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Pessary Insertion

1. Purpose

  • Pessaries are used for treating Pelvic Organ Prolapse
  • Pelvic Organ Prolapse = weakened supports leading to descent of a pelvic organ
  • Descent can lead to obstruction, incontinence, or pressure symptoms
  • Pessaries act as strut or additional support to keep pelvic organ in place and alleviate discomfort associated with prolapse

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2. Risk Factors for Pelvic Prolapse

  • Vaginal deliveries
  • Hysterectomy
  • Vaginal surgeries
  • Large babies

Promoting Factors for Pelvic Prolapse

  • Obesity, weight gain
  • Age
  • Constipation
  • Menopause
  • Smoking, chronic cough
  • Recreation (eg: heavy weight lifting)
  • Occupation (eg: nursing, PSW with liftiing)

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3. Symptoms of Pelvic Organ Prolapse

  • Vaginal bulge
  • Obstruction (weak stream, hesitancy, retention/failure to empty)
  • Overactive bladder (frequency, urgency)
  • Need for manual reduction to void
  • Urinary infections
  • Painful intercourse

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4. Indications for Pessary Use
  • Cystocele
  • Uterine prolapse
  • Vault prolapse
  • Urinary incontinence

Pessaries are suitable for those who are symptomatic, have failed conservative management, and are nonsurgical candidates

  • Conservative management includes:
    • Pelvic floor exercises
    • Weight reduction
    • Avoiding straining and constipation
    • Cessation of smoking
    • Use of estrogen replacement

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5. Types of Pessaries

  • Most are made of medical grade silicone
  • Numerous sizes and shapes chosen based on comfort and type of prolapse

Ring shaped pessaries:

  • Helpful to treat grade 1 and 2 cystoceles, uterine prolapse, and stress incontinence
    • Ring with support (filled-in centre): used for cystocele
    • Ring without support: used to treat uterine prolapse
    • Ring with knob (hollow): Used to treat stress incontinence

Various elements can be combined into one pessary if necessary (eg, a woman with stress incontinence and cystocele would benefit most from a ring with support and a knob.






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6. Complications

  • Vaginal wall erosions/ulcers
  • Bleeding
  • Infection
  • Rectovaginal fistula
  • Complications can be minimized by having a pessary that fits correctly and that does not put too much pressure on the wall of the vagina.
  • In post-menopausal women, estrogen (cream, ring, or tablets) is sometimes used with a pessary to help with irritation caused by the pessary.
  • Regular cleaning reduces the risk of complications

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7. Equipment

  • Sterile Pessary kit
  • Sterile Vaginal speculum
  • Water based lubricant
  • Nonsterile gloves

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8. Preparation

  1. Explain the procedure to the patient
  2. Obtained informed consent
  3. Ask the patient to empty her bladder prior to the pelvic exam
  4. Position the patient in lithotomy position with or without stirrups

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Assessment of Prolapse

  1. Don non-sterile gloves
  2. Examine the patient without instrument first
  3. Assess the patient at rest in lithotomy position
  4. Ask the patient to bear down, look for stress incontinence or obvious prolapse
  5. Now insert single lubricated blade (separate bivalve speculum) posteriorly and apply gentle downward pressure
  6. Ask the patient to bear down
  7. Assess for cystocele, uterine or vaginal vault prolapse and urinary incontinence
  8. Then rotate the blade 180 degrees to check for rectocele with and without valsalva
  9. Remove the vaginal speculum
  10. Repeat the exam digitally by placing your 2-3rd fingers inside the vagina to feel for any palpable prolapse with and without valsalva
  11. See if you can reduce the prolapse with your fingers or whether it self reduces

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Prolapse Grading

  • Grade 1: Mild
  • Grade 2: To introitus with strain
  • Grade 3: Beyond introitus with strain
  • Grade 4: Beyond introitus at all times

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Pessary Fitting

  • Prepare the patient in lithotomy position
  • Don non-sterile gloves
  • Estimate appropriate type and size of pessary
    • Begin by inserting your middle finger behind the cervix in the posterior fornix and index finger against the pubic notch
    • Withdraw your fingers and choose a pessary whose size approximates the distance between the two fingers
    • The average pessary size is 4 or 5, with the range being from 2 to 7
  • Lubricate, gently insert and position pessary (see details in “Pessary Insertion”)
  • Sweep your fingers around the perimeter of the pessary to check for pressure points
  • If pessary is too small it will sink and if too large it will not advance high enough. If necessary, switch to a different size.
  • Let patient walk around for 10-15 min (or up to 1 hr) while filling bladder and trying to void
  • If urinary retention/incontinence, but otherwise good fit, consider a knob version of the same type of pessary
  • If fits well, insert the corresponding size for home and arrange a follow up appt to recheck the fitting

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Pessary Changes

Insertion of Pessary

  1. Place small amount of lubricant inside the vagina
  2. Fold the pessary at the holes/knob and place a small amt of water based lubrication at the entry end (opposite side of knob if present)
  3. Switch gloves or ensure the gloves are not too slippery
  4. With non dominant hand, spread the labia to expose the vagina
  5. The dominant hand advances the folded pessary into the vagina while the nondominant hand keeps the distal end of pessary folded as it advances (this prevents premature unfolding of the pessary before it is high enough)
  6. The dominant hand advances the pessary as far as it can go before releasing the pessary
  7. If there is a ring with knob pessary, ensure the knob is tilted anteriorly against pubis
  8. Ask the patient if the pessary position feels comfortable
  9. If it is uncomfortable, consider reinsertion for better placement

Pessary Removal

  1. Position patient in lithotomy position
  2. Don nonsterile gloves
  3. Put middle finger into vagina to feel for pessary
  4. Fold pessary by applying midline pressure and grabbing the two edges
  5. Ask the patient to bear down as if having a bowel movement
  6. Grab the pessary while folding it and pull it down and out

Cleaning of Pessary

  1. Remove pessary
  2. Wash the pessary with liquid soap or dishwashing soap
  3. Clean all the holes and rinse well
  4. Pat the pessary dry
  5. Reinsert pessary

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10. Aftercare
  • The patient may be taught to remove and replace the pessary herself
  • If possible, the pessary should be washed once a week with mild soap and water (liquid dishwashing soap is an option)
  • Use water based lubricants (KY jelly or astroglide) for insertion
  • Patient may continue to be sexually active
  • To prevent infections and odours, an acidifier (usually supplied with the pessary) or estrogen can be applied vaginally 2 or 3 times weekly
  • Contact MD if difficulty emptying bowels/bladder or if pessary feels uncomfortable
  • Report any unusual vaginal discharge, odor or bleeding
  • FU with MD q3-6months to check for erosions and pessary cleaning
  • If erosions are detected, the pessary should be left out and estrogen applied until healed

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11. Quiz

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12. References

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