Pelvic organ prolapse and urinary incontinence are common problems affecting women. The demand for health services for these pelvic floor disorders is projected to increase from 28.1 million in 2010 to 43.8 million in 2050.1 As advanced practice providers, it is important to understand nonsurgical treatments for these disorders. Specifically, pessaries can be offered to avoid the cost and recovery of surgical interventions.2 A greater understanding of pessaries and the positive effect this treatment may have on patients’ quality of life will help clinicians comfortably recommend pessaries as first-line therapy for pelvic floor disorders.
Historically, patients have treated pelvic floor disorders by placing objects in the vagina to mechanically obstruct descent. In 350 AD, half a vinegar-soaked pomegranate was recommended.3 Modern pessaries are made of hypoallergenic materials, typically silicone, and come in a variety of shapes and sizes to restore normal anatomy, relieve pressure, and correct stress urinary incontinence. Pessaries are divided into 2 categories:
- Support pessaries (eg, ring and gehrung)
- Space-filling pessaries (eg, Gellhorn, cube, and donut)
The ring pessary is most commonly used and can be kept in the vagina for long periods of time, stays in place during sexual intercourse, and is associated with the fewest complications. Most patients can remove/reinsert ring pessaries at home.
Continue Reading
Vaginal pessary use is relatively straightforward. At a baseline visit, a vaginal examination is performed to document pelvic organ prolapse quantification score (POP-Q). This examination not only determines stage of prolapse but also excludes the presence of vaginal epithelial abnormalities. In my practice, a pessary is then placed with instructions to return to the clinic for an interval check in 2 to 4 weeks. Most failures occur within 4 weeks of fittings.4 Early complications that prompt re-evaluation include expulsion, discomfort, vaginal discharge/odor, de novo urinary incontinence, and vaginal bleeding/ulcers. Rarer complications include fistula formation or pessary impaction.2 If successful in this initial period, studies have shown that many women will continue to use a pessary for several years.
It is important to advise patients that pessary use can change the vaginal environment. Vaginal discharge and odor can be more prominent.5 The use of locally administered vaginal estrogen is safe and is recommended to reduce symptoms of vaginal atrophy and ulcerations.2,5 Device removal for short periods is also suggested in some instances.5
Clinical guidelines recommend offering a vaginal pessary to all women with symptomatic pelvic organ prolapse as an alternative to surgery.2 Many women would benefit from conservative treatment with a pessary before seeking surgery for pelvic floor disorders as it is a simple, inexpensive, and effective method of treatment. It is our job as advanced providers to educate ourselves so that we can help women optimize conservative treatments for pelvic floor dysfunction.
Anna Leah Posner, CRNP, MSN, received her Master of Science in Nursing degree at the University of Pennsylvania and has over 10 years of clinical practice. Presently, she is practicing urogynecology at Penn State Hershey Milton S. Medical Center, in Hershey, Penn.
| These letters are from practitioners around the country who want to share their clinical problems, successes, observations, and pearls with their colleagues. We invite you to participate. Submit your Clinical Pearl here. |
References
1. Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor disorders in U.S. women: 2010 to 2050. Obstet Gynecol. 2009;114(6):1278-1283. doi:10.1097/AOG.0b013e3181c2ce96
2. Practice bulletin no. 176: pelvic organ prolapse. Obstet Gynecol. 2017;129(4):e56-e72. doi:10.1097/AOG.0000000000002016
3. Powers SA, Burleson LK, Hannan JL. Managing female pelvic floor disorders: a medical device review and appraisal. Interface Focus. 2019;9(4):20190014. doi:10.1098/rsfs.2019.0014
4. Lone F, Thakar R, Sultan AH, Karamalis G. A 5-year prospective study of vaginal pessary use for pelvic organ prolapse. Int J Gynaecol Obstet. 2011;114(1):56-9. doi:10.1016/j.ijgo.2011.02.006
5. Harvey MA, Lemieux MC, Robert M, Schulz JA. Guideline no. 411: vaginal pessary use. J Obstet Gynaecol Can. 2021;43(2):255-266.e1. doi:10.1016/j.jogc.2020.11.013
