Vaginal Pessaries for Pelvic Organ Prolapse
Pelvic organ prolapse is a common condition that is most commonly seen in women who have given birth vaginally. Most women know that this can be corrected surgically with variable success but very few know that there is a less invasive way to manage this problem that doesn’t involve surgery. Welcome to the world of vaginal pessaries.
A sample of the different types of vaginal pessaries used in my practice.
Essentially, pessaries are inserted into the vagina and help to hold the pelvic organs in their correct anatomical location. This is old technology, in fact the ancient Roman’s and Greeks’s fashioned pessaries to manage this problem. We have much more advanced pessaries now that can be used for varying degrees of prolapse and some that are designed to help with stress urinary incontinence as well, but the concept is the same.
When I was training, I was taught that pessaries were primarily for patients who weren’t fit for surgery. These women would have a pesary fitted and it would stay until they cam back for review where it would be removed and either washed or replaced. This is NOT how I use pessaries in my private practice and there is no good reason that they can’t be used by all women with prolapse.
We have a pessary fitting set in the rooms which has a variety of pessary types and sizes which are autoclaveable. When I fit a pessary, I ask the woman to come in at 8:30am and to have the whole day clear so that I can make sure that the pessary we settle on is right for her. Initially I will fit a pessary that I think is suitable and then ask the patient to go out, do regular activities, make sure that she can pass urine with the pessary in and then come back. Based on what the woman has found I will either try a different pessary or order in the one that she has found works for her.
Once the patient’s pessary has arrived in the office, we make her another appointment where I teach her to insert and remove the pessary herself. Pessaries are like any other prosthesis or aid that can be used or not as the patient wishes. This gives women complete control over this aspect of their bodies.
So what are the risks/downsides associated with pessaries? There are very few risks with pessaries. The main issue we see is vaginal erosions. This is due to the pressure the pessary places on the vaginal wall and is most commonly seen in very elderly people who have had the pessary left inside the vagina for extended periods of time. This is a fairly minor issue and can be fixed by having a break from the pessary for a few weeks as well as the use of an estriol containing vaginal cream. The other downside with pessaries is that most can’t be used during sex. This is one of the reasons that I teach women to insert and remove it themselves and even though it can be a barrier to spontaneity, most women don’t view this as a big issue.
What are the advantages of a pessary over surgery? Firstly, you avoid the risks of prolapse surgery such as bleeding, infection, failure, mesh erosion if mesh is used, chronic pain and pain with sex. Surgery is NOT reversible and if you don’t like the outcome there is very little that can be done. The failure rate of prolapse surgery is such that it is not uncommon for women to end up having multiple procedures in an attempt to get to a functional level.
If you do have pelvic organ prolapse I would encourage you can ask your gynaecologist about the use of a pessary - there is a lot to gain and very little to loose by trying one.
