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

CASE 2. ADVANCED-STAGE POP
BD is an 82-year-old widow (G5P4014) with stage IV vaginal prolapse. She has noticed some scant blood staining on her clothing. She frequently voids small amounts of urine but never feels complete relief. She defecates normally.

Her medical history is significant for coronary artery disease with prior myocardial infarction, with multiple stent placements over the years. She has hypertension, reduced ejection fraction, and diabetes. She is morbidly obese and suffers from degenerative joint disease. She had a vaginal hysterectomy several years ago for benign indications.

Upon examination, BD’s prolapse is large, with excoriations and hyperkeratosis of the skin over the prolapse. It is easily reduced in the office.

What is the best pessary for this patient, and how should she be followed and counseled regarding ongoing care?

Since the failure rate for pessary usage increases with advancing prolapse stage, a space-occupying pessary is most appropriate to try initially. A trial with a support pessary could be useful to allow the excoriations to heal and provide a healthier vaginal environment. A Gellhorn pessary is commonly used. An inflatable pessary could be an alternative if the Gellhorn fails to stay in place. The cube pessary, known to cause more abrasions and erosions than other pessaries, is a poor choice given the state of the patient’s vaginal tissues at baseline.

Space-occupying pessaries are more difficult to insert and remove and have a higher risk of pain or trauma. Start with shorter time intervals between visits, eventually spacing them out for the patient’s convenience. The usual interval for follow-up is 3 to 4 months; longer intervals could be offered if the patient is reliable, adherent, and reports no complaints with pessary use.

Related Article: Update on pelvic floor dysfunction: Focus on urinary incontinence Alexis A. Dieter, MD, and Cindy L. Amundsen, MD (November 2013)

OUTCOMES
Only short- and medium-term outcomes for pessary use have been described in the literature. Short-term (2 months) satisfaction and continued use, along with resolution of prolapse, occurred in 92% of patients.7 Previous hysterectomy or prolapse surgery may influence the short-term success of pessary use.¹⁰

More than half of sexually active women achieved long-term use (up to 2 years), regardless of prolapse severity. Brincat and colleagues found that long-term pessary use (1 to 2 years) approached 60% in 132 women with both urinary incontinence and prolapse. Women being treated for POP were more likely to continue pessary use than women being treated for SUI.11 Age, parity, estrogen use, and sexual activity were characteristics also studied in pessary fitting. Neither sexual activity nor stage of prolapse was a contraindication to use of a pessary; long-term use was found to be acceptable in sexually active women.¹¹

Successful fitting of a vaginal pessary has been associated with improvement in voiding, urinary and fecal urgency, and incontinence. A vaginal pessary is a viable nonsurgical option for the management of POP and urinary incontinence and remains an optimal minimally invasive approach to such disorders.

CASE 2 CONCLUDED
The patient returns to the clinic 1 month after the original insertion. The pessary is removed, and the vagina is inspected, with no abrasions or ulcerations found. The vaginal cavity and pessary are cleaned with a mild soap-and-water mixture. The pessary is lubricated and reinserted. This process is repeated 2 months later, with subsequent follow-up intervals doubled (up to 6 months between visits) when the patient has no complaints of discharge or odor.