Pessaries have a long-established history in the non-surgical management of pelvic organ prolapse and stress incontinence, with Hippocrates documenting the use of pomegranates soaked in vinegar as vaginal pessaries, as well as pieces of wood, cork, gold and silver. Pessaries are now made with non-toxic medical grade silicone that is latex free and does not absorb odours. They can be sterilised and used for years. Most women will be able to have a pessary fitted comfortably, with over 50% continuing use for a year or longer.
Choosing the right type
Pessaries work to reduce prolapse by elevating the pelvic organs out of the vaginal space. This may be achieved through two means: supportive pessaries held in place by levator muscle tone (ring pessaries with or without support, Shaatz, Gehrung, amongst others); and, space-occupying pessaries that instead fill the vaginal space (such as Gellhorn, cube and donut). Continence pessaries also include a thickened knob or rim that creates support under the urethra. Whilst the literature can be conflicting on the factors associated with pessary failure, most would agree causes include a wider genital hiatus, prior hysterectomy, a larger degree of prolapse, and lack of oestrogen use in post-menopausal women. Having said this, the vast majority of women can be successfully fit with either a ring or Gellhorn.
In my practice, all women are offered a pessary as part of their management options for prolapse. Generally speaking, I will generally offer all sexually active women a ring pessary (with or without support), simply because it is easy for the patient to self-manage. They are also an excellent interim measure for younger women with symptomatic prolapse who seek further children and therefore aren’t ideal surgical candidates. At the initial or subsequent visit, I will instruct the patient on how to remove, wash, and replace the pessary on her own. This should be performed weekly, but may be done more frequently if desired. Most will remove the ring pessary for sexual intercourse, however some choose to retain it. Additionally, tampons may be used with a ring pessary in place. Should a ring pessary fail to be retained, I would usually then try a Shaatz.
In most cases, I will reserve Gellhorn or other space-occupying pessaries for women who are no longer sexually active, as these pessaries are harder for the women to self-manage. Given the shape of the Gellhorn and ability to create a suction effect, these pessaries appear to hold in place well. Despite this, some non-sexually active women will be better suited to a ring pessary as this is sometimes the better fit. If a sexually active woman is able to self-manage a Gellhorn or other space-occupying pessary, then there is no reason not to try. Should a Gellhorn fail to be retained, then I would usually try a cube next.
Finding the right size
Choosing the right sized pessary is a hard process to explain. It is not unusual for patients to try a few pessaries before finding the right fit. As a general rule, if it is slipping down too often or coming out easily with defaecation, then it is likely you will need to advise a larger size. The ideal size is when the pessary fills the vagina, but you are still able to run the examining finger between the pessary edge and the vaginal wall. Anteriorly the pessary should sit snug behind the pubic symphysis and if you push the pessary posteriorly, it should only move slightly. A pessary that is able to be flipped in the vaginal cavity is likely too small. Once in place, it should be comfortable for the patient.
To initially decide the size, I take a rough measurement of the distance from the pubic symphysis to the vaginal vault (D point) on stretch, using the examining digit. I then take a second measurement of the width of the mid vagina by spreading the index and middle fingers. This gives me an idea of which pessary size to try by comparing these mental measurements to the pessaries on the shelf. In my opinion, both measurements are useful as ,for example, some women may have a narrow vaginal width, despite a long vaginal length. In this situation, you must fit the pessary with the vaginal width as the limiting factor. Pessary sizing kits with sterilisable (often blue or yellow) pessaries are useful for those with less experience. Having said this, the majority of women most commonly fit a size 3, 4 or 5 ring pessary. Keep in mind that when converting from a ring pessary to a space-occupying pessary, size for size may not fit given the additional bulk of space-occupying pessaries. A step down in size is often required.
The next important component of fitting the pessary involves asking the patient to strain and bear down, to see if the pessary will be easily expelled. If this is the case, then it may be too small or they may require a different type. Once the right fit is confirmed, I will then instruct women with a ring pessary on how to remove and replace it, so that they can continue to self-manage it at home. This is the ideal situation, with pessaries cleaned at each removal by simply rinsing under warm tap water. I will also ask the patient to pass urine before leaving the clinic to ensure voiding is uninterrupted. Vaginal oestrogen for postmenopausal women without contraindications is routinely prescribed.
After the pessary fitting, I will typically organise an initial review appointment after a few weeks to see if any size adjustments need to be made. Once a patient is stable with their pessary, I will advise three-monthly reviews for those not self-managing their pessaries, or earlier if indicated. For those self-managing their pessaries regularly and without complication, this will be increased to six-monthly or yearly reviews. As always, patients should be counselled on the potential complications of pessary use and to return if any concerns arise.
Finally, tips for removing the stubborn pessary
Some pessaries are particularly stubborn and require additional tricks to remove them. This is most often encountered by Gellhorns due to the suction effect they can create on the vagina. To break the suction, one can sweep the examining digit medially between the base of the pessary and the vagina to break the seal. If this fails, one can try attaching a syringe to the drain on the shaft of the pessary and flushing it with 10ml of saline. Alternatively, the combination of a sponge-holding forcep to apply traction to the shaft whilst the examining digit tries to break the seal between the pessary and vagina is often successful.