Download Pelvic Organ Prolapse -Pessary Treatment

4.10
Pelvic Organ Prolapse - Pessary Treatment
Jane A. Schulz and Elena Kwon
Key Message
Pessary treatment of prolapse is one of the oldest
remedies in medicine and is an important conservative treatment that is particularly valuable
for the physically frail. Pessaries can be used for
diagnosis and treatment of prolapse, for voiding
dysfunction and urinary incontinence and for
the management of incontinence or retention
during pregnancy. The guidelines for pessaries
and the role of the woman in taking care of her
pessary is emphasized. The main types of pessary
and the specific indications are reviewed - choice
will depend on the type of prolapse and the
vaginal anatomy. The success rate and the complications and their management are outlined.
The role of pelvic floor exercises and supportive
garments are reviewed. The importance of future
randomized control trials and establishment of
clinical guidelines is emphasized.
Introduction
The lifetime risk for pelvic organ prolapse (POP)
or incontinence surgery for a female by the age of
80 years old is 11.1%. Up to 30% of women will
require repeat prolapse surgery, and up to 10%of
women will require repeat continence surgery.I
Treatment of prolapse depends on several factors,
including the patient's wishes for management,
the severity of prolapse and its symptoms, the
woman's general health, and whether childbearing is completed. In the past, conservative treatment of prolapse has been reserved for those with
mild prolapse, those who are too frail or unwilling to have surgical management, or for those
who wish to have more children. However,
because evidence indicates that we still do not
have good durability of prolapse repairs, and
with women living longer, conservative management options must be considered for all as a
method of treatment.
Historical Perspective
Mechanical devices as a conservative management tool for POP have been used for many centuries. They were described as far back as the
time of Hippocrates. Multiple variations have
been described, such as pomegranates, bone, sea
sponges, and various external braces (see Fig.
4.10.1). Other conservative methods included
repositioning of the prolapse, leg binding, douching, herbal remedies, and the use of leeches.
Pessaries gained popularity in the 1800s for
the management of uterine retroversion. All were
precursors to our current pessaries and were
used very frequently because of the high surgical
morbidity and mortality. However, with advances
in anesthesia and surgical techniques, they fell
out of favor. More recently, with newer pessaries,
and a wide range of styles, the longer lifespan of
women, and the realization of the impermanence
of surgery, mechanical devices for POP are experiencing a rebirth in popularity of use. 2
Research in this area is still lacking. The recent
Cochrane review of mechanical devices for POP
in women found no eligible, completed, published
271
J.A. Schulz and E. Kwon
272
agement. Pessaries can also be used as a diagnostic tool. Examples of their use for diagnosis
include whether pessary insertion corrects the
patient's symptoms of prolapse, and whether
associated symptoms such as voiding dysfunction and urinary incontinence are corrected by
pessary insertion. Pessaries are believed to work
by creating an artificial shelf of levator support
to reduce the prolapse. Incontinence pessaries
also work by elevating the bladder neck back to
the normal anatomic position, and by some
degree of obstructive effect on the urethra.' Pessaries need to be fitted by a health care professional. A nurse-run clinic for pessary fitting
is a good option as a time- and cost-saving
measure.'
FIGURE 4.10.1. Cup and stem pessary with belt. (Source: Repro-
duced with permission from Milex Products Inc., Chicago,
Illinois.)
or unpublished randomized controlled studies;
therefore, no data collection or analysis was
possible.'
Indications for Pessary Fitting
Pessaries can be used for all types and all stages
of POP.Pessaries can also be used for stress, urge,
mixed, and overflow urinary incontinence.
Although, historically, incontinence type pessa-
Types ofPelvic Organ Prolapse
and Evaluation
Conservative Management Options for POP
Pessaries
An extensive range of mechanical devices has
been described for the management of pelvic
floor disorders, and they are listed in Chapter 3.4.
Because these devices are often underutilized,
they are covered separately in this chapter, where
we will consider their use for specific indications
of POP. These mechanical devices consist mainly
of pessaries. Pessaries are primarily made of
medical grade silicone covering surgical steel.
The advantages of silicone are that it has a longer
lifespan for use, it can be autoclaved, it does not
absorb odors or secretions, and it is an inert
material. Pessaries come in a wide range of shapes
and sizes (Fig. 4.1O.2). They may be used to
prevent prolapse from becoming worse, to
decrease the frequency or severity of symptoms
of prolapse, and to avert or delay surgical man-
FIGURE 4.10.2. Milex pessaries. (Source: Reproduced with per-
mission from Milex Products Inc.,Chicago, Illinois.)
4.10. Pelvic Organ Prolapse - Pessary Treatment
ries have been used for stress urinary incontinence, there have been reports of success with
urge incontinence in 64-67% of patients." Pessaries have been used for the diagnosis and management of latent stress urinary incontinence,"
Hextall et al. found stress incontinence was
unmasked in 27% of women in their unit with
prolapse that were being investigated with urodynamics." The use of a pessary before surgery is
also useful to predict whether women will achieve
relief of their prolapse symptoms, and whether
urinary symptoms, such as urgency and voiding
dysfunction, will resolve." Pessaries are a valu able tool for the management of the pregnant
woman who has urinary incontinence, POP, or
urinary retention secondary to uterine retroversion or incarceration. In pregnancy, the size of
the pessary may have to be changed with advancing gestation. Hodge pessaries work best for
uterine incarceration with associated voiding
dysfunction. Once the pregnant uterus moves up
out of the pelvis in the second trimester, symptoms often improve.
There are few contraindications to pessary
fitting. Active infections of the pelvis or vagina,
such as vaginitis or pelvic inflammatory disease,
preclude the use of a pessary until the infection
has resolved. Allergies to the pessary are very
uncommon, especially since now most are made
of silicone. However, any allergic response to a
vaginal pessary would be a contraindication to
fitting. The only other caution is with patients
who are not likely to be compliant with pessary
care and follow-up; these patients should not be
fitted with a device ."
273
inserted and tilted up behind the pubic symphysis (Fig. 4.1O.3). A fingerbreadth should fit between
the pessary and the vaginal mucosa. Once the
pessary has been fitted, the patient should walk
around and exercise in the clinic to ensure it will
not immediately fall out. It is necessary to ensure
that patients are able to void and are given appropriate education before leaving the clinic with
their new pessary. If possible, patients should
be taught to remove, clean, and replace their
pessaries themselves. If pessaries are difficult to
remove, fishing wire or dental floss may be
attached to the pessary to aid in removal. There
are few guidelines for pessary removal and cleaning, and the recommendations that do exist are
variable. Current Canadian practice advises any
woman who is able to remove her own pessary to
remove, wash, and replace it once per week. The
patient is advised to wash the pessary in soap and
warm water. If she cannot remove her pessary,
she should have it removed, cleaned, and replaced
every 3 months by a health care professional.'
Similar guidelines are followed by family physicians and gynecologists." :" Women may have
intercourse with their pessary in place; however,
many elect to remove it .
Guidelines for Pessary Fitting
An adequate amount of time should be allotted
for pessary fitting. A clinical setting in a nurserun pessary clinic is ideal. In postmenopausal
women, pretreatment with local estrogen therapy
for at least 6 weeks is helpful to optimize successful fitting.' A postvoid residual should be checked
before pessary fitting, as pessaries can cause
obstruction of urinary flow. To fit a pessary, size
the vaginal vault by examining the vagina with
two fingers. Start with a covered ring pessary, or
the appropriate design for the diagnosis. The
pessary should be lubricated on the end and then
FIGURE 4.10.3. Pessary fitting. (Source: Reproduced with permission from Milex Products Inc., Chicago, Illinois.)
274
Proper pessary fitting may require trials of
several styles and sizes. Difficulty with pessary
fitting may arise if there is a large posterior wall
defect, poor perineal body support, or a shortened vagina." Many pessaries rely on good perineal support to remain in place. Patients that
have had prior radiation or multiple pelvic surgeries may also encounter difficulties with
pessary fitting because of a scarred or shortened
vagina.":" Peri- or postmenopausal women with
significant vaginal atrophy may have significant
discomfort when pessary fitting is attempted. In
this situation, 4 to 6 weeks of local estrogen
therapy is often helpful to increase the success
rate of pessary fitting. "
Types ofPessaries
Ring pessaries are the most widely available and
most commonly used:" they are available in open
and covered forms . The covered ring pessary has
drainage holes to allow the vaginal secretions to
escape; it is useful in patients that still have a
uterus, to prevent the cervix from slipping
through the ring. Open and covered ring pessaries are best used in POPQ stage I and II prolapse ." The Shaatz pessary is a stiffer circular
pessary that is used when more support is
required for management of the prolapse. Shaatz
pessaries can be used if the rings fall out, or if
there is still protrusion of the prolapse beyond a
ring pessary. Doughnut pessaries are shaped like
their namesake; they are used for more significant uterine prolapse, especially if accompanied
by anterior and posterior wall descent. A variation of the doughnut pessary is the Inflatoball;
this is made of latex and must be deflated daily
for removal and cleaning. The Inflatoball pessary
is used in patients with a narrow introitus but a
capacious upper vagina. The Regula is a newer
pessary for mild prolapse. Its unique bridgeshaped design helps to prevent expulsion."
The Gellhorn, or stem, pessary is indicated for
more advanced stage III or IV prolapse. It is often
useful in reducing a complete procidentia or
vaginal vault eversion. Like the other pessaries,
the Gellhorn creates an artificial levator shelf, but
also creates a suction to provide a little more
support. The stem helps to prevent the pessary
from shifting position. The Gellhorn is more dif-
J.A. Schulz and E. Kwon
ficult to remove, and cannot be used if a patient
is sexually active, unless she is able to remove the
pessary herself. To remove the Gellhorn, the
suction must be broken at the dish of the device;
occasionally, a Kelly clamp is requ ired to pull on
the stem and assist with removal.
The cube or tandem cube pessaries are used
when other pessaries are unsuccessful, or when
there is very poor pelvic tone . They work using
suction to the vaginal walls, as all their sides are
concave. Older cube pessaries did not have drainage holes and required daily removal and cleaning. However, newer versions do have some
drainage holes that allow them to be left for up to
a week. There is a string attached to the cube
pessary; however, this is to assist with locating
the pessary and is not for traction for removal.
There are now a variety of lever pessaries that
are all modifications of Hodge's original design
from the 1860s.15 These include the Hodge, the
Smith-Hodge, the Risser, and the Gehrung. The
Hodge pessary has been used traditionally for
uterine retroversion and incompetent cervix.
Variations of this pessary are for variations in
pubic arch anatomy. Traditionally, the Gehrung
has been used for women with both a cystocele
and rectocele, although it is sometimes difficult
to keep this pessary in position."
Incontinence pessaries are variations on the
other forms of pessaries with an elevated knob to
support the bladder neck. There are incontinence
ring and dish pessaries, and now also incontinence versions of some of the lever pessaries. If a
patient with prolapse develops stress incontinence after being fit with one of the other styles
of pessaries, switching to an incontinence pessary
may address both problems.
Success Rates with Pessaries
The reported success rates for pessaries vary by
diagnosis. Vierhout reported a 63% subjective
improvement or cure rate with pessary use for
stress urinary incontinence." In a prospective
review by Clemons et al. of 100 women being
fitted for a pessary for POP, 73% had a 2-week
successful pessary-fitting trial. I? Of the group
that had successful pessary fitting, almost all had
complete resolution of their prolapse symptoms,
50% had improvement of their urinary symp-
4.10. Pelvic Organ Prolapse - Pessary Treatment
toms, and 92% were satisfied with their pessary.
Dissatisfaction with pessary fitting was associated with occult stress incontinence.
In a retrospective review of 1,216 women in a
tertiary care gynecology unit, 86% of women
were able to be fit with pessaries, and of these 71%
were able to wear them successfully. Successful fit
was achieved in 83% of patients with uterine prolapse, 82% of patients with cystocele, 69% of
patients with vault prolapse/enterocele, and 66%
of patients with cystocele/rectocele."
There is some suggestion that the use of a
pessary may prevent the progression of POP.IS
However, there is still significant study required
in this area.
275
ing or a change in discharge. If left untreated,
they may progress to ulcers. In patients with a
uterus still in place, other causes of abnormal
vaginal bleeding must be ruled out. These areas
may also become secondarily infected, leading to
further tissue breakdown. Erosions occur in 2%
to 8.9% of patients. v" They usually respond well
to local estrogen therapy; addition of an antibiotic cream may also be required if secondary
infection has occurred. Diligent pessary care and
inspection of the vaginal tissues every 6 to 12
months helps to prevent erosions. Pessary size
may also have to be adjusted to prevent further
erosions from developing.
Fistulas
Pessary Complications
Overall pessary complications are uncommon
and affect less than 10% of patients.Y
Vaginal Discharge
Vaginal discharge is one of the more common
complaints with pessary fitting. With insertion of
a foreign body into the vagina, it is normal to see
an increase in the vaginal discharge, especially if
local estrogen treatment is also being used, such
as in the postmenopausal population. However,
if there is patient concern, or if there are other
symptoms such as foul smell, bleeding, or pruritis, the discharge should be investigated. A
vaginal examination and culture can be completed. If there is a yeast infection or bacterial
vaginosis, the pessary should be left out for a
week while the appropriate antibiotic or antifungal treatment is used. Concern about recurrent
vaginal infections is a common patient concern.
However, this is unusual; in the postmenopausal
population this is best prevented with local estrogen use. The use of Trimosan cream, which is
provided with the Milex pessaries, has been recommended to help decrease the amount of odor
and discharge, although it has not been studied
in clinical trials.":":"
Vaginal Erosions
Erosions of the vaginal mucosa usually start as
an area of redness or abrasion where the pessary
is resting. They may present with vaginal bleed-
One of the keys to long-term pessary care is
ensuring that the patient takes adequate precautions to prevent the more serious complications.
Fistulas, although very rare, are among the most
serious complications of neglected pessaries."
They can be rectovaginal, vesicovaginal, or urethrovaginal. An impacted pessary can develop
erosions that break down, or get infected, leading
eventually to fistula. It is very important that
pessaries are regularly removed, washed, and
replaced, and that the vagina inspected for any
signs of infection or erosion. In a cognitively
impaired patient, it is imperative that a caregiver
be committed to ensuring ongoing pessary care
and cleaning.
Pelvic Floor Physiotherapy
Pelvic floor prolapse is an anatomical defect
associated with functional changes. These may
include urinary incontinence (urge, stress, and
overflow), defecatory dysfunction, and pelvic
pressure. There is evidence that pelvic floor exercises are helpful for some of the resultant conditions and functional changes associated with
POP. These include pelvic floor exercises and
bladder retraining for urinary incontinence. i'r"
However, for the direct treatment of pelvic
floor prolapse as an anatomical defect, there is
little documentation regarding the effect of pelvic
floor physiotherapy." For mild prolapse there is
a perceived benefit," however, more severe prolapse is unlikely to be corrected by exercises
J.A. Schulz and E. Kwon
276
alone. Defects such as stress urinary incontinence and POP have been associated with electromyographic changes that may represent either
motor unit loss or failure of central activation,"
and this would certainly impact the potential
success of pelvic floor therapy for these conditions. Randomized clinical trials, and the estab lishment of clinical and referral guidelines, are
required in this area.
Fembrace26
For many centuries, conservative management of
POP relied primarily on the use of pessaries and
pelvic floor exercises. Since the marketing of a new
V-brace" support garment in NewYorkin the fall
of 2000, however, there exists an alternative for
POP symptom relief in patients who cannot use a
pessary for various reasons (Fig. 4.10.4). The Vbrace' garment is a panty with a padded double
crotch and cross elastic straps that acts to reduce
the symptoms of pelvic organ prolapse by providing support and pressure to the vaginal area. The
creators of the V-brace" garment suggest that
even women who use a pessary can alternate and
also use the V-brace" every other day when not
wearing the pessary, for ultimate relief of prolapse
symptoms. The garment is also recommended for
FIGURE 4.10.4. The Fembrace support device for pelvic organ
prolapse.
reducing varicose veins on the vulva, as well as for
reducing hip, leg, or pelvic pain.
Other Alternatives
Other options include the use of tight bicycle
shorts as a perineal support in women that are
unable to fit a pessary and unable to have surgery.
Some women have used their contraceptive diaphragms or tampons to attempt to reduce their
prolapse, or to provide relief for their urinary
incontinence. However, a common complaint of
women with moderate to severe prolapse is the
inability to retain a tampon. Desperate patients
that have come to our clinic have also described
the use of sticky tape across the vaginal opening.
Summary
Pelvic organ prolapse is a prevalent condition
that impacts quality oflife. As women live longer,
further research is needed to study conservative
options to treat prolapse. Pessaries are currently
the main conservative management tool. 27 Other
options that exist include pelvic floor physiotherapy and the Fembrace support.
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