Potential candidates for pessary use
Almost all women with POP—and in many cases accompanying SUI—are potential candidates for a pessary. In fact, many urogynecologists believe that a trial of pessary usage should be the first treatment modality offered for POP.5 Women who cannot use a pessary include those with an extremely short vagina (<6 cm) and those who have severely eroded vaginal mucosa. In the latter situation, the mucosa can be treated with estrogen cream for several weeks and, once the tissue has healed, a pessary can be fitted.
Given that surgical repair is generally a straightforward, one-time procedure that obviates the need for long-term use of an artificial device worn internally, why might a patient or her physician opt for a pessary instead?
Some of the many reasons include:
- Many patients prefer to avoid surgery.
- Many patients are not appropriate candidates for surgery because they have significant comorbid risk factors or high BMI.
- Patients may have recurrent prolapse or incontinence and wish to avoid repeat surgery.
- Patients with SUI may have heard of the occurrence of mesh erosion and wish to avoid that possibility.
- Women who live in low-resource environments or countries where elective surgical care is relatively unavailable may not have the option of surgery.
A clinician might also recommend pessary use:
- as a diagnostic tool to attempt to assess the potential results of vaginal repair surgery
- to estimate the potential effectiveness of a midurethral sling procedure; several investigators have found this to be approximately as accurate as urodynamic testing6,7
- as prophylaxis for pregnant women with either a history of preterm cervical dilation or a short cervix detected on ultrasonography
- for pregnant women with POP that is worsening and becoming increasingly uncomfortable
- for women with POP who wish to have more children
- for short-term use while a patient is delaying or awaiting POP surgery or to allow time for other medical issues to resolve
- for patients who wish only intermittent, temporary support while exercising or engaging in sports.
Patient acceptance may be contingent on counseling
Numerous studies show that women who choose pessaries to treat POP are generally older than women who elect surgery. Still, patient acceptance of a trial of pessary use depends much on the counseling and information she receives. Properly informed, many patients with POP will opt for a trial of pessary placement. One study showed that, of women with untreated POP, 36% preferred pessary placement to surgery.8 Other investigators reported that when women with symptomatic POP had the benefits of a pessary versus surgery explained to them, nearly two-thirds opted for a pessary as their mode of treatment.9
Exceptions to pessary use
Fortunately, there are relatively few contraindications to pessary use. These are vaginal or pelvic infection and an exposed foreign body in the vagina, such as eroded vaginal mesh. In addition, patients at risk for nonadherence with follow-up care are poor candidates, as it could lead to missing such problems as mucosal erosion, ulceration, or even (extremely rarely) fistula formation. Pessaries may be inappropriate for sexually active women who on their own are unable to remove and reinsert pessary types that do not allow for intercourse while in place (see below).
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