Contemporary Use of the Pessary
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Contemporary Use of the Pessary Presentation Transcript

  • 1. Contemporary Use of the Pessary Indications - Fitting Instructions Milex Products, Inc. Chicago, Illinois 60634-1403 Copyright August 2002 All Rights Reserved
  • 2. Outline
    • Historical perspective
    • Prevalence of prolapse
    • Staging
    • Types of pessaries
    • Practical care of the pessary
  • 3. Historical perspective
    • Hippocrates
      • pomegranate
    • A.D.
      • leg binding
      • Astringents
    David Scott Miller, MD Contemporary Use of the Pessary Obstetrics and Gynecology Vol. 1, Chapter 39, January 1991
  • 4. Historical perspective
    • 1500’s
      • vaginal hysterectomy
        • de Carpi--tied string around prolapsed uterus
    • 1800’s
      • uterine malposition
        • Hodge
        • Smith
        • Risser
  • 5. Uses of Pessaries
    • Genital Prolapse
      • Uterine
      • Vaginal
      • Rectal
      • Bladder
    • Urinary Stress Incontinence
    • Mixed Incontinence
    • Cervical Incompetence
    • Retrodisplacement
  • 6. Diagnostic Use of Pessaries
    • Dynamic testing – illustrates urethral and bladder function
    • Predictor of Bladder Function After Pelvic Surgery???
    Linda Brubaker, Rush Medical College Now Professor and Fellowship Director Female Pelvic Medicine and Reconstructive Surgery Loyola University Medical Center, Chicago, IL) Poster Presentation, October 1996, New Orleans
  • 7. Types of Prolapse
    • Uterine
    • Vaginal
    • Cystocele
    • Rectocele
    • Enterocele
  • 8. Nine Measurement Points for Pelvic Organ Prolapse Quantification (POP-Q)
    • Aa Position of distal anterior vaginal wall, 3cm proximal to the external urethral meatus
    • Ba The most distal portion of the remaining anterior vaginal wall above point AaPoint at anterior vaginal
    • C The most distal edge of the cervix or vaginal cuff
    • D The position of the posterior fornix
    • Bp, Ap The most distal position of the posterior vagina; wall above point Ap
    • gH The genital hiatus
    • pb The perineal body
    • tvl The total vaginal length
  • 9. Ordinal Staging of Pelvic Organ Prolapse tvl=total vaginal length Maximal prolapse point protrudes the length of the vagina (2 cm) beyond the hymen. Complete eversion of the vagina +/- cervix ([value >/= + [tvl-2]) IV Maximal prolapse point protrudes beyond 1 cm above hymen but less than 2 cm less than the total vaginal length. (value >+1 but <+(tvl-2)) III Maximal prolapse point protrudes to or beyond 1 cm above hymen but not more than 1 cm below hymen (value >-1 to <+1) II All points are more than 1 cm above hymen (value<-1) I No prolapse: Apex of cervix is at a position above the hymen that equals to or is within +/- 2 cm of vaginal length (value </= (tvl-2)) No prolapse: All points are 3 cm above the hymen (value=-3) 0 Leading Edge of Prolapse: Location of Apex of Vagina or Cervix (Value of Point C or D) Leading edge of Prolapse: Location of the Most Distal Point of the Anterior or Posterior Vaginal Wall (any points Aa, Ap, Ba, Bp) Stage
  • 10. Vaginal Prolapse
    • Anterior or Posterior Wall Prolapse
    • Results in:
      • Cystocele
      • Rectocele
      • Enterocele
  • 11. Cystocele
    • Prolapse of Bladder and Anterior Vaginal Wall
    • Incomplete Emptying of Bladder
    • Can Cause UTI
  • 12. Rectocele
    • Prolapse of Rectum and Posterior Vaginal Wall
    • Incomplete Rectal Emptying
  • 13. Enterocele
    • Herniation of Small Bowel into Upper Posterior Vaginal Wall
  • 14. Symptoms of Prolapse
    • 1 st and 2 nd Degree
      • Lower back pain
      • Pelvic Pressure and Heaviness
      • Difficulty Controlling Urine and Stool
      • Urinary Urgency
  • 15. Symptoms of Prolapse
    • 3 rd and 4 th Degree Prolapse
      • Blockage of Bladder Neck
      • Urinary Retention
      • Increased Urinary Stress Incontinence
      • Palpable Prolapse
      • Incomplete Emptying of Bowels
  • 16. Risk Factors - Prolapse
    • Childbirth
    • Repetitive Bearing Down
    • Heavy Lifting or Coughing
    • Family History of Prolapse
    • Hysterectomy
    • Pelvic Surgery or Trauma
    • Menopause – Endopelvic facia failure
    • Obesity
  • 17. Advantages of Silicone Pessaries
    • Silicone has longer use-Life
    • Silicone can be autoclaved
    • Silicone does not absorb secretions and odors
    • Silicone is an inert material
  • 18. Uses of Pessaries
    • Uterine Prolapse
    • Procidentia
    • Cystocele, Rectocele, Urethrocele
    • Urinary Stress Incontinence
    • Incompetent Cervix
    • Retroverted Uterus
  • 19. Pessaries for Uterine Prolapse
    • Ring with or without Support
    • Shaatz
    • Regula
    1 st and 2 nd Degree Prolapse
  • 20. Ring without Support
    • 1st and 2 nd degree prolapse
    • Posterior Fornix to the Pubic Notch
    • Fitting
    • Removal
  • 21. Ring without Support Fitting and Removal
    • Posterior Fornix to the Pubic Notch
    • Insertion
      • Fold and insert
      • Make 1/4 turn
    • Proper Removal
      • 1/4 turn
      • Feel for notch
      • Fold and pull down
  • 22. Ring with Support Fitting and Removal
    • 1 st and 2 nd degree prolapse complicated by mild cystocele
    • Posterior Fornix to the Pubic Notch
    • Fitting
    • Removal
  • 23. Ring with Support Fitting and Removal
    • Posterior Fornix to the Pubic Notch
    • Insertion
      • Fold and insert
      • Make 1/4 turn
    • Removal
      • 1/4 turn
      • feel for notch and fold
      • and pull down
  • 24. Shaatz
    • Fits between the Levator Ani Muscles
    • Fold and insert
    • Removal - pull down with exam finger and remove
  • 25. Regula
    • Unique design helps prevent expulsion
    • Legs spread with pressure on arch
    • Indicated for 1 st and 2 nd degree uterine prolapse
  • 26. Regula Fitting and Removal
    • Fold pessary by bringing heels together to insert and remove
    • Arch is positioned so prolapse rests behind arch
    • Flanging of heels helps prevent expulsion
  • 27. Pessaries for Uterine Prolapse
    • 3 rd and Complete Procidentia
    • Donut
    • Cube
    • Gellhorn
    • Inflatoball
  • 28. Donut
    • The Donut pessary is very effective for 3 rd degree prolapse.
    • The Donut fits by filling the Vaginal Vault and supporting the prolapse.
  • 29. Inflatoball
    • The Inflatoball pessary works well for 3 rd degree prolapse.
    • This pessary is latex rubber.
    • Must remove daily.
  • 30. Inflatoball Fitting and Removal
    • Squeeze and insert
    • Pump until firm
    • Over inflation causes bulge
    • Secure tubing inside vaginal vault
  • 31. Cube
    • For 3 rd degree prolapse when all others will not be retained.
    • Maintained by suction – can cause vaginal erosion if not removed as directed.
    • Do Not Pull on Cord
    • Available with holes
      • Bulk not suction
  • 32. Cube Fitting and Removal
    • Squeeze and insert
    • Break suction
    • Compress to remove
    • Remove daily.
      • May cause vaginal erosion if not removed as directed.
  • 33. Tandem-Cube
    • Last Resort
  • 34. Tandem Cube Fitting and Removal
    • Trimo San on leading edge
    • Larger size pessary inserted first
    • Held by suction
    • Remove daily.
      • May cause vaginal erosion if not removed as directed.
  • 35. Gellhorn
    • Three Designs:
      • Silicone Flexible
      • Silicone 95% Rigid
    • Levator Ani Muscles
    • Cervix rests behind disk portion of pessary
  • 36. Gellhorn Fitting and Removal
    • Trimo San on leading edge
    • Hold parallel to introitus
    • Barber pole twist
    • Available with short stem
      • Approximately ½ inch shorter
  • 37. Pessaries Urinary Stress Incontinence
    • Incontinence Ring
    • Ring with (and without) Support and Knob
    • Incontinence Dish with and without Support
    • Hodge with and without Support
    • Hodge with and without Support and Knob
    • Gehrung with Knob
    Urinary Stress Incontinence and/or 1 st and 2 nd Degree Prolapse
  • 38. A Word about Mixed Incontinence
    • Best treated by first correcting the anatomical deficiencies causing the SUI.
    • The same anatomic deficiencies causing the SUI are often creating the urgency too.
    • Treat the SUI first – 70 percent cure rate for both SUI and Urge.
    Rodney Appell, MD Professor of Female Urology and Void Dysfunction, Baylor College of Medicine Surgical Therapies Favored by Urologists – Sling American Urology Association Annual Meeting, June 2001 Anaheim, Ca
  • 39. Why Treat Mixed Incontinence with Pessaries?
    • Pessary is good diagnostic tool – urodynamic studies costly.
    • Incontinence pessaries manually support and stabilize the urethrovesical junction which the vaginal sling repair does surgically
    • Limiting the use of drugs for mixed incontinence saves the patient money and avoids side effects (dry mouth, constipation, etc.) and serious drug interactions.
  • 40. Incontinence Ring
    • Stabilizes urethrovesical junction
    • Increases closure pressure
  • 41. Incontinence Ring Fitting and Removal
    • Posterior Fornix to the Pubic Notch.
    • This pessary is effective for a patient who may have incontinence during exercise.
  • 42. Ring with Support and Knob
    • Stabilizes urethrovesical junction
    • Supports a mild uterine prolapse complicated by a mild cystocele.
    • Increases closure pressure
  • 43. Incontinence Dish
    • Stabilizes urethrovesical junction
    • Increases closure pressure
    • Stress Incontinence. Mild Prolapse .
  • 44. Incontinence Dish Fitting and Removal
    • Posterior Fornix to the Pubic Notch.
  • 45. Incontinence Dish with Support
    • Urinary Incontinence with 1 st to 2 nd degree prolapse complicated by a mild cystocele
    • Increases closure pressure
    • Stabilizes urethrovesical junction
  • 46. Gehrung with Knob
    • The Gehrung supports a cystocele and thins out a rectocele.
    • The knob stabilizes urethrovesical junction
  • 47. Pessaries Cystocele and Rectocele
    • Gehrung
    • Gehrung with Knob
    • Hodge with Support
    • Ring with Support and Knob
    • Ring with Support
    • Incontinence Dish with Support
  • 48. Pessaries Lever Pessaries
    • Hodge with Support
    • Hodge without Support
    • Risser
    • Smith
    Incompetent Cervix Retrodisplacement
  • 49. Incompetent Cervix
    • Lever (Hodge) pessary
    • Secures the axis of the cervix in a posterior plane
    • 83% successful in several studies of women at risk of premature cervical dilation
    • Insert at 14 weeks; remove at 38 weeks
    • Cerclage reinforcement – in conjunction with cerclage.
  • 50. Other Lever Pessaries
    • Hodge with Knob
    • Hodge with Support and Knob
    • Smith
    • Risser
  • 51. Lever Pessary Fitting and Removal
    • Trimo San on leading edge
    • Must remove before MRI or X-ray
  • 52. Patient Education and Counseling
    • Discuss Condition
    • Risk Factors
    • Choice of Pessary
    • Follow-Up Care
    • Sexual Activity
    • Need to Change Pessary size or type
      • Art - Not a science
  • 53. Pessary Fitting
    • Determine type of prolapse and severity
    • Decide on pessary
    • Digital exam to size
    • Finger against pessary to size
    • Have patient bear down
    • Stand, sit, walk, use toilet
    • Re-examine patient in erect position to check if pessary “shifts”
  • 54. Pessary Follow-Up Care
    • Return in 24 hours for 1 st exam
    • Return within 3 days for re-exam
    • Return every 4-6 weeks
    • Cube, Inflatoball – remove daily
    • Trimo San
      • ½ applicator 3 times in 1 st week
      • Twice a week thereafter
  • 55. Pessaries and MRIs
    • Remove prior to procedure
    • Metal cord
      • Incontinence Ring
      • Smith
      • Risser
      • Hodge – with or without Support
      • Hodge – with or without Support and Knob
      • Gehrung
      • Gehrung with Knob
      • Regula
      • Ring – check for dimples (Old Metal Style Had No Dimples)
  • 56. Pessary Follow-Up Care Exam
    • Remove
    • Clean pessary
    • Vaginal exam
    • Re-insert if no contraindications
  • 57. Trimo San
    • pH to healthy vagina – helps prevent odor-causing bacteria growth
    • Lubricator
    • Unique Jel-Jector applicator
  • 58. Reimbursement
    • New 2001 Medicare Codes
      • A4561 – Pessary Rubber , any type
      • A4562 – Pessary Non-rubber, any type
      • A4560 – Eliminated
    • Silicone Pessary Reimbursement:
    • Approx: $44.00
    • based on area of the country
  • 59. Reimbursement Change in Jurisdiction
    • Effective January 1, 2002, jurisdiction for claims processing changes from the DMERC (Durable Medical Equipment Regional Carriers) to the local Medicare intermediary (local carrier).
    Program Memorandum Carriers, August 22, 2001 Department of Health and Human Services Centers for Medicare and Medicaid Services