THE VAGINAL PESSARY

Bernie BrennerGynaecologistClinical Director – Pelvic Floor ClinicMilfordAuckland gynaecology@xtra.co.nz

Presentation modified from H Carcio “Bioteque – The Vaginal Pessary”

THE VAGINAL PESSARY

PELVIC ORGAN PROLAPSE QUANTIFICATION EXAM

Measures the descent of the anterior, apical and/or posterior portions of the vagina

Records vaginal length and width of the introitus. Uses centimeters with reference to the hymen

when performing the Valsalva Negative numbers: Distance above the hymen Positive numbers: Distance of prolpase protruding

beyond hymen May simply grade the prolapse from 1 to 3

PURPOSES Supports the vaginal musculature/bladder base in

physiologic alignment Can provide a solution to incontinence in women

unable or unwilling to have surgical correction May unmask Stress Urinary Incontinence Provides a diagnostic means of predicting which

patients would be helped with surgical correction

ADVANTAGESMay reduce the symptoms of incontinence

Supports and corrects retro-displacement of the uterus in early pregnancy

Relieves the discomfort of a pelvic organ prolapse

Repositions pelvic structures during pelvic floor rehabilitation (decreases post op adhesions)

PESSARY CAN SUPPORT A POP

A. Cystocele B. Rectocele C. Enterocele

CAUSES OF PROLAPSE

Constipation Exercise Pregnancy and Childbirth Abnormal collagen/connective tissue Hormonal factors Previous pelvic surgery

STRESS INCONTINECE: Causes Weakened pelvic floor musculature Intrinsic sphincter deficiency Increased intraabdominal pressure Reduced strength of urethral sphincter

HISTORICAL PERSPECTIVES Appears in both Latin

and Greek literature Many different types

of materials and shapes

Over 2000 used throughout history

Fell into disfavour 10-20 years ago

Today offers a viable alternative to surgery

PESSARY FEATURES Silicone

Non-toxic, medical-grade silicone Biologically inert - does not absorb vaginal odor Pliable Can be autoclaved or soaked in Cidex

A few pessaries are made of latex rubber Must assess and document any latex allergy

Available in a variety of sizes and shapes The outside diameter is measured in inches

with a range of one to four inches

SEXUAL ACTIVITY

Intercourse is possible with pessaries that are not vaginally occlusive

Must have the dexterity and know-how to insert and remove as necessary

Note: Always ask about sexual activity – never assume

CONTRAINDICATIONS

Severe untreated vaginal atrophism Vaginal bleeding of unknown origin Pelvic inflammatory disease Abnormal cervical smear Dementia without possibility of

dependable follow-up care Expected non-compliance with follow-up

THE EVALUATION

Pelvic Examination Determine the extent of the

pelvic support problem POP-Q Assess degree of incontinence Rule out any pathology

Cervical smear Assess oestrogen status

Some possible predictors of pessary failure Short vaginal length Wide introitus Posterior-wall defects Patients who desire surgery

FITTING A PESSARY The pubic bone is an important landmark.

The pessary should fit snugly behind it. There is less chance of expulsion if thus anchored

Uterine Prolapse (if present) Insert two fingers in the vagina to push any

uterine prolapse back into place Place opposite hand on abdomen and push on the

fundus (if present) to hold in place Reduce any cystocoele or rectocoele prior to

fitting Put in largest size that will fit comfortably, or

simply tuck a smaller pessary well behind the pubic bone

MEASURING THE WIDTH

Insert first two fingers of dominant hand deep to the posterior fornix

Approximate size by using the fingers to determine the width

Spread fingers wide to measure

Remove fingers and compare to pessary sample or fitting kit

MEASURING THE LENGTH

Reinsert fingers deep into the posterior fornix

Make note of where the hand comes into contact with the pubic bone

Compare to pessary.

Iden

VAGINAL OESTROGEN

The majority of older women with a pessary need vaginal oestrogen

The Estring works nicely since it also needs to be changed every 3 months

Oestrogen use keeps the vagina healthy Oestrogen thickens the layer of the vaginal

mucosa allowing for more support of the pelvic organs.

COMPLICATIONS Increase in vaginal discharge Odor Ulcerations Pelvic discomfort Incarceration

Scar/granulation tissue may form around pessary

Complications are rare in the properly fitted and well maintained pessary

DONUT

The Donut Hole

Description: soft silicone, donut shaped.

Indications: Occludes upper vagina

and supports a uterine prolapse

Useful for cystocoele or rectocoele

Good for prolapse of the vagina after a hysterectomy

Adequate integrity of the introitus is necessary for the pessary to remain in place

CUBEIndications: Third-degree

prolapse, cystocele or rectocele, with or without good vaginal tone.

Often this is the only satisfactory support for women with a complete prolapse, complicated by a cystourethrocoele.

Excellent for vaginal wall prolapse in that it keeps the vaginal wall from collapsing from its six pressure points.

Maybe used by an athlete and removed after exercise.

Mucosa molds to the concavities creating a negative pressure

Description: Each side of the cube has concave suction cups that adhere to the vaginal walls, helping to restore anatomical support to the pelvic organs.

Drainage holes

INCONTINENCE DISH

Description: Dish-shaped pessary with holes to allow for drainage. The flexible membrane of the dish supports and elevates a mild cystocele.

Indications: SUI in conjunction with a 1st or 2nd degree prolapse, or a mild cystocele.

The knob

Membrane support

SHAATZ

Description:A circular pessary with

holes for drainage of secretions.

Indications: For the support of a first or mild second-degree prolapse.

GEHRUNGDescription:U-shaped device that provides

support to the anterior vaginal wall. The arms or heels rest flat on the vaginal floor

It avoids pressure on the rectum while supporting the anterior wall

Arclike – malleable-can be shaped to suit the shape of the vagina

Shape can be expanded once inserted, a distinct advantage

Creates a “bladder bridge”

May be underutilized

HeelArch

GELLHORN Description: Most commonly

used pessary for uterine prolapse, also helpful with SUI. Fits superiorly and anteriorly.

Indications: Provides support for third-degree uterine prolapse and procidentia.

Provides less support for a rectocele since there is less support of the posterior segment.

Holes for drainage

HODGE

Description: The anterior notch prevents

urethral impingement and obstruction.

Available with support for the bladder in patients with stress incontinence.

If properly fitted sexual intercourse is possible

Malleable

Notch

Support for cystocele

RING - with and without support

Description:Round flexible ring.Helps support the urethra and

bladder neck.Membrane provides

additional support for a cystocele.

Indications:Useful for a first or mild

second-degree uterine prolapse associated with a mild cystocele.

Support