Pessary Care

Follow Up and Management of Complications

Katharine O'Dell; Shanna Atnip

Disclosures

Urol Nurs. 2012;32(3):126-137, 145. 

In This Article

Pessary Follow Up

While it seems clear that regular pessary follow up is important, both appropriate intervals for follow-up and interim self-care recommendations continue to be largely based on expert opinion (Cundiff, Weidner, Visco, Bump, & Addison, 2000; Gorti, Hudelist, & Simons, 2009; Pott-Grinstein & Newcomer, 2001). The following sections discuss common self-care and provider care options.

Initial Instructions

New pessary users are generally instructed to note improvement in symptoms and report new problems, such as pain or discomfort, genital bleeding, abnormal vaginal discharge, sexual problems, and problems with elimination of urine or stool (Atnip, 2009). Optimal intervals for self-care have not been determined, and recommendations vary. For example, one pessary manufacturer's packet instruction states that in ideal circumstances, users should be taught to remove all styles of pessary nightly for cleaning and reinsertion (CooperSurgical, 2008). Optional daily removal and cleaning are encouraged during the use of some pessaries, and referred to as mandatory during use of latex inflatable and Cube pessaries, the latter without reference to the presence or absence of drainage holes.

For the newer silicone inflatable pessary, manufacturer recommendations suggest removal for cleansing every day or two (Panpac Medical Corporation, 2010). When pessaries are removed, they can be washed with soap and water, rinsed thoroughly, and re-inserted, or stored for future use. While providers may offer women optional teaching related to self-removal and reinsertion, some may not be either able or willing to perform self-care (Sarma et al., 2009).

In addition, women initiating pessary use are likely to have many questions related to how pessary use may affect their lifestyle and activities. Some answers will require experience. For example, women who are of reproductive age may need to experiment to identify their preference for management of their menses, either by pessary removal through the entire menses, or by more frequent removal and reinsertion after cleaning. As noted in the first article of this series (Atnip & O'Dell, 2012), some pessaries, such as the Ring, are expected to be more compatible with use during intercourse; however, couples' preferences may vary. Well-fit pessaries are expected to allow women to perform a full range of physical activities and exercise comfortably, but experience may identify extreme activities that are not pessary-compatible for an individual. Women may also express concern about pessary use during medical testing, such as colonoscopy and diagnostic imaging. Because preferences may vary, women may be best advised to query the provider performing the endoscopic procedure or imaging regarding the need for pessary removal.

Women planning Magnetic Resonance Imaging can usually be reassured that silicone pessaries do not include metal; however, confirmation of this should be sought through the pessary manufacturer. Finally, women often have questions about the implication of pessary use for security surveillance. While metal detectors will not respond to silicone-only pessaries, newer surveillance technologies, including full-body scanning, are likely to identify a pessary in place. Although the utility is unclear, some clinicians provide women with confirmation of pessary use via brochure, written prescription, or form letter on practice letterhead to help preclude potential delay or embarrassment (Bradway, 2011). Table 1 presents additional provider-generated self-care options for women who use pessaries.

Intervals Between Office Follow Up

Regardless of the follow-up plan, if pessary users report warning symptoms between regular return visits, they will need to be triaged to emergent or urgent care related to the severity of symptoms. Triage options have not been well studied. Clinical judgment related to symptom severity must be used with pain, bleeding, and acute retention of urine or stool likely to be reasons for emergent care.

Recommendations for appropriate routine intervals for follow up of women reporting comfortable, effective pessary use also vary, typically based on expert opinion. For example, one manufacturer's product insert for a variety of pessary types instructs providers to require women to return within 24 hours of initial fitting, again in 72 hours, and every few months, with schedule variations based on clinical judgment (Cooper Surgical, 2008). Another manufacturer's package insert for the Inflatable Donut pessary also provides a mix of very specific recommendations (for example, the device can only be prescribed by a physician, and fitting should be followed within 24 to 48 hours to rule out allergy to the product) with instructions that are more vague (for example, subsequent follow-up visits can be planned to fit the needs of the patient) (Panpac Medical Corporation, 2010). This review of manufacturer concerns suggests that allergic reactions to pessaries may have occurred, and inclusion of the risk may be needed in informed consent discussions, even though cases have not appeared in the medical literature.

When providers make follow-up decisions that deviate from manufacturers' recommendations, decisions should be based on available evidence. However, there is a dearth of interval comparison trials. In observational follow up, 104 women were successfully fitted with Ring pessaries with or without support membrane, and six with Cube pessaries, with the presence or absence of drainage holes not reported (Wu, Farrell, Baskett, & Flowerdew, 1997). These women were followed initially at two weeks post-fitting, then every three months for the first year, and every six months thereafter in the absence of erosion. The authors concluded that participants had no serious complications, although 15 women developed vaginal abrasions (all using Ring pessaries), eight developed vaginal erosions (five with Cube pessaries and three with Rings, p < 0.001), and 10 reported pelvic pain (three Cube-users and seven Ring-users). Complication management was not addressed in the Wu et al. (1997) publication.

In a subsequent survey of pessary providers, the most common follow-up interval pattern was one week, one month, and every three months thereafter, with no variation specified related to type of pessary (Pott-Grinstein & Newcomer, 2001). Standard practice recommendations are also published as incidental elements of broader discussions. One case discussion suggests office-visit intervals varying from three to six months, with closer intervals for pessaries that are self-retaining or lack drainage holes (Kaaki & Mahajan, 2007). Responding to a survey in the United Kingdom, providers also reported intervals between pessary visits ranging from 3 to 12 months with low complication rates, although patient characteristics, self-care practice, and pessary type were not ascertained (Gorti et al., 2009). These reports support the practice of longer intervals between pessary removal and cleaning as safe, standard, and cost-effective care.

Pessary Surveillance

In the absence of a definitive evidence base comparing surveillance practices, standards of care at pessary return visits also rely on expert opinion. These visits generally include some combination of focused history, pessary removal and cleaning, and vaginal inspection, with or without irrigation or topical treatment (Atnip, 2009). Components of a typical interim-focused history are listed in Table 2 .

Removal techniques also remain unstudied. Suggestions to aid difficult removals include tenaculum or Ring forceps, pessary removers, or dental floss tied to the pessary as a loop prior to insertion. Tips for removal of different shapes of pessaries are summarized in Table 3 .

Once the pessary has been removed, an appropriately sized vaginal speculum is used to aid careful inspection of the vaginal epithelium for mechanical irritation (Kaaki & Mahajan, 2007). A proctology swab or other displacement device can be used to increase visualization of cervical fornices or the vaginal apex (see Figure 1). Following complete hysterectomy, the vaginal apex may be as thin as 2 to 4 mm (Tulikangas, Walters, Brainard, & Weber, 2001), increasing the risk of life-threatening erosion into the peritoneum. Careful manipulation of any folds of redundant vaginal tissue, especially of areas that may be more difficult to visualize in standard lithotomy or semi-Fowler's position (including the anterior vaginal wall, cervical fornices, or vaginal cuff post-hysterectomy) is important for identifying mechanical injury of the vaginal epithelium. Typical areas of injury that may result from different styles of pessary are illustrated in Figure 2.

Figure 1.

Proctology Swab Used in Examination of Mechanical Vaginal Erosion

Figure 2.

Mechanical Injury from A) Ring, B) Gellhorn, and C) Cube Pessaries

Vaginal cleansing at pessary follow-up visits or during routine self-care is not universally performed, and there is currently no evidence to support routine irrigation. If excessive discharge is observed in the absence of identifiable pathogens, the vagina can be cleansed in a variety of ways. One cleansing option is wiping of the vagina with a proctology swab moistened with water, saline, vaginal water-based lubricant, or a mild antiseptic solution prepared with diluted povidone-iodine or chlorhexidine gluconate. Similar solutions may also be used for vaginal lavage using a 10 to 60 cc syringe with size choice based on clinical determination of vaginal diameter (Atnip, 2009). Lavage fluid can be contained using waterproof pads, toweling, and/or a collection vessel, such as an emesis basin.

Clinicians should take care if vaginal cleansing products are used. Both chlorhexidine and povidone-iodine have been studied for pre-operative and obstetric vaginal use in attempts to decrease wound infection. While chlorhexidine (4%) has been identified as more effective than povidone-iodine (10%) in reducing vaginal wall bacteria within five minutes (Vorherr, Vorherr, Mehta, Ulrich, & Messer, 1984), this may not translate to decreased infection risk (Webster & Osborne, 2007), is off-label use (Van Wicklin, 2006), and may result in significant irritation, including acute desquamation of the vaginal epithelium (Shippey & Malan, 2004). To avoid this risk, providers may prefer to perform any pessary-related vaginal cleansing with simple saline or water and treat identified microbial infections as discussed below.

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