PART 1 Pessaries for POP and SUI: Your options and guidance on use Gynecologists may not always “think pessary first” when it comes to pelvic organ prolapse management. However, it is important to be familiar with the array of available pessary options and how to select a device based on the patient’s disorder and needs. Henry M. Lerner, MD ver the last 30 years, surgical correc- immediate relief not only of POP but also of tion of the common condition pel- SUI and defecatory difficulties. As an alterna- O vic organ prolapse (POP) and stress tive to surgery, pessaries are especially valu- urinary incontinence (SUI) has become so able, because the other major nonsurgical IN THIS routine and straightforward that many gyne- modality for treatment of POP and inconti- ARTICLE cologists and urogynecologists choose sur- nence—pelvic floor muscle training—often is gery as their first choice for treating these not covered by insurance (making it expensive Candidates conditions, withholding it only from the riski- for patients), takes many weekly sessions to for pessaries est patients or from those who, for a variety complete (which can make access challeng- of reasons, do not choose surgery. Moreover, ing), and frequently is not readily available.1 page 33 as generalist gynecologists increasingly refer POP is very common. An estimated 15% patients with POP or incontinence to their to 30% of women in North America have some Pessary types urogynecologist colleagues, they increasingly degree of prolapse, and more than 500,000 page 34 lack the skills, or have not been trained, to use surgeries for this condition are performed in conservative treatment strategies for these the United States each year.2 Risk factors for History of disorders. Thus, pessaries—devices con- POP include: pessaries structed of inert plastic, silicone, or latex and • vaginal childbirth, especially higher parity page 36 placed inside the vagina to support prolapsed • advancing age pelvic structures—frequently are not part of • high body mass index (BMI) the general gynecologist’s armamentarium. • prior hysterectomy When properly selected, however, pessa- • raised intra-abdominal pressure, such as ries used for indicated purposes and correctly from obesity, chronic cough, or heavy lifting. fitted are an excellent, inexpensive, low- In addition to the discomfort caused by risk, and noninvasive tool that can provide the herniation of pelvic and vaginal struc- tures, POP also is associated with urinary incontinence (73%), urinary urgency and fre- Dr. Lerner is Assistant Clinical Professor (retired), 3 Harvard Medical School, Boston, Massachusetts. quency (86%), and fecal incontinence (31%). Moreover, according to the US Census The author reports no financial relationships relevant to this Bureau, the number of American women article. aged 65 or older will double to more than 40 doi: 10.12788/obgm.0052 million by 2030.4 This will greatly increase the 32 OBG Management | December 2020 | Vol. 32 No. 12 mdedge.com/obgyn population of women at risk for POP who may should be the first treatment modality offered be candidates for pessary use. It therefore for POP.5 Women who cannot use a pessary behooves gynecologists to become familiar include those with an extremely short vagina with the correct usage, fitting, and mainte- (<6 cm) and those who have severely eroded nance of this effective, nonsurgical mode of vaginal mucosa. In the latter situation, the treatment for POP. mucosa can be treated with estrogen cream In this article, I discuss why pessaries are for several weeks and, once the tissue has a good option for many patients with POP, healed, a pessary can be fitted. review the types of pessaries available, and Given that surgical repair is generally a offer guidance on how to choose the right straightforward, one-time procedure that obvi- pessary for an individual patient’s needs. ates the need for long-term use of an artificial In addition, the box on page 36 provides an device worn internally, why might a patient or interesting timeline of pessary history dating her physician opt for a pessary instead? back to antiquity. Some of the many reasons include: Next month in Part 2 of this article, I • Many patients prefer to avoid surgery. cover how to fit a pessary; device aftercare; • Many patients are not appropriate can- potential complications of use; and effective- didates for surgery because they have ness of pessaries for POP, SUI, preterm labor significant comorbid risk factors or high prevention, and defecatory disorders. BMI. • Patients may have recurrent prolapse or incontinence and wish to avoid repeat Potential candidates surgery. for pessary use • Patients with SUI may have heard of the Almost all women with POP—and in many occurrence of mesh erosion and wish to cases accompanying SUI—are potential can- avoid that possibility. didates for a pessary. In fact, many urogyne- • Women who live in low-resource environ- ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT MARTENS KIMBERLY ILLUSTRATION: cologists believe that a trial of pessary usage ments or countries where elective surgical mdedge.com/obgyn Vol. 32 No. 12 | December 2020 | OBG Management 33 Pessaries for POP and SUI: Your options and guidance on use care is relatively unavailable may not have as mucosal erosion, ulceration, or even the option of surgery. (extremely rarely) fistula formation. Pessa- A clinician might also recommend pes- ries may be inappropriate for sexually active sary use: women who on their own are unable to remove • as a diagnostic tool to attempt to assess the and reinsert pessary types that do not allow for potential results of vaginal repair surgery intercourse while in place (see below). • to estimate the potential effectiveness of a midurethral sling procedure; several investigators have found this to be approxi- Types of pessaries mately as accurate as urodynamic testing6,7 The numerous kinds of pessaries available • as prophylaxis for pregnant women with fall into 3 general categories: support, space either a history of preterm cervical dilation or filling, and lever, and devices within each a short cervix detected on ultrasonography group have modifications and variations. As • for pregnant women with POP that is wors- with most areas of prescribing and treatment ening and becoming increasingly uncom- in medicine, it is best to become very familiar fortable with just a few kinds of pessaries, know their • for women with POP who wish to have indications, and use them when appropriate. more children Most pessaries are constructed of inert • for short-term use while a patient is delay- silicone which, unlike earlier rubber pessa- ing or awaiting POP surgery or to allow ries, does not absorb odor or discharge. They time for other medical issues to resolve are easy to clean, long lasting, and are auto- • for patients who wish only intermittent, clavable and hypoallergenic. temporary support while exercising or engaging in sports. Support pessaries Support pessaries look like contraceptive dia- Patient acceptance may be phragms. They are easy to place and remove, contingent on counseling are comfortable, and do an excellent job cor- Numerous studies show that women who recting moderate POP. They also can control choose pessaries to treat POP are generally or eliminate symptoms of SUI by the pressure older than women who elect surgery. Still, they exert on the urethra and their alteration patient acceptance of a trial of pessary use of the urethrovesicular angle. depends much on the counseling and infor- mation she receives. Properly informed, many Ring pessaries patients with POP will opt for a trial of pessary placement. One study showed that, of women with untreated POP, 36% preferred pessary placement to surgery.8 Other investigators reported that when women with symptom- atic POP had the benefits of a pessary versus surgery explained to them, nearly two-thirds opted for a pessary as their mode of treatment.9 Exceptions to pessary use Fortunately, there are relatively few contrain- dications to pessary use. These are vaginal or pelvic infection and an exposed foreign body in the vagina, such as eroded vaginal mesh. In addition, patients at risk for nonadher- ence with follow-up care are poor candidates, DEVICE ILLUSTRATIONS: MARCIA HARTSOCK FOR OBG MANAGEMENT MARCIA HARTSOCK DEVICE ILLUSTRATIONS: as it could lead to missing such problems 34 OBG Management | December 2020 | Vol. 32 No. 12 mdedge.com/obgyn Marland pessary Shaatz pessary The Shaatz pessary is a rigid round pes- sary, smaller in diameter than the standard ring pessary, and similar to the Gellhorn pes- sary (discussed below) but without a stem. It Ring pessaries. The most commonly used is placed the same way one places a ring pes- type of pessary, the ring pessary,10 comes in sary but with its concave surface up against 4 variations: the cervix or, if there is no cervix, against the • a simple open ring upper anterior vaginal wall. Its main benefit • a ring with a web of material, called a “sup- is that it provides firmer support than the ring port shield,” that fills the ring pessary. This pessary is not widely used in the • an open ring with a firm 2-cm “inconti- United States. nence knob” attached that is positioned The Gehrung pessary looks like a flat strip over the urethra of material that has been bent into the shape • a ring with support shield and inconti- of a “U.” It is designed to correct severe cysto- nence knob. celes and rectoceles. For insertion, the edges When in position, the deepest edge of a at the open end of the pessary are squeezed ring pessary fits behind the cervix (or in the together and the pessary is inserted with the vaginal apex for women who have had a hys- closed part of the “U” facing the anterior vagi- terectomy) while the front of the ring slips nal wall.