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Pessary

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Pessary, Pessaries

  • Indications
  1. Pelvic Organ Prolapse
  • Contraindications
  1. Patient unable to comply with care or follow-up (e.g. Dementia, decreased dexterity)
  2. Those not able to remove and insert Pessary may return to clinic for Pessary replacement at 3 month intervals
  • Efficacy
  1. First choice intervention for two thirds of Pelvic Organ Prolapse patients
    1. Kapoor (2009) Int Urogynecol J Pelvic Floor Dysfunct 29(10): 1157-61 [PubMed]
  2. High level of compliance (77% continue Pessary beyond 1 year)
    1. Clemons (2004) Am J Obstet Gynecol 191(1): 159-64 [PubMed]
  3. Effective for all levels of prolapse stages
  • Protocol
  1. Factors interfering with proper fitting
    1. Short vaginal length
    2. Wide vaginal opening (>4 finger breadths)
    3. Hysterectomy
  2. Proper fitting (ring Pessary)
    1. Fold ring Pessary in half for insertion
    2. Pessary fits between Pubic Symphysis and posterior vaginal fornix
    3. Pessary should remain >1 finger breadth above introitus while bearing down
    4. Assess comfort while sitting, walking, voiding
  3. Fitting - too small
    1. Pessary expelled with cough or Valsalva Maneuver
  4. Fitting - too large
    1. Patient aware of Pessary when walking, sitting, voiding or stooling
  5. Device selection
    1. Step 1
      1. Ring with support or
      2. Ring with knob (if Urinary Incontinence)
    2. Step 2
      1. Gelhorn
    3. Step 3
      1. Donut
    4. Step 4 (combination)
      1. Ring with Gelhorn or
      2. Ring with donut or
      3. Two donuts or
      4. Ring with support and knob (Urinary Incontinence)
    5. Step 5
      1. Cube or
      2. Inflatoball
  • Preparations
  • Most common
  1. Ring
    1. Most commonly used Pessary
    2. Easy to use, allows for intercourse and does not require daily removal
    3. Works for all types of Pelvic Organ Prolapse
    4. Ring is available with several modifications
      1. Knob: Assists with Urinary Incontinence (which the ring alone does not)
      2. Support (ring has inner web with holes) - can not be used in severe prolapse
  2. Gellhorn
    1. Used in severe uterine Pelvic Organ Prolapse (stage 3 or 4)
    2. More difficult to insert, can cause vaginal erosions and does not allow for intercourse
    3. Does not have to be removed daily
    4. Does not assist with Urinary Incontinence
  3. Donut
    1. Used in severe uterine Pelvic Organ Prolapse (stage 3 or 4)
    2. More difficult to insert and does not allow for intercourse
    3. Does not have to be removed daily
    4. Does not assist with Urinary Incontinence
  • Preparations
  • Pessaries used in pregnancy
  1. Smith-Hodge
    1. Used for pregnancy uterine retroversion (mid pregnancy if symptomatic prolapse)
    2. Easy to use, need not be removed daily and allows for intercourse
  • Preparations
  • Pessaries for advanced apical prolapse
  1. Cube
  2. Inflatoball
  • Management
  • Home Instructions
  1. Self-care
    1. Instruct patient on insertion
    2. Instruct patient on nightly removal (may advance to weekly, every 2 weeks or monthly removal)
    3. Instruct on cleaning Pessary on removal
  2. Clinic follow-up
    1. Two weeks after insertion to reassess comfort and efficacy
    2. Women able to self-care for Pessary (removal, cleaning, insertion) may then follow-up annually
    3. For women unable to replace Pessary themselves, may return every 3 months for replacement and exam
  • Adverse Effects
  1. Vaginal Discharge or vaginal odor
    1. Bacterial Vaginosis (30% of Pessary users, especially with less frequent Pessary exchange)
  2. Vaginal irritation, Vaginal ulceration, Vaginal Bleeding
    1. More common in postmenopausal women, less frequent Pessary exchange
    2. Not typically prevented with Vaginal Estrogen therapy
  3. Pelvic Pain
  • References
  1. Iglesia (2017) Am Fam Physician 96(3): 179-85 [PubMed]
  2. Kuncharapu (2011) Am Fam Physician 81(9): 1111-7 [PubMed]
  3. Trowbridge (2005) Clin Obstet Gynecol 48(3): 668-81 [PubMed]