Diaphragm Fitting

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Chapter 241 Diaphragm Fitting

DESCRIPTION

Diaphragms (rubber or latex domes with a springy ring) are designed to provide a physical barrier between sperm and egg in conjunction with contraceptive jelly or creams to provide contraception by both barrier and spermicidal actions.

INDICATIONS

Elective. (Approximately 2% of women using contraception choose this method.)

CONTRAINDICATIONS

Known or suspected allergy to latex or other materials used in the contraceptive device. Diaphragms are not a good contraceptive choice for those who have significant pelvic floor support failure or those unwilling or unable to actively participate in the placement or removal process.

REQUIRED EQUIPMENT

• Examination gloves

• Set of graduated diaphragm fitting rings

• Water-soluble lubricant

TECHNIQUE

Diaphragms must be fitted to the individual patient, choosing the largest size that may be comfortably accommodated. (Diaphragms come in sizes that range from 50 to 105 mm in diameter, graduated in 5-mm increments. The most common size prescribed is 75 mm.) The optimal size may change with significant weight change (10 to 15+ pounds), vaginal birth, or pelvic surgery. Following delivery, diaphragms may be fitted at the 6- to 8-week postpartum visit. Diaphragms are made with coiled spring or with a flat or arcing type of rim that somewhat alters the fit. The flat type is better suited to those with a less well-defined subpubic arch; the arcing spring is best for those with less muscle tone.

Diaphragm fitting begins with a gentle, bimanual examination of the patient using the lubricated, gloved examining finger to measure the approximate distance from the back of the symphysis to the posterior vaginal fornix. A fitting ring that approximates this diameter should be selected, lubricated, and inserted into the vagina. The ring should be placed to rest in the posterior vaginal fornix with the outer portion resting in the retropubic notch. The examining finger should easily fit between the ring and the vaginal wall in all areas. The examining hand is removed and the comfort of the fit is checked. The ring should be comfortable or imperceptible when fitted and inserted properly. The patient should be asked to strain to ensure that the ring is not displaced by physical activity. It is not uncommon to have to try one or two sizes to accomplish an optimal fit.

The fitting ring should be removed (by gentle traction on the retropubic edge of the ring). Whenever possible, the actual diaphragm should next be inserted and checked in the same way. The cervix should be clearly palpable through the dome of the device. The patient should also be given the opportunity to perform the insertion and removal and confirm correct positioning and comfort in the office setting prior to actual contraceptive use.

In use, the diaphragm must be inserted before sexual intercourse commences and it must be left in place for 6 to 8 hours after. It is then removed, washed, and stored. Should additional intercourse be desired before the 6- to 8-hour time has expired, additional spermicide is applied to the vaginal side of the diaphragm and the waiting time to removal is restarted. Postcoital douching is not recommended. When correctly positioned, the diaphragm should not be noticeable by either partner.

COMPLICATIONS

Vaginal infection, urinary retention, toxic shock (2.4/100,000 when left in place >24 hours), vaginal wall trauma or erosions are all possible but unlikely with a properly fitted diaphragm that is removed at the proper intervals.

FOLLOW-UP

As needed. If the patient has not had an opportunity to practice insertion, positioning, and removal in the office, this should be offered before the diaphragm is relied on for contraception.

CPT CODE(S)

57170 Diaphragm or cervical cap fitting with instructions

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Cook L, Nanda K, Grimes D. Diaphragm versus diaphragm with spermicides for contraception. Cochrane Database Syst Rev. 2001. CD002031.

Ferreira A, Araújo M, Regina C, et al. Effectiveness of the diaphragm, used continuously, without spermicide. Contraception. 1993;48:29.

Fihn S, Latham R, Roberts P, et al. Association between diaphragm use and urinary tract infection. JAMA. 1985;254:240.

Mauck C, Lai J, Schwartz J, Weiner D. Diaphragms in clinical trials: is clinician fitting necessary? Contraception. 2004;69:263.

Allen RE. Diaphragm fitting. Am Fam Physician. 2004;69:97.

Mishell DRJr. Family planning. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:279.

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