Autumn presentation.pptx

4/15/15 Introduction to Pessaries Autumn Roland, PA-­‐C Dupage Medical Group Urology Outline • 
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Prolapse type and grading IndicaAons and contraindicaAons to pessary use Types of pessaries Pessary fiEng Follow up What is a Pessary? •  Medical device composed of silicone that is used to provide support to the uterus, vagina, bladder or rectum. 1 4/15/15 Indications for pessary use Cystocele •  Cystocele •  Prolapse of bladder Indications for pessary use Rectocele •  Rectocele •  Prolapse of rectum 2 4/15/15 Indications for pessary use Uterine Prolapse •  Uterine Prolapse •  Prolapse of uterus Grading of prolapse Grade 1-­‐4 Cystocele Grading Baden-­‐Walker Halfway System 3 4/15/15 Who is a candidate for a pessary? •  ANY woman with prolapse •  PaAents with significant co-­‐morbidiAes making them unfit for surgical intervenAon •  PaAents not interested in surgical repair •  Recurrence aQer prior surgical correcAon Contraindications to pessary use •  AcAve genital infecAons-­‐ treat infecAon then do pessary fiEng •  Erosion of vaginal mesh •  Remove prior to pessary fiEng •  Non-­‐compliant paAent-­‐ for social or psychological factors. •  Important for paAents with demenAa to have caregiving involved in decision making process and commiTed to follow up •  Think of paAents with cystocele + incomplete bladder emptying + UTIs Ancient Pessaries Ancient Pessaries •  DocumentaAon found about pessary use on early EgypAan papyrus •  Pomegranates were commonly used •  Middle ages used linen or wool soaked with special poAons 4 4/15/15 Types of pessaries • Support pessaries • Ring with support • Ring with knob • Gehrung • Shaatz • Lever pessaries Ring with Knob (with or without support Ring Pessaries •  Ring with and without support •  Most commonly used pessary •  Easy to insert and remove for providers and paAents •  Fits behind the pubic symphisis and posterior fornix Fitting Ring with Knob •  For stress inconAnence •  Knob compresses the urethra and increases urethral close pressure •  Intercourse is ok with ring pessaries, however some paAents wish to remove 5 4/15/15 Gehrung Shaatz •  Use in second and third degree uterine prolapse and cystocele •  Convex porAon placed on bulge Fits around cervix. •  Rarely used. •  For cystocele and rectocele Lever Pessaries Space-­‐Nilling Pessaries •  Hodge •  Smith •  Risser •  Used for uterine prolapse and retroversion and cystocele •  Gellhorn •  Marlan •  Donut •  Inflatable •  Cube •  Difficult to insert and remove •  No sexual intercourse with pessary in place •  For vault prolapse and high grade prolapse 6 4/15/15 Gellhorn Gellhorn •  Most commonly used space filling pessary •  Short and long stem •  SucAons to apex •  Tips for removal •  Ring forceps •  Use finger to release sucAon Donut Marlan •  Cystocele •  Rectocele •  Uterine prolapse •  Third degree prolapses •  Fit like a ring, but fills more space •  More discharge/odor as pessary collects discharge 7 4/15/15 InNlatable Cube •  LATEX •  Pessary inserted, bulb aTached, inflated, bulb detached •  Must be removed nightly •  For very compliant paAents only Pessary Fitting •  EducaAon •  Counsel pt’s on opAons. OQen pt’s come to me from referring physician (pcp or urologist) with diagnosis, but liTle educaAon on a pessary. •  Let them know it isn’t one size fits all. We will try several sizes, you may leave with a pessary only to have it fall out later that day or week. We may have you come back another day if we try 3-­‐4 with no success. •  You will have to follow up in 1-­‐2 wks to check fit and vaginal vault for erosion, then q 3 months if unable to do self-­‐cleanings or q 6 mo if doing self cleanings •  Third degree prolapse •  SucAons to vaginal walls •  Must be removed nightly due to risk of erosion •  No holes for drainage of discharge Pessary Fitting •  EducaAon •  Are they prone to consApaAon? If so recommend starAng stool soQener, Miralax, ect prior. Can hold pessary in place with one finger if prone to falling out when get consApated. •  It can be removed at any Ame if paAent desires. •  InconAnence: occasionally paAents who are retaining due to cystocele, when pessary placed will have more apparent urge inconAnence than prior to pessary •  It should be comfortable – they shouldn’t know it is there. 8 4/15/15 Selecting a pessary •  Is the paAent willing or able to do self cleanings? Pessary Fitting •  Exam •  Yes: Ring or Marlan •  No: any pessary type •  Type of prolapse •  Grade of prolapse •  Measuring-­‐ use fingers to esAmate length and width •  Is the paAent sexually acAve? •  Yes: ring type •  No: any pessary type Pessary Fitting •  Try 3-­‐4 pessaries per day •  Place pessary. •  Ask to Valsalva-­‐ does it descend? Fall out? Do they have more stress inconAnence? •  Have paAent stand and bear down with chux under them •  Use restroom. Bring in commode if poor ambulaAon. Walk halls. •  Re-­‐examine to check posiAon/comfort •  Follow up in 1-­‐2 weeks If width is wider than vaginal length a ring will fall out-­‐ beTer to use a Gellhorn, Gehrung Vaginal Estrogen •  Can help prevent erosion in paAents with vaginal atrophy •  Help prevent small tears at introitus from stretching when pessary removed and re-­‐inserted •  May want to start severely atrophic paAent on 2 wks prior to pessary trial •  Forms: cream, tablet, ring •  Ring is expensive, but very convenient to place in elderly paAents who are forgemul or physical unable to use cream or tablet. •  ContraindicaAons: history of clots, ovarian, breast, endometrial, or cervical cancer. 9 4/15/15 Complications Follow up 1-­‐2 weeks aQer iniAal placement •  Examine for erosion, pressure points •  If paAent is able/willing-­‐ teach how to insert and remove •  Recommend cleaning q 1-­‐4 wks at home •  If unable to do self cleanings follow up q 3 months •  Common: vaginal discharge and odor •  Pessary falling out •  Rare but serious: Vaginal erosion or ulceraAon •  Leave pessary out for 2 weeks •  Start or increase vaginal estrogen •  Try a different size or type of pessary •  Surgical consult Keeping Pessaries in Stock •  Keep track of your pessaries •  Know the common types and sizes that you use and have mulAple in stock. •  Rings 2-­‐6 •  Gellhorn 3-­‐5 Have one of rarely used sizes You don’t need to order every pessary type. If what you have in stock doesn’t work-­‐ you may have to have the paAent return aQer you order it. They are auto-­‐clavable. You can use a pessary to fit, if it falls out in office then can be cleaned and autoclaved. Charges •  Pessary FiEng: CPT 57160 •  Pessary device: A4562 •  Office visit •  Pessary cleanings-­‐ just charge office visit consistent with level of care you provided 10 4/15/15 QUESTIONS??? References •  Tam, Teresa, MD. OBGmanagement hTp://www.obgmanagement.com/home/arAcle/vaginal-­‐
pessaries-­‐video-­‐proper-­‐inserAon-­‐and-­‐removal/
5c5802d605f65d764aca840cfda9ceb7.html •  Shah SM, Sultan AH, Thakar R. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Feb;17(2):170-­‐5. Epub 2005 Apr 14. The history and evolu1on of pessaries for pelvic organ prolapse. •  INDUMATHI KUNCHARAPU, MD, BARBARA A. MAJERONI, MD, DALLAS W. JOHNSON, MD, Am Fam Physician. 2010 May 1;81(9):1111-­‐1117. Prolapse. May 2010 11