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Dr. Kay Daniel's Pessary Presentation (English)

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Vaginal pessary placement training for GO MOMS

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Dr. Kay Daniel's Pessary Presentation (English)

  1. 1. Pessary Management of Pelvic Floor Disorders
  2. 2. There are a large variety of pessaries available
  3. 3. 2 common types we have available for your use • Support – Incontinence ring • Space filling – Donut
  4. 4. Indications 1. Prolapse 2. Urinary incontinence 3. Urinary retention: relieve obstruction and improve renal function 4. Before surgery: allow inflammation and ulceration in procidentia to heal preoperatively 5. Failed surgical correction
  5. 5. When is a pessary most beneficial? • Patient prefers nonsurgical management • Patient has significant risk for surgical morbidity
  6. 6. Contraindications • Severe erosions • Active vaginitis • Pelvic inflammatory disease • Non-compliant patient- unable to return for exams
  7. 7. Fitting a Pessary • Patient should empty bladder • Largest pessary that can be comfortably place • Examiner finger should easily pass between vagina and circumference of pessary • Have patient perform Valsalva – Okay to see pessary edge with maximum force at introitus • Patient should be able to sit, stand, urinate and defecate with pessary in place (not necessary to do all these at initial visit!)
  8. 8. Follow-up/ Management • After Initial fitting: return in 1-2 weeks Specifically ask questions: comfort, voiding, defecation, discharge and ease of care • For the 1st Year: return every 3 months • After 1st Year: every 6 months If patient is removing the pessary regularly (at least once a week), can return every 12 mos
  9. 9. Follow-up/ Management • Pessary removed and cleansed with soap and water • Speculum exam – Evaluate for • Abrasions • Erosions • Vaginal discharge • Atrophy – Irritation common; full thickness ulcer is a problem
  10. 10. Common Problems • Pessary expulsion • New onset urinary incontinence (20%) • Rectal pain • Difficulty with defecation • Vaginal discharge • Vaginal atrophy • Ulceration with bleeding • Impaction
  11. 11. How many continue pessary use? • 2 month: – 92% satisfied • 1 year: – 73% satisfied • 2 Years: – 64% satisfied Clemons JL. AJOG. 2004. Best Predictor of Acceptability: AGE!
  12. 12. What factors predict discontinued use? • Desired surgery at initial visit • Stage 3 and 4 posterior wall prolapse
  13. 13. Vaginal Discharge • Some vaginal discharge is expected • Increased risk for bacterial vaginosis (4X) – If symptomatic, may treat • Vaginal cultures: NOT RECOMMENDED • If discharge is a problem; remove, estrogenize, insert new pessary when irritation gone
  14. 14. Vaginal Atrophy • Local estrogen therapy is recommended in pessary users – Prevention of ulcers, abrasion, incarcerations • If significant atrophy present, use vaginal estrogen for 6 weeks before beginning pessary
  15. 15. Ulceration • Remove pessary • Intravaginal estrogen (0.5-1.0 gm/day) for 2-3 weeks • Replace pessary if healed • Continue local estrogen 2-3x/week • Recurrent/Persistent ulcers -> BIOPSY
  16. 16. Impaction • More common with space-filling pessaries (i.e. Gellhorn or Cube) • Use a Tenaculum • Apply local estrogen daily for 2-3x/week and then attempt removal • May require removal in the OR (rare)
  17. 17. Severe Complications • Incarceration of pessary • Vesicovaginal fistula • Rectovaginal fistula Bottom Line: Neglected Pessary + Noncompliant patient = Potential for Severe Complications
  18. 18. Case Scenarios
  19. 19. 52 year old G2P2 with bulging in the vaginal area • Had a vaginal hysterectomy for prolapse and TVT sling for stress urinary incontinence • Symptoms relieved for a few months, but now has recurrence of prolapse symptoms • No stress incontinence
  20. 20. Good choice Donut • Indications – Uterine and vaginal prolapse, rectocele • Pros – Works well for Stage 3-4 prolapse – Works well for posterior wall prolapse • Cons – Difficult insertion and removal – Coitus not possible
  21. 21. Stress incontinence
  22. 22. Common Pessaries Incontinence Ring • Indications – Stress Urinary Incontinence • Pros – Ease of insertion and removal – Coitus possible • Cons – None noted
  23. 23. 56 year-old G1P1 with bulging in the vaginal area • Referred for incomplete fecal evacuation and symptoms of pelvic pressure • Defecography and POPQ exam reveals a rectocele • Splinting of posterior vaginal wall relieves constipation symptoms
  24. 24. Good choice Donut • Indications – Uterine and vaginal prolapse, rectocele • Pros – Works well for Stage 3-4 prolapse – Works well for posterior wall prolapse • Cons – Difficult insertion and removal – Coitus not possible
  25. 25. Other Common Pessaries Ring with Support • Indications – Uterine and vaginal prolapse – Cystocele • Pros – Ease of insertion and removal – Coitus possible • Cons – Less helpful for more severe forms of prolapse
  26. 26. Other Common Pessaries Incontinence Dish with Support • Indications – Stress Urinary Incontinence – Cystocele • Pros – Ease of insertion and removal – Coitus possible • Cons – Less helpful for more severe forms of prolapse
  27. 27. Other Common Pessaries Gellhorn • Indications – Uterine and vaginal prolapse • Pros – Ideal for Stage 3-4 prolapse • Cons – Difficult insertion and removal – Coitus not possible
  28. 28. Common Pessaries Cube • Indications – Uterine and vaginal prolapse • Pros – Ideal for Stage 3-4 prolapse • Cons – Vaginal ulcerations – Heavy vaginal discharge – Frequent removal
  29. 29. Common Pessaries Inflatoball • Indications – Uterine and vaginal prolapse • Pros – Ideal for Stage 3-4 prolapse • Cons – Difficult insertion and removal – Coitus not possible
  30. 30. Take Home Points • Pessaries are great alternative to surgical management if patient not a good candidate or does not desire surgery at present • Pessary use requires a compliant patient • Physicians and patients need to be aware of potentially serious complications of pessary use

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