Maria Teresa C. Luna, MD
I. VAGINAL PESSARY
A vaginal pessary is a removable device placed into the vagina. It is designed to support different sites of pelvic organ prolapse (POP). Available pessaries are either made of silicone or latex rubber.
1. Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse. (Level III, Grade A)
Summary of Evidence
Vaginal pessaries are the standard nonsurgical treatment for POP. A vaginal pessary can be properly fitted in 78% of patients with approximately 50% of those properly fitted continuing to use a pessary a year later.1-3 Pessaries are most often used when the patient has a strong preference for nonsurgical management of POP or when the patient’s health status confers a significant risk for surgical morbidity and mortality. 4
2. Clinicians should discuss the option of pessary use with all women who have prolapse that warrants treatment based on symptoms. In particular, pessary use should be considered before surgical intervention in women with symptomatic prolapse. (Level III, Grade B)
Summary of Evidence
Patient factors that determine the type of pessary to be used are sexual activity, site of POP and stage of POP. If the patient is fitted with the correct
pessary size, she is not aware of its presence when she wears it, she can void
readily, freely and completely and the pessary stays in place (while seated on a toilet bowl and during ambulation). If the patient is fitted with the correct
pessary type, no site of defect protrudes when the pessary is in place.
Vaginal atrophy should be treated before and concomitant with pessary initiation.
Serious complications such as erosions to adjacent organs are rare with proper use and usually result only after a long time of neglect.
Pessary complications are rare occurrences in medically compliant patients. The most common side effects of vaginal pessaries are vaginal discharge and odor. Other complications include vaginal bleeding, pelvic/vulvar/vaginal discomfort/pain, pessary expulsion, urinary incontinence (UI), and rectal pain, depending on the type of pessary. Rarely, vaginal pessaries can cause major urinary, rectal and genital complications including fistula, fetal impaction, hydronephrosis and urosepsis.5
The vaginal pessary is removed nightly, washed with soap and water and replaced the next morning. After initial pessary placement, the patient is advised to come back for check-up after 1 week, during which time, the
vagina is inspected for erosions, abrasions, ulcerations, granulation tissue formation and infection. Scheduling of subsequent visits is individualized.6
Vaginal estrogen is generally recommended to patients who, at the time of their initial fitting or at subsequent follow up, are noted to have vaginal atrophy or areas of ulceration or abrasions from pessary use. 7
3. Currently there is no evidence from randomized controlled trials (RCT) upon which to base treatment of women with POP through the use of mechanical devices/pessaries.8 There is no consensus on the use of different types of device, the indications, nor the pattern of replacement and follow-up care. (Level III, Grade B)
II. PELVIC FLOOR MUSCLE EXERCISE
Despite of the lack of high quality scientific evidence supporting pelvic floor muscle exercise for prevention and treatment of POP, it poses no risk and cost to the patient. It is offered to all patients who are asymptomatic or mildly symptomatic and are interested in preventing the progression of the condition and who decline other treatments. There is some encouragement from a feasibility study that pelvic floor muscle training (PFMT), delivered by a physiotherapist to symptomatic women in an outpatient setting, may reduce severity of prolapse.10 (Level II-3, Grade B)
Summary of Evidence
The muscles of the pelvic floor help support the abdominal and pelvic contents from below, help control bowel and bladder function and play a role in sexual response.
Pelvic floor muscle exercise helps in reducing the progression of POP. The pelvic floor muscle exercise, also known as the Kegel exercise, has been thought to offer a number of benefits to the patient. Firstly, the patient learns to consciously contract before and during increases in abdominal pressure. Secondly, the pelvic floor muscle exercise builds permanent muscle volume and structure support.9
III. PATIENT EDUCATION AND LIFESTYLE MODIFICATION
Patients with POP should be counseled on the importance of various lifestyle modifications that may prevent or improve their symptoms of prolapse. (Level III, Grade C)
Summary of Evidence
Maintaining an ideal body weight limits the pressure that the abdominal content places on the pelvic floor. Any activity that engages the pelvic floor such as walking or gardening can help strengthen the muscles. Patients should be instructed to contract their pelvic floor muscles when lifting
or straining. Patient education should also include bowel movement retraining. This will teach a passing motion without straining the pelvic floor muscles. Advising women on correct posture will in aid in preventing strain on the pelvic floor muscles.11
References
1. Wu V, Farrel SA, Baskett TF, Flowerdew G. A simplified protocol for pessary management.
Obstet Gynecol 1997;90:990-994.
2. Sulak PJ, Kuehl TJ, Shull BL. Vaginal pessaries and their use in pelvic relaxation. J Reprod
Med 1993;38:919-923.
3. Clemons JL, et al. Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse. Am J Obstet
Gynecol 2004; 190(4): 1025–1029.
4. Rodriguez E, Trowbridge MD and Fenner DE. Conservative management of pelvic organ prolapse. Clin Obstet Gynecol 2005;48(3):668-681.
5. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007;369:1027-1038. 6. Farrell SA. Practice advice for ring pessary fitting and management. J SOGC 1997;19:625. 7. Poma PA. Management of incarcerated vaginal pessaries. J Am Geriatr Soc 1981;29:325-327. 8. Hagen S, Stark D, et al. Conservative management of pelvic organ prolapse in women.
Cochrane Database Syst Rev 2006, Issue 4.
9. Bo K. Pelvic floor muscle training is effective in treatment of stress urinary incontinence, but how does it work? Int Urogynecol J 2004;15:76.
10. Hagen S, Stark D, Maher C, et al. Conservative management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2:CD003882, 2004.
11. Rodriguez E, Trowbridge MD, Fenner DE. Conservative management of pelvic organ prolapse. Clin Obstet Gynecol 2005;48(3):668-681.