Potential complications of pessary use
The most common complications experienced by pessary users are:
Odor or excessive discharge. Bacterial vaginosis (BV) occurs more frequently in women who use pessaries. The symptoms of BV can be minimized—but unfortunately not totally eliminated—by the prophylactic use of antiseptic vaginal creams or gels, such as metronidazole, clindamycin, Trimo-San (oxyquinoline sulfate and sodium lauryl sulfate), and others. Inserting the gel vaginally once a week can significantly reduce discharge and odor.3
Vaginal mucosal erosion and ulceration. These are treated by removing the pessary for 2 weeks during which time estrogen cream is applied daily or an estradiol vaginal ring is put in place. If no resolution occurs after 2 weeks, the nonhealing vaginal mucosa should be biopsied.
Pressure on the rectum or bladder. If the pessary causes significant discomfort or interferes with voiding function, then either a different size or a different type pessary should be tried
Patients may discontinue pessary use for a variety of reasons. Among these are:
- discomfort
- inadequate improvement of POP or incontinence symptoms
- expulsion of the pessary during daily activities
- the patient’s desire for surgery instead
- worsening of urine leakage
- difficulty inserting or removing the pessary
- damage to the vaginal mucosa
- pain during removal of the pessary in the office.
Pessary effectiveness for POP and SUI symptoms
As might be expected with a device that is available in so many forms and is used to treat varied types of POP and SUI, the data concerning the success rates of pessary use vary considerably. These rates depend on the definition of success, that is, complete or partial control of prolapse and/or incontinence; which devices are being evaluated; and the nature and severity of the POP and/or SUI being treated.
That being said, a review of the literature reveals that the rates of prolapse symptom relief vary from 48% to 92% (TABLE 1).4-13
As for success in relieving symptoms of incontinence, studies show improvements in from 40% to 77% of patients (TABLE 2).6,8,14-17
In addition, some studies show a 50% improvement in bowel symptoms (urgency, obstruction, and anal incontinence) with the use of a pessary.9,18
How pessaries compare with surgery
While surgery has the advantage of being a one-time fix with a very high rate of initial success in correcting both POP and incontinence, surgery also has potential drawbacks:
- It is an invasive procedure with the discomfort and risk of complications any surgery entails.
- There is a relatively high rate of prolapse recurrence.
- It exposes the patient to the possibility of mesh erosion if mesh is employed either for POP support or incontinence treatment.
Pessaries, on the other hand, are inexpensive, nonsurgical, removable, and allow for immediate correction of symptoms. Moreover, if the pessary is tried and is found to be unsatisfactory, surgery always can be performed subsequently.
Drawbacks of pessary treatment compared with surgery include the:
- ongoing need to wear an artificial internal device
- need for intermittent pessary removal and cleansing
- inability to have sexual intercourse with certain kinds of pessaries in place
- possible accumulation of vaginal discharge and odor.
Sexual activity and pessaries
Studies by Fernando, Meriwether, and Kuhn concur that for a substantial number of pessary users who are sexually active, both frequency and satisfaction with sexual intercourse are increased.8,19,20 Kuhn further showed that desire, orgasm, and lubrication improved with the use of pessaries.20 While some types of pessaries do require removal for intercourse, Clemons reported that issues involving sexual activity are not associated with pessary discontinuation.21
Using a pessary to predict a surgical outcome
Because a pessary elevates the pelvic organs, supports the vaginal walls, and lifts the bladder and urethra into a position that simulates the results of surgical repair, trial placement of a pessary can be used as a fairly accurate predictive tool to model what pelvic support and continence status will be after a proposed surgical procedure.22,23 This is especially important because a significant number of patients with POP will have their occult stress incontinence unmasked following a reparative procedure.24 A brief pessary trial prior to surgery, therefore, can be a useful tool for both patient and surgeon.
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