Common Problems after Pessary Placement
4/1/2016 - Rana Snipe Berry, MD
Mentor: Lee Learman, MD
Editor: Ronald Burkman, MD
Pessaries are most commonly used for pelvic organ prolapse (POP) and are preferred in patients who have early stage prolapse, desire future pregnancy, are poor surgical candidates, or who prefer to avoid surgery. Pessaries can be used to treat stress urinary incontinence (SUI). Pessaries are available for either support or space-occupying purposes and are available in many shapes and sizes to fit a wide variety of women. Some pessaries have been specifically designed to treat SUI by stabilizing the urethra and increasing urethral resistance. These pessaries include the ring pessary with support and knob, the incontinence ring or the incontinence dish.
Pessaries are generally safer than surgery, have fewer potential side effects than medications, provide more immediate symptom control than behavioral therapy, and have very few contraindications. They offer the advantage of user-mediated control as they can be placed and removed with privacy and convenience.
Contraindications to pessary include infection, ulceration, or allergy to components of the device. Serious complications from pessaries are rare, but include vesicovaginal fistula, rectovaginal fistula, erosion, and impaction with resultant fibrosis. Minor complications are more common and include vaginal discharge and odor. One of the most frequent complications is the unmasking of occult SUI when pessaries are used to treat POP.
Occult SUI is observed only after the reduction of pelvic organ prolapse. Once a pessary is placed, a formerly “kinked” urethra may straighten out, allowing an increase in intraabdominal pressure to surpass its ability to prevent leakage resulting in loss of urine. Occult SUI is present in 36 to 72% of previously continent women after pessary placement.
When used in the treatment of SUI, pessaries work by compressing the urethra against the upper posterior portion of the symphysis pubis and elevating the bladder neck, causing an increase of urethral length, increase in outflow resistance, and correction of the angle between the bladder and the urethra.
If a previously continent patient suffers from occult SUI after an otherwise successful pessary fitting, she should be counseled regarding her options which may include continued pessary use if symptoms are mild, continued pessary use plus collagen injection of the urethra, a change in the pessary type, or surgical repair of prolapse with a concurrent urinary procedure. The patient and provider should establish therapeutic goals and priorities. Many women may prefer to continue with current therapy rather than revert to the discomfort from the pelvic organ prolapse.
Changing to a pessary specifically designed for SUI should be among the first choices in women with occult SUI. Surgery may be appropriate if a change in pessary fails to provide an acceptable outcome.
Pelvic organ prolapse. ACOG Practice Bulletin No. 85. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:717-29.
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