Gynecology Book

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Pessary

Aka: Pessary, Pessaries
  1. Indications
    1. Pelvic Organ Prolapse
  2. Contraindications
    1. Patient unable to comply with care or follow-up (e.g. Dementia, decreased dexterity)
    2. Those not able to remove and insert Pessary may return to clinic for Pessary replacement at 3 month intervals
  3. Efficacy
    1. First choice intervention for two thirds of Pelvic Organ Prolapse patients
      1. Kapoor (2009) Int Urogynecol J Pelvic Floor Dysfunct 29(10): 1157-61 [PubMed]
    2. High level of compliance (77% continue Pessary beyond 1 year)
      1. Clemons (2004) Am J Obstet Gynecol 191(1): 159-64 [PubMed]
    3. Effective for all levels of prolapse stages
  4. Protocol
    1. Factors interfering with proper fitting
      1. Short vaginal length
      2. Wide vaginal opening (>4 finger breadths)
      3. Hysterectomy
    2. Proper fitting (ring Pessary)
      1. Fold ring Pessary in half for insertion
      2. Pessary fits between pubic symphysis and posterior vaginal fornix
      3. Pessary should remain >1 finger breadth above introitus while bearing down
      4. Assess comfort while sitting, walking, voiding
    3. Fitting - too small
      1. Pessary expelled with cough or Valsalva Maneuver
    4. Fitting - too large
      1. Patient aware of Pessary when walking, sitting, voiding or stooling
    5. Device selection
      1. Step 1
        1. Ring with support or
        2. Ring with knob (if Urinary Incontinence)
      2. Step 2
        1. Gelhorn
      3. Step 3
        1. Donut
      4. Step 4 (combination)
        1. Ring with Gelhorn or
        2. Ring with donut or
        3. Two donuts or
        4. Ring with support and knob (Urinary Incontinence)
      5. Step 5
        1. Cube or
        2. Inflatoball
  5. Preparations: Most common
    1. Ring
      1. Most commonly used Pessary
      2. Easy to use, allows for intercourse and does not require daily removal
      3. Works for all types of Pelvic Organ Prolapse
      4. Ring is available with several modifications
        1. Knob: Assists with Urinary Incontinence (which the ring alone does not)
        2. Support (ring has inner web with holes) - can not be used in severe prolapse
    2. Gellhorn
      1. Used in severe uterine Pelvic Organ Prolapse (stage 3 or 4)
      2. More difficult to insert, can cause vaginal erosions and does not allow for intercourse
      3. Does not have to be removed daily
      4. Does not assist with Urinary Incontinence
    3. Donut
      1. Used in severe uterine Pelvic Organ Prolapse (stage 3 or 4)
      2. More difficult to insert and does not allow for intercourse
      3. Does not have to be removed daily
      4. Does not assist with Urinary Incontinence
  6. Preparations: Pessaries used in pregnancy
    1. Smith-Hodge
      1. Used for pregnancy uterine retroversion (mid pregnancy if symptomatic prolapse)
      2. Easy to use, need not be removed daily and allows for intercourse
  7. Preparations: Pessaries for advanced apical prolapse
    1. Cube
    2. Inflatoball
  8. Management: Home Instructions
    1. Self-care
      1. Instruct patient on insertion
      2. Instruct patient on nightly removal (may advance to weekly, every 2 weeks or monthly removal)
      3. Instruct on cleaning Pessary on removal
    2. Clinic follow-up
      1. Two weeks after insertion to reassess comfort and efficacy
      2. Women able to self-care for Pessary (removal, cleaning, insertion) may then follow-up annually
      3. For women unable to replace Pessary themselves, may return every 3 months for replacement and exam
  9. Adverse Effects
    1. Vaginal Discharge or vaginal odor
      1. Bacterial Vaginosis (30% of Pessary users, especially with less frequent Pessary exchange)
    2. Vaginal irritation, Vaginal ulceration, Vaginal Bleeding
      1. More common in postmenopausal women, less frequent Pessary exchange
      2. Not typically prevented with Vaginal Estrogen therapy
    3. Pelvic Pain
  10. References
    1. Iglesia (2017) Am Fam Physician 96(3): 179-85 [PubMed]
    2. Kuncharapu (2011) Am Fam Physician 81(9): 1111-7 [PubMed]
    3. Trowbridge (2005) Clin Obstet Gynecol 48(3): 668-81 [PubMed]

Pessaries (C0031246)

Definition (UMD) Devices, typically made from silicone or rubber, designed to be inserted in the vagina for nonsurgical treatment of pelvic support defects/conditions such as uterine prolapse, uterine retroversion, stress incontinence, or cervical incompetence. They are designed to support the uterus, vagina, bladder, or rectum. These devices are intended for temporary or permanent placement.
Definition (SPN) A vaginal pessary is a removable structure placed in the vagina to support the pelvic organs and is used to treat conditions such as uterine prolapse (falling down of uterus), uterine retroposition (backward displacement), or gynecologic hernia.
Definition (MSH) Devices worn in the vagina to provide support to displaced uterus or rectum. Pessaries are used in conditions such as UTERINE PROLAPSE; CYSTOCELE; or RECTOCELE.
Concepts Medical Device (T074)
MSH D010570
SnomedCT 385174007, 46625003, 350808004
Spanish pesario, dispositivo, óvulo vaginal (producto), pesario (calificador), pesario (producto), óvulo vaginal, pesario (objeto físico), pesario, dispositivo (objeto físico), pesario, Pesarios
English PESSARY, VAGINAL, Pessary appliances, Pessary (product), Pessary, device, Pessary (qualifier value), Pessaries, Therapeutic, pessaries, pessary, vaginal pessary, suppository, suppositories, Pessary appliances (physical object), Suppository appliances, Pessary, Suppository, Pessary, device (physical object), Pessaries
Swedish Pessarer
Czech pesary
Finnish Pessaarit
Russian SVECHI VAGINAL'NYE, VAGINAL'NYE SUPPOZITORII, PESSARII, ВАГИНАЛЬНЫЕ СУППОЗИТОРИИ, ПЕССАРИИ, СВЕЧИ ВАГИНАЛЬНЫЕ
Italian Pessari
French Pessaires
Polish Pessaria, Krążki pochwowe, Pessar pochwowy, Pessary pochwowe, Krążek cewkowy, Pessary szyjkowe, Krążek szyjkowy, Krążki cewkowe, Krążki dopochwowe, Pessary uroginekologiczne, Pessar cewkowy, Pessar szyjkowy, Krążki szyjkowe, Pessary cewkowe
Norwegian Pessarer
German Pessare
Dutch Pessaria, Pessarium
Portuguese Pessários
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Pessary - uterovaginal (C0558655)

Concepts Medical Device (T074)
SnomedCT 274477008, 150747007
English Pessary - uterovaginal, Suppository - uterovaginal, Pessary - uterovaginal (physical object)
Spanish pesario - uterovaginal (objeto físico), pesario - uterovaginal
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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