This chapter should be cited as follows:
Shahid U, Rane A, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.418553

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 4

Benign gynecology

Volume Editor: Professor Shilpa Nambiar, Prince Court Medical Centre, Kuala Lumpur, Malaysia

Chapter

Contemporary Use of the Pessary

First published: June 2023

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INTRODUCTION

A pessary is a removable device usually made of silicone that is placed in the vagina. Pessaries function to provide a conservative approach to managing pelvic organ prolapse (POP) or stress urinary incontinence (SUI). The first documented use of vaginal pessaries dates back to over 2500 years ago.¹ In the modern world, an aging population and increasing medical co-morbidities (whereby patients may not be suitable for surgical management) have made the utilization of pessaries vital in gynecological practice. Overall, a woman has roughly a 40% lifetime risk of pelvic organ prolapse.² Success rates with pessaries adequately managing POP and/or SUI range from 40–70%.³ One study found a 53% continuation of pessary use after 3 years of follow up.³ Thus, the pessary remains a useful and effective tool in conservatively improving a woman’s functionality and quality of life.⁴

INDICATIONS, CONTRAINDICATIONS, AND RISKS

The indications for the use of vaginal pessaries are POP and SUI. Although, the clinical assessment of POP and its standardized documentation is beyond the scope of this chapter, it remains pertinent prior to management. A robust understanding of all management options and thorough patient counseling are essential. A survey of American urogynaecologists found that 77% of them employed pessaries as first-line management for POP.³ The benefits of a conservative management approach with pessary use are the avoidance of surgical/anesthetic risks and the preservation of fertility in younger patients (where a hysterectomy may be required as part of surgically managing their symptoms). As stated earlier, overall pessaries have a high success rate. However, there are independent factors associated with a higher failure rate, these can be found in Table 1.^1,5,6

Vaginal pessaries have very few contradictions. Namely, patient non-compliance, silicone allergy, active pelvic infection, and vaginal ulceration. Like with any procedure the use of vaginal pessaries is associated with risks and disadvantages. These include failure to rectify patient symptoms, vaginal bleeding/ulceration and pain. If a pessary is retained (usually in the context of elderly patients with significant vaginal atrophy and poor compliance) it may need to be removed in theater under a general anesthetic. In addition, retained pessaries can in some severe cases go on to cause tissue necrosis and fistula formation. Finally, pessaries need to be removed for sexual intercourse. Often, sexually active patients find this process cumbersome and it may be a cause of the patient discontinuing the use of her pessary.

TYPES OF PESSARIES

An ideal pessary is one the patient can easily remove and replace, is cheap, rectifies patient symptoms and causes no discomfort. Given the expansive list of patient anatomical variables, symptomatology, and risk profiles; the choice of pessary should be individualized for the patient at hand. Pessaries can be broadly divided into two main groups. Namely, space occupying pessaries and support pessaries.

Space occupying pessaries¹

There are three main types of space occupying pessaries. The first of those is a Gelhorn pessary. This pessary has a concave surface attached to a stem (or horn). It functions through suction against the presenting edge of the prolapse. Because of this, insertion and removal can be difficult. Secondly a donut pessary is also commonly used. Finally, a cube pessary is usually the final option for advanced POP where surgery is not a suitable option. This flexible cube functions to form a suction area of contact across all its surfaces. Therefore, it may be chosen over a Gelhorn or donut pessary if the patient has a deficient perineum.⁷ Disadvantages include difficult removal (it does have a string) and the trapping of vaginal secretions can lead to significant foul-smelling discharge.

Support pessaries¹

The most common support pessary is a ring pessary. Due to its flexibility, a ring pessary provides patients with ease of removal and insertion. In addition, it can be used for all stages of POP and SUI. Two other types of pessaries are occasionally used for the management of SUI. Namely the Gehrung and Mar-land pessaries. These pessaries have a bridge anteriorly and aim to reduce urethral hypermobility and elevate the bladder neck as a means of managing SUI.

PESSARY INSERTION⁸

As stated earlier, a thorough history and examination is required prior to insertion of any pessary. It is important to ensure that the patient has no contraindications, has been adequately counseled on all options of management and understands the risks of a vaginal pessary. Of note, depending on your local healthcare system the costs of a pessary should be explained to the patient. Not only are pessaries prescribed in conjunction with estrogen creams but they may need to be replaced, incurring ongoing costs.

Once adequately consented, the patient is asked to empty her bladder. The pessary that works best is usually the largest pessary that is comfortable for the patient. In order to assess this, the patient should be examined both supine and standing, with and without Valsalva.¹ Different pessaries are inserted in varying ways depending on their design. After lubrication, the stalk of a Gelhorn pessary is grasped with the thumb and index finger of the practitioner’s dominant hand. The Gelhorn pessary is orientated transversely at the level of the introitus and entered at a slightly oblique angle. After going beyond the vaginal introitus, the concave surface is gently pushed inward allowing it to perform its space occupying function. The pessary is then guided behind the pubic symphysis where it forms a suction.

Similarly, a ring pessary is lubricated and folded in half with the non-dominant hand (the pessary may have indentations marking where to fold). It is helpful to lubricate only the inserting side of the pessary as a completely lubricated ring pessary is quite slippery. While keeping the pessary folded with the non-dominant hand it is inserted parallel to the floor and rotated along the posterior vaginal wall. As the pessary is advanced beyond the introitus, it can be released and using the index finger it is then pushed to behind the pubic symphysis. In cases where the patient has a uterus, the cervix should be gently guided posteriorly ensuring that the cervix is in the middle of the ring.

Finally, the insertion of a cube pessary can be quite a logistically difficult process. Due to its shape, often two hands are required to squeeze and compress the cube. Once this is achieved the non-dominant hand is used to part the labia and the pessary is inserted into the vagina posteriorly as far as possible. Once released the index finger of the dominant hand may be required to further advance the pessary. The aim being to site the pessary at the level of the cervix of the apex of the vaginal vault.

When any pessary is inserted, a finger should be able to be passed without difficulty between the pessary and vaginal wall. Often, pessaries are a trial and error process and a different size may need to be inserted. If the pessary is too small, it will likely not serve its desired function and may fall out. On the other hand, if it is too large, it probably won’t be tolerated by the patient and may cause ulcers. In order to monitor this, following insertion ask the patient to perform a Valsalva maneuver. If deemed adequate the patient can get dressed. They should remain in the clinic, walk around, sit and urinate with the pessary in-situ to ensure they are comfortable prior to leaving. Patients can even be asked to remove and re-insert the pessary to confirm that they are comfortable in managing it.

After all pessary insertions the patient should be counseled on routine pessary cares. If a ring pessary is used, ideally it should be removed once weekly, washed and re-inserted in order to help prevent malodorous discharge. Similarly, it should be removed prior to intercourse. Patients should be shown how to remove the pessary and re-insert it. This is usually easiest whilst sitting on the toilet or with one foot stepping up on to a closed toilet lid. In other cases, patients find it easier to remove the pessary in bed with their head propped up with some pillows. If the patient is pre-menopausal some women find it more comfortable to remove the ring pessary during menses but this is not definitively required as long as the pessary can be removed, washed, and replaced by the patient. Menstrual suppression is another option in this case. Given the majority of POP patients are post-menopausal and may have vaginal atrophy, estrogen cream is commonly prescribed to be used twice weekly while the pessary is in situ.

FOLLOW UP

After the initial pessary fitting, patients are usually reviewed in 2 weeks' time. This is to ensure that the pessary is comfortable, has not fallen out and alleviated the patient's symptoms without causing any significant complications. After history taking, the pessary should be removed and a speculum examination performed to visualize the presence of any abrasions, ulcers, or malodorous discharge. If ulcers are noted, the pessary should not be re-sited and the patient instead managed with a 6-week trial of daily estrogen topical cream to aid healing of the vaginal mucosa. Malodorous discharge should be swabbed and treated if indicated (based on the culture results).

The technique used to remove a pessary is dependent on the type of pessary at hand. For ring pessaries, the pessary is hooked with the index finger and rotated to the midline along the axis of the vaginal canal. A Valsalva maneuver may help descend the pessary down the vaginal canal. The thumb and index finger are then used to fold the pessary and retrieve it. When removing a Gelhorn pessary, the stalk is grasped with the dominant hand and the pessary pulled down towards the vaginal introitus. The index finger of the non-dominant hand is then used to sweep behind the concave surface of the pessary. This releases any suction between the pessary and the vaginal wall prior to retrieval. Similar to its insertion, a cube pessary is also quite difficult to remove. The index finger is used to sweep between the cube pessary and the vaginal walls, thereby releasing the suction. Then while the fingers of the non-dominant hand depress the posterior vaginal wall, the dominant hand compresses the cube and retrieves the pessary. If the cube pessary cannot be compressed manually then a sponge forceps can be used for better traction once the suction has been released.⁸

There is no established protocol for patient follow up with pessaries. A commonly used approach is to see patients every 3 months for the first year and then to space appointments out to every 6 months.⁹

PRACTICE RECOMMENDATIONS

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