Pessary Therapy

The Challenge

The challenge is to identify patients who may benefit from pessary therapy and to effectively select, fit, and monitor pessary use.

• Scope of the Problem: As the population ages, the prevalence of pelvic relaxation disorders will increase. Pessary therapy offers an attractive, effective, nonsurgical therapy for many of these patients. Patients with symptomatic pelvic relaxation, uterine retroversion, cervical incompetence, or urinary incontinence may benefit from this therapy. It is estimated that 10%–25% of women suffer from anterior vaginal wall support failure, and this increases to 30%–40% after menopause. Up to 11% of women will undergo surgery for pelvic organ prolapse by the age of 80 years.

• Objectives of Management: To provide symptomatic relief for patients with pelvic relaxation without causing iatrogenic harm.

Tactics

• Relevant Pathophysiology: Pessaries act either by using existing pelvic support mechanisms or by diffusing the forces acting on pelvic structures over a wide area so that support and reposition are achieved. Available in a variety of types and sizes, the most commonly used forms of pessaries for pelvic relaxation are the ring (or doughnut), ball, and cube. To varying degrees, the pessary occludes the vagina and holds the pelvic organs in a relatively normal position. The type of pessary chosen is based on the indications of the individual patient. Pessaries are available in both latex and polyurethane types. The latex type is often less expensive but tends to deteriorate over time; polyurethane pessaries are less likely to retain odor or cause irritation.

• Strategies: Pessaries are fitted and placed in the vagina similar to contraceptive diaphragm (see Chapter 276, Diaphragm Fitting). The pessary is lubricated with a water-soluble lubricant, and most are folded or compressed, and inserted into the vagina. 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 entirely contained 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 should allow the easy passage of an examining finger between the pessary and vaginal wall in all areas. Examination at 5–7 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 24–48 hours) may be advisable for patients who are debilitated, have significant atrophic change, or require additional assistance.

Patient Education: Reassurance.

• American College of Obstetricians and Gynecologists Patient Education Pamphlets:

  • Pelvic Support Problems, 2020

  • Surgery for Stress Urinary Incontinence, 2021

  • Surgery for Pelvic Organ Prolapse, 2018

  • Urinary Incontinence, 2020