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The Vaginal Pessary

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First Return Visit
The woman should return for a pessary check 1 to 3 days after a fitting. One day is best if you are unsure about the fit. At 3 days, any tenderness from the insertion process will have been resolved and any potential discomfort from the pessary will not be confused with it. It also takes a few days for the vaginal tissues to "settle in" around the pessary. Advise patients not to worry if the pessary falls out. It most typically falls out while a woman is sitting on the toilet. The patient should retrieve it, wash it with soap and water, place it in a plastic bag and return with it to the office. It is important to ask about any discomfort or problem with elimination. If a woman complains of this, remove the pessary and perform a speculum examination to observe for any local tissue reaction such as discharge, irritation or ulceration.

Estrogen Status
Assessment of estrogen status and treatment of vaginal atrophism are vital when a woman has a pessary. I perform a maturation index prior to insertion and repeat it every 2 months to assess response to vaginal estrogen. Most older women with a pessary need vaginal estrogen to maintain mucosal integrity. I usually show them the applicators for Premarin cream and the tablet Vagifem. The cream works best with severe atrophism, since the pill needs moisture to absorb and the applicator may be difficult to insert in a dry vagina. A good choice, particularly for elderly women, is the Estring. It remains in for 3 months, just like the pessary. I insert the ring first and tuck the pessary in right after.

Self-Care
Once inserted, the pessary needs to be maintained. When possible, encourage women to care for their own pessaries. A younger woman is more apt to assume this responsibility, particularly if she has prior experience with using a diaphragm. The elderly are more inclined to turn the care over to a provider. They often have little experience in inserting objects into their vagina, and most have never even used a tampon. Dexterity can be an issue since many older women have arthritis in their hands. These women are willing to return every 2 to 3 months. The cleaning schedule should be based on personal preference and the response of vaginal tissue to the presence of the pessary.

Table 4 lists some complications associated with pessary use. These are usually minor. Sometimes the pessary slips down toward the vaginal opening during a particularly hard bowel movement and the patient feels that the device has moved. If displacement occurs, she should lie flat in bed with one leg elevated and tuck the pessary deep behind her pubic bone. Most women are able to do this.

After the first return visit, a patient should return every 8 to 12 weeks. Although the pessary is non-toxic, vaginal tissues have varying responses to the presence of the pessary. Pessaries tend to trap vaginal secretions and obstruct their normal discharge. These accumulated secretions can break down and cause odor. There may be a slight increase in vaginal discharge, which is usually creamy in color. This is normal. If the discharge has any color, perform a wet mount of the secretions. Collect a vaginal culture if there is a strong odor or copious discharge. It is interesting to note that some women with a pessary have only a little discharge while other women have increased discharge, even with proper care. In the latter case, recommend cleaning at more frequent intervals.

Removal
Pessaries must be diligently maintained and removed every 2 to 3 months. Most pessaries can be collapsed and halved to facilitate insertion, but removal is more challenging. It is difficult to fold the pessary in half to remove it because it is within the small confines of the vagina. The normal discharge within the vagina also makes the pessary slippery and difficult to grasp. In some instances, the pessary simply has to be pulled out. I inform the woman of the need for this technique, which can feel abrupt. It can be accomplished in a second or two.

A wonderful device is the pessary remover (Figure 5), which has greatly enhanced the removal process. I sometimes wonder how I ever got along without it! For pessaries with a hole in the support, such as the ring or the plain ring, slide the instrument through the hole or rim, rotate it using the non-dominant hand, and quickly slip it through the introitus with the application of traction.

If you do not have a pessary remover, insert the index fingers of both hands into the vagina and grasp the leading edge of the pessary. Apply traction toward the vaginal opening as you rotate it perpendicular to the introitus. Once visible at the introitus, release the non-dominant hand, grasp the rim between the thumb and forefinger of the dominant hand and pull the pessary out. Sometimes a slight tearing of the delicate vaginal tissue may occur. Bleeding usually stops within a few minutes with the application of pressure.

At each visit, remove the pessary for cleaning and inspect the vagina. This is important since there are limited nerve endings in the vagina and the patient may not be able to sense the presence of any ulcerations or irritation. A slight discoloration of the pessary may occur, but if it is still intact, it can be cleaned and reinserted


The Vaginal Pessary

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2nd comment. After reading most of the posts here, I decided to add an additional comment. The pessary is silicone, not a plastic in the sense one commenter has concerns(No BPA). That's good because I won't even use BPA bottles/ cans. Second,the estrogen or progesterone that is recommended to be used with insertion is often helpful to rebuild the vaginal walls to aid in support of the pessary. I too had atrophy. My GYN also assured me that using hormone therapy vaginally will not affect the client sysetemically, hence one not need to fear estrogen related to the development of cancers. I too was concerned, having declined to use estrogen replacement at 50. I am now 70, and feel better about this application.Try Trimo-san by MILEX, which my GYN gave me to help restore the PH of the vagina. I was experiencing burning, and that has really helped.(available OTC). Doing the research really helps, and reduces worry,I find. I hope my comments have been helpful. Thanks for the opportunity to share.

Trish Roseman,  Ms.,  Moga/GYNJune 10, 2014
Moscow, TN



My RN discovered uterine prolapse on a routine exam . I had been having several UTIs in a year. (Last visit 18 mos ago to GYN was routine, and a vaginal probe found all good). Now I was nervous. Anticipating a hysterectomy, I made an appointment at my GYN. Happily, I then discovered via internet the soution of the pessary.I found at the office visit that my research had paid off. I was able to ask appropriate ?s and understood much more than I would have, had I not done my homework. Then and there,she was able to both measure and fit me correctly, with no pain or discomfort. I had not been so relieved of pressure and pain for many months, and almost cried with relief! I did hug and thank her. Today, I am the grateful owner of a compact little helper than will in years to come heal my womb, and provide me with urinary continence.

Trish Roseman,  Ms.,  Moga/GYNJune 10, 2014
Moscow, TN



I just got fitted with the pessary yesterday May 13, 2014. I have a prolapsed urethra. I will receive mine in about 4 or 5 days. I am so happy. The doctor had me jump up and down and cough with the pessary in when she fitted me. I didn't leak one drop. It was great. I had never heard of a pessary before so it makes me happy I don't need surgery.

Stacey  ShieldsMay 14, 2014
Ellettsville, IN



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