Pessaries for vaginal prolapse: Critical factors to successful fit and continued use A successfully inserted vaginal pessary can improve voiding, urgency, and incontinence for women with urinary incontinence and pelvic organ prolapse, no matter the stage. We encourage you to offer and use this low-cost, minimally invasive approach. More than half of women with prolapse may use a pessary for up to 2 years. Teresa Tam, MD, and Matthew Davies, MD In thIs CASE 1 Early-stage pelvic organ prolapse active with her husband on roughly a weekly Article AC is a 64-year-old white woman with early basis. Pessary indications stage III anterior and apical pelvic organ pro- On examination, the leading edge of her and options lapse (POP). The prolapse is now affecting prolapse is the anterior vaginal wall, protrud- page 43 her ability to do some of the things that she ing 1 cm beyond the introitus, and the cervix enjoys, such as gardening and golfing. is at the hymenal ring. There is no significant She has hypertension controlled with posterior wall prolapse. Essential medication and no other significant medical After she is counseled about all pos- components of issues except mild arthritic changes in her sible treatment approaches for her early- successful fit hands and hips. She reports being sexually stage POP, the patient elects to try the vagi- page 50 nal pessary. Now, it is your job to determine the optimal pessary based on the extent of Dr. Tam is a graduated Fellow in the Division Outcomes her condition and to educate her about the of Urogynecology and Minimally Invasive page 59 Gynecologic Surgery, Department of Obstetrics potential side effects and best practices for and Gynecology, Penn State Milton S. Hershey its ongoing use. Medical Center. She is currently in private practice at All for Women’s Healthcare in Chicago, Illinois. Dr. Davies is Division Chief, Urogynecology and he vaginal pessary is an important Minimally Invasive Gynecologic Surgery, Department component of a gynecologist’s ar- of Obstetrics and Gynecology, at Penn State mamentarium. It is a low-risk, cost- Milton S. Hershey Medical Center, Penn State T College of Medicine, Hershey, Pennsylvania. effective, nonsurgical treatment option for On the WEb the management of POP and genuine stress Dr. Tam reports that she has received a grant or urinary incontinence (SUI).1,2 It is unfortu- Dr. Tam demonstrates research support from Ethicon BioSurgery and is a proper insertion speaker for Merck Pharmaceuticals. nate that training in North America typically and removal Dr. Davies reports that he is a consultant to Boston provides clinicians with only a cursory expe- Scientific and a speaker for Ethicon Endosurgical techniques, at and Boston Scientific. rience with pessary selection and care, mini- obgmanagement.com mizing the device’s importance as a viable 42 OBG Management | December 2013 | Vol. 25 No. 12 obgmanagement.com tool in a practitioner’s ongoing practice. In fact, most clinicians tend to view the pessary Vaginal pessaries: An instructional video with a mixture of reluctance and disregard. This is regrettable, as a majority (89%) Written and narrated by Teresa Tam, MD of patients can be successfully fitted with a pessary,3 regardless of their stage or site In this 15-minute video Dr. Tam demonstrates insertion and removal of prolapse.4 Although high-stage prolapse of the ring and Gellhorn pessaries and illustrates proper technique for estimating pessary size. does not predict failure, ring pessaries are used most successfully with stage II (100%) and stage III (71%) prolapse, while Gellhorn pessaries are most successful with stage IV (64%) prolapse.5 In this article we review the several pes- sary options available to clinicians, as well as how to insert them and the best scenarios Use this QR code to download the video to your for their use. We also discuss the key require- Smartphone, or go to obgmanagement.com. Free QR ments for patient assessment and in-office readers are available at iPhone App Store, Android fitting (meant to optimize the fit and, there- Market, and Blackberry App World. by, the success of use), the possible side ef- © Dr. Teresa Tam fects of pessary use that patients need to be aware of, and appropriate follow-up. pessaries come in different sizes and shapes. When is a pessary your best Most are made of medical-grade silicone, ren- management approach? dering them durable and autoclavable as well There are several indications for pessary as resistant to absorption of vaginal discharge use,6 namely when: and odors. The ring pessary with support is the • the patient has significant comorbid risk most commonly used support pessary. The factors for surgery Gellhorn pessary is the most commonly used • the patient prefers a nonsurgical alternative space-filling pessary. It is used as a second- • a goal is to avoid reoperation line treatment for patients unable to retain the • POP or cervical insufficiency is present ring-with-support pessary. during pregnancy • the patient desires future fertility • surgery must be delayed due to treatment Support pessary options of vaginal ulcerations The support pessaries are used to treat SUI • the pessary will be used as a postoperative and POP. These pessaries typically are the adjunct to mesh-based repair. Pessaries have very few contraindica- Contraindications to pessary use tions (TAblE). However, factors that do nega- tively affect successful fitting include: • Active infection of the pelvis or vagina. Treatment and resolution of the • prior pelvic surgery infection are advisable prior to pessary fitting and use. • multiparity • Latex allergy. Although most pessaries are made of silicone, the Inflatoball • obesity is made of latex, so insertion of this pessary is contraindicated in patients • SUI allergic to latex. • short vaginal length (<7 cm) • Medical or social factors predisposing the patient to nonadherence and • wide vaginal introitus (>4 fingerbreadths) pessary neglect. 5,7-9 • significant posterior vaginal wall defect. • Vaginal mesh erosion. The foreign body should be removed prior to pes- There are two main categories of vagi- sary placement. nal pessaries: support and space-filling. All obgmanagement.com Vol. 25 No. 12 | December 2013 | OBG Management 43 pessaries for vaginal prolapse FIGURE 1 FIGURE 2 A b Ring pessary (A), and ring pessary with support (b) easiest types for patients to use because they are more comfortable and simpler to remove and insert than space-filling pessaries. For example, a ring pessary is two-dimensional and lies perpendicular to the long axis of the With the patient in a horizontal position, the ring pessary is placed behind the cervix, into the vagina, allowing patients to have intercourse posterior fornix with it in place. Support-type pessaries in- clude the ring, Gehrung, Shaatz, and lever. nt e pessary to reopen, and direct it behind the M e Ring cervix into the posterior fornix (FIgure 2). This is the most commonly used pessary Give it a slight twist with your index finger manag because it fits most women. There are four to prevent expulsion (see Vaginal pessaries: obg types of ring pessaries: the ring (FIgure 1A), An instructional video, on page 43). for ring with support (FIgure 1b), inconti- k nence ring, and incontinence ring with sup- gehrung port. The ring pessary is appropriate for all This pessary is designed with an arch-shaped hartsoc The ring pessary, the moset stages of POP. The ring with support has a malleable rim with wires incorporated into diaphragm that is useful in women who have the arms (FIgure 3). Use of the Gehrung marcia commonly used : pessary, is uterine prolapse with or without cystocele. pessary is rare; it is most often used in wom- appropriate for The incontinence ring has a knob that is en with cystocele or rectocele. placed beneath the urethra to increase ure- Insertion. Fold the pessary to insert it into ustration ll all stages of pelvic I thral pressure and is useful in cases of SUI. the vagina. Upon insertion, keep both heels organ prolapse Insertion. Fold the pessary by bringing of the pessary parallel to the posterior vagina . D the two small holes together, and lubricate with the back arch pushed over the cervix in e not the leading edge. Insert it past the introitus the anterior fornix and the front arch resting e R with the folded edge facing down. Allow the behind the symphysis pubis. The concave e wh pt e C FIGURE 3 FIGURE 4 l, ex urgica S R e oop ©C of y S e A b ourt : C Gehrung pessary (A) with knob (b) Shaatz pessary hotos P 44 OBG Management | December 2013 | Vol. 25 No. 12 obgmanagement.com Human immunodeficiency virus (HIV)/Hepatitis C virus (HCV) protease inhib- itors and non-nucleoside reverse transcriptase inhibitors: Significant changes pessaries for vaginal prolapse (increase or decrease) in the plasma concentrations of estrogen and progestin have been noted in some cases of co-administration with HIV/HCV protease inhibitors or with non-nucleoside reverse transcriptase inhibitors. Antibiotics: There have been reports of pregnancy while taking hormonal con- traceptives and antibiotics, but clinical pharmacokinetic studies have not shown surface and diaphragm support the anterior consistent effects of antibiotics on plasma concentrations of synthetic steroids. vagina. Place the convex portion of the curve 7.2 Effects of Combined Oral Contraceptives on Other Drugs " ÃÊVÌ>}Ê Ê>ÞÊ LÌÊÌ iÊiÌ>LÃÊvÊÌ iÀÊV«Õ`Ã°Ê " ÃÊ beneath the bulge. The two bases rest on the have been shown to significantly decrease plasma concentrations of lamotrig- posterior vagina against the lateral levator ine, likely due to induction of lamotrigine glucuronidation. This may reduce sei- zure control; therefore, dosage adjustments of lamotrigine may be necessary. muscles.