Vaginal Pessary - Types, Uses, and Complications

What Is a Vaginal Pessary?

A vaginal pessary is a tiny, detachable object placed inside the vaginal canal to provide support to the pelvic organs or treat certain gynecological conditions. It is a non-surgical option for managing pelvic organ prolapse, urinary incontinence, or other related issues by providing structural support to the pelvic floor. These devices come in various shapes and sizes and are generally made of medical-grade silicone or plastic. The concept of pessaries dates back centuries, with historical records documenting their use in ancient civilizations.

What Are the Indications and Contraindications of Vaginal Pessary?

Indications for Vaginal Pessary Use:

Vaginal pessaries are prescribed for various pelvic floor conditions, including

• Pelvic Organ Prolapse - Pelvic organ prolapse happens when the tissues supporting the pelvic organs weaken or deteriorate, causing organs like the uterus, bladder, rectum, or small intestine to sag or bulge. This condition can lead to various types of prolapses, such as uterine prolapse (dropped uterus), cystocele (dropped bladder), rectocele (dropped rectum), and enterocele (small intestine bulging). In milder cases, organs may droop, while in severe instances, they can protrude outside the vagina. A vaginal pessary for prolapse serves as a non-surgical option to support these organs and relieve symptoms like pelvic pressure, discomfort, and urinary symptoms.

• Stress Urinary Incontinence - Vaginal pessary is also used in stress urinary incontinence to support the bladder, neck, and urethra, reducing episodes of urine leakage during activities like coughing, sneezing, or exercising.

Contraindications for Vaginal Pessary Use:

• Infections in the pelvis or vagina, like vaginitis or pelvic inflammatory disease, need to be cleared up before using a pessary device.

• Patients who are not likely to follow through with their appointments should not get a pessary device.

• If one is allergic to silicone or latex, often used to make pessaries, they should not use them.

What Are the Types of Pessaries?

There are different types of pessaries, and each type serves distinct purposes and comes with advantages and challenges.

Support Pessaries:

• Ring Pessary - A pessary ring is a circular device suitable for early-stage pelvic organ prolapse (Stages I and II), easy to insert and remove, and available with or without support.

• Gehrung Pessary - Beneficial for POP accompanied by cystocele or rectocele, manually moldable to fit individual patients' anatomy.

• Mar-land Pessary - Flexible silicone option for relief of minor prolapse or stress incontinence, reducing urethral hypermobility.

Space-Occupying Pessaries:

• Gellhorn Pessary - Ideal for advanced-stage prolapse or non-sexually active patients, difficult for self-removal, available in various sizes.

• Donut Pessary - This vaginal prolapse pessary reduces symptoms of cystocele, rectocele, or second or third-degree uterine prolapse and is challenging to insert and remove.

• Cube Pessary - Flexible silicone option for stage III and IV prolapse, equipped with a removal string, may trap vaginal secretions, leading to malodorous discharge.

How to Insert a Vaginal Pessary?

Before selecting and fitting a vaginal prolapse pessary, the doctor conducts a thorough examination. This includes the patient's medical history, symptoms, obstetric and surgical background, and treatment expectations.

Selection - The doctor selects the most suitable type of pessary device based on the severity of prolapse, the presence of the uterus, sexual activity, and any concurrent stress on urinary incontinence.

Insertion Process:

• Before inserting a pessary ring or a device, the patient is advised to empty their bladder.

• The doctor estimates the mid-vaginal width to determine the appropriate pessary size.

• The patient is fitted with the largest comfortable pessary size.

• An examination is conducted with the patient lying down and standing, assessing their response to the Valsalva maneuver.

• Adequate space for finger placement around the pessary is ensured.

• If vaginal atrophy is present, estrogen may be prescribed.

• The patient's comfort, mobility, and ability to void with the pessary in place are assessed.

• The patient is encouraged to attempt self-removal and reinsertion, particularly with pessary rings.

• Successful voiding with the pessary in place is confirmed.

• Follow-up appointments are scheduled for two to four weeks post-insertion.

How to Maintain and Care for a Vaginal Pessary?

Self-Removal and Cleaning:

Women who take it out and put back the pessary by themselves can take it out once a week or even every night to clean it. Sexually active people may choose to take out the pessary device before having sex. But they do not have to take it out if they use a support pessary.

Follow-up:

Patients may need to come back for check-ups every six months. The frequency of the follow-up visits depends on how well one can use the pessary, how bad their prolapse is, and the health of their vaginal lining. If patients have trouble removing the pessary, they should visit the doctor every two to three months.

During each visit, the pessary is removed and thoroughly cleaned. After checking the vagina for any sores, bruises, or tissue growth, the pessary is put back in. The pessary is checked for any changes in color, cracks, or damage. It will be replaced if needed to ensure it works well and feels comfortable.

What Are the Benefits of Vaginal Pessary?

• Pessaries offer a non-invasive alternative to surgery for pelvic floor disorders, providing relief without the risks associated with surgical procedures.

• Pessaries effectively reduce symptoms like pelvic pressure, urinary incontinence, and discomfort during intercourse.

• By addressing pelvic floor symptoms, pessaries improve the quality of life for patients, enabling them to participate in daily activities more comfortably and confidently.

• Pessary use does not compromise fertility, making it a suitable option for women planning future pregnancies.

• Pessaries can be easily removed if they cause discomfort or if the patient's symptoms improve, offering flexibility in treatment management.

What Are the Complications Associated With a Vaginal Pessary?

• The primary side effect of using a pessary is heightened vaginal discharge and odor due to its presence as a foreign body in the vagina. The doctor may prescribe certain gels or medications to help with the vaginal discharge.

• Postmenopausal women with thin vaginal mucosa are prone to vaginal ulceration with pessary use. Treatment with estrogen cream before or during pessary fitting can improve vaginal mucosal resistance to erosion.

• Neglected pessaries can become embedded in the vaginal mucosa, making removal challenging. Estrogen cream may facilitate easier pessary removal by reducing inflammation and promoting epithelial maturation.

• In rare cases, surgery may be needed for pessary removal, although the development of a fistula is highly uncommon, even with embedded pessaries.

• An improperly fitted pessary ring may allow the cervix and lower uterus to herniate through its open center, leading to incarceration. If left unrecognized, this could result in strangulation and necrosis of the cervix and uterus.

Conclusion

Vaginal pessaries are a good treatment for pelvic organ prolapse, stress urinary incontinence, and other pelvic floor problems. By knowing about the different types of pessaries, when to use them, and considerations for use, patients and doctors can work together to ensure treatment works well and improves life.