Vaginal Support Pessaries: Indications for Use and Fitting Strategies

SERIES

Shanna Atnip and Katharine O’Dell ESSARIES P elvic floor disorders are © 2012 Society of Urologic Nurses and Associates common in women, and as the population ages, Atnip, S., & O’Dell, K. (2012). Vaginal support pessaries: Indications for use and these disorders may be fitting strategies. Urologic Nursing, 32(3), 114-125. Pseen more frequently by health ERIES ON care providers (Nygaard et al., Flexible silicone vaginal support pessaries offer a low-risk, effective option for S 2008). When pelvic symptoms treatment of symptoms of pelvic organ prolapse. This first article in a three-part series summarizes clinical recommendations and current evidence related to are associated with loss of struc- pessary indications, choice, and fitting. tural support of the pelvic organs and vagina, vaginal support pes-

PECIAL Key Words: Pelvic organ prolapse, pessary, indications, fitting. saries offer an important option S for relief (American College of Objectives: Obstetricians & Gynecologists 1. List the symptoms of pelvic organ prolapse that may be successfully treated [ACOG], 2007). with a vaginal support pessary. Historically, vaginal pessaries have been used to manage pelvic 2. Discuss the various types of pessaries and their uses to treat pelvic organ floor relaxation and were made prolapse. from a variety of materials, 3. Outline the pessary selection process and steps to pessary fitting. including fruit, metal, porcelain,

rubber, and acrylic (Shah, Sultan, genic, and washable, and can gen- & Thakar, 2006). Modern pessaries erally be sterilized using an auto- are made from silicone, acrylic, clave, boiling water, or a cold ster- Shanna Atnip, MSN, WHNP-BC, is a Nurse latex, or rubber. Flexible, medical- ilization product (Cooper Surgical, Practitioner, the Division of Urogynecology grade silicone pessaries are the 2008; Personalmed, 2012). and Reconstructive Pelvic Surgery, Parkland Health & Hospital System, and the primary subject of this article and Support pessaries are experi- University of Texas Southwestern Medical series because they offer many encing a renaissance and are cur- Center, Dallas TX. advantages over other materials. rently recommended as a first-line, For example, flexible, medical- low-risk treatment option for a vari- Katharine O’Dell, PhD, CNM, WHNP-BC, grade pessaries are pliable, long- ety of prolapse-related symptoms is an Assistant Professor of OB/GYN, the Division of Pelvic Medicine and Recon - lasting, non-absorbent (related to (ACOG, 2007; Clemons, Aquilar, structive Surgery, UMass Memorial Medical odor and secretions), biologically Sokol, Jackson, & Myers, 2004). Center, Worcester, MA. inert, non-allergenic, non-carcino- However, to provide satisfactory

Note: Objectives and CNE Evaluation Form appear on page 125. Urologic Nursing Editorial Board Statements of Disclosure Statement of Disclosure: The authors In accordance with ANCC-COA governing rules Urologic Nursing Editorial Board state- reported no actual or potential conflict of ments of disclosure are published with each CNE offering. The statements of disclosure for interest in relation to this continuing nursing this offering are published below. education activity. Susanne A. Quallich, ANP-BC, NP-C, CUNP, disclosed that she is on the Consultants’ This learning activity was partially funded Bureau for Coloplast. by an unrestricted educational grant from CooperSurgical, Inc. All other Urologic Nursing Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

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Table 1. can develop epithelial ulceration Pessary Indications due to dryness and friction on clothing. The risk of infection Relief of prolapse symptoms and hemorrhage can be effective- Convenience in scheduling surgery ly treated in a plan of careful fol- Surgical avoidance low up and pessary use to enhance healing. Diagnostic tool, as in identifying occult stress incontinence In addition to symptom Prediction tool to clarify likely surgical outcomes improvement, use of support Prevention of future increasing prolapse and related morbidity pessaries can help women meet their health improvement goals. S In one study, women who PECIAL achieved their own pre-deter- care, health care providers must Symptom Improvement mined treatment goals (improved effectively evaluate pelvic symp- Symptoms of pelvic organ bladder control, increased com- toms and related health attitudes; prolapse (POP) may include fort with physical activity, de - S assess vaginal size, shape, and pelvic pressure, vaginal bulge, creased prolapse symptoms) ON ERIES support; select a comfortable and irritative voiding symptoms, uri- were more likely to be satisfied effective pessary; and provide nary incontinence (UI), fecal and continue pessary use as com- health education and appropriate incontinence, dyspareunia, con- pared with women who did not follow up. This article addresses stipation, and difficulty emptying meet their treatment goals basic information essential to pre- both the bladder and bowels. (Komesu et al., 2008). Helping P scribing pessaries to women, Many trials have reported signifi- patients set realistic goals for ESSARIES including an overview of current cant improvement of common treatment outcomes based on patterns of clinical use, a review symptoms, including urinary ur - current evidence will help of existing evidence, and sugges- gency and frequency, and urgency women meet their treatment tions for ongoing research. UI; vaginal bulge; pelvic and goals and encourage continued abdominal heaviness and pres- pessary use. Pessary Indications sure; incomplete or difficult While a majority of women bowel emptying; flatal inconti- may note symptom relief with Pessaries are a low-risk option nence; and fecal urgency and pessary use, some women cannot for treatment of pelvic floor disor- incontinence (Barber, Walters, be successfully fitted, and others ders with few absolute contraindi- Cundiff, & the PESSRI Trial may experience burdensome cations. Typically, providers are Group, 2006; Clemons, Aguilar, new symptoms during a pessary advised to use caution if pessary Tillinghast, Jackson, & Myers, trial. New symptoms can include candidates have an active vaginal 2004a; Fernando, Thakar, Sultan, de novo problems with bowel infection, persisting vaginal ero- Shah, & Jones, 2006; Komesu et and bladder emptying, discom- sion or ulceration, or severe vagi- al., 2007, 2008). Improved bladder fort, pressure, or pain; increases nal atrophy (Weber & Richter, emptying subsequent to reduction in vaginal discharge or odor, or 2005). In addition, non-compli- of POP and urethral obstruction new onset stress UI due to ance with follow up can be prob- may prevent many causes of unkinking of an otherwise inade- lematic because it may result in ongoing morbidity or mortality, quately supported urethra late recognition of complications; including recurrent urinary tract (Bump, Fantl, & Hurt, 1988). In therefore, providers are advised to infection, acute urinary retention, one study, the most common risk weigh risks, family support, and and renal injury (Micha et al., factors for dissatisfaction related alternative options carefully 2008). Both stress and mixed to pessary use included de novo before providing pessaries to UI were improved with pessary stress incontinence, a pre-exist- women with dementia or other use in approximately 50% of ing strong desire for surgical conditions that may lead to irreg- women in two separate trials repair, and more advanced pro- ular follow up or pessary neglect (Donnelly, Powell-Morgan, Olsen, lapse (where the leading edge of (Weber & Richter, 2005). Common & Nygaard, 2004; Richter et al., the prolapse is halfway beyond indications for the use of support 2010). Additionally, overall body the hymen or more) (Clemons, pessaries include relief of symp- image improves in many success- Aguilar, Tillinghast et al., 2004b). toms, avoidance of surgery, diag- ful pessary users (Patel, Mellen, Potential distress may be re - nosis and surgical outcome pre- O’Sullivan, & LaSala, 2010). duced if women considering pes- diction, and prevention (see Other areas of symptom- sary use are aware of common Table 1). relief related to pessary use have uses, benefits, and potential risks been less well studied. For exam- prior to their initial pessary fit- ple, women with a vaginal bulge ting.

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Surgical Avoidance or POP – lower abdominal pressure of 42.0 months of follow up Scheduling Convenience and low back pain (Heit, (Matsubara & Ohki, 2010). Conservative management Culligan, Rosenquist, & Shott, Whether this observed prolapse with a pessary, either on a tempo- 2002). In that study, participant- improvement is due to temporary rary or long-term basis, may be rated symptom severity using physiologic tissue response to the optimum choice for many visual analog scales, (n = 152) reduced strain and/or has poten- women for a variety of reasons. was compared with objective tial long-term preventive ramifi- Although evidence is sparse, prolapse determination and cations is currently unclear. clinical examples of indications demonstrated no significant association. Therefore, because include fear of surgery or anes- Pessary Selection thesia, significant co-morbidities prolapse may not be the cause of that preclude surgery, or prior some symptoms, a pessary trial Modern silicone pessaries failed surgery with resultant can play a role in clarifying come in a variety of shapes and higher risk of poor surgical out- treatment expectations during sizes; therefore, selection is pri- come. Temporary use of a sup- pre-operative decision-making. marily determined by the ESSARIES port pessary may improve com- Pessaries have also been lifestyle of the potential wearer, P fort for women delaying surgery useful in predicting successful as well as findings on physical due to career or family priorities, outcomes in cases of pre-opera- examination. Both providers and or for women who have been tive elevated post-void residual patients are likely to benefit if advised to defer vaginal recon- (PVR) due to urethral obstruc- pessary success could be predict- struction until child bearing is tion. A retrospective chart ed because counseling would be

ERIES ON completed. review of women with pre-oper- improved, time would be saved, S ative PVR greater than 100 cc (n and needless discomfort would Diagnostic Assessment = 24) found that pessary use nor- be eliminated; however, predic- And Prediction of Surgical malized PVR in 75% (n = 19) of tive parameters for pessary Outcomes the women, with only one choice and fitting success have

PECIAL A pessary trial can provide woman subsequently experienc- proven difficult to quantify S an opportunity to explore likely ing elevated PVR three months (Cundiff et al., 2007). For that symptom improvement or the post-operatively. A trial pessary reason, expert opinion from clin- potential for onset of new reduction was found to be a reli- ical observation continues to adverse effects, and help women able tool in predicting improve- inform both patient and pessary develop realistic expectations ment in urinary retention selection and is included here for during pre-operative treatment (Lazarou, Scotti, Mikhail, Zhou, the potential benefit of novice planning. In a classic study, & Powers, 2004). providers. researchers used a trial with a lever pessary to successfully Prevention of Progressive Patient-Specific Factors predict surgical cure of stress Prolapse Several recent studies con- incontinence via retropubic ure- Emerging evidence also sug- cluded that the majority of thropexy. In this trial, 24 of 26 gests a potential preventive role women can be successfully fitted women with stress UI became for pessaries. Handa and Jones with a pessary, with POP-reduc- continent with a supine stress (2002) observed a significant tion success rates ranging from test after pessary insertion, and improvement in stage of POP in 63% to 86% (Clemons, Aguilar, all patients remained continent 19 women following one year of Tillinghast et al., 2004b; Hanson, after a retropubic urethropexy successful pessary use, suggest- Schulz, Flood, Cooley, & Tam, was performed (Bhatia & ing a therapeutic effect associat- 2006; Maito, Quam, Craig, Bergman, 1985). In another ed with the use of a supportive Danner, & Rogers, 2006; Mutone, study, de novo stress inconti- pessary. In addition, in an obser- Terry, Hale, & Benson, 2005; nence, which can occur when an vational cohort study of women Nyguyen & Jones, 2005; Wu, otherwise deficient urethra is using pessaries for three months Farrell, Baskett, & Flowerdew, straightened during repair of the (n = 90), measurement of the gen- 1997). However, specific factors prolapsed anterior compart- ital hiatus decreased, leading the that might predict successful fit- ment, was shown to be a major authors to postulate that pessary ting have not been consistently reason for post-treatment dissat- use allows recovery of the levator identified. Some studies have isfaction (Clemons, Aguilar, ani muscles (Jones et al., 2008). suggested that patient satisfac- Tillinghast et al., 2004a). In another small case series (n = tion is higher in women who are Post-surgical expectations 6), prolapse regressed to normal older, have had no prior pelvic have also been explored with after a median duration of pes- surgery (including hysterecto- women reporting two common sary use of 27.5 months and my), have higher parity or less symptoms often attributed to remained resolved for a median severe prolapse, and have no UI

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(Maito et al., 2006; Nyguyen & Figure 1. Jones, 2005; Wu et al., 1997). Pessary Shapes Hanson et al. (2006) assessed the importance of estrogen therapy to successful pessary fitting, reporting that women using vaginal estrogen, with or without systemic hormone replacement therapy (HRT), had higher fitting success compared to both systemic- only and non-HRT users. Maito S et al. (2006) reported presence of PECIAL mild posterior compartment prolapse as a positive predictor of fitting success, and history of a prior prolapse procedure or hys- S terectomy as negative predictors. ON ERIES Clemons, Aguilar, Tillinghast et al. (2004b) also found a shortened vaginal length ( 6 cm) and ≤ Note: The large variety of pessary shapes can be categorized as pessaries that wide genital hiatus (4 finger- require significant introital support (top row), pessaries that are relatively self- breadths) to be predictive of supporting (seond row), and pessaries with an incontinence support (third row). P unsuccessful pessary fitting. ESSARIES Other researchers have reported no significant predictive value regarding age, weight, vaginal options. The pessary can be re - likelihood of symptom and qual- length, size of genital hiatus, moved for intercourse either by ity-of-life improvement for most compartment of prolapse, stage the woman or her partner. If she users, no specific shape of pes- of prolapse, or hormone use prefers leaving the pessary in sary is best for all women. In one (Maito et al., 2006; Mutone et al., place, some styles (for example, crossover study comparing two 2005; Nyguyen & Jones, 2005; Ring pessaries) are more likely to different pessaries (Ring and Wu et al., 1997). Because of this be comfortable for both partners Gellhorn), both shapes were lack of consistent predictors, a during intercourse. However, effective for the majority of pessary trial may be appropriate there is little research to assess this women and significantly im- for any woman seeking treatment specifically, and clinical reports proved urinary, bowel, and pro- for prolapse-related symptoms from individual couples vary lapse symptoms (n = 134, mean (ACOG, 2007; Clemons, Aguilar, greatly. Overall, sexual function age 61 years, median prolapse Sokol et al., 2004). has been shown to improve with Stage 3 – descent halfway Factors related to patient pessary use, including frequency beyond the hymen, satisfaction preference, lifestyle, and ability and satisfaction (Fernando et al., rates – Ring 80%, Gellhorn 76%) may guide pessary choice. For 2006), desire, orgasm, and lubrica- (Cundiff et al., 2007). example, some pessaries may be tion (Kuhn, Bapst, Stadlmayr, Vits, Because no quantitative mea- easier to self-remove and self- & Mueller, 2009). Additionally, sures have been identified to insert. This may affect choice one study found sexually active direct pessary choice and fitting, related to patient comfort with women were more likely to con- providers must continue to rely self-touch, interest in performing tinue pessary use compared to on manufacturer guidelines, self-care, and desire to have vagi- women who were not sexually expert opinion, product avail- nal intercourse. Clinical experi- active (Brincat, Kenton, Fitzgerald, ability, clinical judgment, and ence suggests that arthritis, & Brubaker, 2004). Overall, pes- provider or patient preferences mobility impairment, and obesi- sary use may be acceptable to when choosing initial pessary ty may limit successful self-care, many sexually active women. shape and style. even in very motivated women. One way to conceptualize Women who are not doing self- Pessary-Related Factors support pessary options is to cat- care will need to wear their pes- Many pessary styles and egorize them by their functional sary continuously between the sizes are available, and new design. Using that paradigm, periodic office visits for removal styles continue to be designed. flexible silicone pessaries fall and cleaning. Figure 1 displays a variety of cur- into three categories: those that With the appropriate pessary, rent pessaries. While successful- need some support from the a sexually active woman has a few ly fitted pessaries offer a high woman’s own introital integrity

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to stay in place (basic support pessaries), pessaries Figure 2. with concavities that make them relatively self- Ring and Ring with Support Membrane retaining (self-retaining pessaries), and pessaries with additional urethral support designed to improve stress incontinence (incontinence pessaries). Use of these classifications to guide initial choice is summarized in Table 2. In the authors’ experience, pessaries retained by introital integrity can be folded or deflated to ease insertion through the introitus. Examples include the Ring (see Figure 2), Donut (see Figure 3), and Inflatable Donut (see Figure 4), and the Shaatz and lever pessaries (not pictured separately). Those that have a relatively slim profile and fit along the length of the vaginal shaft, such as the Ring pessary, are

ESSARIES most likely to be comfortable when left in place dur- P ing vaginal intercourse. Others, such as Donut pes- Note: Note the hinge bends at the notch in the left pessary saries, which are sometimes referred to as space-fill- and at the finger-sized holes of the right pessary. This pessary ing pessaries because they occupy more of the vagi- is folded at the hinge for insertion and removal. nal width, may preclude intercourse when in situ. Pessaries designed to easily fold or deflate may also Figure 3.

ERIES ON be most amenable to self-insertion and removal. Donut Pessary

S In contrast, self-retaining pessaries are generally concave in shape. The vaginal walls conform to these areas, allowing the pessaries to stay in place in women with minimal or no introital strength. These

PECIAL include the Gellhorn (see Figure 5) and Cube pes-

S saries (see Figure 6). These are traditionally considered more likely to support advanced POP but may also increase the risk of mechanical injury to the vaginal epithelium. They may also be more difficult for both the patient and provider to remove and re- insert. Incont inence pessaries include a knob that fits behind the pubic symphysis, supporting the urethra during times of increased abdominal pressure to diminish stress incontinence (see Figure 7). Although the topic is not well studied, when a pessary is worn over time (longer than 24 hours), Note: Some clinicians aid insertion and removal by carefully deflating the Donut using a needle and syringe, inserting it, and then re-inflating the pessary once it is in place and viceversa.

Table 2. Figure 4. Sample Simple Pessary Selection Guide Based Inflatable Donut Pessary on a Woman’s Planned Coital Activity and Introital Integrity

Introital Integrity Introital Laxity Present Present Sexual Activity Ring* Cube Planned Oval Lever Pessary* Inflatable Donut Acoital Donut Gellhorn Cube Note: If stress incontinence increases or continues with pessary use, an incontinence pessary can be used,* but coitally active women will need to be able to do self-care. *Pessaries that have a stress urinary incontinence support option.

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Figure 5. Figure 6.

Gellhorn Short and Long-Stem Pessaries Cube Pessaries

PECIAL

S RE ON ERIES

Figure 7. saries) are typically preferred total vaginal length were less like- Incontinence Pessaries

whenever possible. ly to be successfully fitted (Nager P

Providers often prefer to use a et al., 2009). Thus, pessary fitting ESSARIES limited selection of available pes- remains an art, with some reliance saries. For example, in a survey of on trial and error. urogynecologists, the majority reported using Ring pessaries for Pessary Fitting anterior and apical defects, space- filling pessaries (such as a Donut) Because there has been little for women who have introital success in identifying objective integrity and posterior defects, and evidence to improve pessary self-retaining pessaries (such as the choice, new providers must rely Gellhorn) for severe prolapse on expert opinion and mentor- (Cundiff, Weidner, Visco, Bump, & ship. Pessary manufacturers pro- Addison, 2000). General gynecolo- vide recommendations to help the gists reportedly also used Ring pes- novice match pessary styles with saries most frequently, deeming patient findings (Bioteque of them easiest to use, with Gellhorn America, 2011). Successful fitting pessaries used most commonly for also depends on clinician experi- advanced prolapse (Pott-Grinstein ence and training. Few nursing or & Newcomer, 2001). The latter medical programs spend time Note: Examples include, top row: respondents rated Donut pessaries teaching pessary use (Pott- Incontinence Dish (with and without the least easy to wear and Gellhorn Grinstein & Newcomer, 2001). support); middle row: Marland (with pessaries most difficult to remove. However, with a sound general and without support); bottom row left: Generally, providers’ choice of background of women’s health Ring with support membrane and styles of pessary to stock and fit care, even in the absence of opti- incontinence knob; bottom right: appears to be based on the individ- mal mentorship, clinicians can Incontinence Ring. ual’s training, experience, and educate themselves to become product availability. competent and safe providers of Pessary size selection is also this low-risk intervention. presence of drainage holes should currently guided by experience The goal of fitting is to find a allow continuous drainage of nor- because no specific vaginal meas- pessary that improves the target mal vaginal epithelial shedding ures have predicted successful fit. pelvic floor symptoms, is comfort- and discharge. Retained discharge In one study, Pelvic Organ able for the patient, is retained may act as a medium for bacterial Prolapse Quantification (POP-Q), during activity and toileting, and overgrowth, increasing infection parameters were tested as a poten- does not obstruct voiding or defe- risk, and/or odor. For this reason, tial objective predictor but were cation, or cause vaginal irritation. pessary styles with optional not found to predict pessary size; Suggestions for improving fitting drainage holes (such as Cube pes- however, women with a shorter outcomes are listed in Table 3.

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Table 3. Although definitive measure- Pessary Selection and Fitting Tips ments have not been identified to aid size and style choice, experi- Assess for and treat causes of vaginal tenderness prior to fitting (infection, lesions, enced providers typically note or tension myalgia). several digital measurements and Familiarize the woman with the pessary before fitting (let her see, feel, and fold it; use assess pelvic muscle tone and visual aids, such as pelvic models or charts, to show how it will stay in her vagina). support during pelvic examination (see Figure 8). These determi- Fitting will be more comfortable if the woman has an empty bladder and bowel; however, to test for stress incontinence, fitting with the bladder full will facilitate nations can help the provider assessment. If the bowel is full and cannot be emptied voluntarily, an enema onsite develop a mental image of the or rescheduling the appointment may be most helpful. vaginal size, shape, and support. The initial pessary attempt can Autoclavable fitting kits are available, but keeping a small stock of silicone pessaries then be made using the pessary in commonly used sizes and shapes may offer a more true-to-life fitting experience. that fits this visual image. Table 4 Fitting comfort may be improved for women who are very apprehensive or sensitive lists suggested steps in pessary fit-

ESSARIES by the use of lidocaine gel applied to the introitus 5 minutes before fitting. If genital ting based on clinical experience P tissue is very atrophic or non-elastic, several weeks of topical estrogen therapy prior and expert opinion. to fitting may be optimal. The average number of pes- Refitting may be necessary after weight loss or weight gain, any period of temporary saries tried during a successful removal, or during long-term use if atrophic tissue change continues (increased pessary fitting is two to three, typ- stenosis or decreased support). ically at a single session; however,

ERIES ON During post-fitting pessary testing, placement of a urine receptacle (“Hat”) in the up to two follow-up fitting ses-

S commode will ease retrieval if the pessary is expelled. Otherwise, instruct the woman sions have been reported prior to not to flush the pessary into the plumbing system. successful fitting (Jones et al., A pessary that is comfortable and retained except during bowel movements may be 2008; Komesu et al., 2007; Maito a success if the woman chooses to either remove the pessary for defecation or et al., 2006; Robert & Mainprize,

PECIAL support it digitally during evacuation. 2002; Wu et al., 1997). Women

S If the pessary is easily expelled, try a larger size or different style. If the pessary is unable to retain a pessary at an uncomfortable or the patient feels pressure, try a smaller size or different style. initial fitting are less likely to be Successfully sized, the pessary should be comfortable; women often say, “I can’t successful at subsequent fittings even tell it’s there!” (Maito et al., 2006), but persist- Make sure a system is in place to identify missed pessary follow-up visits to avoid ence may pay off. Clemons, potential problems related to pessary neglect. Aguilar, Tillinghast et al. (2004b) found 22 of 49 women who could not be fit at the first visit were suc- Figure 8. cessfully fit on the second visit. In Illustration of Digital Measurement of the Vagina, a Potential Aid to that study, a Gellhorn pessary was Initial Pessary Choice more likely to require refitting than a Ring, suggesting Ring pessaries are easier for providers to size correctly. For women who prefer pessary treatment but have difficulty retaining any single pessary, occasional use of double pessaries, including a Donut with Gellhorn or double Ring, has been reported (Myers, LaSala, & Murphy, 1998; Singh & Reid, 2002). Prior to fitting, women should be informed that the risk of a pessary trial is minimal, while the potential symptom-relief can be great. It may be helpful to be opti- mistic, normalizing the fitting situ- ation, while informing the woman Notes: Line A: The vaginal length from posterior symphysis to apex or posterior prior to fitting that an appropriate fornix can be useful for sizing Ring and Donut pessaries, or the length of a Gellhorn pessary may not be identified. neck. Line B: The vaginal width at the apex can be useful when considering the Clinicians also need to remember diameter of the Gellhorn dish. Line C: The diameter of the introitus and vaginal shaft that successful fitting after three or can help in making an initial Cube choice.

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Table 4. able to remove and replace a Ring Steps to Pessary Fitting pessary without difficulty. Even when a Ring pessary is in place, 1. Review treatment goals and expectations. coitus may be comfortable for 2. Ask the woman to empty her bladder and bowels. both partners. Ring pessaries with or without support are also avail- 3. Ask the woman to assume Semi-Fowler position, a position that is generally able with a urethral support knob comfortable and offers her a view of the fitting if desired. for the treatment of stress UI. 4. Gently replace any vault eversion or procidentia prior to sizing. To fit a Ring pessary, the vagina is measured digitally or with a

5. After amply applying water-based lubricant to the vaginal introitus, digitally vaginal measuring instrument to S

assess vaginal size, shape, and support, and for any relative contraindications assess the depth, obtaining a gen- PECIAL to the fitting (pain with palpation, vaginal infection or lesions, full rectum). eral idea of the shape and size of 6. Select the appropriate stocked pessary or fitting kit model, and clean it with the intra-vaginal space (see Figure soap, rinsing well with water. 8). To insert the pessary, lubrica-

tion of the vagina or a hinged edge S

7. Apply additional water-based lubricant to the leading edge of the pessary if RE ON ERIES needed. of the pessary and not the gloved exam fingers will facilitate a grip 8. Insert the pessary, applying pressure gently toward the posterior vaginal wall on the folded pessary. The pessary and/or obliquely (at 11:00 and 5:00 positions related to the introitus) in the is folded in half at the hinge and largest diameter, avoiding pressure on the sensitive urethra. inserted through the introital

9. To check initial fit, ask the woman to Valsalva and cough (in lithotomy and opening, while applying gentle P

standing postions) – the correct pessary should be comfortable and may downward posterior or perineal ESSARIES advance toward the introitus with pressure and recede with relaxation, but it pressure to avoid the sensitive should not pass through the introitus. The examiner should be able to gently urethral area. Once inside the rock the pessary in place, demonstrating that it is not pressing too tightly on the vagina, the pessary will open vaginal walls. spontaneously. This pessary fol- 10. Ask the woman to stand, move about the examination room, and simulate lows the length of the vagina, activities she would normally do (walking, bending to pick up objects on the from loosely behind the symph- floor, changing from standing to sitting) and report any discomfort. ysis to the vaginal apex or posteri- or fornix. A Ring pessary can be 11. Ask the woman to sit on the toilet, void, and Valsalva gently, simulating rotated 90 degrees while in-place, defecation. For actual defecation, it may be helpful for her to support the which may help prevent sponta- pessary digitally. neous expulsion by placing the 12. If the fitting is successful to this point, review expectations and schedule a hinge transversely to the introitus. return visit. If the pessary is expelled or uncomfortable, start the fitting process A well-fit Ring pessary will stay again. in place without applying undue pressure on the sidewalls, apex, 13. Whether or not the fitting is successful, document any shape and size of or introitus, and will not be pessary used to avoid repeat attempts at subsequent visits. noticeable by the patient. If the woman describes discomfort from the pessary fitting too near the four attempts is less likely. To aid viding support for the anterior, introitus during movement, it is understanding of current pessary posterior, and apical walls. The either too large or there is insuffi- choices, the following sections optional support membrane may cient introital support to hold the look more specifically at common- add additional support if anterior pessary in place. Removal and ly used pessary options. or posterior compartment pro- digital re-sizing may suggest lapse are present (such as cysto- whether a larger or smaller pes- Insertion and Removal of cele or rectocele). The position of sary may work better. If two or Specific Pessaries for Women the hinge is marked either by three tries are not effective, a self- With Introital Support notches in a Ring or finger-sized retaining pessary, such as a Ring with and without sup- holes in the Ring with support Gellhorn or Cube, may be a better port membrane. The Ring pes- membrane. To retain this type of option. sary and Ring with support mem- pessary, the introitus and/or To remove a Ring pessary, brane (see Figure 2) are common pelvic floor must provide enough lubricate the introitus, put an first-line choices for most types support to contain the pessary. examining finger through the fin- of POP. They typically include a Ring pessaries tend to be eas- ger-size hole or at a hinge notch, rigid, hinged nylon ring that fits iest for both clinicians and rotate the pessary to bring the into the length of the vagina, pro- patients to use. Many women are hinge anteriorally to the introi-

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tus, and gently pull downward, injecting air with the syringe. All lengths (short and long) allows diagonally, and out. The vaginal Donut pessaries are typically fit optimal fitting even in women walls will help to fold the pes- either like a Ring pessary – along with a shortened vagina, such as sary as it exits. Atrophic or the length of the vagina – or may post-hysterectomy women. scarred tissue may fissure at the stay in place if fitted snugly into Although the ability of the posterior fornix with removal. the circumference of the vaginal Gellhorn to be somewhat self- Increased lubrication, moistur- apex with appropriate intrinsic retaining can be a considerable ization, or estrogenation may support. advantage, it also makes this pes- ease future use. The most com- To remove a traditional Donut sary more difficult for clinicians mon sizes of Ring pessary are 2 pessary, the introitus is lubricated, and patients to remove. In addi- through 5 (whole numbers). and with the examination finger tion, the Gellhorn pessary may be Donut and Inflatable-Donut in the Donut center, the pessary is more likely to cause mechanical pessaries. If a Ring pessary is not pulled gently downward at a diag- trauma to the vaginal tissue. As successful, but there is some onal angle. Some Donut pessaries with other pessaries, Gellhorn fit- introital support, a Donut or can be carefully deflated in situ ting involves measurement of the

ESSARIES Inflatable-Donut pessary may be an using a needle and syringe to ease vagina, in this case, assessing both P option (see Figures 3 and 4). Donut removal, and the Inflatable Donut the diameter of the introitus and pessaries are essentially thicker pessary should also be deflated the apex to approximate the cor- Rings and may fill a vagina prior to removal. rect size of the dish and of the enlarged by loss of elasticity more Other support pessaries re- vaginal length to determine completely; however, these pes- quire introital integrity, with indi- whether a long or short neck is

ERIES ON saries are in more complete contact cations based on clinical experi- appropriate (see Figure 8).

S with the vaginal epithelium, which ence. They include the Oval To insert the flexible Gellhorn, may increase the risk of mechani- (which may be useful with a nar- the stem can be bent down to the cal tissue injury or discharge pro- row vaginal width); the Hodge and dish and the dish folded, with the duction and retention. Some Smith Lever pessary (which may edge of the dish inserted first. The

PECIAL women may be able to remove and be more comfortable in women pessary is then corkscrewed gently

S replace traditional Donut pessaries with a narrow vaginal introitus); down toward the perineum to themselves, but comfortable vagi- the Gehrung Arch (which may be avoid the urethra, then upward to nal intercourse is unlikely. Infla- effective in women who have an bring the dish perpendicular to table Donut pessaries, which are a isolated anterior or posterior wall the vaginal vault. The pessary can silicone variation of an older latex prolapse), and the Shaatz (which is then be pushed gently upward inflatable pessary called the Inflato- a disc, similar to the Ring, but may using the index finger on the knob ball, have a stem and valve for offer firmer support). Fitting for at the end of the neck, placing the inflation and deflation like a bal- these pessaries is very similar to fit- dish into the vaginal apex. The loon, and are designed to be insert- ting of the Ring pessary. Manu - woman can then bear down as an ed and removed at frequent inter- facturers typically include fitting initial assessment of the likeli- vals (within 48 hours). Manu- instructions with each pessary. If hood of retention. If two to three facturer instructions should be these types of pessaries cannot be adjustments in the size of the pes- reviewed before attempting to auto- retained, a self-retaining pessary sary do not work, a Cube pessary clave Donut pessaries because of may be appropriate. may be an option. their air-filled core. Removal of a flexible Gellhorn During fitting, digital exami- Insertion and Removal is generally achieved by lubricat- nation is used to assess both the Of Self-Retaining Pessaries ing the introitus, pulling the knob depth and width of the vagina. Gellhorn. The flexible Gellhorn at the end of the pessary neck gen- Introital stretching and discomfort pessary is an option in women who tly downward (toward the introi- is more likely with a traditional cannot retain Ring or similar pes- tus) and laterally (toward a thigh), Donut, and with either type, ade- saries due to introital laxity (see and using the index finger to hook quate lubrication is essential. Figure 5). The shape of the and bend down the edge of the With firm digital pressure, a tradi- Gellhorn pessary allows the later- dish. When the knob cannot be tional Donut pessary may be com- al vaginal walls to in-fold under easily grasped, a carefully placed pressed somewhat to slip through the top dish, while the concave tenaculum or ring forceps may be the introitus more comfortably. dish itself may create a suction- helpful to assist removal. Gellhorn Additionally, some Donut pes- like action against the proximal pessaries are sized in quarter-inch saries can be deflated using a nee- vagina, facilitating pessary reten- intervals by the dish diameter, dle and syringe to remove air. tion. The stem of the Gellhorn fol- with common sizes generally rang- After pessary insertion, it can then lows the shaft of the vagina, main- ing from 1.75 to 3 inches. be re-inflated by carefully insert- taining correct alignment. The Cube. The Cube pessary can ing the needle into the Donut and option of two different stem also be considered self-retaining

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(see Figure 6). Compared to a leakage during times of increased junction with other modalities, Gellhorn pessary, a smaller size abdominal pressure. Options such as anticholinergic medica- can be used; however, Cube use include the Incontinence Ring or tions or urethral bulking agents. may also result in mechanical tis- Dish, which are similar to regular Expert opinion regarding indica- sue injury. Cube pessaries are Ring pessaries but offer less vagi- tions for specific pessary types held in place because the concav- nal support; and standard Ring, should be tested in additional ities in the six sides allow vaginal Arch (Gehrung), or Lever (Smith- crossover or head-to-head clinical tissue to conform to the pessary Hodge) pessaries with an optional pessary trials. Cost analyses relat- shape. Because large amounts of incontinence support knob. Most ed to different aspects of pessary epithelium are in contact with the of these pessaries are fitted simi- use are needed. For example, pessary, drainage holes are impor- larly to a standard Ring pessary. comparison of costs of pessary use S tant to allow desquamated cells While some women use inconti- over time versus surgery, and PECIAL and vaginal discharge to drain. nence pessaries only during exer- analysis of potential savings from The Cube is designed for self-care, cise, others use them continuous- morbidity prevention may be use- but like the Gellhorn, some ly. Generally, the incontinence ful both to inform individuals women and providers find it diffi- knob pessaries are fitted more making treatment choices and S cult to remove due to the suction. snugly behind the symphysis, public policy related to reim- ON ERIES Softness and compressibility of beneath the urethra. A pessary bursement. the silicone used vary by manu- that is too loose will not decrease facturer. Softer Cubes can be easi- stress UI and may rotate in the Conclusion er to insert, but firmer devices vagina. Too much pressure may

may be more likely to be retained, cause discomfort, epithelial in- Support pessaries are an P

and choice is typically based on jury, and urinary retention. If the important option for treatment of ESSARIES provider experience. The Cube woman plans to use the pessary many pelvic floor symptoms. pessary can be placed at different only intermittently or during Currently, providers new to the depths in the vagina, which may exercise, it may be fitted more field continue to learn pessary offer an advantage when a woman snugly to retain urine. Although indications, selection, and fitting has an isolated or site-specific pessaries are typically fitted with strategies from a relatively small prolapse. an empty bladder, fitting an evidence base, and occasionally, Size is estimated by digitally incontinence pessary in a woman from conflicting expert opinion. measuring the diameter of the with a full bladder may facilitate This article has summarized basic vaginal shaft and vault. To insert, testing of both stress UI treatment concepts related to initiating pes- lubricate the pessary and introitus, during exercise and voiding ade- sary use. Other articles in this compress the pessary, part the quacy. series will discuss pessary follow introitus gently, and insert the pes- up and business strategies. sary to the depth that best corrects Suggestions for Future Research the bulge and is most comfortable References for the patient. Commonly used Although the evidence base American College of Obstetricians and Gynecologists (ACOG). (2007). Pelvic sizes range from 1 to 4. for pessary use has been building organ prolapse. ACOG Practice To remove, lubricate the in- in recent years, much of practice Bulletin No. 85. 110, 717-729. troitus, apply gentle traction on continues to be based predomi- Barber, M.D., Walters, M.D., Cundiff, G.W., & the pessary cord to stabilize and nantly on expert-opinion. Prac- the PESSRI Trial Group. (2006). Responsiveness of the Pelvic Floor bring the device toward the introi- ticing providers may fill some of Distress Inventory (PFDI) and Pelvic tus, and then insert the tip of the these gaps through their own Floor Impact Questionnaire (PFIQ) in index finger up above the Cube to observations and inventiveness, women undergoing vaginal surgery release it and pull it gently out of as well as in formal clinical trials and pessary treatment for pelvic organ prolapse. American Journal of the vagina. Pulling too hard on the in their own practice. Nurses Obstetrics & Gynecology, 194(5), 1492- cord alone will break the cord. If involved in pessary care may be 1498. doi:10.1016/j.ajog.2006.01.076 removal is difficult, a tenaculum, interested in studying ways to Bhatia, N.N., & Bergman, A. (1985). Pessary ring forceps, pessary remover or improve patient satisfaction and test in women with urinary incontinence. Obstetrics & Gynecology, 65(2), crochet hook, or dental tape tied experience. Questions may in - 220-226. through several holes can be used clude looking at changes in sexu- Bioteque of America. (2011). Pessary prod- to facilitate bringing the Cube to al function; testing appropriate ucts. Retrieved from http://www. the introitus. pre-trial, goal-setting models; bioteque.com/downloads/index Brincat, C., Kenton, K., Fitzgerald, M.P., & comparing methods of providing Brubaker, L. (2004). Sexual activity pre- Incontinence Pessary Options information about pessary op tions dicts continued pessary use. American Incontinence pessaries help for individuals and lay groups; Journal of Obstetrics & Gynecology, stabilize the urethra and the ure- and evaluating symptom relief 191, 198-200. doi:10.1016/j.ajog.2004. thral vesicle junction to prevent when pessaries are used in con- 03.083

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Bump, R.C., Fantl, J.A., & Hurt, W.G. (1988). Heit, M., Culligan, P., Rosenquist, C., & Nager, C.W., Richter, H.E., Nygaard, I., The mechanism of urinary continence Shott, S. (2002). Is pelvic organ pro- Paraiso, M.F., Wu, J.M., Kenton, K., … in women with severe uterovaginal lapse a cause of pelvic or low back Spino, C., for the Pelvic Floor prolapse: Results of barrier studies. pain? Obstetrics & Gynecology, 9(1), Disorders Network. (2009). POP-Q Obstetrics & Gynecology, 72(3), 291- 23-28. measures do not predict incontinence 295. Jones, K., Yang, L., Lowder, J.L., Meyn, L., pessary size. International Uro - Clemons, J.L., Aguilar, V.C., Sokol, E.R., Ellison, R., Zycynski, H.M., … Lee, T.l. gynecology Journal, 20, 1023-1028. Jackson, N.D., & Myers, D.L. (2004). (2008). Effect of pessary use on genital doi:10.1007/s00192-009-0866-1 Patient characteristics that are associated hiatus measurements in women with Nygaard, I., Barber, M.D., Burgio, K.L., with continued pessary use versus sur- pelvic organ prolapse. Obstetrics & Kenton, K., Meikle, S., Schaffer, J., … gery after 1 year. American Journal of Gynecology, 112(3), 630-636. Brody, D.J., for the Pelvic Floor Obstetrics & Gynecology, 191(1), 159-164. Komesu, Y.M., Rogers, R.G., Rode, M.A., Disorders Network. (2008). Prevalence doi:10.1016/j.ajog.2004.04.048 Craig, E.C., Gallegos, K.A., Montoya, of symptomatic pelvic floor disorders Clemons, J.L., Aguilar, V.C., Tillinghast, T.A., A.R., & Swartz, C.D. (2007). Pelvic in US women. Journal of the American Jackson, N.D., & Myers, D.L. (2004a). floor symptom changes in pessary Medical Association 300(11), 1311- Patient satisfaction and changes in pro- users. American Journal of Obstetrics 1316. lapse and urinary symptoms in women & Gynecology, 197, 620.e1-620.e6. Nyguyen, J.N., & Jones, C.R. (2005). Pessary who were successfully fitted with a pes- doi:10.1016/j.ajog.2007.08.013 treatment of pelvic relaxation: Factors sary for pelvic organ prolapse. American Komesu, Y.M., Rogers, R.G., Rode, M.A., affecting successful fitting and contin- ESSARIES Journal of Obstetrics & Gynecology, Craig, E.C., Schrader, R.M., Gallegos, ued use. Journal of Wound Ostomy

P 190(4) 1025-1029. doi:10.1016/j.ajog. K.A., & Villareal, B. (2008). Patient- and Continence Nursing, 32(4), 255- 2003.10.711 selected goal attainment for pessary 261. Clemons, J.L., Aguilar, V.C., Tillinghast, T.A., wearers: What is the clinical relevan- Patel, M., Mellen, C., O’Sullivan, D.M., & Jackson, N.D., & Myers, D.L. (2004b). cy? American Journal of Obstetrics & LaSala, C.A. (2010). Impact of pessary Risk factors associated with an unsuc- Gynecology, 198, 577.e1-577.e5. use on prolapse symptoms, quality of cessful pessary fitting trial in women doi:10.1016/j.ajog.2007.12.033 life, and body image. American with pelvic organ prolapse. American Kuhn, A., Bapst, D., Stadlmayr, W., Vits, K., Journal of Obstetrics & Gynecology, ERIES ON Journal of Obstetrics & Gynecology, & Mueller, M.D. (2009). Sexual and 202(5), 499e14. doi:10.1016/j.ajog. 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Inter - Richter, H.E., Burgio, K.L., Brubaker, L., American Urogynecologic Society. national Urogynecology Journal, 15, Nygaard, I.E., Ye, W., Weidner, A., … Obstetrics & Gynecology, 95(6), 931-935. 175-178. doi:10.1007/s00192-00411 Spino, C. (2010). Continence pessary Cundiff, G.W., Amundsen, C.L., Bent, A.E., 38-8 compared with behavioral therapy or Coates, K.W., Schaffer, J.I,. Strohbehn, Maito, J.M., Quam, Z.A., Craig, E., Danner, combined therapy for stress inconti- K., & Handa, V.L. (2007). The PESSRI K.A., & Rogers, R.G. (2006). Predictors nence: A randomized controlled trial. Study: Symptom relief outcomes of a of successful pessary fitting and con- Obstetrics & Gynecology, 115(3), 609- randomized crossover trial of the Ring tinued use in a nurse-midwifery pes- 617. doi:10.1097/AOG.0b013e318 and Gellhorn pessaries. American sary clinic. Journal of Midwifery & 1d055d4 Journal of Obstetrics & Gynecology, Women’s Health, 51(2), 78-84. doi: Robert, M., & Mainprize, T.C. (2002). 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