The document provides an overview of pessary use, including their historical origins, types, fitting procedures, and care instructions. It discusses various pessary designs and their uses for conditions like uterine prolapse, cystocele, rectocele, urinary incontinence, and cervical incompetence. Guidelines are provided on patient education, fitting procedures, follow-up care, and reimbursement codes.

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