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

CASE 1. EARLY-STAGE PELVIC ORGAN PROLAPSE

AC is a 64-year-old white woman with early stage III anterior and apical pelvic organ prolapse (POP). The prolapse is now affecting her ability to do some of the things that she enjoys, such as gardening and golfing.

She has hypertension controlled with medication and no other significant medical issues except mild arthritic changes in her hands and hips. She reports being sexually active with her husband on roughly a weekly basis.

On examination, the leading edge of her prolapse is the anterior vaginal wall, protruding 1 cm beyond the introitus, and the cervix is at the hymenal ring. There is no significant posterior wall prolapse.

After she is counseled about all possible treatment approaches for her early-stage POP, the patient elects to try the vaginal pessary. Now, it is your job to determine the optimal pessary based on the extent of her condition and to educate her about the potential side effects and best practices for its ongoing use.

The vaginal pessary is an important component of a gynecologist’s armamentarium. It is a low-risk, cost-effective, nonsurgical treatment option for the management of POP and genuine stress urinary incontinence (SUI).^1,2 It is unfortunate that training in North America typically provides clinicians with only a cursory experience with pessary selection and care, minimizing the device’s importance as a viable tool in a practitioner’s ongoing practice. In fact, most clinicians tend to view the pessary with a mixture of reluctance and disregard.

This is regrettable, as a majority (89%) of patients can be successfully fitted with a pessary,³ regardless of their stage or site of prolapse.⁴ Although high-stage prolapse does not predict failure, ring pessaries are used most successfully with stage II (100%) and stage III (71%) prolapse, while Gellhorn pessaries are most successful with stage IV (64%) prolapse.⁵

In this article we review the several pessary options available to clinicians, as well as how to insert them and the best scenarios for their use. We also discuss the key requirements for patient assessment and in-office fitting (meant to optimize the fit and, thereby, the success of use), the possible side effects of pessary use that patients need to be aware of, and appropriate follow-up.

WHEN IS A PESSARY YOUR BEST MANAGEMENT APPROACH?
There are several indications for pessary use,⁶ namely when:

• the patient has significant comorbid risk factors for surgery
• the patient prefers a nonsurgical alternative
• a goal is to avoid reoperation
• POP or cervical insufficiency is present during pregnancy
• the patient desires future fertility
• surgery must be delayed due to treatment of vaginal ulcerations
• the pessary will be used as a postoperative adjunct to mesh-based repair.

Pessaries have very few contraindications (TABLE). However, factors that do negatively affect successful fitting include:

• prior pelvic surgery
• multiparity
• obesity
• SUI
• short vaginal length (<7 cm)
• wide vaginal introitus (>4 fingerbreadths)
• significant posterior vaginal wall defect.^5,7-9

There are two main categories of vaginal pessaries: support and space-filling. All pessaries come in different sizes and shapes. Most are made of medical-grade silicone, rendering them durable and autoclavable as well as resistant to absorption of vaginal discharge and odors. The ring pessary with support is the most commonly used support pessary. The Gellhorn pessary is the most commonly used space-filling pessary. It is used as a second-line treatment for patients unable to retain the ring-with-support pessary.

Related Article: Pessary and pelvic floor exercises for incontinence—are two better than one? G. Willy Davila, MD (Examining the Evidence, May 2010)

SUPPORT PESSARY OPTIONS
The support pessaries are used to treat SUI and POP. These pessaries typically are the easiest types for patients to use because they are more comfortable and simpler to remove and insert than space-filling pessaries. For example, a ring pessary is two-dimensional and lies perpendicular to the long axis of the vagina, allowing patients to have intercourse with it in place. Support-type pessaries include the ring, Gehrung, Shaatz, and lever.

Ring
This is the most commonly used pessary because it fits most women. There are four types of ring pessaries: the ring (FIGURE 1A), ring with support (FIGURE 1B), incontinence ring, and incontinence ring with support. The ring pessary is appropriate for all stages of POP. The ring with support has a diaphragm that is useful in women who have uterine prolapse with or without cystocele. The incontinence ring has a knob that is placed beneath the urethra to increase urethral pressure and is useful in cases of SUI.

Insertion. Fold the pessary by bringing the two small holes together, and lubricate the leading edge. Insert it past the introitus with the folded edge facing down. Allow the pessary to reopen, and direct it behind the cervix into the posterior fornix (FIGURE 2). Give it a slight twist with your index finger to prevent expulsion.