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 Fitting

Because there has been little success in identifying objective evidence to improve pessary choice, new providers must rely on expert opinion and mentorship. Pessary manufacturers provide recommendations to help the novice match pessary styles with patient findings (Bioteque of America, 2011). Successful fitting also depends on clinician experience and training. Few nursing or medical programs spend time teaching pessary use (Pott-Grinstein & Newcomer, 2001). However, with a sound general background of women's health care, even in the absence of optimal mentorship, clinicians can educate themselves to become competent and safe providers of this low-risk intervention.

The goal of fitting is to find a pessary that improves the target pelvic floor symptoms, is comfortable for the patient, is retained during activity and toileting, and does not obstruct voiding or defecation, or cause vaginal irritation. Suggestions for improving fitting outcomes are listed in Table 3.

Although definitive measurements have not been identified to aid size and style choice, experienced providers typically note several digital measurements and assess pelvic muscle tone and support during pelvic examination (see Figure 8). These determinations can help the provider develop a mental image of the vaginal size, shape, and support. The initial pessary attempt can then be made using the pessary that fits this visual image. Table 4 lists suggested steps in pessary fitting based on clinical experience and expert opinion.

Figure 8.

Illustration of Digital Measurement of the Vagina, a Potential Aid to Initial Pessary Choice
Notes: Line A: The vaginal length from posterior symphysis to apex or posterior fornix can be useful for sizing Ring and Donut pessaries, or the length of a Gellhorn neck. Line B: The vaginal width at the apex can be useful when considering the diameter of the Gellhorn dish. Line C: The diameter of the introitus and vaginal shaft can help in making an initial Cube choice.

The average number of pessaries tried during a successful pessary fitting is two to three, typically at a single session; however, up to two follow-up fitting sessions have been reported prior to successful fitting (Jones et al., 2008; Komesu et al., 2007; Maito et al., 2006; Robert & Mainprize, 2002; Wu et al., 1997). Women unable to retain a pessary at an initial fitting are less likely to be successful at subsequent fittings (Maito et al., 2006), but persistence may pay off. Clemons, Aguilar, Tillinghast et al. (2004b) found 22 of 49 women who could not be fit at the first visit were successfully fit on the second visit. In that study, a Gellhorn pessary was more likely to require refitting than a Ring, suggesting Ring pessaries are easier for providers to size correctly. For women who prefer pessary treatment but have difficulty retaining any single pessary, occasional use of double pessaries, including a Donut with Gellhorn or double Ring, has been reported (Myers, LaSala, & Murphy, 1998; Singh & Reid, 2002).

Prior to fitting, women should be informed that the risk of a pessary trial is minimal, while the potential symptom-relief can be great. It may be helpful to be optimistic, normalizing the fitting situation, while informing the woman prior to fitting that an appropriate pessary may not be identified. Clinicians also need to remember that successful fitting after three or four attempts is less likely. To aid understanding of current pessary choices, the following sections look more specifically at commonly used pessary options.

Insertion and Removal of Specific Pessaries for Women With Introital Support

Ring With and Without Support Membrane. The Ring pessary and Ring with support membrane (see Figure 2) are common first-line choices for most types of POP. They typically include a rigid, hinged nylon ring that fits into the length of the vagina, providing support for the anterior, posterior, and apical walls. The optional support membrane may add additional support if anterior or posterior compartment prolapse are present (such as cystocele or rectocele). The position of the hinge is marked either by notches in a Ring or finger-sized holes in the Ring with support membrane. To retain this type of pessary, the introitus and/or pelvic floor must provide enough support to contain the pessary.

Ring pessaries tend to be easiest for both clinicians and patients to use. Many women are able to remove and replace a Ring pessary without difficulty. Even when a Ring pessary is in place, coitus may be comfortable for both partners. Ring pessaries with or without support are also available with a urethral support knob for the treatment of stress UI.

To fit a Ring pessary, the vagina is measured digitally or with a vaginal measuring instrument to assess the depth, obtaining a general idea of the shape and size of the intra-vaginal space (see Figure 8). To insert the pessary, lubrication of the vagina or a hinged edge of the pessary and not the gloved exam fingers will facilitate a grip on the folded pessary. The pessary is folded in half at the hinge and inserted through the introital opening, while applying gentle downward posterior or perineal pressure to avoid the sensitive urethral area. Once inside the vagina, the pessary will open spontaneously. This pessary follows the length of the vagina, from loosely behind the symphysis to the vaginal apex or posterior fornix. A Ring pessary can be rotated 90 degrees while in-place, which may help prevent spontaneous expulsion by placing the hinge transversely to the introitus. A well-fit Ring pessary will stay in place without applying undue pressure on the sidewalls, apex, or introitus, and will not be noticeable by the patient. If the woman describes discomfort from the pessary fitting too near the introitus during movement, it is either too large or there is insufficient introital support to hold the pessary in place. Removal and digital re-sizing may suggest whether a larger or smaller pessary may work better. If two or three tries are not effective, a self-retaining pessary, such as a Gellhorn or Cube, may be a better option.

To remove a Ring pessary, lubricate the introitus, put an examining finger through the finger-size hole or at a hinge notch, rotate the pessary to bring the hinge anteriorally to the introitus, and gently pull downward, diagonally, and out. The vaginal walls will help to fold the pessary as it exits. Atrophic or scarred tissue may fissure at the posterior fornix with removal. Increased lubrication, moisturization, or estrogenation may ease future use. The most common sizes of Ring pessary are 2 through 5 (whole numbers).

Donut and Inflatable-donut Pessaries. If a Ring pessary is not successful, but there is some introital support, a Donut or Inflatable-Donut pessary may be an option (see Figures 3 and 4). Donut pessaries are essentially thicker Rings and may fill a vagina enlarged by loss of elasticity more completely; however, these pessaries are in more complete contact with the vaginal epithelium, which may increase the risk of mechanical tissue injury or discharge production and retention. Some women may be able to remove and replace traditional Donut pessaries themselves, but comfortable vaginal intercourse is unlikely. Inflatable Donut pessaries, which are a silicone variation of an older latex inflatable pessary called the Inflatoball, have a stem and valve for inflation and deflation like a balloon, and are designed to be inserted and removed at frequent intervals (within 48 hours). Manufacturer instructions should be reviewed before attempting to autoclave Donut pessaries because of their air-filled core.

During fitting, digital examination is used to assess both the depth and width of the vagina. Introital stretching and discomfort is more likely with a traditional Donut, and with either type, adequate lubrication is essential. With firm digital pressure, a traditional Donut pessary may be compressed somewhat to slip through the introitus more comfortably. Additionally, some Donut pessaries can be deflated using a needle and syringe to remove air. After pessary insertion, it can then be re-inflated by carefully inserting the needle into the Donut and injecting air with the syringe. All Donut pessaries are typically fit either like a Ring pessary – along the length of the vagina – or may stay in place if fitted snugly into the circumference of the vaginal apex with appropriate intrinsic support.

To remove a traditional Donut pessary, the introitus is lubricated, and with the examination finger in the Donut center, the pessary is pulled gently downward at a diagonal angle. Some Donut pessaries can be carefully deflated in situ using a needle and syringe to ease removal, and the Inflatable Donut pessary should also be deflated prior to removal.

Other support pessaries require introital integrity, with indications based on clinical experience. They include the Oval (which may be useful with a narrow vaginal width); the Hodge and Smith Lever pessary (which may be more comfortable in women with a narrow vaginal introitus); the Gehrung Arch (which may be effective in women who have an isolated anterior or posterior wall prolapse), and the Shaatz (which is a disc, similar to the Ring, but may offer firmer support). Fitting for these pessaries is very similar to fitting of the Ring pessary. Manufacturers typically include fitting instructions with each pessary. If these types of pessaries cannot be retained, a self-retaining pessary may be appropriate.

Insertion and Removal of Self-retaining Pessaries

Gellhorn. The flexible Gellhorn pessary is an option in women who cannot retain Ring or similar pessaries due to introital laxity (see Figure 5). The shape of the Gellhorn pessary allows the lateral vaginal walls to in-fold under the top dish, while the concave dish itself may create a suction-like action against the proximal vagina, facilitating pessary retention. The stem of the Gellhorn follows the shaft of the vagina, maintaining correct alignment. The option of two different stem lengths (short and long) allows optimal fitting even in women with a shortened vagina, such as post-hysterectomy women. Although the ability of the Gellhorn to be somewhat self-retaining can be a considerable advantage, it also makes this pessary more difficult for clinicians and patients to remove. In addition, the Gellhorn pessary may be more likely to cause mechanical trauma to the vaginal tissue. As with other pessaries, Gellhorn fitting involves measurement of the vagina, in this case, assessing both the diameter of the introitus and the apex to approximate the correct size of the dish and of the vaginal length to determine whether a long or short neck is appropriate (see Figure 8).

To insert the flexible Gellhorn, the stem can be bent down to the dish and the dish folded, with the edge of the dish inserted first. The pessary is then corkscrewed gently down toward the perineum to avoid the urethra, then upward to bring the dish perpendicular to the vaginal vault. The pessary can then be pushed gently upward using the index finger on the knob at the end of the neck, placing the dish into the vaginal apex. The woman can then bear down as an initial assessment of the likelihood of retention. If two to three adjustments in the size of the pessary do not work, a Cube pessary may be an option.

Removal of a flexible Gellhorn is generally achieved by lubricating the introitus, pulling the knob at the end of the pessary neck gently downward (toward the introitus) and laterally (toward a thigh), and using the index finger to hook and bend down the edge of the dish. When the knob cannot be easily grasped, a carefully placed tenaculum or ring forceps may be helpful to assist removal. Gellhorn pessaries are sized in quarter-inch intervals by the dish diameter, with common sizes generally ranging from 1.75 to 3 inches.

Cube. The Cube pessary can also be considered self-retaining (see Figure 6). Compared to a Gellhorn pessary, a smaller size can be used; however, Cube use may also result in mechanical tissue injury. Cube pessaries are held in place because the concavities in the six sides allow vaginal tissue to conform to the pessary shape. Because large amounts of epithelium are in contact with the pessary, drainage holes are important to allow desquamated cells and vaginal discharge to drain. The Cube is designed for self-care, but like the Gellhorn, some women and providers find it difficult to remove due to the suction. Softness and compressibility of the silicone used vary by manufacturer. Softer Cubes can be easier to insert, but firmer devices may be more likely to be retained, and choice is typically based on provider experience. The Cube pessary can be placed at different depths in the vagina, which may offer an advantage when a woman has an isolated or site-specific prolapse.

Size is estimated by digitally measuring the diameter of the vaginal shaft and vault. To insert, lubricate the pessary and introitus, compress the pessary, part the introitus gently, and insert the pessary to the depth that best corrects the bulge and is most comfortable for the patient. Commonly used sizes range from 1 to 4.

To remove, lubricate the introitus, apply gentle traction on the pessary cord to stabilize and bring the device toward the introitus, and then insert the tip of the index finger up above the Cube to release it and pull it gently out of the vagina. Pulling too hard on the cord alone will break the cord. If removal is difficult, a tenaculum, ring forceps, pessary remover or crochet hook, or dental tape tied through several holes can be used to facilitate bringing the Cube to the introitus.

Incontinence Pessary Options

Incontinence pessaries help stabilize the urethra and the urethral vesicle junction to prevent leakage during times of increased abdominal pressure. Options include the Incontinence Ring or Dish, which are similar to regular Ring pessaries but offer less vaginal support; and standard Ring, Arch (Gehrung), or Lever (Smith-Hodge) pessaries with an optional incontinence support knob. Most of these pessaries are fitted similarly to a standard Ring pessary. While some women use incontinence pessaries only during exercise, others use them continuously. Generally, the incontinence knob pessaries are fitted more snugly behind the symphysis, beneath the urethra. A pessary that is too loose will not decrease stress UI and may rotate in the vagina. Too much pressure may cause discomfort, epithelial injury, and urinary retention. If the woman plans to use the pessary only intermittently or during exercise, it may be fitted more snugly to retain urine. Although pessaries are typically fitted with an empty bladder, fitting an incontinence pessary in a woman with a full bladder may facilitate testing of both stress UI treatment during exercise and voiding adequacy.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....