Surgical Techniques

Pessaries for vaginal prolapse: Critical factors to successful fit and continued use

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References

To see insertion demonstrated, watch Vaginal pessaries: An instructional video

Gehrung
This pessary is designed with an arch-shaped malleable rim with wires incorporated into the arms (FIGURE 3). Use of the Gehrung pessary is rare; it is most often used in women with cystocele or rectocele.

Insertion. Fold the pessary to insert it into the vagina. Upon insertion, keep both heels of the pessary parallel to the posterior vagina with the back arch pushed over the cervix in the anterior fornix and the front arch resting behind the symphysis pubis. The concave surface and diaphragm support the anterior vagina. Place the convex portion of the curve beneath the bulge. The two bases rest on the posterior vagina against the lateral levator muscles.

Shaatz
This support pessary has a circular base similar to the Gellhorn pessary but without the rigid stem (FIGURE 4).

Insertion. Because it is stiff, insert this pessary vertically and then turn it to a horizontal position once it is inside the vagina.

Lever
The Hodge, Smith, and Risser pessaries are collectively called the lever pessaries. They are used to manage uterine retroversion and POP. They are rarely used.

The Hodge pessary is beneficial to patients with a narrow vaginal introitus, mild cystocele, and cervical insufficiency. The anterior portion of a Hodge pessary is rectangular (FIGURE 5A).

The Smith pessary is useful for patients with well-defined pubic notches because the anterior portion is rounded (FIGURE 5B).

For patients with a very shallow pubic notch, the Risser pessary is useful. The Risser’s anterior portion is rectangular with indentation but wider than the Hodge pessary (FIGURE 5C).

Insertion. Fold the pessary and insert it into the vagina with the index finger on the posterior curved bar until the pessary rests behind the cervix and the anterior horizontal bar rests behind the symphysis pubis.

SPACE-OCCUPYING PESSARIES
The second pessary category is the space-filling pessary. These pessaries are used primarily to support severe POP, especially posthysterectomy vaginal vault prolapse. They have larger bases to support the vaginal apex or cervix; therefore, they are more difficult to insert and remove. When this pessary type is in place, sexual intercourse is not possible. Examples include the Gellhorn, donut, cube, and inflatable pessaries.

Gellhorn
The Gellhorn pessary is the most commonly used space-filling pessary. It has a broad base with a stem (FIGURE 6). The broad base supports the vaginal apex while the stem keeps the circular base from rotating and prevents pessary expulsion. The stem comes in long or short lengths. The concave base provides vaginal suction and keeps the pessary in place. The holes in the stem and base provide vaginal drainage. The Gellhorn pessary is useful for women with more advanced prolapse and less perineal support.

Insertion. Folding one side of the base to the stem, insert the Gellhorn pessary vertically inside the vagina. To facilitate insertion, separate the labia with the nondominant hand or depress the perineum with the index finger. Once the circular base is inside the vagina, push the pessary upward until the tip of the stem is just inside the vaginal introitus (FIGURE 7). Many medical illustrations inaccurately depict the Gellhorn pessary in a final placement that appears too high in the pelvis. This figure, which has the patient in a standing position, shows how low in the pelvis this space-filling pessary can sit in a patient with advanced prolapse.

Remove this pessary by gently pulling the stem while inserting the opposite hand beneath an edge of the pessary base to break the vaginal suction (Watch Vaginal pessaries: An instructional video).

Donut
The donut pessary is used for advanced prolapse because it fills a larger space. It is difficult to insert and remove because it is large, thick, and hollow (FIGURE 8).

Insertion. Insert it vertically and, once it is placed inside the vagina, rotate it to a horizontal position. A Kelly clamp can be used to grasp the pessary and facilitate removal.

Cube
The cube pessary supports third-degree uterine prolapse by holding the vaginal wall with suction (FIGURE 9). Because of the risk of vaginal erosion and lack of drainage in some designs, the cube pessary requires nightly removal and cleaning.

Insertion. Squeezing the pessary with the thumb, index, and middle fingers, insert the cube pessary at the vaginal apex.

Removal requires breaking the suction by placing a fingertip between the vaginal mucosa and the pessary and compressing the cube between the thumb and forefinger to remove. Gently tugging on the string also helps with removal.

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