Pessary Care: Follow up and Management of Complications
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SERIES Pessary Care: Follow Up and Management of Complications Katharine O’Dell and Shanna Atnip ESSARIES P ven after a successful pes- sary fitting, a woman’s © 2012 Society of Urologic Nurses and Associates level of satisfaction and O’Dell, K., & Atnip, S. (2012). Pessary care: Follow up and management of com- duration of pessary use plications. Urologic Nursing, 32(3), 126-137, 145. Eare difficult to predict. In one qualitative study, successful pes- Successful use of vaginal support pessaries requires provider and patient under- ERIES ON sary use was described by partic- standing of expected symptom-relief, potential complications, self-care options, S and evaluation and treatment of pessary-related problems. This second article in ipants as a learning process, lead- a three-part series summarizes clinical recommendations and evidence related ing to increasing comfort and to pessary management. confidence (Storey, Ashton, Price, Irving, & Hemmens, 2009). Key Words: Pelvic organ prolapse, pessary, therapy, complications. PECIAL Women initially reported feel- S ings of isolation and embarrass- Objectives: ment about pessary use. How- 1. Describe complications that may arise in women who use pessaries. ever, through encouraging inter- actions with providers, most 2. Explain the course of pessary follow up, including instructions, intervals between office visits, and pessary surveillance. commonly the office nursing staff, positive attitudes toward 3. Discuss pessary management and prevention of pessary-related complica- wearing a pessary developed tions. during follow up, and visits became anticipated social out- Duration of Pessary Use ings for several users (Storey et The first article in this series al, 2009). (Atnip & O’Dell, 2012) discussed Because women use pessaries clinical issues related to initiating for different reasons (for example, support pessary use, including a to totally avoid or defer surgery), Katharine O’Dell, PhD, CNM, WHNP-BC, summary of evidence related to is an Assistant Professor of OB/GYN, the patient and pessary selection, and duration of pessary use can be Division of Pelvic Medicine and Re - the likelihood of symptom relief. expected to vary. Reported use constructive Surgery, UMass Memorial continuation rates range from Medical Center, Worcester, MA. This article summarizes evidence related to pessary use, follow up, 56% to 70% in up to three years Shanna Atnip, MSN, WHNP-BC, is a Nurse and complications; describes cur- of follow up (Clemons, Aguilar, Practitioner, the Division of Urogynecology rent recommendations for clini- Sokol, Jackson, & Myers, 2004; and Reconstructive Pelvic Surgery, Komesu et al., 2007). One long- Parkland Health & Hospital System, and the cal practice where data are not University of Texas Southwestern Medical available; and identifies potential term follow-up study concluded Center, Dallas TX. areas for future research. that women are more likely to Note: Objectives and CNE Evaluation Form appear on page 137. 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 All other Urologic Nursing Editorial Board members reported no actual or potential CooperSurgical, Inc. conflict of interest in relation to this continuing nursing education activity. 126 UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 continue pessary use if they are moval, bowel perforation and Bump, & Addison, 2000; Gorti, over 65 years or have comorbidi- sepsis, and uremia, urosepsis, Hudelist, & Simons, 2009; Pott- ties that increase surgical risk and/or kidney damage due to Grinstein & Newcomer, 2001). (Clemons, Aguilar, Sokol et al., infection and/or obstruction The following sections discuss 2004). In a case series of women (Arias, Ridgeway, & Barber, 2008). common self-care and provider seeing a single provider in Although these cases repre- care options. Australia (n = 273), 60% contin- sent severe morbidity and occa- ued pessary use for four weeks, sional mortality, only 39 of these Initial Instructions while 14% were continuing major complications were re - New pessary users are gener- users over an average follow up ported during a period of more ally instructed to note improve- of seven years (range: 2 to 14 than 50 years. Most cases oc - ment in symptoms and report S years) (Sarma, Ying, & Moore, curred in women with neglected new problems, such as pain or PECIAL 2009). During their period of fol- or forgotten pessaries, though discomfort, genital bleeding, low up, 44% of initial pessary two cases of vesicovaginal fistula abnormal vaginal discharge, sex- users opted to return to no inter- occurred in older adult women ual problems, and problems with vention, and 30% proceeded to who were obtaining regular care. elimination of urine or stool S surgery. These findings confirm The first was discovered two (Atnip, 2009). Optimal intervals ERIES ON that some, though not all, women hours after initial insertion of a for self-care have not been deter- can expect to experience an Ring pessary, suggesting a possi- mined, and recommendations extended period of satisfactory ble pre-existing, unidentified vary. For example, one pessary pessary use. vaginal wall abnormality. The manufacturer’s packet instruc- second occurred in a woman tion states that in ideal circum- P using a Gehrung (arch) pessary stances, users should be taught to ESSARIES Potential Complications During over a 12-year period. During remove all styles of pessary Pessary Use that time, she reportedly per- nightly for cleaning and reinser- The importance of on-going, formed daily self-removal, clean- tion (CooperSurgical, 2008). regular re-evaluation, even for ing, and re-insertion, and attend- Optional daily removal and women who are comfortable and ed regular follow-up visits. The cleaning are encouraged during asymptomatic during pessary latter case reminds providers the use of some pessaries, and use, must be emphasized to all and pessary-users that occasion- referred to as mandatory during providers and users. Because al serious complications may use of latex inflatable and Cube there is no centralized reporting occur even with the most dili- pessaries, the latter without refer- option, true pessary complica- gent care. ence to the presence or absence tion incidence is not known. Finally, in a recent case of drainage holes. In the 14-year follow-up of report, an 82-year-old woman For the newer silicone inflat- Australian Ring pessary users, experienced vaginal evisceration able pessary, manufacturer rec- 56% reportedly had some type of during initial fitting, causing dis- ommendations suggest removal complication, including genital placement of the pessary into the for cleansing every day or two bleeding, involuntary pessary abdomen, with resultant emer- (Panpac Medical Corporation, expulsion, unusual vaginal dis- gency colpocleisis (Rubin, Jones, 2010). When pessaries are re- charge, pain, and constipation & Harmanli, 2010). While the moved, they can be washed with (Sarma et al., 2009). Un - scarcity of reports suggests an soap and water, rinsed thorough- fortunately, this study design overall low-risk of serious pes- ly, and re-inserted, or stored for does not help women compare sary complications, these publi- future use. While providers may risks of pessary use with risks of cations highlight the need for offer women optional teaching untreated prolapse. careful assessment prior to pes- related to self-removal and re- While mild and/or transient sary placement at each routine insertion, some may not be either symptoms appear to be fairly visit and whenever new symp- able or willing to perform self- common during pessary use, rare toms occur. care (Sarma et al., 2009). serious adverse effects can also In addition, women initiat- occur, particularly if pessary ing pessary use are likely to have Pessary Follow Up care is neglected. In a review of many questions related to how individual case studies pub- While it seems clear that reg- pessary use may affect their lished between 1950 and 2007, ular pessary follow up is impor- lifestyle and activities. Some serious adverse events related to tant, both appropriate intervals answers will require experience. pessary use included vesicovagi- for follow-up and interim self- For example, women who are of nal and rectovaginal fistulas, care recommendations continue reproductive age may need to impaction or entrapment of the to be largely based on expert experiment to identify their pref- pessary requiring surgical re - opinion (Cundiff, Weidner, Visco, erence for management of their UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 127 SERIES Table 1. urine or stool likely to be reasons Self-Care Options for Women Using Vaginal Support Pessaries for emergent care. Recommendations for appro- Removal Intervals Between Visits: priate routine intervals for follow • Regularly (nightly, weekly, monthly) and re-insert post-cleansing up of women reporting comfort- • Regularly removed and leave out overnight able, effective pessary use also