Complications of Pessary Use
Mentor: Paula White, MD
Editor: Abimbola Famuyide, MBBS
Pessary devices have been used for centuries for a number of indications including pelvic organ prolapse, urinary incontinence, 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 candidates for surgery. There are currently around 20 different pessary types in use worldwide. They are generally made of silicone, rubber, or plastic. Medical grade silicone has superior properties including long durability and tolerance of repeated cleaning. Silicone pessaries do not absorb vaginal secretions or odors and are hypo-allergenic.
Minor complications are common and occur with all types of pessaries. Pessaries alter vaginal flora, often producing a thin, watery, physiologic discharge. This discharge does not need to be treated unless there is itching, burning, or odor. Superficial vaginal mucosal erosion is the most frequently reported complication and may result in foul odor and purulent discharge. Erosion can usually be managed by removing the pessary until the erosion is healed. If untreated, continued pressure of the pessary on the erosion may lead to local ulcerations, infections, and rarely, fistulas or ulceration of the uterus. Risk factors for erosion include continuous long term use and placement of a large pessary.
Other minor complications include vaginal discomfort or pain, bleeding, constipation, or material allergy. Some of these complications can be avoided by careful pessary fitting. A successful fit occurs when the biggest pessary is comfortably retained upright with walking, coughing, or squatting without patient discomfort or obstruction of bladder or bowel emptying. Women with genital atrophy may benefit from a short course of topical estrogen treatment before or after pessary placement.
Some types of pessary shapes and materials are associated with more serious complications, usually in a setting of neglect, for example, nursing homes residents or patients with dementia. Vesicovaginal fistulas have been associated with the Gellhorn or shelf design pessaries. Rectovaginal fistulas have a higher association with rubber or PVC pessaries use when compared with polythene pessaries. A neglected pessary can also lead to fecal impaction, bowel fistula, hydronephrosis, and urosepsis. Some small case series correlated long term use of pessaries with very rare occurrences of primary vaginal cancer, with postulated mechanistic pathways including chronic inflammation in the setting of viral infection or inducement of metaplastic changes that progress to dysplasia and cancer.
Overall, pessaries remain a safe, viable and important non-surgical treatment option for many patients. Complications are generally minor. More serious complications can occur, and are more frequent with improper care as well as with some device designs and materials. Frequent removal and cleaning of the pessary as well as periodic vaginal examinations can minimize complications.
Abdulaziz M, Stothers L, Lazare D, Macnab A. An integrative review and severity classification of complications related to pessary use in the treatment of female pelvic organ prolapse. Can Urol Assoc J. 2015 May-Jun;9(5-6):E400-6. doi: 10.5489/cuaj.2783.
Initial approval 1/2/18.
********** Notice Regarding Use ************
The Foundation for Exxcellence in Women’s Health, Inc (“Foundation”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.
This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.
Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The Foundation reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. The Foundation does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither the Foundation, the ABOG, SASGOG nor their respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.
Copyright 2017 - The Foundation for Exxcellence in Women's Health, Inc. All rights reserved. No publication, reuse or dissemination allowed without written permission.Back to Search Results