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 Selection

Modern silicone pessaries come in a variety of shapes and sizes; therefore, selection is primarily determined by the lifestyle of the potential wearer, as well as findings on physical examination. Both providers and patients are likely to benefit if pessary success could be predicted because counseling would be improved, time would be saved, and needless discomfort would be eliminated; however, predictive parameters for pessary choice and fitting success have proven difficult to quantify (Cundiff et al., 2007). For that reason, expert opinion from clinical observation continues to inform both patient and pessary selection and is included here for the potential benefit of novice providers.

Patient-specific Factors

Several recent studies concluded that the majority of women can be successfully fitted with a pessary, with POP-reduction success rates ranging from 63% to 86% (Clemons, Aguilar, Tillinghast et al., 2004b; Hanson, Schulz, Flood, Cooley, & Tam, 2006; Maito, Quam, Craig, Danner, & Rogers, 2006; Mutone, Terry, Hale, & Benson, 2005; Nyguyen & Jones, 2005; Wu, Farrell, Baskett, & Flowerdew, 1997). However, specific factors that might predict successful fitting have not been consistently identified. Some studies have suggested that patient satisfaction is higher in women who are older, have had no prior pelvic surgery (including hysterectomy), have higher parity or less severe prolapse, and have no UI (Maito et al., 2006; Nyguyen & Jones, 2005; Wu et al., 1997). Hanson et al. (2006) assessed the importance of estrogen therapy to successful pessary fitting, reporting that women using vaginal estrogen, with or without systemic hormone replacement therapy (HRT), had higher fitting success compared to both systemic-only and non-HRT users. Maito et al. (2006) reported presence of mild posterior compartment prolapse as a positive predictor of fitting success, and history of a prior prolapse procedure or hysterectomy as negative predictors. Clemons, Aguilar, Tillinghast et al. (2004b) also found a shortened vaginal length (≤ 6 cm) and wide genital hiatus (4 fingerbreadths) to be predictive of unsuccessful pessary fitting. Other researchers have reported no significant predictive value regarding age, weight, vaginal length, size of genital hiatus, compartment of prolapse, stage of prolapse, or hormone use (Maito et al., 2006; Mutone et al., 2005; Nyguyen & Jones, 2005; Wu et al., 1997). Because of this lack of consistent predictors, a pessary trial may be appropriate for any woman seeking treatment for prolapse-related symptoms (ACOG, 2007; Clemons, Aguilar, Sokol et al., 2004).

Factors related to patient preference, lifestyle, and ability may guide pessary choice. For example, some pessaries may be easier to self-remove and self-insert. This may affect choice related to patient comfort with self-touch, interest in performing self-care, and desire to have vaginal intercourse. Clinical experience suggests that arthritis, mobility impairment, and obesity may limit successful self-care, even in very motivated women. Women who are not doing self-care will need to wear their pessary continuously between the periodic office visits for removal and cleaning.

With the appropriate pessary, a sexually active woman has a few options. The pessary can be removed for intercourse either by the woman or her partner. If she prefers leaving the pessary in place, some styles (for example, Ring pessaries) are more likely to be comfortable for both partners during intercourse. However, there is little research to assess this specifically, and clinical reports from individual couples vary greatly. Overall, sexual function has been shown to improve with pessary use, including frequency and satisfaction (Fernando et al., 2006), desire, orgasm, and lubrication (Kuhn, Bapst, Stadlmayr, Vits, & Mueller, 2009). Additionally, one study found sexually active women were more likely to continue pessary use compared to women who were not sexually active (Brincat, Kenton, Fitzgerald, & Brubaker, 2004). Overall, pessary use may be acceptable to many sexually active women.

Pessary-related Factors

Many pessary styles and sizes are available, and new styles continue to be designed. Figure 1 displays a variety of current pessaries. While successfully fitted pessaries offer a high likelihood of symptom and quality-of-life improvement for most users, no specific shape of pessary is best for all women. In one crossover study comparing two different pessaries (Ring and Gellhorn), both shapes were effective for the majority of women and significantly improved urinary, bowel, and prolapse symptoms (n = 134, mean age 61 years, median prolapse Stage 3 – descent halfway beyond the hymen, satisfaction rates – Ring 80%, Gellhorn 76%) (Cundiff et al., 2007).

Figure 1.

Pessary Shapes
Note: The large variety of pessary shapes can be categorized as pessaries that require significant introital support (top row), pessaries that are relatively self-supporting (seond row), and pessaries with an incontinence support (third row).

Because no quantitative measures have been identified to direct pessary choice and fitting, providers must continue to rely on manufacturer guidelines, expert opinion, product availability, clinical judgment, and provider or patient preferences when choosing initial pessary shape and style.

One way to conceptualize support pessary options is to categorize them by their functional design. Using that paradigm, flexible silicone pessaries fall into three categories: those that need some support from the woman's own introital integrity to stay in place (basic support pessaries), pessaries with concavities that make them relatively self-retaining (self-retaining pessaries), and pessaries with additional urethral support designed to improve stress incontinence (incontinence pessaries). Use of these classifications to guide initial choice is summarized in Table 2.

In the authors' experience, pessaries retained by introital integrity can be folded or deflated to ease insertion through the introitus. Examples include the Ring (see Figure 2), Donut (see Figure 3), and Inflatable Donut (see Figure 4), and the Shaatz and lever pessaries (not pictured separately). Those that have a relatively slim profile and fit along the length of the vaginal shaft, such as the Ring pessary, are most likely to be comfortable when left in place during vaginal intercourse. Others, such as Donut pessaries, which are sometimes referred to as space-filling pessaries because they occupy more of the vaginal width, may preclude intercourse when in situ. Pessaries designed to easily fold or deflate may also be most amenable to self-insertion and removal.

Figure 2.

Ring and Ring with Support Membrane
Note: Note the hinge bends at the notch in the left pessary and at the finger-sized holes of the right pessary. This pessary is folded at the hinge for insertion and removal.

Figure 3.

Donut Pessary
Note: Some clinicians aid insertion and removal by carefully deflating the Donut using a needle and syringe, inserting it, and then re-inflating the pessary once it is in place and viceversa.

Figure 4.

Inflatable Donut Pessary

In contrast, self-retaining pessaries are generally concave in shape. The vaginal walls conform to these areas, allowing the pessaries to stay in place in women with minimal or no introital strength. These include the Gellhorn (see Figure 5) and Cube pessaries (see Figure 6). These are traditionally considered more likely to support advanced POP but may also increase the risk of mechanical injury to the vaginal epithelium. They may also be more difficult for both the patient and provider to remove and reinsert. Incontinence pessaries include a knob that fits behind the pubic symphysis, supporting the urethra during times of increased abdominal pressure to diminish stress incontinence (see Figure 7).

Figure 5.

Gellhorn Short and Long-Stem Pessaries

Figure 6.

Cube Pessaries

Figure 7.

Incontinence Pessaries
Note: Examples include, top row: Incontinence Dish (with and without support); middle row: Marland (with and without support); bottom row left: Ring with support membrane and incontinence knob; bottom right: Incontinence Ring.

Although the topic is not well studied, when a pessary is worn over time (longer than 24 hours), presence of drainage holes should allow continuous drainage of normal vaginal epithelial shedding and discharge. Retained discharge may act as a medium for bacterial overgrowth, increasing infection risk, and/or odor. For this reason, pessary styles with optional drainage holes (such as Cube pessaries) are typically preferred whenever possible.

Providers often prefer to use a limited selection of available pessaries. For example, in a survey of urogynecologists, the majority reported using Ring pessaries for anterior and apical defects, space-filling pessaries (such as a Donut) for women who have introital integrity and posterior defects, and self-retaining pessaries (such as the Gellhorn) for severe prolapse (Cundiff, Weidner, Visco, Bump, & Addison, 2000). General gynecologists reportedly also used Ring pessaries most frequently, deeming them easiest to use, with Gellhorn pessaries used most commonly for advanced prolapse (Pott-Grinstein & Newcomer, 2001). The latter respondents rated Donut pessaries the least easy to wear and Gellhorn pessaries most difficult to remove. Generally, providers' choice of styles of pessary to stock and fit appears to be based on the individual's training, experience, and product availability.

Pessary size selection is also currently guided by experience because no specific vaginal measures have predicted successful fit. In one study, Pelvic Organ Prolapse Quantification (POP-Q), parameters were tested as a potential objective predictor but were not found to predict pessary size; however, women with a shorter total vaginal length were less likely to be successfully fitted (Nager et al., 2009). Thus, pessary fitting remains an art, with some reliance on trial and error.

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