Pessaries provide pelvic organ support within the vaginal vault. Two categories of pessaries— support and space filling—exist for prolapse (39). The ring pessary (with diaphragm) is a commonly used support pessary, and the Gelhorn pessary is a commonly used space-filling pessary. The ring and other support pessaries are recommended for stage I and II prolapse, whereas the space-filling pessaries are used for stage III and IV prolapse (40). It is unclear whether pessaries can prevent the progression of POP with regular use. A prospective cohort study addressed this issue in a series of 56 women who were fitted with a pessary, of which 33.9% (n = 19) continued use for at least 1 year (41). Baseline and follow-up pelvic examinations were performed using the POP-Q system (23). The women removed the pessary 48 hours before one visit, but there was no information to ascertain adherence to pessary use. No woman had worsening of the prolapse, and four women (21.1%; 95% confidence interval [CI], 0.2%–43.7%) had an improvement. Improvement overall was noted in women with anterior compartment prolapse.
In women with stages I and II prolapse with stress urinary incontinence, a continence pessary may be considered and has been shown to produce patient satisfaction above 50% at 12 months (42). There are no randomized controlled trials of pessary use in women with POP (43). Likewise, there are no consensus guidelines on the care of pessaries (i.e., intervals between changes), the role of local estrogens, or the type of pessary indicated for specific types of POP (43). Manufacturers recommendations and different pessary types can be seen in Figure 27.11. Effective and satisfactory outcomes have been reported for stage II or greater prolapse using the Gelhorn and ring diaphragm pessary (36). After 2 to 6 months, 77% to 92% of women with a successful pessary fitting were satisfied and, using intention-to-treat analysis, 44% to 67% of all women who were treated initially with a pessary for prolapse were satisfied. There are few other series describing pessary use for prolapse with greater than 4 weeks follow-up (36,38,44,45).
Possible complications associated with pessary use include vaginal discharge and odor. Failure to retain the pessary may occur or, conversely, the pessary may be too large, which could lead to excoriation or irritation. With reduction of vaginal prolapse, de novo or
Figure 27.11 Pessaries used to treat the various degrees of prolapse. (Milex Company, a Division of Cooper Surgical.) increased stress incontinence may occur, and in rare instances, more severe complications, including vesicovaginal or rectovaginal fistula, small bowel entrapment, hydronephrosis, and urosepsis, have been described (46–48).
Pessary placement involves consideration of a number of issues, primarily the patient’s desire and motivation to use this type of device. Typically, if she has had previous surgery or strongly desires to avoid surgery, she may be motivated enough for a primary attempt at pessary placement. Other issues include current sexual function status, type and duration of exercise in which the patient engages, and the status of the vaginal walls and cervix. In hypoestrogenic women, treatment of the vagina with estrogen and maintenance of intravaginal estrogen treatment is recommended.
The patient should be examined in the lithotomy position after emptying her bladder.