Pessary

A vaginal pessary is designed to support the vaginal walls and allow the prolapsed organs to return to their normal position, thereby alleviating symptoms.

Pessaries have been used to manage pelvic organ prolapse for many years, with descriptions dating back to ancient Greece of inserting a pomegranate into the vagina to anatomically return the prolapsed organs. Pessaries are widely used as a first-line treatment for pelvic organ prolapse. They are made of a flexible polymer and are available in a variety of types and sizes.

The fitting process is a “trial and error” process, and several different sizes and types may need to be tried before the woman feels comfortable during activity, urination, or bowel movements.

In terms of indication for use, it is recommended that any woman suffering from symptomatic prolapse be informed of the possibility of treatment with a pessary.

Pessary treatment may be considered in the following clinical cases:

Women who prefer conservative treatment over surgical correction, medical conditions for which the woman cannot undergo surgery, as an interim solution until surgery is performed, and as an attempt to examine the benefit of surgery, women of childbearing age who present with symptomatic prolapse and wish to postpone surgical treatment, symptomatic prolapse during pregnancy.

Pessaries can also be used to treat stress urinary incontinence. There are pessaries that are specially designed to support the urethra and bladder wall by lightly compressing the urethra against the pubic bone and are intended to reduce leakage events when intra-abdominal pressure increases.

Contraindications for the use of pessaries include:

Inability to attend for check-ups at the agreed frequency if the pessary is not operated independently, acute inflammatory condition in the vagina and/or pelvis or unexplained vaginal bleeding until the investigation is complete, significant mesh exposure (Mesh Erosion), latex sensitivity in latex-containing devices.

*In cases of severe vaginal atrophy that has not responded to local estrogen treatment/radiation that has affected the vaginal mucosa – more frequent monitoring than usual is recommended due to a higher risk of vaginal ulcer formation.

Pessary devices are divided into two main groups:

- Ring-shaped support pessary with/without membrane (pessary)

-Disc - Schaatz Pessary (not available in Israel). These devices are placed between the pubic bone (Pubis) and the posterior wall of the vagina and create support for the walls of the vagina and the uterus / dome of the vagina.

- Space Filling Pessary - Cube, GELLHORN and DONUT type. This group is used as support mainly in cases of advanced pelvic organ prolapse.

Use of a pessary is associated with a low rate of complications. The presence of a pessary sometimes leads to a change in the composition of the vaginal microbiome, an inflammatory response and mechanical pressure on the vaginal mucosa.

The main side effect of using a pessary is vaginal discharge and the formation of an unpleasant odor, the use of a pessary causes increased vaginal discharge in more than 50% of patients. The increased discharge can be physiological or caused by a bacterial or fungal infection. Use of an estrogenic cream, more frequent douching of the The pessary, reassurance and explanation that the discharge is physiological, treatment of infection if present, removal of the pessary for the treatment period or changing the type of pessary are recommended actions that can reduce symptoms.

Other complications are uncommon and usually appear in the first four weeks of use. These include expulsion of the pessary, pain and discomfort or constipation. Local pressure from the pessary can lead to a local reduction in blood flow (devascularization). This phenomenon can cause the formation of a vaginal ulcer. This complication in rare cases may lead to the formation of a fistula (seizure) between the vagina and the abdominal cavity, digestive tract, or bladder. Other rare and serious complications include: incarceration of the pessary in the vagina, and even the development of malignancy in cases where the pessary is forgotten for a long period of time (neglected pessary).

With successful pessary adjustment, many women will report an improvement in symptoms related to pelvic organ prolapse.

Satisfaction

The desire and persistence in using a pessary tends to decrease over time, with the main reasons for discontinuing pessary use being: difficulty in self-operation or persistence in visits to the treating physician, repeated episodes of pessary expulsion, continued side effects (mainly vaginal discharge), and recurrent development of ulcers in the vaginal mucosa.

Proper operation of the pessary requires removing the pessary from time to time and cleaning it with soap and water. It is recommended that the patient be encouraged to operate the pessary herself, as this increases the rate of persistence and success in treatment and even reduces the complications associated with the use of the pessary.

There is a lack of satisfactory studies regarding the frequency of pessary removal and cleaning. It is recommended that the patient be encouraged to remove the pessary, clean it, and leave it outside the vagina overnight once or twice a week. If necessary, the patient should be instructed to remove the pessary before intercourse (according to her wishes). If the patient cannot operate the pessary herself, or if she chooses not to do so, she should be given the opportunity to do so. For the first check-up, it is possible to space the appointments out by up to six weeks, and subsequently, the appointments can be spaced out by up to three months. It is recommended to instruct the patient to arrive earlier in cases of abnormal discharge, vaginal bleeding, or any other unusual disturbing symptom.