Before a vaginal pessary is offered, it is important to confirm that the patient does not have any known contraindications to its use, including known genital tract malignancy, unexplained vaginal bleeding, or severe vaginal atrophy. It is also important to confirm the patient is able to comply with follow up (Thakar 2013). This is also the ideal time to explore if the patient currently is or wishes to be sexually active to aid selection of the most appropriate pessary. If the patient will be self-managing the pessary, an assessment of manual strength and dexterity is crucial (Thakar 2014).
The patient should be informed that pessary fitting is a process of trial and error and may require several attempts at sizing before the best fit is found. A correctly fitted pessary should not be noticeable to the patient while relieving their symptoms, should remain in place, and should not interfere with urination or defecation. Pessary sizing involves performing a vaginal examination to assess the length and width of the vagina using the index and middle finger to first estimate the distance between the posterior fornix and pubic symphysis and horizontally at the level of the cervix or vaginal vault to determine the vaginal width (Thakar 2014). The measurements taken can then be used to size the correct pessary, starting with the smallest size and increasing if necessary. Ensure any manufacturers’ advice regarding care of the pessary is read as some pessaries require washing prior to use.
To aid insertion, many pessaries are foldable. The ring pessaries can be folded in two or folded into a figure 8 to reduce the diameter. If difficulty is experienced bending the pessary, running it under warm water can make it easier to manipulate and using an oestrogen-based cream in post-menopausal women can further aid insertion and reduce abrasions. The pessary is inserted into the vagina in a vertical position and once inside the vagina released to assume a horizontal position. A correctly sized pessary should allow a finger to be passed easily around the circumference of the pessary. Following pessary insertion, the patient should be asked to walk around and pass urine in the department; pessaries that are expelled on walking are usually too small and those obstructing urination are too large. Before discharge, the patient should be instructed on how to correctly remove the pessary if they experience discomfort and should be aware to expect an increase in vaginal discharge, especially if an oestrogen cream is being used concomitantly. A contact number for the unit should be provided in the event of pain, expulsion, or signs of infection.
Pessary removal is often simpler than insertion. Removal can be achieved by hooking a single finger under the rim of the pessary in a ring pessary and gently pulling down towards the rectum while keeping the pessary folded. When difficulty is experienced removing a pessary, ask the patient to bear down, then use a Cusco speculum to identify the pessary and a sponge holding forceps to grasp the stem of the pessary. Pessaries rely on a suction seal being created to stay in place, therefore breaking this seal can allow removal. Inserting a finger under the rim of the pessary or squirting warm water into the stem of the pessary with a syringe can also achieve this.
REFERENCES
Thakar R. Pessaries for treatment of pelvic organ prolapse and incontinence. Rogers R, Sung WV, Thakar R, Iglesia C (Eds). Female Pelvic Medicine and Reconstructive Surgery: Clinical Practice and Surgical Atlas. Williams Gynecology, McGraw- Hill Education Ltd, 2013:339-52.
Thakar, R, Glob. libr. women's med., (ISSN: 1756-2228) 2014; DOI 10.3843/GLOWM.10479.