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Vaginal Support Pessaries: Indications for Use and Fitting Strategies

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Vaginal Support Pessaries: Indications for Use and Fitting Strategies SERIES Vaginal Support Pessaries: Indications for Use and Fitting Strategies 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. 114 UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 SERIES 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) ERIES ON 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, pro viders 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. UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 115 SERIES 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
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