Pessaries have been used for thousands of years in various forms to treat pelvic organ prolapse (POP). There is evidence that points to vaginal pessary use as early as 1550 BC with linen or wool soaked in various solutions.1 Over time, cork and brass were used to construct more modern-day pessaries, and as technology advanced, these materials were replaced by rubber.2 Today, pessaries often are made of medical-grade non-reactive silicone, rubber, latex, or a combination thereof, and are shaped in various configurations and sizes to suit individual anatomy. They can be a permanent solution for women who do not desire surgery or who are not surgical candidates for other medical reasons. They can also be used as a temporizing step for women who wish to complete childbearing or to delay surgical treatment.
Indications and contraindications
A pessary fitting can be attempted for the majority of women with POP, stress urinary incontinence (SUI), or both. While there are few true contraindications, relative contraindications do exist. For example, a pessary should not be placed in a patient with evidence of active pelvic or vaginal infection, severe ulceration, or allergies to silicone, latex, or rubber. Caution is also advised to avoid placing pessaries in patients who are noncompliant or unlikely to follow up, as this may lead to long-term retained pessary complications such as infection, severe ulceration, or even fistula.3
It is helpful to have a fitting kit (separate from pessaries dispensed to patients), which consists of a variety of pessaries, each with a range of sizes. These fitting pessaries are made of silicone and can be sterilized with an autoclave between fittings for different patients. There are two main types of pessaries: support and space-filling. Support pessaries use leverage against firm or bony structures. They include rings, rings with support, dishes, and Shaatz pessaries. Ring and dish pessaries are commonly available with incontinence knobs. In our practice, support pessaries typically are used more commonly for patients with stages 2 and 3 prolapse. In our experience, they are more comfortable and easier to place and remove than other types of pessaries (Figure 1).
Space-filling pessaries occupy the vaginal vault and include Gellhorn, cube, and donut type devices (Figure 2). In our practice, typically these pessaries are used more commonly for patients with stages 3 and 4 prolapse, or when support-type pessaries fail. In our experience, space-filling pessaries are more challenging and uncomfortable for patients to place and remove.
To fit a pessary, the provider inserts a finger into the vaginal posterior fornix posterior to the cervix, and the distance between the posterior fornix and the pubic notch is measured using the finger length. With that rough guide, the diameter of the pessary should match, but generally, not exceed the vaginal measurement. The leading, apical edge of the pessary is then placed (bending along the flexible axis to accommodate the vaginal introitus if a ring pessary, for example) posterior to the cervix and the following (last to be inserted) edge is placed behind the pubic notch. The largest size that fits comfortably should be used. Pressure points are identified digitally after the pessary is in place. As a rule of thumb, the provider’s finger should be able to be placed between the pessary and the vagina circumferentially around the pessary. If a pressure point is identified, a smaller size or different type of pessary should be used.4
To further assess if the pessary is the correct size and shape, the patient is instructed to Valsalva with it in place, then ambulate, jump, and sit to simulate normal activities. In addition, she should be able to void spontaneously with the pessary in place, or else be able to remove the pessary herself to void. In our practice, the provider would then examine the patient again to ensure that the pessary has not slid out of place or shifted. If the fitting pessary is comfortable, a personal pessary can then be dispensed to the patient new from the package or ordered from the manufacturer.
Dr. Rockefeller reports no conflicts. Dr. Ninivaggio receives research support from Cook MyoSite®.
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