Pessaries of various shapes and sizes have been used for centuries to treat pelvic organ prolapse (174). They are a safe alternative to surgery, with the most common complications being increased vaginal discharge and erosion or ulceration of the vaginal wall. Although pessaries represent a common therapeutic modality, there are limited data regarding fitting and management (175). Even less is known about which type of pessary is better for enteroceles and rectoceles, although the site of prolapse does not appear to affect the ability to retain a pessary (176). Pessaries can be divided into subtypes of supportive and space occupying (177). Some of the space-occupying pessaries, such as the Gellhorn and cube, use a suction mechanism to maintain vaginal retention, whereas others, like the donut, do not. In theory, space-occupying pessaries and those that exert forces against the posterior wall and vaginal apex (donut, inverted Gehrung) should aid in treatment of rectoceles and enteroceles. However, there are few data regarding the efficacy of pessaries for relieving symptoms of disordered defecation. One prospective study found that stage III or IV posterior vaginal wall prolapse was an independent predictor for discontinuation of pessary use in favor of surgical repair (178). The only randomized crossover trial comparing different types of pessaries (ring and Gelhorn) found improvement in quality-of-life measures with each pessary that did not differ. Protrusion and voiding dysfunction symptoms were most improved (179). More research is needed to determine the role of pessaries for treatment of rectoceles and enteroceles as well as symptoms that are likely to be improved using a pessary.
Surgical Treatment Following is a review of the efficacy of various surgical treatments for specific conditions associated with constipation and disordered defecation.