1. THE VAGINAL PESSARY
Bernie Brenner Gynaecologist Clinical Director – Pelvic Floor Clinic Milford Auckland
Presentation modified from H Carcio “Bioteque – The Vaginal Pessary”

2. THE VAGINAL PESSARY
The vaginal pessary is indeed a thing of beauty since the benefits of successful pessary use are certainly beautiful and welcome to see! Pessary use is an important, even vital, part of a bladder health program. It should be used as an adjunct to pelvic floor rehabilitation, behavioral modification therapies, treatment of vaginal estrogen and possible medication use in the management of incontinence and prolapse.
The baby boomers are aging and sagging. As a result bladder problems are becoming more prevalent and there will be an increased need for pessaries in the conservative management of prolapse.

3. PELVIC ORGAN PROLAPSE QUANTIFICATION EXAM
Measures the descent of the anterior, apical and/or posterior portions of the vagina
Records vaginal length and width of the introitus.
Uses centimeters with reference to the hymen when performing the Valsalva
Negative numbers: Distance above the hymen
Positive numbers: Distance of prolpase protruding beyond hymen
May simply grade the prolapse from 1 to 3
Defined points for measurement in the POPQ system Anterior vaginal wall: Point Aa: A point located in the midline of the anterior vaginal wall 3cm proximal to the external urethral meatus. This corresponds to the approximate location of the 'urethrovesical crease,' a visible landmark of variable prominence that is obliterated in many patients. By definition, the range of position of Point Aa relative to the hymen is -3 to +3 cm. Point Ba: A point that represents the most distal position of the upper portion of the anterior vaginal wall from the vaginal cuff or anterior vaginal fornix to Point Aa. By definition, Point Ba is at -3 cm in the absence of prolapse. Vaginal apex: Point C: A point that represents either the most distal edge of the cervix or the leading edge of the vaginal cuff scar in a woman who has undergone total hysterectomy. Point D: A point that represents the location of the posterior fornix in a woman who still has a cervix. It represents the level of the uterosacral ligament attachment to the proximal posterior cervix. Posterior vaginal wall: Point Bp: A point that represents the most distal of the upper portion of the posterior vaginal wall from the vaginal cuff or posterior vaginal fornix to Point Ap. By definition, Point Bp is at -3 cm in the absence of prolapse. Point Ap: A point located in the midline of the posterior vaginal wall 3 cm proximal to the hymen. By definition, the range of position of Point Ap relative to the hymen is -3 to +3 cm. Other landmarks and measurements The genital hiatus (GH): Is measured from the middle of the external urethral meatus to the posterior midline hymen. If the location of the hymen is distorted by a loose band of skin without underlying muscle or connective tissue, the firm palpable tissue of the perineal body should be substituted as the posterior margin for this measurement. The perineal body (PB): Is measured from the posterior margin of the genital hiatus (as just described) to the midanal opening. Measurement of the genital hiatus and perineal body are expressed in centimeters. The total vaginal length (TVL): Is the greatest depth of the vagina in cm when Point C or D is reduced to its full normal position.

4. PURPOSES
Supports the vaginal musculature/bladder base in physiologic alignment
Can provide a solution to incontinence in women unable or unwilling to have surgical correction
May unmask Stress Urinary Incontinence
Provides a diagnostic means of predicting which patients would be helped with surgical correction
The stabilization of the bladder base can provide relief from incontinence by increasing the closing pressure of the urethra. This is particularly true with a mild to moderate cystocele. Many women, particularly the elderly, find pessary use a viable, permanent solution to their incontinence problem. It does have to be maintained and cleaned 3-4 times a year but is often preferable to other surgical options.
In women with a moderate to marked cystocele the kink in the urethra created by the pull of the prolapse may uncover a hidden incontinence problem. In fact, most women with an extensive cystocele do not leak for this reason. It is important to elevate the cystocele with a pessary prior to any surgical interventions in order to eliminate incontinence following the repair.
It also helps to determine the necessary surgery, which would probably include a type of bladder neck suspension. Pessary use is also important prior to surgery because relief of incontinence with a pessary in place is an excellent predictor of positive outcomes with surgical correction.

5. ADVANTAGES May reduce the symptoms of incontinence
Supports and corrects retro-displacement of the uterus in early pregnancy
Relieves the discomfort of a pelvic organ prolapse
Repositions pelvic structures during pelvic floor rehabilitation (decreases post op adhesions)
The pessary also plays an important role in the management of other conditions unrelated to incontinence. It often reduces and may even eliminate the symptoms of overactive bladder (OAB). The principle behind this is that lower urinary tract function (LUT) is a gravity system. Urine flows naturally from a high point to a lower point to exit the body. When a cystocele is present the urine may pool in a dependent part of the dropped bladder. The bladder may not empty completely. OAB is the uncontrollable contraction of the bladder muscle. It is likely that this is in response to its inability to empty completely. It is contracting in a vain attempt to rid itself of its contents. Hence, the symptoms of frequency and urgency associated with bladder contractions.
In early pregnancy the pessary realigns the uterus.
A prolapse can cause discomfort. The most common complaint is lower back pain or a “dragging sensation” down the thighs. There is also discomfort in the perineum as the delicate vaginal tissue is stretched. The majority of nerve endings in the vulva-vaginal area are around the area of the introitus and just a few mm’s inside. Once the prolapse descends to this sensitive area, pain and discomfort are common.
The pessary is instrumental in assuring positive outcomes during pelvic floor rehabilitation (PFR) in a woman with a prolapse. PFR utilizes the principles of muscle strength training. A muscle that is stretched against the pressure of a prolapse is much more difficult to contract than one that is repositioned and aligned in proper anatomical position. A pessary can achieve this.

6. PESSARY CAN SUPPORT A POP
A cystocele is a bulging or prolapse of the upper anterior vaginal wall involving the bladder. The cystocele can be either medial or lateral. It is graded on a scale of 1 to 3
Grade 1
Mild
Bladder droops only a short way into the vagina.
Grade 2
More severe
Bladder has herniated into the vagina far enough to reach the introitus
Grade 3
Most advanced
Bladder bulges out through the opening of the vagina.
A rectocele is the prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina.
An enterocele is the prolapse of the upper posterior wall of the vagina usually containing loops of small bowel.
A. Cystocele B. Rectocele C. Enterocele

7. CAUSES OF PROLAPSE Constipation Exercise Pregnancy and Childbirth
Abnormal collagen/connective tissue
Hormonal factors
Previous pelvic surgery
Chronically increased intra-abdominal pressure caused by repetitive straining will exacerbate any potential weaknesses in the pelvic floor. In one study, a history of constipation and chronic straining of stool as a young adult was significantly more common in women who subsequently developed prolapse (61%).
Modern day exercise regimes such as high impact aerobics, long distance running and weight lifting can also exacerbate pelvic floor weakness, thus increasing the incidence of prolapse.
Pregnancy can damage the muscular and fascial support of the pelvic floor. Multiple pregnancies and high birth weight also contribute to the incidence of prolapse. Denervation of the pelvic floor musculature also occurs during childbirth thus increasing the chances of prolapse and incontinence.
The quality of the connective tissue may also be a factor. There is a known reduction in tissue collagen content following menopause. There are estrogen receptors in the cardinal and uterosacral ligaments and there would appear to be a positive correlation with the number of postmenopausal years. Research found no estrogen receptors in the levator ani muscle fibers but receptors were found in the levator ani fascia. There are numerous estrogen receptors in the vaginal walls and uterosacral ligaments also.
Past surgeries may also have an effect on the incidence of developing prolapse. Defects in other pelvic compartments can occur. The association between prolapse and prior hysterectomy is not clear. Anecdotally, there seems to be quite a connection.

8. STRESS INCONTINECE: Causes
Weakened pelvic floor musculature
Intrinsic sphincter deficiency
Increased intraabdominal pressure
Reduced strength of urethral sphincter
Stress urinary incontinence is the involuntary or accidental leaking of urine, often at inappropriate times. Occurrence increases with age but it is prevalent among women of all ages. It is associated with activities that exert a sudden increase in abdominal pressure such as coughing, laughing, tripping, sneezing, heavy lifting, or strenuous physical activity. Any increase in abdominal pressure is transmitted directly to the bladder. Normally the backboard of the pelvic muscles absorbs most of this pressure. Leaking occurs when the pressures transmitted to the bladder from the abdomen are greater than the strength of the muscles of the urethra to remain closed and retain urine. This is most often due to the loss of anatomic support of the urethra, bladder, and urethrovesicular junctions resulting in hypermobility of the bladder neck.
Hypermobility of the bladder neck occurs when weakened pelvic floor muscle descend downward. This damage may be due to pregnancy, delivery, or advancing age. Vaginal delivery has been reported to produce partial denervation of the pudendal nerve during the labor. Intrinsic sphincter deficiency is a less common cause of SUI although some experts believe that all women with SUI have some degree of ISD. It occurs when the urethral sphincter does not close tightly and remains open at rest. ISD may be related to urethral scarring from previous incontinence surgeries, pelvic radiation, traumatic childbirth, or neurological conditions. Although only small spurts of urine are typically lost, it often has a dramatic affect on the woman’s sense of well being because of her inability to control any leaking. Women additionally complain about leakage that occurs with position changes such as getting out of bed in the morning, or rising from a sofa or chair. Leakage can also occur with orgasm and is certainly devastating for the woman. Not very romantic to say the least. Stress incontinence rarely occurs at night as there is little pressure on the abdomen and bladder when lying down. Urine loss is not preceded by a sense of urgency.

9. HISTORICAL PERSPECTIVES
Appears in both Latin and Greek literature
Many different types of materials and shapes
Over 2000 used throughout history
Fell into disfavour years ago
Today offers a viable alternative to surgery
Pessaries were first used thousands of years ago. Even Cleopatra is believed to have been treated for prolapse with a ball soaked in an astringent. Even the pomegranate did not escape a trail application! Other unfortunate women were suspended upside down and shaken until the prolapse was reduced. Of course it reappeared within a few hours of returning to the upright position. It is no wonder its use fell into disfavor.
Ten to twenty years ago most gynecologists were anxious to try their skills at the new sling procedures and therefore rarely recommended pessaries, considering them only a temporary solution.
Today’s pessary allows for easier insertion and removal and offers an excellent option for the woman who is unwilling or unable to have a surgical correction.

10. PESSARY FEATURES Silicone Non-toxic, medical-grade silicone
Biologically inert - does not absorb vaginal odor
Pliable
Can be autoclaved or soaked in Cidex
A few pessaries are made of latex rubber
Must assess and document any latex allergy
Available in a variety of sizes and shapes
The outside diameter is measured in inches with a range of one to four inches
Pessaries are made of a very benign material. They are non-toxic and do not absorb most vaginal odors. There is often a slight discoloration of the pessary which is usually normal. Pessary use may increase vaginal secretions which may have a slight discoloration. This is also considered normal. They are biologically inert and rarely cause any tissue reaction. It is important that the pessary be fitted properly so that there is no erosion from excess pressure which may be cause by a pessary that is too tight a fit, putting pressure against the delicate vaginal tissue.
In the past many pessaries were made of latex, but this is rare today. Pessaries can be easily cleaned by soaking in Cidex after an initial cleansing with soap and water. They may also be autoclaved. A cytobrush used for a cervical pap smear is very effective in cleaning the holes in pessaries such as the gellhorn and cube.
A properly fitted pessary is safe and not associated with any risk of cancer.

11. SEXUAL ACTIVITY
Intercourse is possible with pessaries that are not vaginally occlusive
Must have the dexterity and know-how to insert and remove as necessary
Note: Always ask about sexual activity – never assume
One must always ask about sexual activity. Many men and women remain sexually active well into their eighties and nineties. Never assume that just because a woman is elderly, or widowed for the matter, that she is not sexually active. You must always ask.
Some pessaries are similar in size to the contraceptive diaphragm and intercourse is certainly possible with the pessary in place.
Intercourse is not possible with a vaginally occlusive pessary such as the Gellhorn, Donut, or Cube. The Gellhorn and Donut are difficult to insert and remove and are therefore not a good choice for the woman who is sexually active. The Cube is designed to be easily removed and inserted since it should not remain in for any more than a few days.
The woman should always be given the option of choosing a pessary that can be removed prior to intercourse or one that can remain in her vagina.

12. CONTRAINDICATIONS Severe untreated vaginal atrophism
Vaginal bleeding of unknown origin
Pelvic inflammatory disease
Abnormal cervical smear
Dementia without possibility of dependable follow-up care
Expected non-compliance with follow-up
Pessary use is contraindicated in women with severe vaginal atrophism. Hypoestrogenism associated with menopause causes the wall of the vagina to thin. The walls become friable. A pessary would most likely damage the delicate tissues. Vaginal estrogen can dramatically reverse these atrophic changes. Vaginal estrogen should be used for 4 to 6 weeks prior to insertion of the pessary. Once the walls have responded to treatment, a pessary can be safely used.
Vaginal bleeding of unknown causes is a second contraindication. Often times the bleeding is caused by the vaginal atrophy discussed above and needs to be treated prior to insertion. Bleeding could also be from endometrial hyperplasia or cancer. The woman would need an endometrial biopsy to determine a uterine cause. This would be impossible to do with a pessary in place. There are many practitioners who might not be comfortable with pessary removal in order to perform the biopsy.
Again, a pap smear might not be able to be done if a pessary is in place. The more occlusive type pessary might put pressure on the already sensitive cells of the cervix. The dysplasia needs to be treated prior to pessary insertion.
Both dementia and non-compliance may increase the risk of a “forgotten pessary”. The assurance of proper follow-up is essential.

13. THE EVALUATION Pelvic Examination Cervical smear
Determine the extent of the pelvic support problem POP-Q
Assess degree of incontinence
Rule out any pathology
Cervical smear
Assess oestrogen status
A thorough pelvic examination is important to determine whether a pessary is indicated. The bimanual examination may reveal the presence of a cystocele or rectocele, or uterine prolapse. The woman should first be examined in the lithotomy position and asked to bear down. Always state that she may pass gas and reassure her not to be embarrassed in that it is expected and normal. She should next be examined in the standing position, and asked to bear down as the examiner feels for any descent of the prolapse.
If marked atrophism is noted on exam, the friable vagina needs to be estrogenized prior to any pessary insertion. It usually only takes 4 to 8 weeks of vaginal estrogen use to improve vaginal estrogen status.
A wet mount is important since a pessary should never be inserted in a woman with an active infection. Also assess the maturation index to determine the extent of any vaginal atrophism. Assessment of vaginal pH is simple to do using litmus paper and additionally determines if vaginal atrophism is present. A postmenopausal vagina will have a pH that is alkaline (green) due to the absence of lactobacilli which makes lactic acid.
The examiner should inquire when the woman had her last pap smear. It is a good idea to perform a pap smear, if it is time, since many providers might not know how to insert and remove a pessary for this screening procedure.

14. Some possible predictors of pessary failure Short vaginal length
Wide introitus
Posterior-wall defects
Patients who desire surgery
A single type of pessary may work for many conditions. Please refer to the manufacturer’s information for a list of helpful suggestions. It is important that a pessary help reduce a prolapse or provide urethral support but there is no need to recreate the pelvic anatomy. A pessary that is able to remain in the vagina, even though it may turn sideways or become lopsided can still work very well.

15. FITTING A PESSARY The pubic bone is an important landmark.
The pessary should fit snugly behind it.
There is less chance of expulsion if thus anchored
Uterine Prolapse (if present)
Insert two fingers in the vagina to push any uterine prolapse back into place
Place opposite hand on abdomen and push on the fundus (if present) to hold in place
Reduce any cystocoele or rectocoele prior to fitting
Put in largest size that will fit comfortably, or simply tuck a smaller pessary well behind the pubic bone
The examiner should first place fingers into the vagina and palpate the pubic bone anteriorly. Extend fingers deep into the vaginal vault. Next place the opposing thumb against the examining finger at the level of the pubic bone. Remove, keeping the thumb as a marker. Measure against a pessary to size for a proper fit. Once again, place fingers inside vagina and spread them wide laterally, as wide as possible. Keep in position and pull fingers through vagina. If fingers easily slide through in the extended position, then it is unlikely that a pessary can be retained. If the fingers close as they go through the orifice, then it is probable that the orifice is narrow enough to retain a pessary.
Once a good fitting is achieved, sweep finger around the pessary. As with diaphragm fitting, the examiner should be able to sweep fingers around the rim of the pessary. This is important in order to prevent too much pressure on the delicate vaginal tissues which may cause erosion and bleeding.

16. MEASURING THE WIDTH
Insert first two fingers of dominant hand deep to the posterior fornix
Approximate size by using the fingers to determine the width
Spread fingers wide to measure
Remove fingers and compare to pessary sample or fitting kit

17. MEASURING THE LENGTH Reinsert fingers deep into the posterior fornix
Make note of where the hand comes into contact with the pubic bone
Compare to pessary.
Iden

18. VAGINAL OESTROGEN
The majority of older women with a pessary need vaginal oestrogen
The Estring works nicely since it also needs to be changed every 3 months
Oestrogen use keeps the vagina healthy
Oestrogen thickens the layer of the vaginal mucosa allowing for more support of the pelvic organs.
Post menopausal woman who have a pessary need estrogen supplementation. A vaginal pH can help diagnose the presence of atrophic vaginitis. When estrogen declines the amount of lactobacilli in the vaginal fluids diminishes. Therefore there is less lactic acid causing the vagina to be alkaline as demonstrated on pH paper. Vaginal estrogen should be initiated prior to pessary use. It usually takes 4-6 weeks of estrogen supplementation for the vagina to be well estrogenized.
The best source of vaginal estrogen is the Estring. This is an excellent choice since the ring has to be changed every 3 months and can be removed and the new reinserted at the scheduled 3 month pessary change. It fits nicely, tucked right next to the pessary.
Other choices are Premarin vaginal cream or Vagifem tablets. Both come with applicators which need to be demonstrated. It may be difficult to insert the applicator around the pessary but most manage it pretty well. Application is easier if the woman is lying down, with one knee bent. The lying position takes some of the pressure off the pessary, making it easier to insert the applicator around the pessary and into the vagina.
Some women develop a vaginal yeast infection from the estrogen. This must be monitored for and treated should it occur. The estrogen should be discontinued for a few weeks. Most infections are easily treated and tend not to reoccur even when restarting the estrogen.

19. COMPLICATIONS Increase in vaginal discharge Odor Ulcerations
Pelvic discomfort
Incarceration
Scar/granulation tissue may form around pessary
Complications are rare in the properly fitted and well maintained pessary
Atypia from inflammatory changes.
A poorly fitted pessary may have the cervix herniate through. Atrophism may greatly compromise pessary care.
Poor fitting.

20. DONUT Description: soft silicone, donut shaped. Indications:
Occludes upper vagina and supports a uterine prolapse
Useful for cystocoele or rectocoele
Good for prolapse of the vagina after a hysterectomy
Adequate integrity of the introitus is necessary for the pessary to remain in place
The Donut Hole

21. CUBE
Indications: Third-degree prolapse, cystocele or rectocele, with or without good vaginal tone.
Often this is the only satisfactory support for women with a complete prolapse, complicated by a cystourethrocoele.
Excellent for vaginal wall prolapse in that it keeps the vaginal wall from collapsing from its six pressure points.
Maybe used by an athlete and removed after exercise.
Mucosa molds to the concavities creating a negative pressure
Drainage holes
Description: Each side of the cube has concave suction cups that adhere to the vaginal walls, helping to restore anatomical support to the pelvic organs.

22. INCONTINENCE DISH
Membrane support
Description: Dish-shaped pessary with holes to allow for drainage. The flexible membrane of the dish supports and elevates a mild cystocele.
Indications: SUI in conjunction with a 1st or 2nd degree prolapse, or a mild cystocele.
The knob

23. SHAATZ
Description:
A circular pessary with holes for drainage of secretions.
Indications: For the support of a first or mild second-degree prolapse.

24. GEHRUNG Arch Heel Description:
U-shaped device that provides support to the anterior vaginal wall. The arms or heels rest flat on the vaginal floor
It avoids pressure on the rectum while supporting the anterior wall
Arclike – malleable-can be shaped to suit the shape of the vagina
Shape can be expanded once inserted, a distinct advantage
Creates a “bladder bridge”
May be underutilized
Arch
Heel

25. GELLHORN
Description: Most commonly used pessary for uterine prolapse, also helpful with SUI. Fits superiorly and anteriorly.
Indications: Provides support for third-degree uterine prolapse and procidentia.
Provides less support for a rectocele since there is less support of the posterior segment.
Holes for drainage

26. HODGE
Description:
The anterior notch prevents urethral impingement and obstruction.
Available with support for the bladder in patients with stress incontinence.
If properly fitted sexual intercourse is possible
Malleable
Notch
Support for cystocele

27. RING - with and without support
Description:
Round flexible ring.
Helps support the urethra and bladder neck.
Membrane provides additional support for a cystocele.
Indications:
Useful for a first or mild second-degree uterine prolapse associated with a mild cystocele.
Support