Pessaries

Sandra M. Sulik, MD, MS, FAAFP, Amber Shaff, MD and Alessandra D’Avenzo, MD
Email

Send Email

Recipient(s) will receive an email with a link to 'Pessaries' and will have access to the topic for 7 days.

Subject: Pessaries

(Optional message may have a maximum of 1000 characters.)

×


Introduction

Pessaries are effective tools in the managements of the pelvic floor prolapse (PFP) and stress urinary incontinence. PFP is more common with increasing age and is both uncomfortable and distressing for many women. It is estimated that PFP affects approximately 50% of women older than age 50, with a lifetime prevalence of 30% to 50%. Women with clinically significant PFP may complain of a sensation of a vaginal bulge that can be accompanied by symptoms of urinary, bowel, or sexual dysfunction. Nevertheless, most of these women do not seek medical advice because of the fear of cancer or simply because of embarrassment. The etiology of the PFP is complex and multifactorial. Risk factors include multiparity, childbirth, congenital or acquired connective tissue abnormalities, denervation or weakness of the pelvic floor, aging, menopause, and factors associated with chronically raised intra-abdominal pressure (i.e. constipation). 
Treatment of PFP depends on the severity of the prolapse, its symptoms, and the woman’s overall health. Options include conservative, mechanical, and surgical treatments. Generally, conservative or mechanical management is reserved for those women who cannot or are unwilling to have surgery or in women who have not completed child-bearing. An extensive range of mechanical devices have been described for prolapse. These consist mainly of silicone Pessaries that are inserted and left in the vagina to prevent PFP. 
Uterine prolapse is classified as first degree when the cervix is visible when pushing down on the perineum, as second degree when the cervix is visible outside the vaginal introitus while the uterine fundus remains inside, and as third degree (procidentia) when the entire uterus is outside of the vaginal introitus. Uterine prolapse can lead to incontinence, vaginitis, cystitis, and possible uterine malignancy. Vaginal prolapse includes rectocele, where the rectum herniates into the posterior vaginal wall; cystocele, where the bladder herniates into the anterior vaginal wall; and vaginal vault prolapse, where any vaginal portion may prolapse. 
Women who are considered poor surgical candidates because of severe co-morbidities, such as cardiovascular disease, osteoporosis with multiple compression fractures, and steroid-dependent chronic obstructive pulmonary disease are excellent candidates for pessary placement. In different surveys, 87% to 98% of practitioners reported the use pessaries in their practice and 77% as first line of treatment of PFP. 
Most symptoms related to PFP, such as bulge and pressure, improve in 71% to 90% of patients with pessary use. Urgency and voiding difficulties have also been shown to improve in 40% of women. In 20% of patients, however, an occult incontinence can occur when the pessary is used. The pessary can also be used preoperatively to predict how a woman will respond to prolapse surgery. There is a risk that 4% to 6% of women will develop de novo urge incontinence or voiding difficulty when the pessary is placed. Approximately 50% of patients continued to use the pessary at 24 months. Previous hysterectomy and increasing parity were risk factors associated with pessary failure, whereas no difference has been found in age, ethnicity, or degree of PFP. 
Patient evaluation starts with an accurate history of her daily activities, level of functioning, symptoms, and the impact of PFP or urinary incontinence on patient quality of life. Another important part of the history is the assessment of the patient’s capacity to understand the pessary function, maintenance, and the importance of follow-up. It is important to assess degree of discomfort with sexual activity as well. Recent data demonstrate a substantial number of pessary patients have increased frequency of intercourse and improvement in the quality of sexual life. 
Important in the physical exam is the evaluation of the pelvic floor strength, severity of prolapse, specific pelvic floor defects, and health of the vaginal epithelium. The exam should be performed while the patient is in a semirecumbent lithotomy position. Careful examination of the genitalia identifying excoriation, erythema of the vulva, and vaginal introitus is important. The genital hiatus, defined as the middle of the external urethral meatus to the posterior midline hymenal ring, is measured, and a size >5 cm decreases the likelihood of success for pessary fitting. A short vagina (<6 cm) also decreases the success of pessary fitting. Pelvic floor strength is important in retaining the pessary and is evaluated by placing two fingers in the patient’s vagina while she is performing a Kegel maneuver. The use of vaginal estrogen cream is generally recommended if the epithelium is atrophic. 
More than 200 types of pessaries have been developed in the past, of which approximately 20 types are still in use today, although not all pessary types are available in all countries. Pessaries are divided into two general categories: support pessaries and space-filling pessaries. Support pessaries, like the ring pessary, use a spring mechanism that rests in the posterior fornix and against the posterior aspect of the pubic symphysis. The space-filling pessaries, like the cube pessary or the donut, function either by creating suction between the device and the vaginal walls or just filling a larger space than the genital hiatus. The Gellhorn works by combining both of the two mechanisms. 
Pessaries are currently made of silicone or, rarely, of latex. Rigid pessaries are no longer recommended, and if found during the pelvic exam, should be promptly removed. Generally speaking, a clinician should choose a pessary based on the type of pelvic organ prolapse (POP) found on the pelvic exam. Another approach is to choose the same pessary for all defects. 
There are some basic rules that can aid in the choice of a pessary. Anterior vaginal wall defects, like a cystocele, as well as stage II apical compartment defects are best controlled with ring pessaries. Lever pessaries also seem to work well in controlling cystoceles. Gellhorns are best used for the management of stage III or IV uterine or vaginal vault prolapse or rectocele. The donut pessary can be useful in managing the uterine procidentia or vaginal vault eversion. Posterior vaginal wall defects, such as enterocele or rectocele, are better managed by using space occupying pessaries, such as the donut or the Gellhorn. A wide genital hiatus is generally caused by a damaged levator muscles and if the patient is unable to contract the pelvic floor, a space-filling device is recommended. 

Equipment

  • Pessary kit or various sizes of different pessaries

  • Water-based lubricant

  • Fluid absorbent pads

  • Vaginal speculum

  • Nonsterile gloves

Indications

  • Stress urinary incontinence

  • Vaginal vault prolapse

  • Cystocele

  • Rectocele

  • Enterocele

  • Uterine prolapse

  • Preoperative preparation/evaluation

Contraindications

  • Active vaginitis, atrophic changes, and vaginal ulcerations should be treated and fully resolved before the use of the pessary.

  • Noncompliance

  • Silicone or latex allergy (if using an Inflatoball)

The Procedure

Step 1

If fitting the patient for pelvic organ prolapse, fit with an empty bladder. If fitting for stress incontinence, fit with a full bladder. Place patient in the dorsal lithotomy position and perform bimanual exam. Examine the vulva and vaginal epithelium. Assess vaginal floor length in the same fashion as measuring for a diaphragm. During the bimanual examination, place the middle finger into the posterior cul-de-sac. Use the thumb to mark the point where the symphysis pubis abuts the index finger. Assess pelvic floor strength by having the patient tighten her muscles around your fingers. Identify the type of prolapse, cystocele, or rectocele. 
  • PEARL: If severely atrophic epithelium noted, the use of vaginal estrogen cream will help prevent erosions and aid in comfort.

Step 2

Determine pessary type and size (see below). Lubricate the chosen pessary with a water-based lubricant and gently insert it into vagina. Check the fit of the pessary. The examiner should be able to pass a finger between the pessary and the vaginal walls, without discomfort to the patient. 

Step 3

Have patient sit, stand, Valsalva, and cough to determine if pessary will dislodge or if prolapse or urine leakage occurs. If the pessary dislodges or there is leakage of urine, try the next larger size. If the pessary is uncomfortable, try the next smaller size. If there is correct placement, the patient should be unable to feel the pessary in place. Once the correct pessary is determined, have patient void. 
  • PITFALL: If the patient is unable to void, the pessary is too large and the next smaller size should be tried.

Step 4

The patient should be instructed in how to insert and remove the pessary. Have the patient insert and remove the pessary before she leaves the office. 
  • PITFALL: Some patients are unable to remove the pessary on their own. In this case, the patient should return to the office every 6 to 8 weeks for removal, cleaning of the pessary, and inspection of the vaginal walls.

  • PEARL: If the patient is unable to remove the pessary daily, she should insert one applicator of Trimo-San into the vagina three times per week to help decrease the amount and odor of the vaginal discharge.

Choosing and Using a Pessary

Ring Pessary
Step 5
There are two types of ring pessaries, without and with support. The ring is a support-type device and comes in sizes from 0 to 9. Special orders can be placed for sizes 10 to 15. Sizes 3 to 5 are the most commonly used. The ring pessary is excellent for mild uterine and vaginal prolapse, cystocele, and stress incontinence. It is acceptable for enterocele. 
Step 6
Ring pessaries are easy to insert, using the same folding technique as for fitting a diaphragm. Insert the pessary after applying a water-soluble lubricant on the rim of the device. Fold the device in half at the notch. 
Step 7
Spread the labia open and the insert the device in a downward fashion toward the posterior fornix. The pessary will spring open. Check placement by sweeping the finger around the rim of the pessary to ensure it reaches the posterior fornix. The anterior rim should be one fingers breadth from the symphysis pubis. It does not interfere with the coitus. 
Step 8
The pessary sits high in the vagina from the posterior fornix to just behind the symphysis pubis. Removal is achieved by turning the notch until it is anterior, then the pessary is pulled in a downward fashion and withdrawn. 
Incontinence Ring Pessary
Step 9
The incontinence ring is a ring pessary with a knob that is placed at the anterior vagina just at the pubic notch. The knob provides additional support to the bladder neck during any increased abdominal pressure (i.e., Valsalva, cough, or laugh) to further prevent leakage of urine. 
Step 10
Sizing, insertion, position, and removal are similar to the ring above. 
Step 10
Step 10
Shaatz Pessary
Step 11
The Shaatz pessary lies in the supportive category and is best-suited for mild uterine prolapse, cystocele, and stress urinary incontinence. It is fit like the ring pessary. Most common used sizes are 3 to 6. This pessary can be used in cases where the ring does not provide enough support. 
Step 11
Step 11
Step 12
The Shaatz pessary is measured and inserted in the same fashion as any of the other round pessaries. 
Step 12
Step 12
Step 13
It sits high in the vagina from the posterior fornix to just behind the symphysis pubis. Removal is achieved by grasping the pessary with a finger in the center hole and pulling in a downward fashion. 
Step 13
Step 13
Lever Pessary
Step 14
There are three types of lever pessaries (support pessary): the Hodge, Hodge-Smith and Risser. Any of the three are indicated in second-degree uterine and vaginal prolapse, or cystocele. The lever pessaries have also been used in pregnancy for cervical incompetence with or without cerclage. The Hodge pessaries are designed for patients with a shallow pubic arch and, without support, can be used for cervical incompetence in pregnancy. The Smith variant was modified to fit patients with a narrow pubic arch, whereas the Risser was further modified to accommodate patients with a flatter arch. They come in size 0 through 9. Generally, sizes 2 to 4 are the most commonly used. 
Step 14
Step 14
Step 15
To insert the Lever pessary, the uterus should be manually anteverted, and the pessary folded along its axis is inserted into the vagina with the posterior bar positioned behind the cervix and the anterior bar behind the pubic symphysis. The curved portion of the posterior bar should be positioned into the posterior fornix. 
Step 15
Step 15
Regula Pessary
Step 16
The Regula pessary is best-suited for first- and second-degree uterine prolapse. A number of different sizes of this pessary must be available to adequately fit the patient. Warn the patient that a number of different sizes are often needed to find the best fit to the vaginal vault while accommodating the degree of prolapse. 
Step 16
Step 16
Step 17
This pessary is shaped with a flexible bridge that abuts the cervix expanding horizontally when pressure in the pelvic cavity occurs. As the pressure is exerted by the cervix/uterus onto the arch of the pessary, it automatically spreads the heels outward. This mechanism helps prevent expulsion of the pessary. 
Step 17
Step 17
Step 18
The pessary is folded in half lengthwise, inserted into the vagina, and then turned and pushed up towards the cervix. Removal is accomplished by grasping one of the sides of the pessary and pulling downward. 
Step 18
Step 18
Gellhorn Pessary
Step 19
This pessary combines the two mechanisms of support and space filling. It is useful in patients with procidentia or second- to third-degree uterine prolapse and/or rectocele. The available sizes range from 1.50 to 3.50 inches. The Gellhorn pessary can also be used in women post hysterectomy for vaginal vault prolapse or for a rectocele. The Gellhorn relies on an intact perineum for adequate support. If the perineum is damaged and/or the hiatus too big, the Gellhorn is ineffective. 
Step 19
Step 19
Step 20
To insert the Gellhorn, the labia must be spread and pressure must be applied on the perineum. The knob of the Gellhorn is bent to one side. 
Step 20
Step 20
Step 21
The Gellhorn is inserted obliquely through the introitus with the concave part directed toward the cervix, and the stem folded and oriented toward the introitus. 
Step 21
Step 21
Step 22
When in place, the dish part of the pessary lies over the cervix with the stem pointing outward. Coitus is contraindicated with the Gellhorn in place. Removal of this pessary is often difficult, as the suction must be broken before the pessary is pulled out. This is accomplished by wedging the tip of the index finger anywhere along the side of the pessary, then grasping the pessary or handle if necessary and pulling down and out. It can be difficult for some patients to insert and remove the pessary on their own. 
Step 22
Step 22
Donut Pessary
Step 23
The donut is a space-filling type of device that works very well for all prolapse types, except for major posterior wall defects. It can be used in presence of decreased perineal support, but with good introital integrity. The pessary size is available from 0 to 7, and sizes 2 to 4 are generally most used. 
Step 23
Step 23
Step 24
The donut is inserted similar to the ring, squeezing the sides to reduce its diameter. 
Step 24
Step 24
Step 25
It is then inserted into position and allowed to resume its formed shape. 
Step 25
Step 25
Step 26
Once in the vagina, it should comfortably fit. Removal is accomplished by grasping the donut using the hole in the center and pulling downward. Although easy to insert and remove, because of its hard rubbery consistency, the donut can be difficult to manage for the older patients with arthritis. 
Step 26
Step 26
Inflatoball Pessary
Step 27
The Inflatoball is another donut-type pessary. This is the only latex rubber pessary available and, therefore, cannot be used in the latex-allergic patient. 
Step 27
Step 27
Step 28
The Inflatoball comes in three sizes, and insertion and removal are easily taught to the patient. The pump is attached to the inflation tube and the ball stopper moved into the side tube. 
Step 28
Step 28
Step 29
The pessary is placed in the vagina and inflated with the pump. Then, the ball stopper is pressed into the inflation tube so that the pessary cannot deflate. To remove, push the ball stopper into the side tube and allow the pessary to deflate. Pull it out with a finger, not the inflation tube, which can break. This pessary must be removed on a daily basis. 
Step 29
Step 29
Cube Pessary
Step 30
The cube pessary is used for complete vaginal or uterine prolapse. It is also useful in the presence of posterior wall defects. The cube is available in sizes 0 through 7, and the most used sizes are 2 to 4. Secretions can be retained by the cube; therefore, the pessary cannot be left in place for more than 1 day. It must be removed nightly and cleaned with soap and water. The tandem cube is a double cube design with the larger cube inserted first and placed against the cervix. The larger cube is 2 sizes bigger than the smaller one. Sizes range between 2/0 and 7/5, and the most common size are 4/2 and 7/5. The cube should be used first. If it fails, then the tandem cube can be tried. 
Step 30
Step 30
Step 31
The cube is compressed and inserted in the vagina. The removal can be difficult for some patients and should be accomplished passing the finger between the pessary and the vaginal wall to break the suction, then squeezing and removing the pessary. Tell the patient not to pull on the pessary’s tail, because it can break off easily. It is only used to help locate the pessary. 
Step 31
Step 31
Gehrung Pessary
Step 32
The Gehrung (saddle) pessary provides support for cystocele, rectocele, and some cases of procidentia. It is available in sizes 0 to 8, although the most used sizes are 2 to 5. The Gehrung with knob can be used for the same indications as the Gehrung but treats stress incontinence as well as cystocele/recotcele. 
Step 32
Step 32
Step 33
The pessary is folded and inserted, then rotated into the vagina. 
Step 33
Step 33
Step 34
It rests along the anterior vaginal wall to support the bladder, while the lateral bars straddle the rectum providing support via the levator sling and avoiding pressure on the rectum. To remove, grasp the pessary along either side and rotate and pull downward. 
Step 34
Step 34

Complications

  • Vaginal discharge

  • Vaginitis

  • Bleeding or spotting

  • Vaginal erosion or ulceration

Rare Complications

  • Pessary impaction

  • Vesicovaginal fistula

  • Urosepsis

  • Bowel or bladder erosion

  • Cervical perforation

  • Urinary incontinence

  • Urinary obstruction

  • Pessary expulsion or shifting

Pediatric Considerations

Pessaries can be used in female infants with uterine prolapse occurring in the first days of their life due to spinal cord defects. 

Postprocedure Instructions

There is no consensus or evidence regarding the management of pessaries, and most recommendations are based on expert opinion. Ideally, patients should remove their device nightly, clean with mild soap and water, and replace in the morning. Many patients find this practice cumbersome and, therefore, remove the pessary several times during the week but not on a daily basis. Ideally the patient should be seen within 24–48 hours after initial fitting and should be seen more frequently in the first year. It is recommended that during the first year, visits should be at 3 month intervals, and then increased to 6 month intervals. Patients who need more assistance or have decreased capacity should be seen more frequently. Pessaries should be removed and cleansed at every visit. A pelvic exam should also be performed at each visit to inspect for signs of vaginitis, vaginal atrophy, erosions, ulcerations or any other complications. If the patient experiences itching or irritation, a vaginal douche with dilute vinegar or hydrogen peroxide can be infrequently used. If the patient experiences vaginal ulceration, remove pessary until healing occurs, and use estrogen cream one-half of an applicator every night or a full applicator 3 times a week. Recheck the vaginal walls before reinsertion. 

Coding Information and Supply Sources

ICD9 Diagnostic Codes

Suppliers

  • Milex Products, Inc., 311 N. Normandy, Chicago, IL 60634 (phone: 1-800-621-1278; Web site: http://www.milexproducts.com).

  • Uromed, 1095 Windward Ridge Parkway, Suite 170, Alpharetta, GA 30005 (phone 1-888-987-6633; Web site: http://www.uromed.com).

Bibliography

Bash K. Review of vaginal pessaries. Obstet Gynecol Surv.  2000;55:455–460. [View Abstract]
Clemons JL, Aguilar VC, Tillighast TA, et al. Patients satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with pessary for pelvic organ prolapse. Am J Obstet Gynecol. 2004;190:1025–1029. [View Abstract]
Cundiff GW, Weidner AC, Visco AG, et al. A Survery of pessary use by American Urogynecologist Society. Obstet Gynecol. 2000;95:931–935. [View Abstract]
de Mola J, Carpenter S. Management of genital Prolapse in neonates and young women. Obstet Gynecol Survey 1996;51:253–260.
Fernando R, Thakar R, Sultan A, et al. Pessaries in symptomatic pelvic organ prolapse. Is College Obstet Gynecol. 2006;108:93–99. [View Abstract]
Rodriguez-Trowbridge E, Fenner D. Practicalities and pitfalls of pessaries in older women. Clin Obstet Gynecol. 2007;50:709–719.
Subak LL, Waetjen LE, van den Eeden S, et al. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol. 2001;98:646–651. [View Abstract]
Trowbridge E, Fenner D. Practicalities and pitfalls of pessaries in older women. Clin Obstet Gynecol. 2007;50:709–719. [View Abstract]
Trowbridge E, Fenner D. Conservative management of pelvic organ prolapse. Clin Obstet Gynecol. 2005;48:668–681. [View Abstract]
Weber AM, Richter HE. Pelvic organ prolapse. Obstet Gynecol. 2005;106:615–634. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’sPhysicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.2007.
 
×