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