Pessary Fitting

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Chapter 249 Pessary Fitting

DESCRIPTION

Pessaries are devices fitted and worn in the vagina to provide support to the pelvic organs. Pessaries are available in various sizes and shapes and are categorized as supportive (e.g., ring, Gellhorn, Gehrung) or space occupying (e.g., doughnut, cube).

INDICATIONS

Pelvic organ prolapse, urinary incontinence, cervical incompetence (lever or ring type), drug delivery. Pessaries are often used as either an alternative to surgery or as a presurgical trial.

CONTRAINDICATIONS

Undiagnosed vaginal bleeding, significant vaginal atrophy. Patients who are unable or unwilling to manage the periodic insertion and removal of the device are poor candidates.

REQUIRED EQUIPMENT

• Vaginal speculum

• Water-soluble lubricant

• Nonsterile examination gloves

• Examples of appropriate pessaries in a variety of sizes (generally the “average size” and at least one size larger and smaller)

TECHNIQUE

Pessaries will not be well tolerated or provide optimal support in the patient who is poorly estrogenized. Therefore, a minimum of 30 days of topical estrogen therapy should be instituted prior to a trial of pessary therapy in these patients.

The type of pessary chosen for a given patient is determined by the anatomic defect and the symptoms the patient is experiencing. The most commonly used forms of pessary for pelvic relaxation are the ring (or doughnut), the ball, and the cube. The indications for various types of commonly used pessaries are shown in the box. The type of pessary that can be fitted is related to the severity of prolapse. Ring pessaries are frequently a first choice, followed by Gellhorn or other pessaries if the rings do not stay in place.

Pessaries are fitted and placed in the vagina in much the same way as a contraceptive diaphragm: the depth of the vagina and the integrity of the supporting structures of the vagina are gauged as a part of the pelvic examination. The size of pessary to be fitted is based on the findings of the pelvic examination. The pessary is lubricated with a water-soluble lubricant, folded or compressed, and inserted into the vagina. (Some pessaries require specific maneuvers for their insertion; always consult the manufacturer’s instructions.)

The pessary is next adjusted so that it is in the proper position based on the type: ring and lever pessaries should sit behind the cervix (when present) and rest in the retropubic notch, the Gellhorn pessary should be contained entirely within the vagina with the plate resting above the levator plane, the Gehrung pessary must bridge the cervix with the limbs resting on the levator muscles on each side, and the ball or cube pessaries should occupy and occlude the upper vagina. All pessaries must allow the easy passage of an examining finger between the pessary and the vaginal wall in all areas. The only situation in which a pessary is allowed to exert any significant pressure beneath the urethra is in the case of those devices designed for the control of urinary incontinence.

After the pessary has been placed and the fit checked, the patient should be asked to strain. The pessary may descend slightly, but its integrity should be maintained and it should return to its normal position when the patient relaxes. The patient should be allowed to stand and walk a bit with the pessary in place to ensure comfort and retention. The pessary may then be removed (if a “fitting” pessary has been used) or may be left in place (if this is to be the patient’s final device). If necessary, the process should be repeated until an appropriate, comfortable fit is obtained. The fit should also be confirmed by a follow-up visit in 5 to 7 days. In most patients (50% to 73%), an appropriately sized pessary can be fitted successfully in one or two office visits.

The patient should be instructed on both the proper insertion and removal techniques. Ring pessaries should be removed by hooking a finger into the pessary’s opening, gently compressing the device, and then withdrawing the pessary with gentle traction. Cube pessaries must also be compressed, but the suction created between the faces of the cube and the vaginal wall must be broken by gently separating the device from the vaginal sidewall. (The locator string often attached to these pessaries should not be used for traction.) Inflatable pessaries should be deflated prior to removal. Gellhorn and Gehrung pessaries are removed by a reversal of their insertion procedures.

COMPLICATIONS

Vaginal erosion, bleeding, infection, vaginal discharge, pain, expulsion, urinary retention, fistula formation (rare with proper fit, care, and estrogen therapy).

FOLLOW-UP

Examination 5 to 7 days after initial fitting is required to confirm proper placement, hygiene, and the absence of pressure-related problems (vaginal trauma or necrosis). Earlier evaluation (in 24 to 48 hours) may be advisable for patients who are debilitated or who require additional assistance. Follow-up should then occur in approximately 1 month and then quarterly for the duration of use. (Some authors recommend maintaining a monthly schedule indefinitely, especially in those with limited abilities to maintain the device themselves.)

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