219, 68%) wanted education about complex cases, others about adverse events (n = 131, 40%) and risk mitigation (n = 126, 39%).

Pessary practice

Physiotherapists reported using 14 different types of pessaries (in descending order of frequency): ring, ring with support, cube, Gellhorn, donut, dish, shaatz, C-POP, ring with knob, cup, marland, hodge, oval, inflatoball. The first choice of pessary was a ring for 262 (84%) physiotherapists and for 22 (7%) the first choice was a cube pessary. Cubes were the most common second choice for 164 (55%) of physiotherapy respondents, while 3 (1%) and 32 (11%) respectively chose a Gellhorn as their first or second choice. Twelve (4%) physiotherapists only fitted ring pessaries. Fifty-five (18%) reported fitting combinations of two or more pessaries.

Physiotherapists reported fitting a median of three pessaries per month. While a small number (n = 28, 9%) fitted 10–20 per month, there were 40 (13%) who fitted less than one pessary per month. Three hundred and three respondents provided further information about their PM: 298 (98%) provided pessary sizing and fitting, 288 (95%) provided follow-up, and 301 (99%) taught pessary self-management.

Physiotherapists as pessary providers

There have been few studies internationally describing the role of physiotherapists in managing pessaries for women with POP and none with comparably detailed data. Our finding of 324 physiotherapists managing pessaries in Australia is remarkable when compared with previous reports. A French multidisciplinary survey of pessary practice reported 208 physiotherapists (20% of all respondents) provided pessary care⁷ while a recent UK survey of pessary practice reported only 22 physiotherapists (2% of 917 survey respondents).⁶ In a survey of organisations delivering pessary care in the UK, 10 physiotherapists were reported to be part of multidisciplinary teams across 10 organisations.² Our data may represent a very successful recruitment campaign for this survey among our pelvic health physiotherapy colleagues. Accordingly, we have been able to demonstrate large numbers of physiotherapists providing pessary care compared with international reports, possibly corresponding with the availability of training opportunities in Australia in the last decade.

The provision of PM by physiotherapists to women in their local and regional areas may also relieve pressure on gynaecology and UG services in the public sector, where, anecdotally, there have been some recent initiatives to develop physiotherapy-led pessary clinics. These have been inspired by the demonstrated efficiencies of Advanced Practice physiotherapy practitioners providing first contact services in gynaecology/UG services.^11,12 The outcomes of these initiatives are yet to be reported but they may provide a template for the expansion of physiotherapy scope of practice to enable more women to receive PM in a timely way.

The finding that physiotherapists are providing pessary care across all states and regions of Australia is novel information indicating that physiotherapists can provide opportunities for women to access PM in their primary health care setting. This may be more convenient and save travel to potentially distant tertiary care centres, a model suggested to increase accessibility of health care services.²⁶ The distribution map suggests considerable areas of service inequality, and although we have indicated the location of all physiotherapists according to their MMM classification, we are unable to say from our data whether these new pessary services were able to rectify any inequality in access to pessary services for women with prolapse. We were able to report that 56% physiotherapists stated that women had to travel ‘a long distance’ to see them for PM. Future research is warranted to clarify women’s equitable access to pessary services.

Our data indicated that around a quarter of privately practising physiotherapists did not have shared-care arrangements with other health care providers. There are several possible explanations for this finding. Firstly, we did not formally test the survey questions for their construct validity so that respondents may have misinterpreted the question. Secondly, co-management requires a local medical practitioner who has an interest in women’s health and is able to provide the necessary medical care. Thirdly, respondents may not have been aware of the need to have medical or specialised nursing support for aspects of pessary care that are not within the scope of physiotherapy practice, such as routine speculum examination and the diagnosis and management of complications such as bleeding and vaginal infections. This last possibility would suggest the need for national professional standards in pessary training to protect both the public and practitioners from harm. We also highlight the need for the woman’s GP to be upskilled in the management of pessaries to provide effective co-management, particularly for women with prolapse living in rural and remote Australia, where access to medical practitioners is limited.

Experience and training

There have been no previous reports profiling the experience and training of physiotherapists managing pessaries for comparison with our study. Our data show that Australian physiotherapists have between 2 and 45 years’ experience since graduation. By contrast, the longest any had been managing pessaries was 15 years and nearly a quarter had less than 1 year’s experience. The finding that some physiotherapists were inexperienced as pelvic health practitioners and were already managing pessaries deserves further scrutiny and consideration of minimum training standards in the interests of patient safety and access to best practice care.¹⁸

There was also a range in the number of pessaries fitted per month, in keeping with the only other survey to report comparative physiotherapy data.⁶ Our survey found that some physiotherapists were fitting less than one pessary per month, while some in the UK were fitting less than one pessary per year, further highlighting the need to consider minimum standards to develop and maintain competence.

Our findings reflect differences between the Australian and UK healthcare systems. Locally, 291 (90%) of physiotherapists currently providing PM worked in private practices, whereas a recent UK survey of pessary practice found only 10, out of the 22 physiotherapists identified, worked in private practice, with the others employed in the public health system.⁶ This suggests that assumptions about education and training suitable in one jurisdiction, e.g. the UK, may not be appropriate for Australia. In the UK, for example, most physiotherapists’ scope of practice and competence will be governed by their institution. In Australia, physiotherapy private practice, including pessary management, is only subject to the professional code of conduct and registration board requirements.

To our knowledge, the first documented recommendations for pessary training for health care professions were published in the UK in 2021,²⁰ followed by an Australian E-Delphi study in 2022 with specific training recommendations for Australian physiotherapists.²⁷ This latter study identified a number of differences in scope of practice for Australian physiotherapists and made recommendations for competence standards to address variability in clinical practice and training specific to the Australian healthcare setting. However, at the time of writing, there were no national pessary-specific training recommendations for physiotherapists to address variations in service delivery.

Various methods of teaching PM have been proposed⁶ but there are currently no data to demonstrate which is the most effective. In a national survey of nursing practices in the United States, mentoring was reported by 65% of 323 respondents as the main form of learning about PM.⁴ We have reported that Australian physiotherapists both provide and receive mentoring in PM to support their own learning and that of others. However, the finding that inexperienced physiotherapists are mentoring others raises the question of the qualifications deemed necessary for mentors to provide evidence-based and best-practice training in PM.

Shadowing another clinician was a popular form of training used by 83% of clinicians in the UK⁶ but this method is only feasible for clinicians in public hospital settings. In Australia, opportunities for physiotherapists to work in public pessary clinics or shadow experts are limited, as most physiotherapists provide pessary care in private practices. Different approaches to training may therefore be needed to meet physiotherapists’ desire for more training and to equip them with the knowledge and skills necessary to competently manage pessaries in clinical practice.

We reported on various training methods in Australia (1–2 day courses, mentoring/on-the-job training, university-based training) which may have had differences in the rigour of the training and assessment processes undergone by physiotherapists. Recommended training standards have been published,²⁷ but it is not clear to what extent they have been adopted by training providers.

Respondents to the survey indicated that more than half of workplaces did not require evidence of practitioner competence in pessary management. To our knowledge, current registration and insurance requirements do not mandate that physiotherapists have participated in a specific type or standard of training, or that workplaces demand evidence of competence. However, the Ahpra Physiotherapy Code of Conduct [2022]²⁸ requires physiotherapists to be competent when moving into a new area of practice. Failure to demonstrate competence may have implications for potential misconduct claims or litigation.

Competence in pessary management encompasses the knowledge and skills to identify and manage the associated risks and complications, including the long-term maintenance of women with a pessary.^20,27 Physiotherapists who have undergone training which encompasses the competencies recommended in a recent E-Delphi study²⁷ will be well-equipped to do this, in collaboration with the woman’s medical doctor. Women who are unable to self-manage a pessary will need to be managed by a medical/nursing team.

Pessary self-management

We reported that physiotherapists in the current study almost all taught pessary self-management, which differs from other studies where only 65% of the health care providers, not specifically physiotherapists, taught women how to remove and insert their pessary.⁷ A recent randomised controlled trial demonstrated the benefits of pessary self-management with reduced risk of complications, cost benefits and improved self-efficacy, with equivalent quality of life outcomes compared with clinic-based care.²⁹ The Australian healthcare system appears well placed to have physiotherapists deliver this evidence-based pessary service, provided that training programmes meet competency standards.

Pessary practices

Australian physiotherapists reported using a wider range of pessaries compared with physiotherapists in the UK,⁶ an understandable finding when more Australian physiotherapists were providing PM. Ring pessaries were also the most commonly used by physiotherapists in several other studies^6,7 and, also consistent with our data, cube pessaries were the next most frequently used pessary.^6,7 The frequent use of cube pessaries possibly reflects the younger age of women, less than 60 years of age, receiving PM from physiotherapists¹⁵ and their ability to remove and re-insert a cube pessary themselves daily, as required by current guidelines.²⁰ Similarly, some physiotherapists reported fitting women with Gellhorn pessaries, in line with recent research.³⁰ As suggested in the case of cube pessaries, the younger women will likely have had greater flexibility and dexterity, potentially enabling them to successfully self-manage a Gellhorn.

Our findings suggest several opportunities. Firstly, there is an opportunity for enhanced interdisciplinary collaboration with the woman’s GP and her gynaecologist/UG to meet the needs of women wishing to manage their prolapse with a pessary co-managed by a physiotherapist. One cogent reason for co-management is that clinical practice guidelines require the exclusion of pathology and management of complications by a medical practitioner,²⁰ as these are not within the scope of physiotherapy. Secondly, the trend in PM delivery from publicly funded institutions to private physiotherapy practice in primary care settings that we have identified demands a review of the funding structure for PM. Currently women bear the cost of PM when exercising their right to choose local treatment from a physiotherapist, at the same time reducing the financial impact on the public purse.

Thirdly, we suggest an opportunity to develop joint competencies and training standards with all professionals managing pessaries, in order to ensure that all women receive best-practice, evidence-based pessary care. Further research to understand optimal pessary care arrangements, including professional and financial barriers, is warranted. However, we affirm the need for specific Australian physiotherapy competencies as clarity is needed to support physiotherapists to safely navigate the limits of their current scope of practice.

Our results also highlight a number of challenges which potentially impact the delivery of best-practice PM. Challenges include variability in physiotherapists’ experience in women’s health practice, lack of a requirement for standardised, competency-based training in PM, unregulated mentoring practices, the perceived need for more training, and variable governance of pessary provision. It has been argued that PM demands advanced knowledge and skills for the practitioner to deliver a high standard of safe care¹⁸ and that standardised, quality, competence-assessed training should be available.^6,8,18,31 In line with these recommendations, our data suggest that Australian pessary training standards are urgently needed for physiotherapists, ‘to protect themselves as practitioners, to protect the availability of pessaries as a treatment option, and, most importantly, to protect patients’.¹⁸

Strengths and limitations

We believe that this is the first international study to describe physiotherapy practices in PM in detail. A major strength of our study was the high number of responses, identifying the large number of physiotherapists involved in pessary care in Australia. This response rate was likely due to our extensive professional connections as physiotherapy researchers and the willingness of pelvic health physiotherapists in Australia to contribute to research. However, we acknowledge a limitation in our study design, which prevents us from estimating the total number of physiotherapists delivering pessary care. As a result, we could not determine how many did not receive or did not respond to our survey.

A possible limitation in the interpretation of our survey results arises from the timing of the survey soon after the Covid pandemic. It is unknown what effect the pandemic had within public and private settings, but it is possible that services may not have been fully functional again. However, we have reported large numbers of physiotherapists working in the private sector and the relatively small number working in the public sector (4 in pessary clinics, 47 in public hospital outpatient departments¹⁵) could also have been related to the historical staffing of pessary clinics by doctors and nurses.