Surgical Techniques

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

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Inflatable
This space-filling pessary is an air-filled ball that is inflated via an attached stem that also enables insertion and removal. The older Inflatoball pessary is made of latex, so its use is contraindicated in patients with latex allergy. Newer inflatable pessaries are silicone-based and consist of an air-filled donut, a stem with a valve, and an air pump (FIGURE 10). Some models also include a deflation key. The inflatable pessary comes in small, medium, large, and extra-large sizes. This pessary type must be removed and cleaned daily.

Insertion. Place the deflated pessary into the vagina. Move the ball-bearing valve within the stem (which controls the air flow) to a lateral projection on the side of the stem. To inflate, attach the inflation bulb. (Inflation typically requires 3 to 5 pumps of the bulb.) Move the ball bearing back into position to maintain the inflation, then detach the bulb. You can leave the stem outside the body or tuck it gently into the introitus (FIGURE 11).

INCONTINENCE PESSARIES
These devices are used specifically for SUI. The incontinence ring (FIGURE 12) and incontinence dish pessaries compress the urethra against the pubic symphysis. The knob is placed beneath the urethra, increasing the urethral closure pressure and thereby preventing urinary incontinence.

Related Article: Update on Urinary Incontinence Karen L. Noblett, MD, MAS, and Stephanie A. Jacobs, MD (December 2011)

CASE 1 CONCLUDED
Given that AC has early-stage POP and is sexually active, a space-occupying pessary is not the optimal choice. Instead, a ring pessary with support is fitted for her trial.

What side effects might a patient anticipate with pessary use?
Vaginal discharge and slight odor
are common. Pessary removal and cleaning are usually adequate to eliminate them. Temporary discontinuation of pessary use may be warranted until symptoms subside. If these maneuvers do not resolve the issue, then the patient should be examined to rule out other sources of infection.

Vaginal bleeding. Bleeding from vaginal abrasion and ulceration could be caused by trauma from pessary removal or vaginal impingement. Evaluation is warranted for any vaginal bleeding.

Changes in urinary function. Less commonly, women using a pessary may notice changes in their urinary function. Many women with anterior or apical prolapse will have altered urine streams with slow or trickling flow and possible hesitation upon initiation of voiding.

Alternatively, pessary placement may instigate stress-type incontinence akin to that seen after prolapse surgery. Changing pessary size may alleviate this condition. Otherwise, these side effects may reduce a patient’s willingness to continue pessary use.

How can a patient optimize her use of a pessary?
A patient can remove the pessary on a periodic basis or try to use it continuously. If she cannot or will not remove the pessary, then she will need to come back for scheduled visits, as described in the sidebar, “Essential components of a successfully fitted pessary.” If she is able to remove the pessary on her own, then she can use the device as needed or remove it for intercourse (though it is not necessary). She must remove it weekly, at a minimum, however, to both clean the pessary and give the vaginal walls a “rest,” which can minimize the potential for abrasions or erosions

ESSENTIAL COMPONENTS OF A SUCCESSFULLY FITTED PESSARY
Patient assessment
Accurate selection and placement of a pessary requires appropriate examination and fitting, beginning with determination of the patient’s stage of prolapse and introitus. Key steps include:
– Examine the patient with an empty bladder in the lithotomy position
– Perform bimanual pelvic and speculum examination using a Sims speculum (or bivalve speculum broken in half) with the patient in a supine position
– Administer the Pelvic Organ Prolapse Quantification (POP-Q) exam
– Perform digital examination
– Assess vaginal atrophy, vaginal introitus, and vaginal width and length
– Evaluate pelvic floor muscle strength (Kegel squeeze).

Next, gauge the correct pessary size by approximating the number of fingerbreadths accommodated across the vaginal width.

Another method of estimating pessary size is to insert two fingers inside the vagina and estimate the distance between the posterior fornix and the posterior pubic symphysis (Watch Vaginal pessaries: An instructional video). An easy reference is to start with a size 3 or 4 ring pessary if the vaginal introitus is 1 to 2 fingerbreadths in width and the prolapse is stage II to III. If the vagina accommodates 3 to 4 fingerbreadths, or there is stage IV prolapse, use a Gellhorn pessary.

Here are the different types of pessaries and the most common sizes available. (Pessary sizes change in quarter-inch increments.)


In-office trial
Insert the pessary into the vagina using the dominant hand. Using the nondominant hand, separate the introitus and depress the perineal body. Apply a small amount of lubricant to the leading edge of the pessary.

After insertion, ask the patient to strain and cough, ambulate in the office, and void. Reexamine the patient to ensure that the pessary is still in the correct position and that placement has not shifted. Perform the cough leak test with the patient in a standing position and the pessary in place. Re-examine the patient while she is in a standing position. Use the largest pessary that is comfortable for her. Advise her to bring the pessary back to the office if it gets expelled.

This is a trial-and-error process; advise the patient of this. It may require a trial of several styles and sizes to find the right pessary fit. Once you find the correct size, document the final pessary size.
Follow-up
Schedule a follow-up appointment 1 to 2 weeks after insertion. Ask the patient whether she has experienced any discomfort, malodorous discharge, or vaginal bleeding. Also inquire about any changes in urinary habits or bowel movements and related complaints.

Remove the pessary and clean it with mild soap and water. Examine the vagina for pressure points, abrasions, ulcerations, and erosions.

Teach the patient how to remove, clean, and reinsert the pessary, and advise her to perform these tasks on a weekly basis.

Schedule a follow-up visit in 1 to 2 months, and another visit 6 to 12 months after that.

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Update on pelvic floor dysfunction: Focus on urinary incontinence

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