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The Vaginal Pessary

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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To EM with the question about the ring that shifts to a vertical orientation.
A Gelhorn pessary is much like the ring except that the stem of it will prevent the vertical rotation that you are describing. Contrary to what I see posted these pessaries are not difficult to insert or remove.

Deborah Lehmann,  MD,  Private aPracticeJune 21, 2015
Fort Worth, TX



I have an acutely retroverted uterus that is pulling my bladder down. The uterus is 12 weeks size with damage from Adenomyosis. (Will need hysterectomy eventually.)

What does it mean if a Size #5 Ring pessary keeps turning to vertically, instead of staying horizontal.

I want to use it, but walking or moving about even for 1 hour dislodges it.

Using a Size #6 blocked my ability to urinate, so upsizing isn't working.

Thanks for any ideas.

Em WrightJune 14, 2015



I was fitted tor a Pessary on March 2015, it sort of felt find, but after I felt, heaviness in my chest area and slight hurt on the left side of my lower body of the stomach area. I called the doctor office and I explained to them what I was going through after having the pessary inserted. I was given an appoint to go in, I am not sure if it was within two weeks or not. I explained to the doctor I was having chest pain and a slight hurt to the bottom on my left side. I was told the passary would not give me chest pain.
I continued to have the chest pains, so I went to see my family physician, he did an EKG and sent me to the hospital to do an ECO gram. I do not know the result of either one right now.
My bladder control was fine before the insertion of the pessary, but now I empty my bladder more often and have slight urine passage from the bladder and I must go when my bladder need to be emptied.
After catching a dry cough, my bladder gushiest water like a water fountain, I explained this to the nurse at the doctor’s office on April 17, 2015 and she said that’s when we have to start using (really do not remember exact name, but it pertaining to depends) for protection. I am wondering how I can work with this condition.
I than called the OBGYN doctor’s office and the person on the phone (Ms. Kelly) explained they had no opening, but she scheduled me an appointment for Wednesday, April 22 to come in, which is five days waiting time before I can see the OBGYN doctor. My bladder gushiest when I cough, my clothing are wet, even though I used a pad, so I started using a small bladder protection pad and a Sanitary napkin for protection.
Are there anyone having this type of problem? (4/18/2014)

Thanks
Stella Collins


Stella CollinsApril 18, 2015
New Iberia, LA



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