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

COLPOCLEISIS: VAGINAL OBLITERATIVE PROCEDURE

Colpocleisis is a vaginal obliteration procedure for treatment of advanced pelvic organ prolapsed (POP) or Global pelvic floor failure (GPFF).  Obliteration of the vagina is a surgical option for patients with advanced symptomatic POP who are not engaging in vaginal intercourse.

Colpoclesis can be divided into total (complete) colpoclesis or partial (Le Fort) colpocleisis.

These procedures are indicated in a selected group of patients, usually frail elderly patients, who are unable or do not wish to undergo more involved procedures such as hysterectomy and vaginal vault suspension. These patients are no longer desire for sexual function. These procedures can sometimes be performed under local, pudendal blocks, intravenous sedation or regional anaesthesia.

It has  relatively good success rate  of between 85-100% patients claim to be satisfied or very satisfied with the sugery.

Indications:

·         Advanced pelvic organ prolapsed/ Global Pelvic Floor Failure 

·         Medical unfit patients/ patients with comorbidity

·         Frail elderly patients

·         Patient request simpler operation

·         Patient who could not stand long surgery

·         Sexually not active/ disinterested in maintain sexual function

·         Unsuccessful trial of vaginal pessaries or surgeries 

 Advantage:

  ·      Shorter operating time, takes half the time of vaginal  hysterectomy

 ·       Minimal blood loss and complications

 ·       Excellent cure rates or success rate

 Disadvantage: 

·         Recurrence of Pelvic organ prolapse

·         Injuries to bladder/ rectum

·         Unable to perform sexual intercourse

·         If uterus still in situ as in Le Fort operation, there is a remote possibility of cervical or endometrial carcinoma.

A.  Partial Colpocleisis ( Le Fort): 

First performed by Neugebaucer in 1867, in this procedure the cervix and uterus is left behind and segment of anterior and posterior vaginal mucosa are removed.

Procedure:

 ·         Can be done under local, iv sedation, pudendal block or regional anesthesia

·         The rectangular epithelial areas on the anterior and posterior vaginal wall are denuded.

·         The denuded epithelial areas are then sutured to each other with the uterus reduced to a proximal position            so that the anterior rectal wall and the base of the perivesical fascia around the bladder base are fused.

·         Approximating the opposing walls of the vagina prevents descent of the uterus and practically obliterates              the vagina.

·        The rectangular areas are designed so that a continuous lumen from the vaginal apex on both sides of                  the obliterated space will persist. This lumen serves to drain vaginal and uterine secretions.

B. Total Colpoclesis (Complete Colpectomy):

Total colpocleisis can be performed in post-hysterectomised vaginal vault prolapse patients or after a vaginal hysterectomy. This procedure was first described by DeLancey and Morley.

 Procedure:

 ·         The vaginal mucosa is completely excised from the base of the prolase by a circumscribing incision.                      Subsequently the vaginal skin is denuded. 

·         A series of purse-string sutures are placed so that the vaginal fascial and muscular layers are inverted                  cephalad. 

·         The vagina is completely obliterated. 

·         This can be followed by standard Kelly’s placation, Levator ani plication or perineorhaphy

 Complications:

 Immediate/ Intermediate:

 ·         De novo urinary incontinence in 27%

 ·         Persistent stress urinary incontinence in 28% patients

 ·         Transient Ureteral occlusion in 10% patients

 Late/delayed:

·         Risk of injuries to bladder or rectum

·         Infection

·         De Nova or persistence of stress urinary incontinence   (25-30%)

·         Vaginal Evisceration ( very rarely)

·         Post operative regret of loss of sexual function in 5% of patients

Consent & permission has been taken to publish this pictures & video from the patients for the purpose of teaching junior doctors)

References:

1. Denehy TR, Choe JY, Greori CA et al. Modified Le Fort Partial Colpoclesis with Kelly urethral placation and posterior colpoperineoplasty in medically compromised elderly. Am J Obstet Gynaecol 1995; 173(6): 1697-1702.

 2. Le Fort L. Nouveau precede pour ia guerison du prolapsus uterin. Bull Gen Therp. 1877; 92:337-346

3.  DeLancey Jo, Morley GW. Total colpocleisis for vaginal eversion. Am J Obstet Gynaecol, 1997;176(6): 12278-1235.

 4. FitzGerald MP, Brubaker L. Colpoclesis and urinary incontinence. Am J obstet Gynaecol, 2003;189(5): 1241-1244.

 5. Von Pechmann WS, Mutone M, Fyffe J et al. Total Colpocleisis with high levator plication for the treatment of advance pelvic organ prolapsed. Am J Obstet Gynaecol, 2003;189(1): 121-126

 6. Ubachs JM, Van santé TJ, Schellekens LA. Partial colpocleisis by a modification of Le Fort’s operation. Obstet Gynaecol, 1973; 42(3): 415-420

 

Prevention of OASIS

Predicting OASIS and tears in individual women is inaccurate and midwifery practices can do little to prevent them. 

§  Clinicians need to be aware of the risk factors for obstetric anal sphincter injuries (OASIS) (Grade D)

§  Elective / low thresh-hold for LSCS in patients with the following risk factor/s:

•         Nulliparity 

•         Macrosomia  of more than 4kg

•         Gestational diabetes mellitus (GDM)

•         Prolonged 1st stage of labour (7-to-10 interval >3hours)

•         Prolonged active 2nd stage of labour >60 mins)

•         No/poor descent during instrumental delivery

•         High head (not visible on parting vagina, PA & VE)

§  Encourage epidural analgesia

§  Perineal protection at crowning can be protective, control delivery of the head may prevent burst injuries.  (Grade C) PINCHING TECHNIQUE

§  Left hand slowing down the delivery of the head, the head is flexed and the right hand protecting the perineum (Pinching Technique as in Finish Intervention Trial).

§  Clinicians should explain to women that the evidence for the protective effect of episiotomy is conflicting. ( Grade C)

§ If an episiotomy is warranted than, a medio-lateral episiotomy (60 degree angulation) has been shown to reduce OASIS.

§   Early extension of episiotomy should be performed to avoid further damage

§   Forcible delivery should be avoided,  it should be replaced with vacuum delivery by use the Kiwi cup for OT & OP positions

§ Delivery the head should be in between contraction. The mother should not push vigorously when head is crowning (communicate).

§ Do take care during the delivery of the shoulder, continue to protect the perineum (midwife/assistant) during delivery of the head & shoulders

The above is video demonstrating how to perform a 60 degrees episiotomy & how to do the perineal protection using PINCHING TECHNIQUE

Consent Has been Taken from Patient to publish this video ( For Teaching Purpose)

Reference : RCOG Greentop guidelines No 29. June 2015

                   Justine RL , Episiotomy & repair. Medscape April 2021

Spontaneous and complete uterine scar rupture occurred 26 days after caesarean section: A case report

 Kartina Ariffin, Jumaida Abu Bakar, Aruku Naidu

 Department of obstetrics & Gynaecology, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

Abstract:

Caesarean section rates have increased worldwide. Following this, the rate of uterine scar dehiscence or rupture is also increased in pregnancy. Rupture of lower uterine segment incision at post-partum is extremely rare clinical condition. We present a 25 year old patient at day 26 post caesarean section, presented with lower abdominal pain with copious vaginal discharge. The examination was unremarkable. On Pelvic ultrasound and Computerized Tomography, an anterior hyperechoic mass with fat attenuation with the mass was visible, measuring 3.3x 7.2x 7.7cm , an anterior uterine wall defect was also noted.  The patient underwent an exploratory laparotomy. There was a spontaneous and complete rupture of the lower uterine segment with omentum enclosing the defect. The debris, clot & fluids were evacuated, followed by repair of the defects in 2 layers with polyglactin suture material size 1. The patient’s post-operative recovery was uneventful. In conclusion, the diagnosis of post-partum caesarean scar dehiscence or rupture is difficult clinically, but radiological modality is essential to establish the diagnosis. As this patient is young, primiparous and with future reproduction function in mind, an exploratory laparotomy was performed as it is both diagnostic & therapeutic in this rare case.

Key words: post- partum, caesarean scar, rupture uterus

Introduction

The post-partum lower abdominal pain and per vaginal discharge is common presentation in patients after caesarean section or childbirth. The common cause is urinary tract infection, endomyometritis and retained placenta. Spontaneous caesarean scar dehiscence or rupture at post-partum is unusual and difficult to diagnose clinically. Radiological modality is a usual tool to help in the diagnosis. Scar dehiscence or rupture not only can be missed but can be potentially life-threatening in her subsequent pregnancy if not address properly. Preoperative diagnosis is usually difficult, thus exploratory laparotomy is both diagnostic and therapeutic for this rare condition. We report a case of spontaneous and complete rupture of a caesarean scar at day 26 post-partum.

Case Report:

The patient was a 25-year-old primiparous woman who underwent emergency caesarean section for deep transverse arrest. The course of her pregnancy had been normal and uneventful. She had no significant medical or surgical history. The labour was spontaneous and progress smoothly until she reach the second stage. The second was prolonged for 1 and half hours with OS fully. Caesarean section was decided as there was large caput & it was not suitable for instrumental delivery. Her caesarean section operation was complicated with bilateral extended uterine tear, the tears was extended and involved the broad ligaments. These tears were repaired in two layers using polyglactin suture size 1. The uterine incision was also sutured in two layers using the same material by a specialist. There were no active bleeding. The abdomen was closed in layers.

She was clinically stable, with normal vital signs throughout her hospital stay and was discharged well on day 2 post-operative day. She was perfectly well during her post-delivery visits. On the Day 26 postpartum, she presented with lower abdominal pain and foul smelling lochia/discharge. She had no fever, any evidence of sepsis or any excessive per vaginal bleeding.

On examination, she was afebrile, her blood pressure was 104/62mmHg, pulse rate was 100bpm and abdomen was soft, but mild tender on palpation. Uterus was contracted well at 16 weeks. Vaginal examination revealed copious amount of yellowish vaginal discharge, and draining from the OS. A pelvic ultrasound showed irregular and hyperechoic mass above the uterine incision. The mass appeared like haematoma measuring 4.1x 6.7x7.0cm. Computerized Tomography was carried out, which also reported the same finding and a possibility of caesarean scar rupture with blood or abscess collection. An anterior hyperechoic mass with fat attenuation with the mass was visible, measuring 3.3x 7.2x 7.7cm. The bladder wall was separate and well defined. The hemoglobin concentration was 10.9 g/L, the total white blood cell was 9.0x 10⁹ /L. The high vaginal swab was no growth detected.  Histology report suggest acute on chronic inflammation with granulation tissue formation.

As the patient was young and primiparous, a decision was made to perform an exploratory laparotomy and repair of the ruptured uterine defect.  The patient & her husband was adequately counseled prior to the operation. At laparotomy, there was minimal pus in peritoneum. The omentum was adhered to anterior uterine wall. The omentum was released from the scar. There was a complete scar rupture of the lower segment uterine incision. The margins of the incision were unhealthy, with some collection of blood and pus. The scar was debrided until a fresh layer of uterine wall. The uterine cavity was normal. The bladder wall was intact.

Uterine defect margins were refashioned and approximated in 2 layers with continuous closure and interrupted suture respectively using polyglactin suture material size 1. Thorough abdominal lavage done and abdominal drain was inserted. The integrity of the bladder and ureters was confirmed prior abdominal closure. Her blood pressure remained stable throughout the surgery.

The patient’s postoperative course was uneventful and she received broad spectrum antibiotics for 14 days. She was discharged well on the 3rd day postoperative day and remained well thereafter. She was reviewed 6 weeks after the laparotomy. The abdominal wound has healed well. A repeat pelvic Ultrasound reveal well define uterine margins.

Ultrasound picture:

Intraoperative picture

Discussion

Abdominal pain and per vaginal discharge after post caesarean delivery is a common complaint. The common causes for such symptoms are urinary tract infection, endomyometritis and retained placenta However, pain secondary to uterine dehiscence or rupture are a rare clinical condition. The incidence of post-partum uterine scar dehiscence or rupture is between 0.6% - 3.8%¹. Delayed presentation of caesarean scar rupture up until 6 weeks postpartum period has been reported in literature². Postpartum scar dehiscence or rupture can present as secondary post-partum hemorrhage, localized or generalized pain and peritonitis, sepsis or even shock. In our case, the presenting complaint was only tenderness at the lower abdomen associated with copious vaginal discharge, which may suggested a possibility of endomyometritis. This case report shows that it is important to have high index of suspicion to exclude uterine dehiscence or rupture in patients who present with localized tenderness or even pelvic haematoma or abscess. Risk factors for lower segment uterine incision rupture during the post-partum period are advance age, multiparity, diabetes, immune compromised, wound infection and hematoma. In our case, we postulated that the extended tear may have led to haematoma and subsequently developed infection that caused tissue necrosis and scar dehiscence. This was evident by presence of copious vaginal discharge vaginally. Among other factor that is associated with poor wound healing is malnutrition. The body mass index of the patient during booking was 16. Whether this has a direct relationship with uterine dehiscence, is unknown.

Ultrasound is the commonly used imaging modality to help with the diagnosis. On ultrasonography, the uterine incision site may show full thickness defect, some hypoechoiec area along the uterine incision line or in some cases some blood or abscess collection anterior to the incision site. Other imaging modality that we can use to aid in our diagnosis is computed tomography (CT) an magnetic resonance imaging ( MRI). An MRI with a heavily T2 weighted image may show a bright fluid filled tract³. However, the clinical usefulness using this modality in acute setting needs to be defined.

Management of these patient’s will depend on the clinical situation taking into account the haemodynamic stability, the severity of infection and patient future reproductive potentials. The management includes conservative or surgical management. In conservative management, broad spectrum antibiotics should be considered and long term follow is need. Patient uterine integrity is difficult to test if this patients plan for further pregnancies and deliveries. In those patients who are unstable, exploratory laparotomy is recommended. Option between refashioning of the edges of the uterine incision or hysterectomy should depend on the intraoperative findings and patient future needs. In our case, the scar margins was intact, hence re-suturing of the incision site was carried out. If the edges are necrotic and irregular, hysterectomy may be considered.

The consequence of this complication for a future pregnancy remains unknown. Mode of delivery in next pregnancy is preferably a repeat caesarean section. For our patient, we have recommended for an elective caesarean delivery at around 37 weeks. 

Disclosure

None of the authors has anything to disclose

Consent Taken from Patient to use the pictures & publish this article

References:

1. El-Agwany AS et al. Conservative management of infected post partum uterine dehiscence after   c   cesarean section. J Med Ultrasound. 2018;26(1):59. doi:10.4103/jmu.jmu_5_18.

2. Wagner MS, Bédard MJ. Postpartum Uterine Wound Dehiscence: A Case Report. J Obstet Gynaecol Canada. 2006;28(8):713–5.doi:10.1016/s1701-2163(16)32236-8

3. Jastrow N, Chaillet N, Roberge S, Morency AM, Lacasse Y, Bujold E. Sonographic lower uterine segment thickness and risk of uterine scar defect: a systemic review. J Obstet Gynaecol Can 2010;32:321-7

4.  Sengupta Dhar R, Misra R. Postpartum uterine wound dehiscence leading to secondary PPH: Unusual sequelae. Case Rep Obstet Gynecol 2012;2012:154685.

 

Algorithm for Management Of Urinary Incontinence In Women