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Pessary For Pelvic Organ Prolapse

 

The human body, like all things organic, will degrade over time. And while we would all like to hope that we’re ageless, perfect creatures from birth to death, we have to face the fact that our bodies will decline starting at about middle age.

Starting around that period, some parts of our organs can no longer defy gravity to a point where it may need external support while other get weak, degenerate, break or fail. For those with heart ailments, they may require pacemakers. Those with busted knees may require knee implant surgery, while those who broke their hips may have to have hip replacement surgery. You get the picture.

In like manner, the vagina may not keep its structure over time, as well. For some poor unfortunate souls, bowels and other tubular structures around the vagina may droop into the vaginal walls, requiring the use of tools like the vaginal pessary.

Before we discuss what a vaginal pessary is, we need to understand the reason why an individualmight need it. The chief condition that necessitates the use of a vaginal pessary is called the “pelvic organ prolapse.” We discuss what it is in the next section.

What Is Pelvic Organ Prolapse?

 

Before we define “pelvic organ prolapse” in itself, let’s define what “prolapse” means.

Here are some definitions of “prolapse”:

● A falling down of an organ, such as the uterus, from its normal position. [Dictionary.com]
● To slip down or fall out of place. [Dictionary.com]
● The slipping or falling down of a body part from its usual position or relations. [Merriam-Webster]

So when one of the structures within the pelvic area falls out of place and impinge on the vagina and vice versa, you have a “pelvic organ prolapse.”

Here are the types of pelvic organ prolapse (POP):  

 

● Cystocele — When the bladder prolapses into the vagina. This is the most common condition under pelvic organ prolapse.
● Urethrocele — When the urethra (the tube where urine passes through) prolapses into the vagina. [Alberta MyHealth]
● Uterine Prolapse — As the term suggests, this is the prolapse of the uterus into the vagina.
● Vaginal Vault Prolapse — When the vagina itself prolapses. In this condition, it is the upper part of the vagina that prolapses down into the vaginal canal (or in the structures outside the vagina). [Michigan Medicine]
● Enterocele — When the small intestines descend into the lower pelvic cavity, and especially into the vagina, creating a bulge. [Cleveland Clinic]
● Rectocele — When the rectal walls (walls of the rectum) weaken and push into the vagina, creating a bulge. Usually, it is the front wall of the rectum that pushes into the posterior, or back wall of the vagina. [Cleveland Clinic]

These conditions listed, you may now have an idea of what a pelvic organ prolapse is, and the types of pelvic organ prolapses there are.

In more recent years, a condition called stress urinary incontinence (SUI), which happens when a person cannot control passing small amounts of urine while sneezing, coughing, or exercising, is another common problem among women. SUI can warrant the use of a vaginal pessary.  

What Is A Vaginal Pessary?

 

A vaginal pessary is a flexible, firm device placed inside your vagina to hold up or mechanically push up your prolapsing tissue. This may be prescribed to manage conditions you may have, including POP, SUI, or both. It can also serve to support and reposition your urethra or uterus.

For your information, the vaginal pessary has been around for centuries. It has provided women a conservative (non-surgical) alternative for managing the symptoms of both POP and SUI.

Generally, the vaginal pessary is inert and made of plastic or silicone material. Nowadays, this device may be recommended by a healthcare provider for the following reasons:

1. For older women who may be too frail to withstand a surgical procedure
2. For pregnant women with POP/SUI or both
3. For women with weak, thin, or pale vaginal tissue (with estrogen)
4. As temporary measure until a more definitive treatment (e.g., surgery) is done
5. An alternative for women who do not opt for surgical repair

For a clearer picture of what a vaginal pessary is, we can take a look at the different definitions of what it is around the web:

● A vaginal pessary is a flexible, removable device that goes into your vagina. It supports areas that are affected by POP. This happens when the bladder, rectum, or uterus drops or bulges down toward the vagina. [WebMD]
● A pessary is a soft, prosthetic device inserted into the vagina to reduce the protrusion of pelvic structures. The device can be a route of administration of medication and provides a slow and consistent release of the drug. Pessaries are of varying shapes and sizes. [Wikipedia]
● A vaginal pessary is a flexible, removable device placed into the vagina. It is designed to support the areas of pelvic organ prolapse. There are a variety of pessaries available, including the inflatable doughnut, the ring, the and Gellhorn. These come in different sizes and should be fitted carefully. [Peter M. Lotze, MD]

Contraindication

 

You need to consult a medical provider regarding your condition before using this device because some women are not good candidates for using the vaginal pessary. These may include women who have severe forms of POP, or if your vaginal opening is too large. In this case, the vaginal pessary will simply be pushed out, or fall out, once you stand up.

Sizes & Shapes

If you’re planning to use a vaginal pessary, you should know that this device comes in all sizes and shapes. Hence, you may need to have your condition assessed by your health provider to choose the best pessary for you. And be sure to get one that fits your size.

According to a study in the International Urogynecology Journal & Pelvic Floor Dysfunction, most women with SUIs can be successfully fitted by a trained nurse practitioner, registered nurse, or physical therapist after one or two fittings.

Sizes typically range from 0 (1.75 in/44 mm diameter) to 10 (4.25 in/108 mm diameter). In the study, among women with SUIs in the US, approximately 2/3 could be fitted with a size 2-4. It was found that the average diameter was 69 mm, which is approximately a size 3.

Before fitting, your healthcare provider will assess the conditions of your POP and do some measurements of the internal dimensions of your vagina to fit you with the best style and size of device for your needs.

Credits: LabIVF Vaginal Ring Pessaries

Does it hurt?

A good fit should not be felt within your vagina, and should not be too tight against your vaginal walls. This can be checked by running a fingertip between the outer edge of the device and your vaginal walls. Additionally, you should have no discomfort when going to the bathroom, and it should not fall out even when you bear down.

During fitting with your healthcare provider, the vaginal pessary should not cause you vaginal or low abdominal discomfort/pain in a lying down or upright position. Although, some women report experiencing minimal pelvic discomfort during fitting.

If you feel any discomfort/pain after the process of fitting, you need to inform your health provider, so assessment of your symptoms can be done accordingly.

Types of Vaginal Pessaries

 

There are different types of vaginal pessaries, but here are the common classifications:

Functionality

● Therapeutic Pessary — The kind of pessaries used in Pelvic Organ Prolapse.
● Pharmaceutical Pessary — These pessaries are used to administer medicine, such as yeast infection medicine.
● Occlusive Pessary — Usually used with spermicide as a contraceptive.

Shape

● Ring — Circle-shaped and can be inserted on your own, without medical assistance.
● Gehrung –This is U-shaped and molded to fit the individual. This is used in more advanced uterine prolapse.
● Gellhorn — The Gellhorn Pessary has a disc-shaped structure on one end, then a knob on the other. The disc end supports the uterus in more advanced uterine prolapse, while the knob end faces the cervix or vagina.  
● Cube — Another pessary that’s specifically for advanced-stage prolapse, this pessary can be inserted on your own, as well. However, this needs to be taken out daily. It works via a suction mechanism that supports the vaginal walls and corrects the prolapse. [Your Pessary]

More types of pessaries can be used. Dr. Peter M. Lotze, MD, lists the ring, inflatable, doughnut, and Gellhorn, while the American Family Physician has a table of the pessaries that a patient can consider using.

Health Products For You also has a great page about the types of pessaries available, and what they can be used for.

Insertion & Removal of the Device

 

Using the vaginal pessary may be done in the comfort of your home. But for first-timers, you may need to ask for instructions from a healthcare provider. The following are general steps that are advised:

1. Be sure to wash your hands thoroughly using soap and water before insertion or removal of your vaginal pessary.
2. To insert, note that the notches inside the ring together with the openings (in the ring-with-support) are flexible points.
3. Grasp the vaginal pessary midway between these points, then fold the device in half. The curved portion should face the ceiling (imagine a taco).
4. Next, place a small amount of lubricant (e.g., KY Jelly) on the insertion edge.
5. With one hand, hold the vaginal pessary, then spread the lips of the vagina with your other hand.
6. Gently push the device as far back as it can go into the vagina. This may be done with you standing with one foot propped on the toilet/tub, sitting with feet propped up, or squatting–whichever position you are most comfortable with.
7. To remove, wash your hands first and foremost.
8. Look for the rim of the vaginal pessary under the pubic bone at the front of the vagina.
9. Then locate the opening or notch and hook your finger over or under the rim.
10. Finally, tilt the vaginal pessary to about 30 degrees, and pull it down out of your vagina gently. If you can fold the device, it will be easier to remove.

Note that bearing down (as if you are having a bowel movement) can help push forward the rim of the device, so you can take it out more easily. Moreover, if you are interested to learn how to remove or reinsert the device by yourself, seek help from your health provider for proper home instructions and supervision.

Although there are types of pessaries that you can insert on your own, it is really best to consult the doctor first so that you can also be monitored for adverse reactions to the pessary.

Evidence-based Safety

 

Generally, the vaginal pessary as management for POP and SUI is considered well-tolerated, safe, and cost-effective. Although some claim that the overall effectiveness is not yet established due to limited data.

In a 2019 study in the Journal Medicine (Baltimore), the long-term use of the vaginal pessary is considered safe and cost-efficient. The device use seems to be more acceptable to olderindividuals, as it significantly impacts their quality of life. Additionally, it was found that severe stress urinary incontinence was noted among more aged women who were treated with the vaginal pessary for POP, but with poor long-term compliance.

Take note that all vaginal pessaries have some risk of infection or irritation. Let your healthcare provider know if you notice adverse complications including:

• High fever or feeling unwell
• Bleeding
• Difficulty with urination
• Difficulty/pain with sexual intercourse
• Foul–smelling discharges
• Irritation
• Stress incontinence

Tips, Care, and Cleaning

 

Hygiene is very important in the use of pessaries. Misused, pessaries can do more harm than good, such as in the case of this 80-year-old widow in India, who had a vaginal pessary inserted to treat her prolapse after childbirth. She apparently forgot that the pessary was inserted inside her, so she ended up seeking treatment for a foul feminine odor and a discharge, which ended up in the discovery of the forgotten pessary. Thus, here are the tips in how to take care of a vaginal pessary, if you have one:

● Caring for your vaginal pessary at home. It is typically recommended to take out the device and clean it daily to avoid infection and other complications. Mild soap and water should be used. You need to rinse and dry the device thoroughly before reinserting it into your vagina the next morning.
● Take note of the insertion and removal recommendations for your specific pessary.For example, the ring pessary is supposed to be removed and cleaned weekly, while the cube pessary, daily. Other pessaries may be kept inserted for months. Just pay attention to your health provider’s instructions, and remember to keep written instructions in an accessible and easy-to-remember spot.
● NEVER miss a follow-up visit to your doctor. Just like having an IUD (intrauterine device) for contraception, you MUST go to your doctor for regular check-ups. Don’t be like the cases of the ladies with the forgotten pessaries! Avoid unnecessary injuries and health risks by being vigilant with your follow-up check–ups. If you care for your own device at home, you are usually advised to be re-examined initially after two weeks, and then in three months. After a year of use, visiting your health provider 2-3 times a year is recommended.
● Always discuss all the relevant concerns with your doctor. Although some women are comfortable having sexual intercourse with the device left inside, it may be a good idea to clarify your concerns with a medical provider based on your specific condition. And besure to follow instructions, every time.

Where to Buy a Vaginal Pessary

Recently, a disposable, single-use vaginal pessary was approved for use in the US. It can be purchased over-the-counter even without a prescription. Typically, the disposable kind can stay in for a maximum of eight hours. The disposable type is inserted with an applicator (like a tampon), and can be removed by pulling a string.

 

You can buy the device from your local store or hospital, or even on-line. If you want to be sure of the brand to use, seek advice from your healthcare provider in acquiring the device. On average, the price with delivery may range from $50 to $100.

 

Healthline details the process of obtaining a pessary, as well as when/why you should go back to your doctor (even before your scheduled follow-up appointment).

Options for Managing Pelvic Organ Prolapse

 

When you feel the symptoms of pelvic organ prolapse: feeling the pressure, pain, or a sensation of fullness in the pelvic area, feeling like something is falling out of your vagina, backache, among others, don’t take matters into your own hands and do a DIY. Always speak with your doctor or OB-GYN and discuss your options.

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