A one day update in Gynaecology The National Association for Premenstrual Syndrome 19th June 2015 Ring pessary management including the use of silicone vaginal rings Mr Mike Cust, Consultant Gynaecologist Royal Debry Hospital Dr Carrie Sadler, GPwSI in Gynaecology Clifton Road Surgery, Ashbourne

Summary  Overview of types of prolapse  Presenting symptoms  Conservative treatment options  Types of pessaries  Pessary management

Definition of prolapse ‘A protrusion of an organ or structure beyond its normal confines. Classified according to its location and the organ contained within it’

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Grading of prolapse There are 3 degrees of prolapse. The lowest or most dependent portion of the prolapse is assessed whilst the patient is straining: 1 st : Descent within the vagina 2 nd : Descent to the introitus 3 rd : Descent outside the introitus 3 rd degree uterine prolapse is termed procidentia and is usually accompanied by cystourethrocele and rectocele

Classification Anterior vaginal wall prolapse: Urethrocele: urethral descent Cystocele: bladder descent Cystourethrocele: descent of bladder and urethra Posterior vaginal wall prolapse: Rectocele: rectal descent Enterocele: small bowel descent Apical vaginal prolapse Uterovaginal: uterine descent with inversion of the vaginal apex Vault: post hysterectomy inversion of the vaginal apex

Aetiology/risk factors  Aging, particularly post menopause with oestrogen deficiency  Congenital or acquired connective tissue defects  Family history of prolapse  Pregnancy, childbirth  Pelvic surgery or trauma  Chronic cough and constipation (raised intra-abdominal pressure)  Obesity

Clinical features  Lump  Local discomfort, back ache, dyspareunia  If ulcerated- bleeding/infection  Rarely renal impairment due to kinking of ureter  Cystourethrocele: urinary frequency/urgency/ voiding difficulty/ stress incontinence/urinary tract infections  Rectocele: incomplete bowel emptying

Management  Address medical problems/weight loss  Avoid heavy lifting  Treat constipation  HRT: local/systemic  Pelvic floor exercises  Pessaries  Surgery

Indications for pessary treatment  Patient’s wish  As a therapeutic test- can aid pelvic floor assessment and treatment  Childbearing not complete  Medically unfit for surgery  While awaiting surgery

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PVC Pessary Ring  Sizes 50-95mm in 5mm increments  Can be worn during sexual intercourse

Milex pessaries available on an FP10  Ring without support  Ring with support  Gellhorn – long and short stem

Page 15 Ring without Support 1st and 2 nd degree prolapse mm For mild prolapse Measure from posterior fornix to the pubic notch

Page 16 Ring with Support Fitting and Removal 1 st and 2 nd degree prolapse complicated by mild cystocele Measure from posterior fornix to the pubic notch

Page 17 Gellhorn Short or long handle (latter if long vagina) Cervix rests behind disk portion of pessary For use when rings have failed and woman not sexually active Can be difficult to remove- injecting some sterile water into stem can help

Fitting Milex pessaries  Examine and assess prolapse and size of pessary that will be needed (use PVC rings for sizing)  Pessaries are powdered. The powder needs to be washed off with mild soap and water and the pessary rinsed well before insertion.  On fitting should not be too tight- slight give  After fitting assess comfort, relief of symptoms and urinary symptoms  Review after 4 weeks and then 3-6 monthly. Company suggest check at 1 and 3 days  Replace every 5 years or sooner if damaged/discoloured. Do not absorb secretions.  At review check position, comfort and effectiveness  Also examine to exclude ulceration/erosions. Treat with local oestrogen/ break from pessary  Can encourage women to remove pessary themselves, wash in dish soap, leave overnight and then reinsert – on weekly basis

Why to pessaries fail?

Page 21 Case # 1 30 year-old G2P2 Marathon runner Future wishes for childbearing uncertain Leaks with intercourse Grade 2 cystocele, Grade 1 rectocele

Page 22 Case #2 79 year-old G4P4, heaviness and bulge Bloody discharge, difficulty defecating and voiding Dyspareunia Vaginal Hysterectomy, no HRT Complete vault eversion with erosion

Page 23 Case #3 85 year-old with Alzheimer's disease No history available Vaginal odour and discharge Gelhorn pessary found