THE VAGINAL PESSARY

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THE VAGINAL PESSARY

• Bernie Brenner
• Gynaecologist
• Clinical Director Pelvic Floor Clinic
• Milford
• Auckland gynaecology_at_xtra.co.nz

Presentation modified from H Carcio Bioteque
The Vaginal Pessary
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THE VAGINAL PESSARY
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PELVIC ORGAN PROLAPSE QUANTIFICATION EXAM

• Measures the descent of the anterior, apical
  and/or posterior portions of the vagina
• Records vaginal length and width of the
  introitus.
• Uses centimeters with reference to the hymen when
  performing the Valsalva
• Negative numbers Distance above the hymen
• Positive numbers Distance of prolpase protruding
  beyond hymen
• May simply grade the prolapse from 1 to 3

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PURPOSES

• Supports the vaginal musculature/bladder base in
  physiologic alignment
• Can provide a solution to incontinence in women
  unable or unwilling to have surgical correction
• May unmask Stress Urinary Incontinence
• Provides a diagnostic means of predicting which
  patients would be helped with surgical correction

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ADVANTAGES

• May reduce the symptoms of incontinence
• Supports and corrects retro-displacement of the
  uterus in early pregnancy
• Relieves the discomfort of a pelvic organ
  prolapse
• Repositions pelvic structures during pelvic floor
  rehabilitation (decreases post op adhesions)

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PESSARY CAN SUPPORT A POP
A. Cystocele B. Rectocele C.
Enterocele
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CAUSES OF PROLAPSE

• Constipation
• Exercise
• Pregnancy and Childbirth
• Abnormal collagen/connective tissue
• Hormonal factors
• Previous pelvic surgery

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STRESS INCONTINECE Causes

• Weakened pelvic floor musculature
• Intrinsic sphincter deficiency
• Increased intraabdominal pressure
• Reduced strength of urethral sphincter

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HISTORICAL PERSPECTIVES

• Appears in both Latin and Greek literature
• Many different types of materials and shapes
• Over 2000 used throughout history
• Fell into disfavour 10-20 years ago
• Today offers a viable alternative to surgery

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PESSARY FEATURES

• Silicone
• Non-toxic, medical-grade silicone
• Biologically inert - does not absorb vaginal odor
• Pliable
• Can be autoclaved or soaked in Cidex
• A few pessaries are made of latex rubber
• Must assess and document any latex allergy
• Available in a variety of sizes and shapes
• The outside diameter is measured in inches with a
  range of one to four inches

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SEXUAL ACTIVITY

• Intercourse is possible with pessaries that are
  not vaginally occlusive
• Must have the dexterity and know-how to insert
  and remove as necessary
• Note Always ask about sexual activity never
  assume

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CONTRAINDICATIONS

• Severe untreated vaginal atrophism
• Vaginal bleeding of unknown origin
• Pelvic inflammatory disease
• Abnormal cervical smear
• Dementia without possibility of dependable
  follow-up care
• Expected non-compliance with follow-up

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THE EVALUATION

• Pelvic Examination
• Determine the extent of the pelvic support
  problem POP-Q
• Assess degree of incontinence
• Rule out any pathology
• Cervical smear
• Assess oestrogen status

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• Some possible predictors of pessary failure
• Short vaginal length
• Wide introitus
• Posterior-wall defects
• Patients who desire surgery

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FITTING A PESSARY

• The pubic bone is an important landmark.
• The pessary should fit snugly behind it.
• There is less chance of expulsion if thus
  anchored
• Uterine Prolapse (if present)
• Insert two fingers in the vagina to push any
  uterine prolapse back into place
• Place opposite hand on abdomen and push on the
  fundus (if present) to hold in place
• Reduce any cystocoele or rectocoele prior to
  fitting
• Put in largest size that will fit comfortably, or
  simply tuck a smaller pessary well behind the
  pubic bone

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MEASURING THE WIDTH

• Insert first two fingers of dominant hand deep to
  the posterior fornix
• Approximate size by using the fingers to
  determine the width
• Spread fingers wide to measure
• Remove fingers and compare to pessary sample or
  fitting kit

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MEASURING THE LENGTH

• Reinsert fingers deep into the posterior fornix
• Make note of where the hand comes into contact
  with the pubic bone
• Compare to pessary.

Iden
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VAGINAL OESTROGEN

• The majority of older women with a pessary need
  vaginal oestrogen
• The Estring works nicely since it also needs to
  be changed every 3 months
• Oestrogen use keeps the vagina healthy
• Oestrogen thickens the layer of the vaginal
  mucosa allowing for more support of the pelvic
  organs.

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COMPLICATIONS

• Increase in vaginal discharge
• Odor
• Ulcerations
• Pelvic discomfort
• Incarceration
• Scar/granulation tissue may form around pessary
• Complications are rare in the properly fitted and
  well maintained pessary

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DONUT

• Description soft silicone, donut shaped.
• Indications
• Occludes upper vagina and supports a uterine
  prolapse
• Useful for cystocoele or rectocoele
• Good for prolapse of the vagina after a
  hysterectomy
• Adequate integrity of the introitus is necessary
  for the pessary to remain in place

• The Donut Hole

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CUBE

• Indications Third-degree prolapse, cystocele or
  rectocele, with or without good vaginal tone.
• Often this is the only satisfactory support for
  women with a complete prolapse, complicated by a
  cystourethrocoele.
• Excellent for vaginal wall prolapse in that it
  keeps the vaginal wall from collapsing from its
  six pressure points.
• Maybe used by an athlete and removed after
  exercise.
• Mucosa molds to the concavities creating a
  negative pressure

Drainage holes
Description Each side of the cube has concave
suction cups that adhere to the vaginal walls,
helping to restore anatomical support to the
pelvic organs.
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INCONTINENCE DISH

• Description Dish-shaped pessary with holes to
  allow for drainage. The flexible membrane of the
  dish supports and elevates a mild cystocele.
• Indications SUI in conjunction with a 1st or 2nd
  degree prolapse, or a mild cystocele.

Membrane support
The knob
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SHAATZ

• Description
• A circular pessary with holes for drainage of
  secretions.
• Indications For the support of a first or mild
  second-degree prolapse.

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GEHRUNG

• Description
• U-shaped device that provides support to the
  anterior vaginal wall. The arms or heels rest
  flat on the vaginal floor
• It avoids pressure on the rectum while supporting
  the anterior wall
• Arclike malleable-can be shaped to suit the
  shape of the vagina
• Shape can be expanded once inserted, a distinct
  advantage
• Creates a bladder bridge
• May be underutilized

Arch
Heel
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GELLHORN

• Description Most commonly used pessary for
  uterine prolapse, also helpful with SUI. Fits
  superiorly and anteriorly.
• Indications Provides support for third-degree
  uterine prolapse and procidentia.
• Provides less support for a rectocele since there
  is less support of the posterior segment.

Holes for drainage
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HODGE

• Description
• The anterior notch prevents urethral impingement
  and obstruction.
• Available with support for the bladder in
  patients with stress incontinence.
• If properly fitted sexual intercourse is possible
• Malleable

Notch
Support for cystocele
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RING - with and without support

• Description
• Round flexible ring.
• Helps support the urethra and bladder neck.
• Membrane provides additional support for a
  cystocele.
• Indications
• Useful for a first or mild second-degree uterine
  prolapse associated with a mild cystocele.

Support