Pelvic organ prolapse (POP) is a common problem affecting many women worldwide, with a lifetime prevalence of 30-50% (Subak et al, 2001). About 10% will undergo surgery for the management of prolapse symptoms. In the Unites States, a recent study reported that prevalence for POP increases with age at a peak of 5% in the 6th decade and it is forecasted that the number of women with POP will increase by 46% to 4.9 million (Wu et al, 2009; Wu et al, 2014). Surgery is not without its own risks including a known reoperation rate of 10-30% (Olsen et al, 1997; Price et al, 2008). Some women may be reluctant to undergo surgery, have an anesthetic, or are unfit for surgery. Nonsurgical management of POP with pessaries has been employed for a very long time (Shah et al, 2006).
The mechanism of action by which pessaries help in managing POP symptoms is simply by providing support to the vaginal hernia defect. This includes anterior, posterior, apical, or combined sites. They are held in place proximally by the uterus or vaginal apex (hysterectomy), laterally by the levator muscles, and distally by the pubic bone and vaginal introitus.
Indications
A pessary trial can be offered to all women with symptomatic POP. Some patient characteristics may contribute to its success or failure.
- Patient preference to avoid surgery
- Need to delay surgery/wait list
- Poor surgical candidate (severe medical comorbidities)
- Recurrent prolapse (patient preference to avoid reoperation)
- Vaginal ulceration due to severe POP
- POP during pregnancy
- Desire for future fertility
Contraindications
- Local infection
- Foreign body: mesh exposure
- Noncompliance for follow-up
- Sexually active women unable to manage own pessary
- Unexplained genital tract bleeding
Types
Pessaries are classified as either support or space-occupying pessaries. Most are made out of silicone, but some may be made from latex in which case it is essential to check for latex allergy prior to insertion. Silicone is hypoallergenic and can be autoclaved.
Types of support pessaries include Ring, Shaatz, Hodge and Gehrung. A survey of 2000 gynecologists reported ring pessary was the most commonly used pessary (Pott-Grinstein et al 2001). Ring pessaries are readily available in a wide range of sizes, fit many women, and are inexpensive. They are easy to fit and sexual intercourse may be possible with the pessary in place. Ring pessaries may fit up to 70% of women (Clemons et al, 2004). Other support pessaries may be more useful for advanced prolapse but difficult for the patient to self-manage.
Types of space-occupying pessaries include Gellhorn, donut, cube, spherical, and inflatable ball. Gellhorn is the most commonly used space-occupying pessary, beneficial for more advanced prolapse – stage IV, wide genital hiatus, rectocele and related symptoms (Clemons et al, 2004). It has a firm, circular broad base with a stem preventing it from rotating along the long axis of the vagina. The surface is concave, providing suction to stabilize it in place, however, this can make removal difficult.
For very severe POP, a combination of ring and Gellhorn pessaries may be indicated (Myers et al, 1998).
Fitting
Pessary fitting is mostly by trial and error. Once the bladder is emptied, assess for POP stage, check post void residual, vaginal length and genital hiatus in dorsal position. Stage II or III POP can usually be managed with a ring pessary size 3, 4 or 5. If there is a wider genital hiatus, more advanced POP (stage IV), or previous hysterectomy, a Gellhorn pessary is more suitable.
The ideal pessary is the smallest sized which resolves symptoms and is retained. If the initial pessary falls out, try a larger size until it is retained and comfortable. If initially uncomfortable, swap for a smaller size. If a ring pessary continues to fail, consider a Gellhorn pessary. There should be a finger gap between the pessary and vaginal wall to prevent excessive tension and erosion. Following insertion of the pessary, test with valsalva maneuver, coughing, pushing, and walking around for a few minutes to assess proper fit and/or expulsion. Perform a cough stress test as symptoms of occult urinary incontinence may be bothersome post-pessary insertion due to urethral splinting.
Several cohort studies have looked at the outcomes of pessary fitting. On average, two or three pessaries were tried before an adequate fit was achieved. Ring pessary was used in 70-75% and space occupying in 26-29% of the cases (January 21, 2021: www.uptodate.com/contents/vaginal-pessaries-insertion-and-fitting-management-and-complications#).
Risk factors for a failure of pessary trial include (Clemons et al, 2004):
- Previous prolapse surgery
- Previous hysterectomy
- Short vaginal length <6cm
- Wide vaginal introitus >4cm
Follow-up at 1-2 weeks post-insertion to assess for comfort, expulsion, and de novo urinary incontinence symptoms should be scheduled. Regular follow-up every 6-12 months for cleaning of pessary and assessment of complications should also be organized.
Outcomes
Short- and medium-term studies have noted improvement in symptoms post-pessary insertion. Prolapse symptoms were reported to be resolved in 70-90% of patients. 40-50% reported resolution of urinary symptoms and 30-50% reported resolution of bowel symptoms. Improvement in sexual function was also reported; 70% reported removing the pessary for intercourse (January 21, 2021:www.uptodate.com/contents/vaginal-pessaries-insertion-and-fitting-management-and-complications#!).
Complications
Common complications of pessary use include vaginal discharge/odor, bleeding, erosion, and failure.
Vaginal discharge with or without odor can be common post-pessary insertion. This is more likely due to inflammation from the pessary than infection. This can be easily managed by temporarily removing the pessary and using low dose vaginal estrogen or pH lowering agents.
Vaginal bleeding can occur as a result of atrophy, trauma from insertion and removal, or vaginal erosion. Once any endometrial pathology or erosion has been excluded, this can be managed with low dose estrogen for atrophy.
Vaginal erosions are excoriations of vaginal mucosa caused by the pessary. This can present as bleeding or irritative vaginal symptoms. This can be managed by leaving the pessary out for 4-6 weeks and using low dose vaginal estrogen.
Pessary discontinuation rates are high in the long-term. A retrospective study with long-term follow up of 14 years reported a continuation rate of only 14% (Sarma et al, 2009).
Serious and uncommon complications include pessary incarceration, fistula, and urinary or colonic obstruction. These tend to occur in older women with severe atrophy and noncompliance of follow-up.
Implications of COVID-19 Pandemic
The COVID-19 pandemic has led to significant interruption of routine patient care. Many health institutes have cancelled elective surgery and routine clinic visits to increase and maintain the availability of inpatient care and intensive care beds and have redeployed medical and nursing staff. This has especially interrupted care for non-urgent conditions like pelvic organ prolapse. Although these conditions are usually not life threatening, the symptoms from severe POP can be quite debilitating and significantly effect quality of life.
With cancellation of elective surgery, pessary use seems to be an effective short-term alternative while waiting for an elective surgery date. However, with cancellation of several face-to-face clinic appointments and the transition to telehealth, this can be challenging. One approach can be to discuss the option of a pessary in a telehealth consultation. If the patient would like to consider this, then organizing a face-to-face appointment with appropriate personal protective equipment seems reasonable. Further follow-up via telehealth instead of in the hospital can be employed if the pessary is retained.
Pessary change and vaginal health assessment for patients who were due for their 6-month review have also been complicated by COVID-19. This subgroup of the population may also be more vulnerable to the effects of COVID-19. This subgroup includes patients who have already opted for a pessary instead of surgery, usually due to medical comorbidities and advancing age. It would be reasonable in such situations to delay the change of pessary by an additional 3 months and then review. Vaginal pessary ‘neglect’ can lead to serious complications like urinary/colon retention or fistula. Telehealth appointments to screen patients at risk of this and offering a face-to-face appointment should be considered. Another at-risk group are those with severe POP and obstructive uropathy. Pessary management can be tried, however, if this fails urgent surgery is indicated.
In conclusion, pessaries are a safe and effective short-term management option for pelvic organ prolapse, especially during the COVID-19 pandemic. The biggest limitation of pessaries is high discontinuation rate.
REFERENCES
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Vaginal pessaries: Insertion and fitting, management, and complications [Internet]. 2020 [cited 11/01/2021]. Available from: https://www.uptodate.com/contents/vaginal-pessaries-insertion-and-fitting-management-and-complications#!
Sarma S, Ying T, Moore KH. Long-term vaginal ring pessary use: discontinuation rates and adverse events. BJOG. 2009;116(13):1715-21.