PART 2 Pessaries for POP and SUI: Their fitting, care, and effectiveness in various disorders A refresher on how to fit a pessary, instructions for patients, goals for pessary aftercare visits, and the various conditions for which pessaries may or may not be effective Henry M. Lerner, MD n Part 1 of this article in the December 2020 • should be comfortable for the patient to issue of OBG Management, I discussed wear I the reasons that pessaries are an effective • is not easily expelled treatment option for many women with pel- • does not interfere with urination or defeca- IN THIS vic organ prolapse (POP) and stress urinary tion ARTICLE incontinence (SUI) and provided details on • does not cause vaginal irritation. the types of pessaries available. The presence or absence of a cervix or Fitting In this article, I highlight the steps in fit- uterus does not affect pessary choice. process ting a pessary, pessary aftercare, and poten- Most experts agree that the process for tial complications associated with pessary fitting the right size pessary is one of trial this page use. In addition, I discuss the effectiveness of and error. As with fitting a contraceptive pessary treatment for POP and SUI as well as diaphragm, the clinician should perform a Pessary for preterm labor prevention and defecatory manual examination to estimate the integrity aftercare disorders. and width of the perineum and the depth of page 23 the vagina to roughly approximate the pes- sary size that might best fit. Using a set of “fit- Pessary The pessary fitting process ting pessaries,” a pessary of the estimated size effectiveness For a given patient, the best size pessary is the should be placed into the vagina and the fit page 24 smallest one that will not fall out. The only evaluated as to whether the device is too big, “rule” for fitting a pessary is that a woman’s too small, or appropriate. If the pessary is eas- internal vaginal caliber should be wider than ily expelled, larger sizes should be tried until her introitus. the pessary remains in place or the patient is When fitting a pessary, goals include that uncomfortable. Once the pessary is in place, the selected pessary: the clinician should be able to run his or her finger around the entire pessary; if this is not possible, the pessary is too tight. In addition, Dr. Lerner is Assistant Clinical Professor (retired), Harvard Medical School, Boston, Massachusetts. the pessary should remain more than one finger breadth above the introitus when the The author reports no financial relationships relevant to this patient is standing or bearing down. article. Since many patients who require a pes- doi: 10.12788/obgm.0057 sary are elderly, their perineal skin and 20 OBG Management | January 2021 | Vol. 33 No. 1 mdedge.com/obgyn vaginal mucosa may be atrophic and fragile. that if the pessary is expelled, it does not drop Inserting a pessary can be uncomfortable into the bowl.) and can cause abrasions or tears. Successfully Re-examination. After these provocative fitting a pessary may require extra care under tests, examine the patient again to ensure that these circumstances. The following steps may the pessary has not slid out of place. help alleviate these difficulties: Depending on whether or not your office • Explain the fitting process to the patient in stocks pessaries, at this point the patient is detail. either given the correct type and size of pes- • Employ lubrication liberally. sary or it is ordered for her. If the former, the • Enlarge the introitus by applying gentle patient should try placing it herself; if she is digital pressure on the posterior fourchette. unable to, the clinician should place it for • Apply 2% lidocaine ointment several min- her. In either event, its position should be utes prior to pessary fitting to help decrease checked. If the pessary has to be ordered, the patient discomfort. patient must schedule an appointment to FAST • Treat the patient for several weeks with return for pessary insertion. TRACK vaginal estrogen cream before attempting Whether the pessary is supplied by the to fit a pessary if severe vulvovaginal atro- office or ordered, instruct the patient on Evaluate the phy is present. how to insert and remove the pessary, how patient with the Once the type and size of the pessary are frequently to remove it for cleansing (see pessary in place selected and a pessary is inserted, evaluate below), and signs to watch for, such as vagi- for discomfort, the patient with the pessary in place. Assess nal bleeding, inability to void or defecate, or expulsion, and for the following: pelvic pain. urination, and Discomfort. Ask the patient if she feels It is advisable to schedule a subsequent then re-examine discomfort with the pessary in position. A visit for 2 to 3 weeks after initial pessary place- to ensure that the patient with a properly fitting pessary should ment to assess how the patient is doing and to pessary has not not feel that it is in place. If she does feel dis- address any issues that have developed. slid out of place comfort initially, the discomfort will only increase with time and the issue should be Special circumstances addressed at that time. It is safe for a patient with a pessary in place Expulsion. Test to make certain that the pes- to undergo magnetic resonance imaging.1 sary is not easily expelled from the vagina. Patients should be informed, however, that Have the patient walk, cough, squat, and even full body scans, such as at airports, will detect jump if possible. pessaries. Patients may need to obtain a phy- Urination. Have the patient urinate with the sician’s note to document that the pessary is pessary in place. This tests for her ability to a medical device. void while wearing the pessary and shows Finally, several factors may prevent suc- whether the contraction of pelvic muscles cessful pessary fitting. These include prior during voiding results in expulsion of the pelvic surgery, obesity, short vaginal length pessary. (Experience shows that it is best to (less than 6–7 cm), and a vaginal introitus ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT MARTENS KIMBERLY ILLUSTRATION: do this with a plastic “hat” over the toilet so width of greater than 4 finger breadths. CONTINUED ON PAGE 22 mdedge.com/obgyn Vol. 33 No. 1 | January 2021 | OBG Management 21 Pessaries for POP and SUI: Their fitting, care, and effectiveness in various disorders CONTINUED FROM PAGE 21 Ring pessary Marland pessary Shaatz pessary Gehrung pessary Gellhorn pessary Cube pessary Donut pessary Inflatable pessary Lever pessary ILLUSTRATIONS: MARCIA HARTSOCK FOR OBG MANAGEMENT MARCIA HARTSOCK ILLUSTRATIONS: 22 OBG Management | January 2021 | Vol. 33 No. 1 mdedge.com/obgyn Necessary pessary aftercare • check for vaginal mucosal erosion or ulcer- Once a pessary is in place and the patient ation; such vaginal lesions often can be is comfortable with it, the only mainte- prevented by the prophylactic use of either nance necessary is the pessary’s intermittent estrogen vaginal cream twice weekly or the removal for cleansing and for evaluation of continuous use of an estradiol vaginal ring the vaginal mucosa for erosion and ulcer- in addition to the pessary ations. How frequently this should be done • evaluate the condition of the pessary itself varies based on the type of pessary, the and clean it with soap and water. amount of discharge that a woman produces, whether or not an odor develops after pro- longed wearing of the pessary, and whether Potential complications or not the patient’s vaginal mucosa has been of pessary use abraded. The most common complications experi- enced by pessary users are: The question of timing Odor or excessive discharge. Bacterial for pessary cleaning vaginosis (BV) occurs more frequently in Although there are many opinions about women who use pessaries. The symptoms how often pessaries should be removed and of BV can be minimized—but unfortunately cleaned, no data in the literature support not totally eliminated—by the prophylactic any specific interval. Pessaries that are eas- use of antiseptic vaginal creams or gels, such ily removed by women themselves can be as metronidazole, clindamycin, Trimo-San cleaned as frequently as desired, often on a (oxyquinoline sulfate and sodium lauryl sul- weekly basis. The patient simply removes the fate), and others. Inserting the gel vaginally pessary, washes it with soap and water, and once a week can significantly reduce dis- FAST reinserts it. For pessaries that are difficult to charge and odor.3 TRACK remove (such as the Gellhorn, cube, or donut) Vaginal mucosal erosion and ulceration. or for women who are physically unable to These are treated by removing the pessary for For difficult-to- remove their own ring pessary, the clinician 2 weeks during which time estrogen cream remove pessaries should remove and clean the pessary in the is applied daily or an estradiol vaginal ring or for women office every 3 to 6 months. It has been shown is put in place. If no resolution occurs after physically unable that there is no difference in complications 2 weeks, the nonhealing vaginal mucosa to remove their from pessary use with either of these intervals.2 should be biopsied. own ring pessary, Prior to any vaginal surgical procedure, Pressure on the rectum or bladder. If the clinician should patients must be instructed to remove their the pessary causes significant discomfort or remove and clean pessary 10 to 14 days beforehand so that the interferes with voiding function, then either the pessary in the surgeon can see the full extent of prolapse a different size or a different type pessary office every 3 to when making decisions about reconstruction should be tried 6 months and so that any vaginal mucosal erosions or Patients may discontinue pessary use for abrasions have time to heal.