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

Prevention of Pessary-Related Complications

Although providers often advise routine use of vaginal products in conjunction with pessary use, the relative costs, preventive role, and comparative outcomes of these products have not been well-studied. Current evidence related to the role of three strategies is summarized below, including topical estrogen treatment of urogenital atrophy, vaginal moisturizers, and vaginal acidification.

Vaginal Estrogens

Urogenital atrophy due to low estrogen levels results in thinning of the epithelial lining, loss of elasticity, contraction of the introitus, and dryness due to decreased vascularity and transudate (Freedman, 2008). Factors that contribute to urogenital atrophy include post-menopausal status, smoking (which increases estrogen metabolism), and use of certain medications and breast cancer treatments, such as some selective estrogen receptor modulators (Al-Baghdadi & Ewies, 2009). Atrophic changes can result in increased discomfort or tissue injury with pessary insertion and removal, and have been associated with higher rates of mechanical vaginal erosion during pessary use (Arias et al., 2008). It may be possible to modify problems related to pessary use in the presence of vaginal atrophy by modifying reversible risks (such as through smoking cessation). In the absence of comparative evidence, provider prescription of vaginal estrogen continues to vary and includes use prior to initial pessary fitting as needed during ongoing pessary follow up and/or continuously throughout pessary use (Arias et al., 2008; Sarma et al., 2009).

Estrogens used vaginally are more effective than systemic estrogens in relieving symptoms of urogenital atrophy (North American Menopause Society [NAMS], 2010). Vaginally applied estrogen relieves vulvovaginal symptoms by promoting epithelial cell growth and cellular maturation, fostering re-colonization with normal lactobacilli, enhancing vaginal blood flow, decreasing vaginal pH to premenopausal levels, increasing vaginal wall thickness and elasticity, and improving sexual response (Freedman, 2008).

Several options for low-dose or ultra-low-dose vaginal estrogen therapy are available and listed in Table 4. It is important for women to understand that estrogens used vaginally do not offer the same risks and benefits as systemic hormone therapy. For example, while topical estrogen use can improve dyspareunia, recurrent urinary tract infection (UTI), and urinary urgency, low doses do not improve vasomotor symptoms or osteoporosis, or affect breast cancer risk (NAMS, 2010).

In addition, concomitant use of progestogens is not required for endometrial protection in women with intact uteri, although surveillance to confirm this recommendation during intermittent use or for use longer than 12 months is still not available (NAMS, 2010).

Although bioidentical hormones (those that are chemically identical to ovarian estrogens) are increasingly marketed, there is no evidence to support claims of their enhanced safety or efficacy (NAMS, 2010).

Generally, the lowest effective estrogen dose needed to decrease symptoms is recommended (NAMS, 2010). One new option, an ultra-low-dose vaginal tablet containing 10 micrograms of estrogen, has been shown to result in serum estradiol levels that are 50% lower than prior 25 microgram vaginal tablets (Eugster-Hausmann, Waitsinger, & Lehnick, 2010). However, because ultra-low-dose products have not been tested in pessary users, it is not yet clear if they provide sufficient estrogenic effect to improve comfort or decrease complications during pessary use, or what the optimum dose interval and duration will be.

Vaginal Acidification

The normal vaginal pH in women who are of reproductive age is typically 3.5 to 4.5 but rises to greater than 4.5 within 12 months of becoming hypoestrogenic (Freedman, 2008). This alkaline environment is thought to be a risk factor for atypical bacterial over-growth. Some women report increased discharge or odor during pessary use, and acidification of the vagina has been suggested as a potential deterrent or remedy. One pessary manufacturer in cludes an acidifying gel for use with all their pessaries (CooperSurgical, 2006). While some pessary users report a positive clinical response to vaginal acidification, there appears to be little data to support a universal recommendation. In woman of reproductive age, vaginal acidification has not been shown to decrease the risk of pathogenic bacterial overgrowth (Holley, Richter, Varner, Pair, & Schwebke, 2004). Outcomes related to vaginal acidification in postmenopausal women are even less well studied.

When vaginal acidification is part of the follow-up plan, two options include douching with vinegar and water, and using an acidifying gel. Generally, vaginal douching remains contra-indicated in pre-menopausal women because of concerns of altered vaginal flora and increased risk of vaginal and upper genital tract infections (Cottrell, 2010). These concerns may have little application to post-menopausal pessary users with atrophy-related absence of normal vaginal flora, or to women who have undergone hysterectomy and/or bilateral salpingo-oophorectomy. In those cases, clinicians may be best advised to review potential risks and benefits, allow women to make their own choice and help them evaluate their individual symptom outcomes during subsequent visits. If douching is chosen because optimal solutions, intervals, and outcome expectations are understudied, specific practice is based on expert opinion and preferences of the individual pessary user. One suggested option involves weekly use of a solution of one-fourth cup of vinegar mixed in one cup of warm water (Atnip, 2009).

A non-prescription acidifying gel recommended to pessary users contains triethanolamine, hydroxyquinolone sulfate, and sodium lauryl sulfate in a glycerin base (Trimosan™) (CooperSurgical, 2006). It is recommended for use two to three times per week, reportedly to adjust and maintain a vaginal pH of 4.0, and lubricate the vaginal walls, reducing odor-causing bacteria (CooperSurgical, 2008). While no specific supportive references are provided, the pessary manufacturer describes the product as non-perfumed, and compatible with latex and silicone pessaries. The gel appears to be a low-risk intervention, which may im prove temporary lubrication, comfort, and pessary satisfaction for symptomatic women who prefer a non-hormonal choice.

Vaginal Moisturizers

Vaginal moisturizers have also not been widely studied with pessary use but offer another over-the-counter option to counter-act symptoms associated with atrophic vaginal changes. Unlike more temporary vaginal lubricants, they affect epithelial cells directly. For example, some moisturizers contain the negatively charged bioadhesive polymer, polycarbophil (Fiorilli, Molteni, & Milani, 2005). This polymer has both acidifying and water-carrying qualities, and adheres to the superficial cells of the vaginal epithelial tissue until they are normally shed in two to three days. This adherence is thought to temporarily increase intracellular electrolyte and water volume, and may have a vasodilating effect, increasing blood flow. Polycarbophil products have been shown to lower vaginal pH, improving signs of bacterial overgrowth seen with bacterial vaginosis (Fiorilli et al., 2005; Wu, Fielding, & Fiscella, 2007). On the other hand, non-polymer-based moisturizers, such as those with a pectin base, may offer similar temporary symptom relief (Caswell & Kane, 2002). In comparison trials with estrogen-products, polycarbophil-based moisturizers provided only transient symptom improvement, and did not provide the sustained subjective and objective changes seen with the use of vaginal estrogen products (Biglia et al., 2010). With regular use, vaginal moisturizers may limit vaginal discharge, odor, and dyspareunia for pessary users, but are unlikely to prevent ongoing atrophic change or associated mechanical irritation and erosion. Pending conclusive data, helping women extrapolate research results such as these may also help them evaluate the costs and benefits of various self-care products.

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