Transcript The New Age of Pessaries

THE VAGINAL PESSARY
Bernie Brenner
Gynaecologist
Clinical Director – Pelvic Floor Clinic
Milford
Auckland
[email protected]
Presentation modified from H Carcio “Bioteque – The Vaginal Pessary”
THE VAGINAL PESSARY
PELVIC ORGAN PROLAPSE
QUANTIFICATION EXAM
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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
PURPOSES
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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
ADVANTAGES
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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)
PESSARY CAN SUPPORT A POP
A. Cystocele
B. Rectocele
C. Enterocele
CAUSES OF PROLAPSE
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Constipation
Exercise
Pregnancy and Childbirth
Abnormal collagen/connective tissue
Hormonal factors
Previous pelvic surgery
STRESS INCONTINECE: Causes
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Weakened pelvic floor musculature
Intrinsic sphincter deficiency
Increased intraabdominal pressure
Reduced strength of urethral sphincter
HISTORICAL PERSPECTIVES
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Appears in both Latin
and Greek literature
Many different types
of materials and
shapes
Over 2000 used
throughout history
Fell into disfavour 1020 years ago
Today offers a viable
alternative to surgery
PESSARY FEATURES
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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
SEXUAL ACTIVITY
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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
CONTRAINDICATIONS
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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
THE EVALUATION
Pelvic Examination
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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
FITTING A PESSARY
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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
MEASURING THE WIDTH
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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 LENGTH
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Reinsert fingers
deep into the
posterior fornix
Make note of where
the hand comes
into contact with
the pubic bone
Compare to
pessary.
I
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VAGINAL OESTROGEN
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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.
COMPLICATIONS
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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
DONUT
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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
CUBE
Indications: Third-degree
prolapse, cystocele or
rectocele, with or without
good vaginal tone.
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Drainage holes
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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.
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
INCONTINENCE DISH
Membrane support
The knob
Description: Dishshaped 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.
SHAATZ
Description:
A circular pessary with
holes for drainage of
secretions.
Indications: For the
support of a first or
mild second-degree
prolapse.
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”
Heel
Arch
May be underutilized
GELLHORN
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Holes for drainage
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.
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
Notch
Support for
cystocele
Malleable
RING - with and without support
Description:
Round flexible ring.
Helps support the urethra and
bladder neck.
Membrane provides additional
support for a cystocele.
Support
Indications:
Useful for a first or mild
second-degree uterine
prolapse associated with a
mild cystocele.