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1/1/2018

Complications of Pessary Use

Pessary devices have been used for several indications including pelvic organ prolapse, urinary incontinence, prevention of preterm labor, and cervical insufficiency. They are considered a safe and reasonable long-term option for patients who either do not wish to undergo surgery or may be poor surgical candidates. About 1 in 5 patients has a documented complication associated with pessary use of greater than 1 year, with one-third of those patients eventually requiring surgical management.

There are many different pessary types and are generally made of silicone, rubber, or plastic (Polyvinyl-Chloride [PVC] or Polythene). Silicone pessaries are usually preferred since they have longer durability, better tolerance of repeated cleanings, do not absorb vaginal secretions or odors, and are hypoallergenic.

Minor adverse events are common up to about 80% and are most frequent among women continuing to use pessaries beyond 1 year. Pessaries, as foreign bodies, alter vaginal flora and often produce a thin, watery, physiologic discharge not requiring treatment unless there is pruritis, burning, or offensive odor. Superficial vaginal mucosal erosion is the most frequently reported complication. Erosion can usually be managed by removing the pessary and expectant management until the erosion is healed. Other minor complications include vaginal discomfort or pain, bleeding, constipation, or material allergy.

Minor complications can be mitigated by proper pessary fitting. A successful fit occurs when the biggest pessary is comfortably retained upright with walking, coughing, or squatting without hindrance to bladder or bowel function. Women with vagina atrophy may benefit from vaginal estrogen treatment.  Vaginal estrogen use with a pessary may also decrease the incidence of bacterial vaginosis.

Severe complications are uncommon and usually develop in the setting of inappropriately long pessary retention between cleanings. Persistent erosions may develop into local ulcerations, infection, and rarely fistulas.

Gellhorn and donut pessaries are more commonly associated with pessary erosions than ring-with-support pessaries or incontinence rings. Vesicovaginal fistulas have been associated with the Gellhorn or shelf design pessaries. Rectovaginal fistulas have a higher association with rubber or PVC pessaries when compared with polythene pessaries. Inappropriately long retention of pessaries can also lead to serious complications such as fecal impaction, hydronephrosis, and urosepsis.

Overall, pessaries remain a safe, viable, and important non-surgical treatment option for many patients. Appropriate and consistent removal/cleaning intervals in conjunction with periodic vaginal examinations can minimize both minor and severe complications.

Further Reading:

Omosigho U, Propst K, Ferrando CA. Outcomes in Women With Pelvic Organ Prolapse Presenting With Pessary-Related Complications. Urogynecology (Phila). 2024 Feb 1;30(2):147-152. doi: 10.1097/SPV.0000000000001402. Epub 2023 Jul 26. PMID: 37556384.

Kakkar A, Reuveni-Salzman A, Bentaleb J, et al. Adverse events associated with pessary use over one year among women attending a pessary care clinic. Int Urogynecol J. 2023 Aug;34(8):1765-1770. doi: 10.1007/s00192-023-05462-z. Epub 2023 Jan 30. PMID: 36715742.

Ai F, Wang Y, Wang J, et al; Effect of estrogen on vaginal complications of pessary use: a systematic review and meta-analysis. Climacteric. 2022 Jun 13:1-10. doi: 10.1080/13697137.2022.2079973. Epub ahead of print. PMID: 35695119.

Initial approval January 2018. Reaffirmed July 2019. Reaffirmed March 2021. Revised September 2022; Revised May 2024.

 

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