This document discusses the management of pelvic floor disorders using pessaries. It describes the types of pessaries available for prolapse and incontinence, including support and space-filling options. Common indications for pessary use include prolapse, incontinence, and as a preoperative measure. Factors that predict discontinued use are a desired surgery initially or more advanced prolapse. Complications can include discharge, atrophy, ulceration, and impaction if not properly fitted and followed up. Case examples demonstrate selecting appropriate pessary types based on a patient's symptoms and examination findings.

1. Pessary Management
of Pelvic Floor Disorders

2. There are
a large
variety of
pessaries
available

3. 2 common types we have
available for your use
• Support
– Incontinence ring
• Space filling
– Donut

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. When is a pessary most
beneficial?
• Patient prefers nonsurgical
management
• Patient has significant risk for surgical
morbidity

6. Contraindications
• Severe erosions
• Active vaginitis
• Pelvic inflammatory disease
• Non-compliant patient- unable to return for
exams

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. 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. 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. Common Problems
• Pessary expulsion
• New onset urinary incontinence (20%)
• Rectal pain
• Difficulty with defecation
• Vaginal discharge
• Vaginal atrophy
• Ulceration with bleeding
• Impaction

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. What factors predict discontinued
use?
• Desired surgery at initial visit
• Stage 3 and 4 posterior wall prolapse

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. 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. 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. 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. Severe Complications
• Incarceration of pessary
• Vesicovaginal fistula
• Rectovaginal fistula
Bottom Line:
Neglected Pessary + Noncompliant patient
= Potential for Severe Complications

18. Case Scenarios

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

21. 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

22. Stress incontinence

23. Common Pessaries
Incontinence Ring
• Indications
– Stress Urinary
Incontinence
• Pros
– Ease of insertion and
removal
– Coitus possible
• Cons
– None noted

24. 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

26. 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

27. 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

28. 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

29. Other Common Pessaries
Gellhorn
• Indications
– Uterine and vaginal
prolapse
• Pros
– Ideal for Stage 3-4
prolapse
• Cons
– Difficult insertion and
removal
– Coitus not possible

30. Common Pessaries
Cube
• Indications
– Uterine and vaginal
prolapse
• Pros
– Ideal for Stage 3-4
prolapse
• Cons
– Vaginal ulcerations
– Heavy vaginal discharge
– Frequent removal

31. Common Pessaries
Inflatoball
• Indications
– Uterine and vaginal
prolapse
• Pros
– Ideal for Stage 3-4
prolapse
• Cons
– Difficult insertion and
removal
– Coitus not possible

32. 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