THE VAGINAL PESSARY

1. THE VAGINAL PESSARY Bernie Brenner Gynaecologist Clinical Director – Pelvic Floor Clinic Milford Auckland gynaecology@xtra.co.nz Presentation modified from H Carcio “Bioteque – The Vaginal Pessary”

2. THE VAGINAL PESSARY

3. 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

4. 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

5. 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)

6. PESSARY CAN SUPPORT A POP A. Cystocele B. Rectocele C. Enterocele

7. CAUSES OF PROLAPSE • Constipation • Exercise • Pregnancy and Childbirth • Abnormal collagen/connective tissue • Hormonal factors • Previous pelvic surgery

8. STRESS INCONTINECE: Causes • Weakened pelvic floor musculature • Intrinsic sphincter deficiency • Increased intraabdominal pressure • Reduced strength of urethral sphincter

9. 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 HISTORICAL PERSPECTIVES

10. 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

11. 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 SEXUAL ACTIVITY

12. 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

13. 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

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

15. 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

16. 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 MEASURING THE WIDTH

17. Reinsert fingers deep into the posterior fornix Make note of where the hand comes into contact with the pubic bone Compare to pessary. MEASURING THE LENGTH Iden

18. 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.

19. 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

20. The Donut Hole 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 DONUT

21. 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.

22. 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

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

24. 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

25. 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

26. 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

27. 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