Pessaries in the treatment of Pelvic organ prolapse

Disclosure: information in this blog is intended for information and educational purposes only, and should not replace medical treatment or advice. Please consult your health care professional for advice about your personal health conditions.

This year I completed a professional certificate in prolapse management through the University of South Australia.

The yearlong course trains us to be competent prescribing and fitting pessaries for pelvic organ prolapse (POP), under a ‘shared care’ health model, which involves the patients GP and sometimes Gynaecologist.

Traditionally pessaries have been fitted by Gynecologists, however, extending the scope of practice of Physio’s and other health professionals (continence nurses) aims to relieve waiting times for patients whilst maintaining safety and quality.

In this blog I’m going to impart some of the knowledge I’ve gained on POP, the history of pessaries, difference types, the indications for them, what are the benefits and risks, and some information on pessary hygiene.

1. History of pessaries

First use of pessaries traces back to 1500BC in Egypt, the word pessary is derived from the Greek for “peso” which means an oval stone, probably referring to a stone inserted into the uterus of camels to prevent contraception during long desert journeys (Abdulaziz et al., 2015).

The development of pessaries to treat pelvic organ prolapse in women has come a long way since their origin, we now have access to medical grade silicone pessaries in a variety of shapes and sizes.

Whilst pessaries are commonly used (more than 85% of gynecologists prescribe them), the public perception of them is often negative (Brown et al., 2016).

Interestingly when compared to surgery, pessaries offer similar benefit in reducing symptoms of prolapse (Lotte et al., 2018). Whilst the risks of surgery are beyond the scope of this blog, it is well known that POP surgery is associated with a high failure rate.
With appropriate fitting and care, pessaries are well tolerated by women with continued pessary use reported in over 60% after 12 months (Thys et al., 2020).

In a 2009 study, two thirds of women initially opted for conservative (pessary) over surgical treatment for their POP. Women were more likely to choose surgery if they were younger, sexually active, and reporting more severe symptoms (quality of life, bowel emptying, sexual dysfunction) (Kapoor et al., 2009).

2. Pelvic Organ Prolapse (POP)

POP is a condition that is commonly associated with pregnancy and vaginal childbirth in women. It is defined as the descent of one or more of the anterior, posterior vaginal walls or uterus (referred to as a vault prolapse in women who have underdone hysterectomy). It is graded using the POP-Q measurement system, from least to most severe (Stage 0,1,2,3 and 4).

The most common symptoms of POP is the feeling of a vaginal bulge, however, other symptoms include changes to bladder or bowel function (difficulty emptying, frequency, urgency, incontinence), sexual dysfunction, low backache, and vaginal heaviness.

Risk factors for POP include: pregnancy, childbirth, pelvic floor muscle injury (levator avulsion), chronic straining (constipation, repetitive heavy lifting, chronic cough), and obesity.

Whilst 50% of women demonstrate POP on examination, only 20% will be symptomatic in their lifetime. The estimated lifetime risk of surgery for POP is approximately 11%. 

Whilst mortality is very unlikely, POP causes significant impact on women by affecting their physical comfort, confidence with exercise, self-esteem and relationships.

After confirmed diagnosis by a Doctor, the treatment options for POP can include: watchful waiting, pelvic floor muscle training (PFMT), pessaries, or surgery.

3. Pessaries

The most commonly fitted pessary is a ring pessary, this is because it is the easiest to insert and remove, and it can be left in during penetrative intercourse.

The ring is folded for insertion, and then expands at the apex of the vagina, sitting behind the pubic bone. It offers support to the walls of the vagina, much like the ropes and pegs on a tent- acting to splint and elevate.

There are many types of pessaries, some of the more commonly used include: cube, gelhorn, cup, and donut.

The main indication for pessaries is to relieve symptoms of POP, and enable the woman to engage in activities or exercise that previously worsened her POP symptoms.

Some important points to consider:

·      Pessaries do not cure POP, there is some emerging research that suggests pessaries may improve the pelvic anatomy and reduce the severity of POP over time, however, we need more information on this.

·      Pessaries may enable the pelvic floor muscles to contract and relax more effectively, thereby improving the function of the pelvic floor over time.

·      A foreign body inserted into the vagina has potential to cause infection; it is for this reason that pessaries are removed and cleaned regularly, and your Physio/Doctor will need to examine your vaginal tissue.

·      Finding the correct size and fit with pessaries is a process of trial and error, much like trying on shoes, it can take a few types and sizes to find one that is both comfortable and effective at reducing your symptoms.

·      If pregnant, pessary use must be cleared with your obstetrician and or doctor prior to use. The safety of pessary use during pregnancy has not been well studied.

·      If you are menopausal or have low oestrogen (breastfeeding), the vaginal tissues can be drier and more susceptible to erosion and infection. Your doctor may recommend vaginal oestrogen cream prior to, and during pessary use.

Benefits

ü  May improve symptoms

ü  Minimally invasive

ü  Some types can be left in during penetrative intercourse

ü  Allow women to engage in exercise that previously worsened their symptoms (e.g. running)

ü  Cost effective

ü  Low risk

Risks

Complications of pessaries are associated with prolonged use and neglect of the pessary (Abdulizaz et al., 2015).

Under Physio care we reduce risks by: involving a doctor when indicated, regular check-ups, ultrasound to check bladder emptying, education and educational materials

Mild/ Common

§  Increased vaginal discharge

§  Bleeding (caused by erosion between pessary and vaginal wall)

§  Discomfort

§  Expulsion (falls out)

Serious/ Rare

§  Fistula

§  Infection of the bladder due to retention

§  Cancer

§  Death

4. Hygiene

Under Physiotherapy care, pessary use is considered ‘self-care’ based, where the patient is taught how to insert and remove their own pessary, with recommendations currently for removal for 1 night, at least 1x per week (International Centre for Allied Health Evidence, 2012).

Some women prefer to insert their pessary for activity only (e.g. 30-45 minute run).

Note**

If managed under the care of a Gynaecologist, pessaries may be left in for prolonged periods (3-4 months), and then removed and cleaned by the Gynaecologist. Women who feel uncomfortable or having difficulty with self-care for their pessary may prefer this option.

Once removed pessaries must be cleaned with soap and warm water, and allowed to air-dry. Inserting a pessary should always be done after cleaning your hands, and applying lubricant to the pessary.

If pessaries show signs of damage, or are dropped into the toilet, cleaning or replacement should be discussed with your Physio.

Summary:

Pessaries offer a low-risk, minimally invasive treatment option for prolapse. Women often report significant improvement in their symptoms with pessary use, and it can delay or completely eliminate the need for prolapse surgery.

My personal hope is that the perception of pessaries in the community improves and that with appropriate pessary fitting, more women are able to engage in exercise they enjoy without the fear of worsening their prolapse.

References:

Abdulaziz, M., Stohters, L., Lazare, D., & Macnab, A. 2015. An integrative review and severity classification of complications related to pessary use in the treatment of female pelvic organ prolapse. Canadian Urogynacological Association, Volume 9 (5-6), http://dx.doi.org/10.5489/cuaj.2783

Brown, L., Fenner, D., Delancey, J., & Schimpf, M. 2016. Defining patient knowledge and perceptions of vaginal pessaries for prolapse and incontinence. Female Pelvic Medicine and Reconstructive Surgery, vol. 22, no. 2, pg. 93–97.

Coolen, A.-L. W., Troost, S., Mol, B. W., Roovers, J.- P., & Bongers, M. Y. 2018. Primary treatment of pelvic organ prolapse: Pessary use versus prolapse surgery. International Urogynecology Journal, Volume 29,1,pg. 99–107. https://doi.org/10.1007/s00192-017-3372-x

International Centre for Allied Health Evidence. 2012. Guidelines for the use of support pessaries for women with pelvic organ prolapse. University of South Australia. Retreived 5/11/22 from https://www.unisa.edu.au/siteassets/episerver-6-files/global/health/sansom/documents/icahe/the-pessary-guideline_18-7-2012.pdf

Kapoor, D. S., Thakar, R., Sultan, A. H., & Oliver, R. 2009. Conservative versus surgical management of prolapse: What dictates patient choice? International Urogynecology Journal, Volume 20,10, pg.1157-1161. doi:10.1007/s00192-009-0930-x

Thys, S., Hakvoort, R., Milani, A., Roovers, J., & Vollebregt, A. 2021. Can we predict continued pessary use as primary treatment in women with symptomatic pelvic organ prolapse (POP)? A prospective cohort study. International Urogynaecology Journal. DOI: 10.1007/s00192-021-04817-8