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

Management of Pessary Complications

Complications can occur even in women who initially report satisfactory pessary-related symptom relief and comfort. Problems may present as genital bleeding, unusual vaginal discharge, pain or pressure, and/or defecatory complaints, or may only be identified on routine vaginal examination (Sarma et al., 2009; Wu et al., 1997). Some pelvic symptoms, including constipation, urinary frequency, dysuria due to UTI, and incomplete or difficult bladder emptying, are also common in postmenopausal women without pessaries, and the relative rate of symptoms in users and non-users is not well studied. Although management of these common problems is beyond the scope of this article, when they occur in pessary users, the pessary's potential role as an aggravating or mitigating factor should be carefully evaluated. In addition, all clinicians providing pessary care must consider their own knowledge base and scope of practice, the resources available in their office setting, and the general health or frailty of each pessary user in deciding which complications to manage and which to refer to specialty care.

Generally, when clinical assessment of any complication suggests pessary use as an etiology, management options include refitting for pessary size and shape, temporary or permanent removal of the pessary, treatment of any active infection, and/or modifying the vaginal environment with acidifying products or vaginal estrogen. Table 5 describes general clinical suggestions for common pessary-related problems. Manage ment of two common pessary-related problems – mechanical injury of the vaginal epithelium and abnormal discharge – is presented in greater depth below.

Mechanical Injury of the Vaginal Epithelium

Vaginal inspection at regular visits detects early signs of significant mechanical injury, allowing for alterations in the clinical plan to avoid serious sequelae, such as fistula formation. To determine which women were at higher risk of mechanical epithelial injury, Wu and colleagues (1997) assigned study participants to visually determine categories using assessment criteria not extrapolated in the text. Women were described as having epithelium that was normal thickness (n = 14), moderate thickness (n = 28), or atrophic (n = 33). Atrophic tissue was more likely to develop epithelial abrasion when compared to the other two groups (range = 0% to 18%; p ≤ 0.05), and abrasion occurrence was more common in Cube versus Ring pessary users (83% versus 3%, p ≤ 0.001). There was no correlation related to oral estrogen use. These findings support current recommendations for more frequent return visits for users of self-retaining pessaries (such as Cubes) and for the use of vaginal estrogens for treatment of atrophy.

Description and management of epithelial pressure injury has not been as well studied as cutaneous pressure wounds (National Pressure Ulcer Advisory Panel, 2010). When mechanical erosion is identified, follow-up planning is based on clinical factors (such as the location and depth of the injury related to fistula risk, friability and use of anticoagulants related to bleeding risk, degree of atrophy and potential benefits of vaginal estrogen use, evidence of treatable infection, and risk of coexisting pathology, such as cancers of the vagina, cervix, or endometrium) (Kaaki & Mahajan, 2007; Kenton, 2003). Temporary pessary removal to eliminate mechanical pressure is often recommended (Wu et al., 1997). Typical practice then includes a recheck in two to four weeks, depending upon the extent of the epithelial injury (Atnip, 2009; Sarma et al., 2009). During that time, any exposed vaginal epithelium is typically protected from dryness and chaffing on clothing or pads. Potential treatment products, including vaginal acidifiers, moisturizers, vaginal estrogens, and/or oral or vaginal antimicrobials, are described in more depth elsewhere in this article, although their comparative effectiveness has not been studied. Once repeat vaginal inspection confirms epithelial health, a follow-up routine is reinitiated, typically including pessary re-fitting, with or without modifications in size or shape and/or ongoing use of treatments, such as vaginal estrogen.

Although temporary pessary removal can be expected to quickly relieve mechanical pressure and facilitate healing, some women experience serious, acute symptoms during pessary removal. These can include acute prolapse recurrence, pain, urinary retention, UTI, and bowel dysfunction. For these women, a trial of other options may be beneficial. For example, use of a different shape or size of pessary may alter the area of mechanical pressure enough to allow healing. Another unstudied option might be temporary use of an inflatable Donut pessary that is removed nightly. If an alternate pessary does not seem safe or practical, other options must be formulated. For example, acute urinary retention due to recurrence of anterior compartment prolapse might be mitigated through use of intermittent support of the anterior vaginal wall digitally or with a device such as a proctology swab, which can straighten the urethra and allow voiding. If this is unsuccessful, intermittent self-catheterization or temporary use of an indwelling urinary catheter may be necessary.

When erosions do not resolve within one month, biopsy is indicated because occasional cases of vaginal and cervical cancer in pessary users have been reported (Schraub et al., 1992). In addition, recurring or poorly healing mechanical injuries may make pessary use impractical, suggesting the need to re-examine benefits and risks of alternate treatments, such as surgery.

Abnormal Discharge

Typical complaints related to vaginal discharge during pessary use include changes in discharge amount, color, or odor. Some temporary increase in vaginal discharge is commonly reported by new pessary users, which may be reassuring for some women to hear. When bothersome symptoms continue, treatment planning is generally based on extrapolation of data from other contexts and on expert opinion.

Initial assessment of changes in discharge should include very careful inspection of the vaginal epithelium in its entirety, looking for mechanical injury. Vaginal pH and microscopy can be assessed, although little is known about the implications of typical changes seen in post-menopausal pessary users (Alnaif & Drutz, 2000). Vaginal culture is typically not helpful unless otherwise unidentified yeast organisms are suspected. If vaginal bleeding is present, an endometrial biopsy should be considered even when vaginal erosion is identified to rule out co-existing problems, such as endometrial hyperplasia or cancer.

Management strategies for abnormal discharge in pessary users may include a variety of options: the woman can opt for temporary or permanent removal of the pessary; pessary drainage holes can be added to limit pooling of vaginal exudate, a potential medium for growth of odor-producing micro-organisms; atrophy or vaginal infections can be treated; or acidifying products may be used (see also "Vaginal Acidification" and "Vaginal Moisturizers" sections above). If an overgrowth of yeast or bacterial pathogens is suspected, treatment options include the use of antimicrobials in regimens extrapolated generally from vaginitis treatment guidelines.

Use of Antimicrobials. Comparisons of the typical vaginal microscopy findings in symptomatic and asymptomatic pessary users have not been described, and implications in clinical practice are not known. One study reported higher rates of gram stain findings consistent with bacterial vaginosis (BV) in pessary users than in controls (32% versus 10%, relative risk of developing BV 4.37, 95% confidence interval, 2.15 to 9.32) (Alnaif & Drutz, 2000). Although it is not clear whether the pessary users were symptomatic, the authors hypothesized that pessary removal 10 days pre-operatively might normalize vaginal flora and decrease risk of vaginal cuff cellulitis. There is no direct evidence that treatment of pessary users with findings consistent with BV is beneficial related to decreasing vaginal discharge symptoms, prevention of upper tract infection, or protection of vaginal epithelium from future injury.

If overgrowth of abnormal microbes, such as bacteria or yeast, is suspected from clinical signs, symptomatic relief is the treatment goal. If yeast is identified, any available over-the-counter or oral anti-fungals may be helpful. It is not known whether pessary removal during treatment would improve outcomes. If bacterial infection is suspected, oral treatment options recommended in the United States include metronidazole, clindamycin, or tinidazole (Centers for Disease Control and Prevention [CDC], 2010). Recommended topical vaginal antimicrobials include creams containing clindamycin (CleocinTM) or metronidazole (MetrogelTM) (CDC, 2010). Outcome studies in pessary users have not been reported. Associated options, such as pessary sterilization, replacement, or temporary removal during treatment, can be considered but have not been studied.

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