Pessaries for Pelvic Organ Prolapse

Pelvic floor disorders and pelvic organ prolapse (POP) affect a substantial proportion of women with increasing age. The Pelvic Floor Disorders Network estimates that 24% of American women are affected by this problem.1 When pelvic symptoms a re associated with a loss of structural support of the pelvic organs and vagina, vaginal support pessaries offer an important option for relief.2 Given the benefits of nonsurgical management of POP with pessary use, it is important for the obstetrician/gynecologist to be comfortable offering this treatment option to all patients with prolapse. This article reviews the types of pessaries available for use in patients with POP, the fitting and placement of pessaries, and care instructions related to each type. We also review management options for common symptoms associated with pessary use. After reading this article, the obstetrician/ gynecologist should be able to identify women with symptomatic POP who are candidates for a pessary trial, counsel patients with regard to various treatment options available, offer a pessary fitting as an option, be able to successfully predict which pessary type to use on the basis of a woman’s presenting symptoms and physical examination findings, and manage common symptoms associated with pessary use. Conservative, nonsurgical management of POP should be offered to all women regardless of age. Pessaries may be offered to avoid pelvic reconstructive surgery, to prevent worsening of prolapse, or to diagnose and provide relief of bothersome prolapse symptoms . Pessaries have been used to alleviate the discomfort of pelvic floor disorders for thousands of years. Ancient Egyptians first described the treatment of prolapse with ancient remedies such as honey and petroleum.3 Later, Hippocrates described reduction of uterine prolapse and placement of a pomegranate fruit in the vagina to prevent recurrence of the disease.4 Today, medical-grade silicone or rubber pessaries are flexible, pliable, long-lasting, nonabsorbent, biologically inert, nonallergenic, noncarcinogenic, and washable, and can be sterilized using an autoclave or a cold sterilization product.5 The modernization of the device, including various shapes and sizes, has allowed for broader use of the pessary. Up to 74% of women with POP can be fitted successfully with a pessary.6 Unfortunately, a successful pessary fitting does not guarantee successful long-term use. Sarma et al demonstrated that only 14% of pessary users were still using the device 6 years after successful fitting.7 Although one third of women will choose to proceed with pelvic reconstructive surgery, it is our opinion that women are less likely to discontinue use of the pessary with proper preplacement counseling and discussion of expectations. Learning objectives: After participating in this CME activity, the obstetrician/gynecologist should be better able to: 1. Identify women with pelvic floor disorders who may be candidates for a pessary trial. 2. Choose the appropriate type of pessary to use based upon a woman’s presenting symptoms and physical examination findings. 3. Manage common symptoms associated with pessary use.