Pessary

1. Indications
   1. Pelvic Organ Prolapse
2. Protocol
   1. Fitting - too small
      1. Pessary expelled with cough or valsalva maneuver
   2. Fitting - too large
      1. Patient aware of Pessary when walking, sitting, voiding or stooling
   3. 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
3. 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
4. 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
5. Preparations: Pessaries for advanced apical prolapse
   1. Cube
   2. Inflatoball
6. References
   1. Kuncharapu (2011) Am Fam Physician 81(9): 1111-7
   2. Trowbridge (2005) Clin Obstet Gynecol 48(3): 668-81