Vaginal pessary placement training for GO MOMS

1. Pessary Management
of Pelvic Floor Disorders

2. There are
a large
variety of
pessaries
available

3. 2 common types we have
available for your use
• Support
– Incontinence ring
• Space filling
– Donut

4. Indications
1. Prolapse
2. Urinary incontinence
3. Urinary retention: relieve obstruction and
improve renal function
4. Before surgery: allow inflammation and
ulceration in procidentia to heal preoperatively
5. Failed surgical correction

5. When is a pessary most
beneficial?
• Patient prefers nonsurgical
management
• Patient has significant risk for surgical
morbidity

6. Contraindications
• Severe erosions
• Active vaginitis
• Pelvic inflammatory disease
• Non-compliant patient- unable to return for
exams

7. Fitting a Pessary
• Patient should empty bladder
• Largest pessary that can be comfortably place
• Examiner finger should easily pass between
vagina and circumference of pessary
• Have patient perform Valsalva
– Okay to see pessary edge with maximum force at
introitus
• Patient should be able to sit, stand, urinate and
defecate with pessary in place (not necessary to
do all these at initial visit!)

8. Follow-up/ Management
• After Initial fitting: return in 1-2 weeks
Specifically ask questions: comfort, voiding,
defecation, discharge and ease of care
• For the 1st
Year: return every 3 months
• After 1st
Year: every 6 months
If patient is removing the pessary regularly (at
least once a week), can return every 12 mos

9. Follow-up/ Management
• Pessary removed and cleansed with soap
and water
• Speculum exam
– Evaluate for
• Abrasions
• Erosions
• Vaginal discharge
• Atrophy
– Irritation common; full thickness ulcer is a
problem

10. Common Problems
• Pessary expulsion
• New onset urinary incontinence (20%)
• Rectal pain
• Difficulty with defecation
• Vaginal discharge
• Vaginal atrophy
• Ulceration with bleeding
• Impaction

11. How many continue pessary
use?
• 2 month:
– 92% satisfied
• 1 year:
– 73% satisfied
• 2 Years:
– 64% satisfied
Clemons JL. AJOG. 2004.
Best Predictor of Acceptability: AGE!

12. What factors predict discontinued
use?
• Desired surgery at initial visit
• Stage 3 and 4 posterior wall prolapse

13. Vaginal Discharge
• Some vaginal discharge is expected
• Increased risk for bacterial vaginosis (4X)
– If symptomatic, may treat
• Vaginal cultures: NOT RECOMMENDED
• If discharge is a problem; remove,
estrogenize, insert new pessary when
irritation gone

14. Vaginal Atrophy
• Local estrogen therapy is recommended in
pessary users
– Prevention of ulcers, abrasion, incarcerations
• If significant atrophy present, use vaginal
estrogen for 6 weeks before beginning pessary

15. Ulceration
• Remove pessary
• Intravaginal estrogen (0.5-1.0 gm/day) for
2-3 weeks
• Replace pessary if healed
• Continue local estrogen 2-3x/week
• Recurrent/Persistent ulcers -> BIOPSY

16. Impaction
• More common with space-filling pessaries
(i.e. Gellhorn or Cube)
• Use a Tenaculum
• Apply local estrogen daily for 2-3x/week
and then attempt removal
• May require removal in the OR (rare)

17. Severe Complications
• Incarceration of pessary
• Vesicovaginal fistula
• Rectovaginal fistula
Bottom Line:
Neglected Pessary + Noncompliant patient
= Potential for Severe Complications

18. Case Scenarios

19. 52 year old G2P2 with bulging in the
vaginal area
• Had a vaginal hysterectomy for prolapse
and TVT sling for stress urinary
incontinence
• Symptoms relieved for a few months, but
now has recurrence of prolapse symptoms
• No stress incontinence

21. Good choice
Donut
• Indications
– Uterine and vaginal
prolapse, rectocele
• Pros
– Works well for Stage 3-4
prolapse
– Works well for posterior
wall prolapse
• Cons
– Difficult insertion and
removal
– Coitus not possible

22. Stress incontinence

23. Common Pessaries
Incontinence Ring
• Indications
– Stress Urinary
Incontinence
• Pros
– Ease of insertion and
removal
– Coitus possible
• Cons
– None noted

24. 56 year-old G1P1 with bulging in the
vaginal area
• Referred for incomplete fecal evacuation and
symptoms of pelvic pressure
• Defecography and POPQ exam reveals a
rectocele
• Splinting of posterior vaginal wall relieves
constipation symptoms

26. Good choice
Donut
• Indications
– Uterine and vaginal
prolapse, rectocele
• Pros
– Works well for Stage 3-4
prolapse
– Works well for posterior
wall prolapse
• Cons
– Difficult insertion and
removal
– Coitus not possible

27. Other Common Pessaries
Ring with Support
• Indications
– Uterine and vaginal
prolapse
– Cystocele
• Pros
– Ease of insertion and
removal
– Coitus possible
• Cons
– Less helpful for more
severe forms of prolapse

28. Other Common Pessaries
Incontinence Dish with
Support
• Indications
– Stress Urinary Incontinence
– Cystocele
• Pros
– Ease of insertion and removal
– Coitus possible
• Cons
– Less helpful for more severe
forms of prolapse

29. Other Common Pessaries
Gellhorn
• Indications
– Uterine and vaginal
prolapse
• Pros
– Ideal for Stage 3-4
prolapse
• Cons
– Difficult insertion and
removal
– Coitus not possible

30. Common Pessaries
Cube
• Indications
– Uterine and vaginal
prolapse
• Pros
– Ideal for Stage 3-4
prolapse
• Cons
– Vaginal ulcerations
– Heavy vaginal discharge
– Frequent removal

31. Common Pessaries
Inflatoball
• Indications
– Uterine and vaginal
prolapse
• Pros
– Ideal for Stage 3-4
prolapse
• Cons
– Difficult insertion and
removal
– Coitus not possible

32. Take Home Points
• Pessaries are great alternative to surgical
management if patient not a good
candidate or does not desire surgery at
present
• Pessary use requires a compliant patient
• Physicians and patients need to be aware
of potentially serious complications of
pessary use