Vaginal Support Pessaries

Indications for Use and Fitting Strategies

Shanna Atnip and Katharine O'Dell

Disclosures

Urol Nurs. 2012;32(3):114-125. 

In This Article

Pessary Indications

Pessaries are a low-risk option for treatment of pelvic floor disorders with few absolute contraindications. Typically, pro viders are advised to use caution if pessary candidates have an active vaginal infection, persisting vaginal erosion or ulceration, or severe vaginal atrophy (Weber & Richter, 2005). In addition, non-compliance with follow up can be problematic because it may result in late recognition of complications; therefore, providers are advised to weigh risks, family support, and alternative options carefully before providing pessaries to women with dementia or other conditions that may lead to irregular follow up or pessary neglect (Weber & Richter, 2005). Common indications for the use of support pessaries include relief of symptoms, avoidance of surgery, diagnosis and surgical outcome prediction, and prevention (see Table 1).

Symptom Improvement

Symptoms of pelvic organ prolapse (POP) may include pelvic pressure, vaginal bulge, irritative voiding symptoms, urinary incontinence (UI), fecal incontinence, dyspareunia, constipation, and difficulty emptying both the bladder and bowels. Many trials have reported significant improvement of common symptoms, including urinary urgency and frequency, and urgency UI; vaginal bulge; pelvic and abdominal heaviness and pressure; incomplete or difficult bowel emptying; flatal incontinence; and fecal urgency and incontinence (Barber, Walters, Cundiff, & the PESSRI Trial Group, 2006; Clemons, Aguilar, Tillinghast, Jackson, & Myers, 2004a; Fernando, Thakar, Sultan, Shah, & Jones, 2006; Komesu et al., 2007, 2008). Improved bladder emptying subsequent to reduction of POP and urethral obstruction may prevent many causes of ongoing morbidity or mortality, including recurrent urinary tract infection, acute urinary retention, and renal injury (Micha et al., 2008). Both stress and mixed UI were improved with pessary use in approximately 50% of women in two separate trials (Donnelly, Powell-Morgan, Olsen, & Nygaard, 2004; Richter et al., 2010). Additionally, overall body image improves in many successful pessary users (Patel, Mellen, O'Sullivan, & LaSala, 2010).

Other areas of symptom-relief related to pessary use have been less well studied. For example, women with a vaginal bulge can develop epithelial ulceration due to dryness and friction on clothing. The risk of infection and hemorrhage can be effectively treated in a plan of careful follow up and pessary use to enhance healing.

In addition to symptom improvement, use of support pessaries can help women meet their health improvement goals. In one study, women who achieved their own pre-determined treatment goals (improved bladder control, increased comfort with physical activity, decreased prolapse symptoms) were more likely to be satisfied and continue pessary use as compared with women who did not meet their treatment goals (Komesu et al., 2008). Helping patients set realistic goals for treatment outcomes based on current evidence will help women meet their treatment goals and encourage continued pessary use.

While a majority of women may note symptom relief with pessary use, some women cannot be successfully fitted, and others may experience burdensome new symptoms during a pessary trial. New symptoms can include de novo problems with bowel and bladder emptying, discomfort, pressure, or pain; increases in vaginal discharge or odor, or new onset stress UI due to unkinking of an otherwise inadequately supported urethra (Bump, Fantl, & Hurt, 1988). In one study, the most common risk factors for dissatisfaction related to pessary use included de novo stress incontinence, a pre-existing strong desire for surgical repair, and more advanced prolapse (where the leading edge of the prolapse is halfway beyond the hymen or more) (Clemons, Aguilar, Tillinghast et al., 2004b). Potential distress may be reduced if women considering pessary use are aware of common uses, benefits, and potential risks prior to their initial pessary fitting.

Surgical Avoidance or Scheduling Convenience

Conservative management with a pessary, either on a temporary or long-term basis, may be the optimum choice for many women for a variety of reasons. Although evidence is sparse, clinical examples of indications include fear of surgery or anesthesia, significant co-morbidities that preclude surgery, or prior failed surgery with resultant higher risk of poor surgical outcome. Temporary use of a support pessary may improve comfort for women delaying surgery due to career or family priorities, or for women who have been advised to defer vaginal reconstruction until child bearing is completed.

Diagnostic Assessment and Prediction of Surgical Outcomes

A pessary trial can provide an opportunity to explore likely symptom improvement or the potential for onset of new adverse effects, and help women develop realistic expectations during pre-operative treatment planning. In a classic study, researchers used a trial with a lever pessary to successfully predict surgical cure of stress incontinence via retropubic urethropexy. In this trial, 24 of 26 women with stress UI became continent with a supine stress test after pessary insertion, and all patients remained continent after a retropubic urethropexy was performed (Bhatia & Bergman, 1985). In another study, de novo stress incontinence, which can occur when an otherwise deficient urethra is straightened during repair of the prolapsed anterior compartment, was shown to be a major reason for post-treatment dissatisfaction (Clemons, Aguilar, Tillinghast et al., 2004a).

Post-surgical expectations have also been explored with women reporting two common symptoms often attributed to POP – lower abdominal pressure and low back pain (Heit, Culligan, Rosenquist, & Shott, 2002). In that study, participant-rated symptom severity using visual analog scales, (n = 152) was compared with objective prolapse determination and demonstrated no significant association. Therefore, because prolapse may not be the cause of some symptoms, a pessary trial can play a role in clarifying treatment expectations during pre-operative decision-making.

Pessaries have also been useful in predicting successful outcomes in cases of pre-operative elevated post-void residual (PVR) due to urethral obstruction. A retrospective chart review of women with pre-operative PVR greater than 100 cc (n = 24) found that pessary use normalized PVR in 75% (n = 19) of the women, with only one woman subsequently experiencing elevated PVR three months post-operatively. A trial pessary reduction was found to be a reliable tool in predicting improvement in urinary retention (Lazarou, Scotti, Mikhail, Zhou, & Powers, 2004).

Prevention of Progressive Prolapse

Emerging evidence also suggests a potential preventive role for pessaries. Handa and Jones (2002) observed a significant improvement in stage of POP in 19 women following one year of successful pessary use, suggesting a therapeutic effect associated with the use of a supportive pessary. In addition, in an observational cohort study of women using pessaries for three months (n = 90), measurement of the genital hiatus decreased, leading the authors to postulate that pessary use allows recovery of the levator ani muscles (Jones et al., 2008). In another small case series (n = 6), prolapse regressed to normal after a median duration of pessary use of 27.5 months and remained resolved for a median of 42.0 months of follow up (Matsubara & Ohki, 2010). Whether this observed prolapse improvement is due to temporary physiologic tissue response to reduced strain and/or has potential long-term preventive ramifications is currently unclear.

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