VAGINAL PESSARIES FOR PELVIC ORGAN PROLAPSE

Vaginal pessary is a device used in conservative management of pelvic organ prolapse (POP) or urinary incontinence. Vaginal pessary is placed in the vagina to provide support and prevent pelvic organ prolapse. Continence pessaries act by providing mechanical support to the urethra. In the pass, various materials had been used which include: Pomegranate soaked in vinegar, fruits, mould, cotton etc. Modern vaginal pessaries are made of silicone as it is inert, does not absorb secretions and resistant to degradation by the majority of the antiseptics. Patients satisfaction rate ranges 70-92%.  

Types of pessaries 

·         There different sizes, shapes and configurations.

·         Mainly two basic mechanisms: supportive and/or space occupying

·         Space occupying pessaries preclude sexual intercourse

·         Commonly used vaginal pessaries: Ring, Gellhorn , Hodge, Cube and Donut

·    Continence pessary: usually equipped with a knob which should be placed in the midline under the urethra. For example: incontinence ring pessary, ring pessary with knob, and incontinence dish pessary Mar-land pessary and Uresta pessary are incontinence pessary which are unique in the design.

 Indications

      ·         Symptomatic pelvic organ prolapse or stress urinary incontinence

·         In frail elderly with multiple co-morbid and not fit for surgery

·         In women prefer conservative management

·         In women with prolapse in pregnancy or awaiting surgery for temporary support

·    Temporary use for diagnostic purposes: to demonstrate occult stress incontinence along with POP, to determine whether surgery would alleviate vague symptoms such as backache/dragging pain

Pessary selection

      ·         Ring pessary is commonly used as first choice due to its easy insertion and removal.

·         Ring pessary can be used in most of the stages of POP.

·         In concurrent stress incontinence, ring pessary with knob can be used

·         If failed fitting of ring pessary or advanced POP, a Gellhorn, cube or donut pessary can be used.

Procedure 

·      This is usually done as out-patient setting

·       Can be inserted on supine or lithotomy position, the severity of prolapse, type of prolapsed will help in the choice of pessary

·       Often the correct fitting is trial and error. However, the size of pessary can be estimated by measuring the distance between the symphysis pubis and posterior fornix.

·         Following insertion, the patients are instructed to perform Valsava, maneuvers to confirm fitting.

·         Ability to void without difficulty should be checked before sending home.

·      Patients or caregivers can be thought to remove and insert the pessaries. This is usually permissible in ring pessary or cube pessary.

·     Follow up period between 2-3 months to clean and re-insertion if patient is unable to do it. An interval follow-up of 6-12 months is acceptable if the patients are able to manage themselves.

Complications

·       Minor complications include: vaginal discharge, odor, bleeding, abrasion

·     Erosion or ulceration of the vagina wall, particularly if the pessary is left unattended for long periods of time. It can be managed by a short period of rest and use of topical oestrogen.

·        Concurrent use of topical oestrogen may reduce the incidence of erosion and ulceration.

·     Decreased efficacy over time, a larger pessary may be necessary. Though an improvement of POP-Q stage had been reported.

·         Impaction of pessary, fistula formation especially in neglected cases

·         Vaginal cancer has been reported in long term use

·         Proper patient education and counseling are essential to minimize neglected cases 

Factors predicting success or failure of fitting

      ·         The likelihood of successful fitting ranges from 74%-94%

·         Some women may need a second fitting

·    Prior hysterectomy, short vaginal length (<6cm), wide introitus (≥ 4 fingers breath), large posterior prolapse and poor perineal support may give a higher failure of fitting

 

Consent & permission has been obtained from patients to use the pictures for teaching purposes

 References

 1. Scott Miller D. Contemporary use of the pessary. Gynecol Obstet 1991; 39: 1-12

 2. Baydock SA, Farrell SA. Chapter 5. Selection of pessaries for pelvic organ prolapse. Pessaries in clinical practice. 32-45 

3. Farrell SA. Pessaries for the management of stress urinary incontinence. J Obstet Gynaecol Can. 2001; 23: 1184-1189

4. Cundiff GW, Weidner AC, Visco AG, Bump RC, Addison WA. A survey of pessary use be members of the American Urogynecology Society. Obstet Gynecol 2000; 95(6): 931-935

 5. Baydock SA. Chapter 2. Pessaries for pelvic organ prolapse: The evidence. Pessaries in clinical practice 10-16

 6. Amir-Khalkhali B, Farrel SA. Chapter 6 Selection of pessaries for urinary incontinence. Pessaries in clinical practice 46-53

 7. Schraub A, Sun XS, Maingon P et al. Cervical and vaginal cancer associated with pessary use. Cancer 1992; 69(10): 2505-2509

 8. Handa VL, Jones M. Do pessaries prevent the progression of pelvic organ prolapse? Int Urogynecol J 2002; 13: 349-352

 9. Wu V, Farrel SA, Baskett TF, Flowerdew G. A simplified protocol for pessary management. Obstet Gynecol 1997; 90: 990-994

 10. Clemons JL, Anguilar VC, Tillinghast TA, Jackson ND, Myers DL. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol 2004; 190: 345-350