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PESSARY CARE

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PESSARY CARE Raed Sayed Ahmed BACKGROUND Some degree of prolapse seen in up to 50% of parous women in a clinic setting although many are asymptomatic. – PowerPoint PPT presentation

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Title: PESSARY CARE


1
PESSARY CARE
  • Raed Sayed Ahmed

2
BACKGROUND
  • Some degree of prolapse seen in up to 50 of
    parous women in a clinic setting although many
    are asymptomatic.
  • The aetiology of pelvic organ prolapse is complex
    and multi-factorial.

3
BACKGROUND
  • Risk factors include pregnancy, childbirth,
    congenital or acquired connective tissue
    abnormalities, denervation or weakness of the
    pelvic floor, ageing, menopause and factors
    associated with chronically raised
    intra-abdominal pressure .

4
BACKGROUND
  • Symptoms, only some of which are directly related
    to the prolapse, include pelvic heaviness,
    dragging sensation in the vagina, bulge/lump or
    protrusion coming down from the vagina, and
    backache.
  • Symptoms of bladder, bowel or sexual dysfunction
    are frequently present. These may be directly
    related to the prolapsed organ, eg poor urinary
    stream when a cystocoele is present, or
    obstructed defecation when a rectocoele is
    present.

5
BACKGROUND
  • They may also be independent of the prolapse, eg
    symptoms of detrusor overactivity when a
    cystocoele is present.

6
BACKGROUND
  • Treatment of prolapse depends on the severity of
    prolapse and its symptoms, and the woman's
    general health.
  • Options available for treatment are conservative,
    mechanical and surgical.
  • Generally, conservative or mechanical treatment
    is considered for women with a mild degree of
    prolapse, for those who wish to have more
    children, and the frail or those unwilling to
    undergo surgery.

7
BACKGROUND
  • An extensive range of mechanical devices have
    been described for the treatment of prolapse.
  • Pessaries need to be removed regularly and the
    vaginal mucosa checked for erosions although the
    optimum frequency for this has not been
    established.

8
BACKGROUND
  • Some patients will be able to remove and replace
    the pessary themselves, which may lengthen the
    intervals between gynaecological examinations.
  • The role of local estrogens in preventing
    complications has not been established.
  • Mechanical devices are cheap and complications
    are rare, but their efficacy in the management of
    prolapse is unknown.

9
BACKGROUND
  • The aims of mechanical treatment in the
    management of pelvic organ prolapse include
  • To prevent the prolapse becoming worse.
  • To help decrease the frequency or severity of
    symptoms of prolapse.
  • To avert or delay the need for surgery.

10
BACKGROUND
  • The era of modern surgery has witnessed a steady
    decline in pessary use as well as a decline in
    instruction in the use of pessaries,such that for
    many physicians, pessaries have become a medical
    curiosity.
  • This trend was promoted by much quoted article
    from 1961 that attributed a number of
    complications, including vaginal malignancy,
    vaginal ulceration, fistulas, and pelvic
    cellulitis to the use of pessaries.

11
BACKGROUND
  • This has led some authors to describe pessaries
    as obsolete and even dangerous.
  • Differences of opinion regarding pessary use are
    even clearer when more specific criteria for
    pessary use are considered.
  • Some authors consider vaginal pressure ulcers a
    contraindication to pessaries, while others
    recommend them to permit the healing of vaginal
    pressure ulcers.

12
BACKGROUND
  • There are no level I or level II data addressing
    the indications, or appropriate choice of pessary
    for different support defects.
  • There is one prospective study addressing the
    effectiveness of pessary use and the impact of
    clinical characteristics including stage of
    prolapse, hormone replacement, and perineal
    support on the success of pessary use.

13
Pessary Efficacy in Improving Prolapse Symptoms
  • Only a few studies have evaluated the efficacy
    and patient satisfaction of pessaries in
    relieving symptoms of prolapse.
  • Clemons et al followed 100 women fitted with
    pessaries for stage II prolapse for changes in
    prolapse and urinary symptoms.
  • At 2 months, 92 of women fitted with a pessary
    were satisfied.

14
Pessary Efficacy in Improving Prolapse Symptoms
Contd
  • Nearly all prolapse symptoms (bulge, pressure,
    discharge, and splinting) had resolved and
    concurrent urinary symptoms (baseline stress
    incontinence, urge incontinence, and voiding
    difficulty) had improved in approximately half of
    patients.
  • However, among women with no urinary symptoms at
    baseline, 21 complained of occult (de novo)
    incontinence with pessary use.

15
Pessary Efficacy in Improving Prolapse Symptoms
Contd
  • Many clinicians have noted the decrease in
    prolapse stage after long-term pessary use and
    the successful role of pessaries in preventing
    progression of prolapse.

16
Handa et 2002
  • Suggested that there was a therapeutic effect of
    wearing a supportive pessary as evidenced by an
    improvement of stage of pelvic organ prolapse in
    21 of patients followed for 1 year.
  • The mechanism of this improvement might be the
    result of improved levator ani function, and that
    pessary support of pelvic organs may allow for
    recovery of passive stretch, thus improving
    levator function and muscular support of pelvic
    organs.

17
Factors Effecting Successful Pessary Fitting
  • Achieving optimal results and satisfaction with
    pessary use requires accurate identification of
    appropriate patient candidates and proper choice
    of pessary type.
  • Successful pessary fitting rates range from 56
    to 74.

18
Factors Effecting Successful Pessary Fitting
Contd
  • The two studies with the highest rates of success
    used similar protocols.
  • Patients were first fitted with ring pessaries
    and, if expelled, a space-filling pessary such as
    the Gellhorn was then attempted.

19
Factors Effecting Successful Pessary Fitting
Contd
  • Important in the discussion of successful pessary
    fitting is to speculate which patients are likely
    to choose pessary management over surgery or
    expectant management.
  • A study evaluating the clinical factors that
    affect a patient's treatment choice for
    symptomatic pelvic organ prolapse found that
    older patients (age 70 12 years) were 10 more
    likely to choose pessary over surgery.

20
Factors Effecting Successful Pessary Fitting
Contd
  • History of prior pelvic surgery, on the other
    hand, was the strongest predictor of a patient
    choosing surgery as their form of treatment.

21
Factors Effecting Successful Pessary Fitting
Contd
  • Clemons et al fitted 100 women with pessaries for
    symptomatic pelvic organ prolapse and found that
    no patient demographic or comorbidity could be
    identified as a risk factor for an unsuccessful
    pessary fitting trial.
  • However, this study did find an association with
    shorter vaginal length (lt6 cm) and wider vaginal
    introitus (4 finger breaths) on pelvic
    examination predicted an unsuccessful pessary
    fitting trial.

22
Factors Effecting Successful Pessary Fitting
Contd
  • Interestingly, stage III or IV prolapse in each
    compartment (anterior vaginal wall, posterior
    vaginal wall, and vault/uterine prolapse) was not
    a risk factor for an unsuccessful fitting.

23
Factors Effecting Successful Pessary Fitting
Contd
  • A similar study also evaluated variables, which
    would diminish a patient's ability to retain a
    pessary.
  • In this particular study, physical examination
    findings that predicted a patient's inability to
    retain a pessary were absence of sacral reflexes,
    inability to Kegel, higher stage of prolapse, and
    an enlarged genital hiatus (greater than 4 cm).

24
Factors Affecting Continued Pessary Use
  • Factors that affect a patient's likelihood to
    continue with pessary use have been evaluated by
    several studies.
  • Clemons et al found that 72 of women satisfied
    with their pessary after 2 months continued to
    use their pessary after 1 year and 64 continued
    use after 2 years.

25
Factors Affecting Continued Pessary Use
  • In their study, older age (gt65 years) was the
    strongest predictor of continued pessary use
    after a successful fitting.
  • Stage III and IV posterior wall prolapse was
    associated with discontinued use of the pessary.
  • This finding is not surprising because
    anecdotally, women with large posterior wall
    defects are less likely to experience relief of
    their prolapse symptoms with pessary use.

26
Factors Affecting Continued Pessary Use
  • Initial desire for surgical management of
    prolapse symptoms was also found to be associated
    with discontinued use of pessaries.
  • Brincat performed a retrospective chart review of
    136 current users versus nonusers (women who
    stopped wearing the pessary during the study
    period) to determine clinical variables
    predicting continued pessary use.

27
Factors Affecting Continued Pessary Use
  • The authors reported that women with prolapse and
    incontinence or prolapse alone were more likely
    to continue with long-term pessary use than women
    with isolated incontinence.
  • Their most significant finding of this study was
    that long-term pessary use was acceptable to
    sexually active women.

28
Indications for Pessary use
  • Indications for pessary use are
  • Primary therapy for prolapse symptoms.
  • Diagnosis and preoperative evaluation of patients
    with pelvic prolapse.
  • Temporary treatment of prolapse symptoms.
  • Urinary incontinence and obstetric indications.

29
Diagnosis and preoperative evaluation of patients
with pelvic prolapse.
  • Occult incontinence, urinary retention, and
    pelvic pain are conditions that should be
    evaluated preoperatively to allow for
    comprehensive counseling as to the best surgical
    or nonsurgical form of treatment.

30
Lazarou et al
  • Addressed the question of whether preoperative
    reduction of the anterior vaginal wall in
    patients with urinary retention PVR gt100 cc
    with a pessary would predict voiding function
    after reconstructive surgery.
  • concluded that pessary reduction of the anterior
    vaginal wall in patients with urinary retention
    has good sensitivity, specificity, and positive
    predictive value for postoperative voiding
    function.

31
Temporary treatment of prolapse symptoms.
  • Preoperatively, a pessary can be useful in the
    healing of vulvar erosions secondary to a large
    prolapse.
  • Second, mechanical devices can be used as an
    interim measure while a patient prepares for
    surgery and considers nonsurgical options for
    relief of symptoms.
  • Younger women will benefit from the symptomatic
    relief of their prolapse symptoms as they wait to
    complete childbearing.

32
Urinary incontinence and obstetric indications.
  • Pessaries are an important conservative mode of
    therapy used for urinary incontinence as well as
    the use of pessaries in obstetrics for the
    management of an incarcerated uterus or
    incompetent cervix.
  • Pessaries designed to support the urethrovesical
    junction with a knob or prongs may be successful
    alternatives for surgery for the management of
    stress incontinence with a success rate ranging
    from 15 to 59 (Ferrell et al 2002).

33
Urinary incontinence and obstetric indications
Contd.
  • In obstetrics, pessary use has been reported in
    the first trimester for the treatment of
    incarcerated uterus.
  • Rarely pessaries have been used in cases of
    incompetent cervix.

34
Urinary incontinence and obstetric indications
Contd.
  • A recent review of the use of pessaries in women
    at risk for preterm delivery reports that they
    might be helpful and seem to be without risks.
  • However, the existing data are limited by a lack
    of inclusion criteria and selection bias.
  • The review recommends that pessaries be used as
    an adjunct to cerclage and not to replace the use
    of cerclages in the treatment of incompetent
    cervix

35
Health of the Vaginal Epithelium
  • Evaluation for vaginal and vulvar atrophy
    secondary to estrogen deficiency should be
    assessed on examination.
  • Little to no data is currently available to
    dictate whether vaginal atrophy is indeed a
    contraindication for pessary fitting.
  • Wu and colleagues reported on their experience
    and reported that hormone replacement therapy
    (HRT) did not predict successful pessary fitting.

36
Health of the Vaginal Epithelium Contd
  • The health of the vaginal epithelium was recorded
    in 75 of these women, and no correlation was
    found between current hormone replacement status
    and vaginal abrasions rates.
  • Most experts would advocate local estrogen
    therapy in pessary users provided that there are
    no contraindications to its use.

37
Hendrix et al 2002
  • Showed that oral HRT/estrogen replacement therapy
    (ERT) provides no functional improvement of the
    lower urinary tract.
  • To definitively answer the question of estrogen
    use and pessaries, we need trials on type, route,
    frequency, and so on.

38
Cundiff et al 2000
  • A two-page anonymous survey distributed to the
    members of the American Urogynecologic Society.
  • The response rate was 48 (359 of 748).

39
Cundiff et al 2000 contd
  • Practice and number of years in practice and
    questions regarding indications for a pessary in
    patients with pelvic organ prolapse.
  • The impact of other factors hormonal status,
    sexual activity, prior hysterectomy, and stage
    and site of pelvic organ prolapse.

40
Cundiff et al 2000 contd
  • The choice of pessary for specific support
    defects. The long-term management of pessaries.
  • 50 of respondents urogynecologists, while a
    third obstetrician-gynecologists, and 10
    gynecologists.

41
Cundiff et al 2000 contd
  • Those who described themselves as gynecologists
    tended to have been in practice longer (mean 20
    years).
  • Only 4 of respondents described themselves as
    urologists.

42
Cundiff et al 2000 contd
  • 98 reported using pessaries in their practice.
    77 used them as a first line of therapy for
    pelvic organ prolapse, while 12 only offered
    pessaries to women who were not surgical
    candidates.
  • Gynecologists and urologists were less apt to use
    pessaries as first-line therapy and more apt to
    reserve them for nonsurgical patients than
    obstetrician-gynecologists and urogynecologists.

43
Cundiff et al 2000 contd
  • Practitioners with more than 20 years in practice
    were less likely to use a pessary as a first-line
    therapy and more likely to reserve them for women
    who could not undergo surgery.
  • Less than half of the respondents considered a
    prior hysterectomy 42, or current sexual
    activity 45 to be contraindications for a
    pessary, while two thirds or 64 considered
    hypoestrogenism to be a contraindication.

44
Cundiff et al 2000 contd
  • A variety of pessary removal regimens were
    described with no clear prevailing regimen.
  • 53 of physicians reported teaching all their
    patients to change their own pessary,while 45
    reserved this approach for a subset of women
    using support pessaries.

45
Cundiff et al 2000 contd
  • 94 recommended concurrent estrogen replacement
    therapy and 61 asked patients to perform pelvic
    muscle exercises while using a pessary.

46
Pessary use by specialty including first-line use
and for patients declining surgery .
47
(No Transcript)
48
Wu et al
  • 110 patients with a mean age of 65.
  • patients were seen in follow up in 2 weeks.self
    care was encouraged.
  • at each visit the pessary was removed,rinsed in
    tap water and dried.the vagina was inspected by
    speculum for evidence of abrasion or erosion.

49
Wu et al contd
  • the pessary was replaced if
  • too stiff
  • encrusted with secretion.
  • developed defects.
  • been used for 1 year.

50
Wu et al contd
  • in the 1st year following insertion following was
    scheduled at 3 month intervals.
  • if the patient remaind free of complications,the
    follow up interval was extended to 6 months in
    the 2nd and subsequent year.
  • Patients using cube pessaries were managed using
    a different protocol.

51
Wu et al contd
  • Current hormone replacement therapy use did not
    predict successful pessary fitting.
  • The incidence of abrasions increased sig as the
    mucosa became thinner.

52
Wu et al contd
  • There was no correlation between the hormone
    replacement status and the abrasion rate.
  • The highest rate of pessary discontinuation was
    in the first year.

53
Wu et al contd
  • Minor vaginal abrasions usually were managed with
    vaginal estrogen cream.
  • Those patients were reexamined after shorter
    follow-up intervals.
  • Vaginal discharge were common and were managed
    successfully in the majority of patients by
    periodic douching and / or the use of Trimo-San.

54
Complications and Contraindications
  • Pessary complications are rare occurrences in
    medically compliant patients.
  • The most common complications are pessary
    expulsion, urinary incontinence, and rectal pain,
    depending on the type of pessary.

55
Complications and Contraindications
  • Vaginal discharge is common.
  • A study comparing pessary users with nonusers
    found that the presence of a foreign body
    increased the risk for bacterial vaginosis by
    4-fold.
  • If the patient is symptomatic, bacterial
    vaginosis may be treated, but vaginal cultures
    are not recommended.

56
Complications and Contraindications
  • Vaginal estrogen is generally recommended to
    patients who are noted to have vaginal atrophy or
    areas ulceration or abrasions from pessary use.
  • Typically, if ulceration occurs, the pessary is
    left out and the patient is advised to use
    intravaginal estrogen cream daily (0.5-1.0 g/d)
    for 2 to 3 weeks.

57
Complications and Contraindications
  • If the ulcerations have healed, the pessary can
    be replaced, and it is recommended that the
    patient continue to use the vaginal cream 2 to 3
    times per week.
  • If ulcerations recur, despite estrogen therapy,
    it may be best to discontinue pessary management
    and consider biopsy of the site.

58
Complications and Contraindications
  • More serious complications associated with
    pessary use are generally attributable to a
    neglected device.
  • Pessaries may become impacted. This is more
    commonly seen with space-filling pessaries such
    as the Gellhorn and cube pessary.
  • These pessaries are more likely to cause vaginal
    erosions.
  • Applying estrogen cream to an impacted pessary
    will generally aid in its removal (Poma et al
    1981)

59
Complications and Contraindications
  • However, an impacted pessary can require surgical
    removal.
  • Other less common serious complications have been
    described in case reports.
  • These include incarceration of the cervix, small
    bowel prolapse and incarceration, vesicovaginal
    fistula, and urosepsis.

60
Complications and Contraindications
  • what these reports all share in common is that
    the patient had not been examined by a physician
    for several years.
  • This highlights the importance of evaluating
    patient compliance in the initial evaluation.

61
Evidence for Pessary Use (Cochrane)
  • In 2004, 2 Cochrane Database Systematic Reviews
    were performed on the topics of Mechanical
    Devices for Pelvic Organ Prolapse in Women and
    Conservative Management of Pelvic Organ Prolapse
    in Women.

62
Evidence for Pessary Use (Cochrane)
  • The review of mechanical devices concluded that
    currently there is no evidence from randomized
    controlled trials (RTC) upon which to base
    treatment of women with pelvic organ prolapse
    through the use of mechanical devices/pessaries.
  • Likewise, the review of conservative management
    came to a similar conclusion that there was no
    evidence from RTC regarding conservative
    interventions in the management of pelvic organ
    prolapse.

63
Evidence for Pessary Use (Cochrane)
  • The conservative management review reported that
    evaluating the effectiveness of pelvic floor
    muscle training (PFMT) in treating pelvic
    prolapse is the most pressing research need, in
    that it is a costly management option.
  • A feasibility study is currently underway that
    has an ultimate goal of progressing to a
    multicenter randomized trial (Pelvic Organ
    Prolapse Physiotherapy POPPY).

64
Evidence for Pessary Use (Cochrane)
  • Two other randomized studies were identified by
    the Cochrane database that evaluated the
    effectiveness of PFMT in conjunction with surgery
    for symptomatic prolapse.
  • One of the studies continues to recruit patients,
    and the other has been completed and awaiting
    publication.

65
Summary
  • There is insufficient evidence to allow a
    practitioner to know which patients are likely to
    accept and continue pessary use.
  • There is no strong evidence to guide the
    management of a patient with a pessary.

66
Summary
  • All patients with symptomatic prolapse should be
    offered conservative management of prolapse using
    pessaries.
  • It is difficult to control for various aspects of
    HRT and its role in maintaining healthy vaginal
    epithelium with pessary use.

67
Summary
  • Patients at risk for poor follow up should be
    considered poor candidates for pessary management.
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