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.
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.
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.
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