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Exclusions: limited manual dexterity; cognitive deficit; pregnancy; requiring non\u2010English SM teaching.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>SM group received a 30\u2010min teaching session; information leaflet; 2\u2010week follow\u2010up call; and telephone support. CBC group received routine appointments. Allocation was by remote web\u2010based application, minimised on age, user type (new\/existing) and centre with no blinding. Participants were invited to opt into a 4\u2010year follow\u2010up. The primary analysis was intention to treat.<\/jats:p><\/jats:sec><jats:sec><jats:title>Outcome Measures<\/jats:title><jats:p>The primary outcomes were pelvic floor\u2010specific QoL (PFIQ\u20107) and incremental net monetary benefit (INB) 4\u2009years post\u2010randomisation. Secondary outcomes included complications and prolapse symptoms.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Of 340 women randomised, 186 (55%) responded at 4\u2009years (86\/169 [51%] SM, 100\/171 [58%] CBC). There was no statistically significant group difference in PFIQ\u20107 at 4\u2009years (mean SM 32.9 vs. CBC 31.4, adjusted mean difference [AMD] SM\u2010CBC 4.86, 95% CI \u22126.41 to 16.12). There was a statistically non\u2010significant lower percentage of pessary complications for SM (SM 17.7% vs. CBC 22.0%, AMD 3.01 CI \u22120.58 to 6.61). At 4\u2010years, SM was cost\u2010effective (INB \u00a32240). There was one potentially related serious adverse event (SM group).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Pessary self\u2010management is an effective and cost\u2010effective long\u2010term option for women with prolapse.<\/jats:p><\/jats:sec><jats:sec><jats:title>Trial Registration<\/jats:title><jats:p>ISRCTN number: 62510577 (<jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"https:\/\/doi.org\/10.1186\/ISRCTN62510577\">https:\/\/doi.org\/10.1186\/ISRCTN62510577<\/jats:ext-link>)<\/jats:p><\/jats:sec>","DOI":"10.1111\/1471-0528.18333","type":"journal-article","created":{"date-parts":[[2025,8,20]],"date-time":"2025-08-20T09:11:33Z","timestamp":1755681093000},"page":"1762-1771","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Four Year Clinical and Cost Effectiveness of Vaginal Pessary Self\u2010Management Versus Clinic\u2010Based Care for Pelvic Organ Prolapse (<scp>TOPSY<\/scp>): Long Term Follow\u2010Up of a Randomised Controlled Superiority Trial"],"prefix":"10.1111","volume":"132","author":[{"given":"Carol","family":"Bugge","sequence":"first","affiliation":[{"name":"School of Health and Life Sciences\/Research Centre for Health Glasgow Caledonian University  Glasgow UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1489-4397","authenticated-orcid":false,"given":"Rohna","family":"Kearney","sequence":"additional","affiliation":[{"name":"The Warrell Unit, Saint Mary's Hospital, Manchester University NHS Foundation Trust Manchester Academic Health Science Centre  Manchester UK"},{"name":"Division of Developmental Biology and Medicine, School of Medical Sciences University of Manchester  Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Catherine","family":"Best","sequence":"additional","affiliation":[{"name":"Faculty of Health Sciences and Sport University 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