Pessaries for the GYN Patient, feat. Dr. Edward Kim
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What are pessaries?
Pelvic organ prolapse (or POP) and stress urinary incontinence (or SUI) are common problems that impact millions of women in the world.
A pessary is a support device placed vaginally that can be used to treat symptoms of POP, SUI, or both.
Pessaries are generally cost effective, well-tolerated, safe and can help avoid surgery.
For POP, up to 90% of patients report relief of symptoms like pressure and bulge.
For SUI, about half of patients report improvement in urinary symptoms.
History of the pessary
Historically, the first use of pessary for reduction of pelvic organ prolapse was described by Hippocrates.
He put a halved pomegranate soaked in wine into the vagina.
In 1860, Dr. Hugh Lenox Hodge, an ob/gyn faculty at the University of Pennsylvania, used newly developed vulcanized rubber to create a pessary shaped more anatomically.
Today, most pessaries are made of soft, flexible silicone thus considered non-allergenic.
The Modern Pessary
The most commonly used pessaries are ring, Gellhorn and donut.
Ring pessary is a go-to in practice.
Subtypes: Ring without support
Ring with support (kinda looks like a mini frisbee),
Ring without support with a knobRing with support with a knob.
The knob sits under the pubic bone and helps with stress urinary incontinence. So a ring with support and a knob will address POP and SUI. Rings can be removed by patients fairly easily.
A Gellhorn has a stem and a concave disc (kinda looks like a baby pacifier).
The concave disc part sits below the vaginal apex and creates somewhat of a suction.
The stem sits posteriorly and prevents the pessary from flipping around.
Gellhorns are little more difficult to place. Patients seldom can remove them on their own.
For removal, a provider usually needs to grasp the stem with their fingers or a ring forceps, gently wiggle it out to break the suction allowing for removal.
Gellhorns are generally used for more severe prolapse.
A donut (as the name implies) looks like a mini donut and it achieves its function by occupying the vagina.
A donut works better for more severe prolapse, as well, and difficult for patients to remove on their own.
Indication and counseling:
Patients with symptomatic POP or SUI who desire to avoid surgery, poor candidate for surgery, desire further childbearing, current pregnancy or within 12 months postpartum.
Contraindications include:
active pelvic infection,
latex allergy (as some inflatable pessary are composed of latex),
non adherence to care and follow up
Studies report a very wide range of patient acceptance of pessary: from 42 to 100%.
Patients who decline tend to be younger, sexually active, nulliparous, or have severe POP or SUI and desire surgical correction.
But it also depends on the counseling. In our practice, we discuss pessary in the range of management options for POP and SUI. We sometimes use it as a bridge between now and surgery for patients who prefer symptom relief now.
Placement:
Placement comes with practice and it often involves trial and error.
There have been no identified reliable predictors of which size pessary should be tried first.
Start with a ring with support pessary (ring with support and a knob if also trying to address SUI).
Identifying the starting size (say, 3, 4, 5) comes with practice and pelvic exam. Wet it with warm water first.
You could use lubricant but if you use too much it may be too slippery for you to handle and also easier for it to be expelled.
Fold it in half like a taco, insert, and allow it to resume its disc shape in situ. Remember, it should NOT be painful. If the patient says it’s painful once it’s placed, then it is often too big.
Liken it to a corrective device like glasses or contact lens. When you first start using it, you notice that it’s there. But it should not be painful and with time you often forget it’s there.
Then have pt Valsalva.
It’s okay that you can see the pessary descend as long as it does not completely get expelled.
Then have them ambulate and go to the toilet and Valsalva with a toilet hat to catch the pessary if it does get expelled.
If it’s still in situ after that and patient has no discomfort, we send them home with it.
Placement of Gellhorn, donuts, and other types of pessaries are little different and may be best reserved for providers who have more experience with them. But I think ring pessaries can be something everyone can have in their toolbox.
Maintenance:
Patients who wish to and have the dexterity to maintain the pessaries on their own are instructed to take it out and clean with warm soapy water as often as they want but usually at least once a week.
If they are unable to, then typically they come to the clinic every 3-4 months for maintenance.
Patients with Gellhorn, donut, or other types of pessaries that patients cannot remove easily on their own also follow up every 3-4 months. At these visits, the pessary is removed, gently cleaned, and a speculum exam is done to assess for any excoriation or abrasion.
For postmenopausal patients without contraindication for topical vaginal estrogen, we typically have them use it to prevent significant vaginal excoriation or abrasion since atrophy can worsen these.
Complications:
Most common complaints are increase or change in vaginal discharge or odor. Reassurance and ruling out for vaginitis and bacterial vaginosis are reasonable next steps. Reports of vaginal bleeding long after placement warrants exam in the office.
Spontaneous expulsion or difficulty with voiding or defecation or pain often means a different size or shape should be tried.
Pessaries that have been left in situ and neglected for prolonged period of time should be taken seriously. Embedded pessaries may need removal under general anesthesia.
But overall, it is generally very safe.
