Vaginal Support Pessaries: Indications for Use and Fitting

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Vaginal Support Pessaries: Indications for Use and Fitting
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SPECIAL SERIES
ON
PESSARIES
Vaginal Support Pessaries:
Indications for Use and Fitting
Strategies
Shanna Atnip and Katharine O’Dell
P
elvic floor disorders are
common in women, and
as the population ages,
these disorders may be
seen more frequently by health
care providers (Nygaard et al.,
2008). When pelvic symptoms
are associated with loss of structural support of the pelvic organs
and vagina, vaginal support pessaries offer an important option
for relief (American College of
Obstetricians & Gynecologists
[ACOG], 2007).
Historically, vaginal pessaries
have been used to manage pelvic
floor relaxation and were made
from a variety of materials,
including fruit, metal, porcelain,
Shanna Atnip, MSN, WHNP-BC, is a Nurse
Practitioner, the Division of Urogynecology
and Reconstructive Pelvic Surgery,
Parkland Health & Hospital System, and the
University of Texas Southwestern Medical
Center, Dallas TX.
Katharine O’Dell, PhD, CNM, WHNP-BC,
is an Assistant Professor of OB/GYN, the
Division of Pelvic Medicine and Reconstructive Surgery, UMass Memorial Medical
Center, Worcester, MA.
Note: Objectives and CNE Evaluation Form
appear on page 125.
Statement of Disclosure: The authors
reported no actual or potential conflict of
interest in relation to this continuing nursing
education activity.
This learning activity was partially funded
by an unrestricted educational grant from
CooperSurgical, Inc.
114
© 2012 Society of Urologic Nurses and Associates
Atnip, S., & O’Dell, K. (2012). Vaginal support pessaries: Indications for use and
fitting strategies. Urologic Nursing, 32(3), 114-125.
Flexible silicone vaginal support pessaries offer a low-risk, effective option for
treatment of symptoms of pelvic organ prolapse. This first article in a three-part
series summarizes clinical recommendations and current evidence related to
pessary indications, choice, and fitting.
Key Words:
Pelvic organ prolapse, pessary, indications, fitting.
Objectives:
1.
List the symptoms of pelvic organ prolapse that may be successfully treated
with a vaginal support pessary.
2.
Discuss the various types of pessaries and their uses to treat pelvic organ
prolapse.
3.
Outline the pessary selection process and steps to pessary fitting.
rubber, and acrylic (Shah, Sultan,
& Thakar, 2006). Modern pessaries
are made from silicone, acrylic,
latex, or rubber. Flexible, medicalgrade silicone pessaries are the
primary subject of this article and
series because they offer many
advantages over other materials.
For example, flexible, medicalgrade pessaries are pliable, longlasting, non-absorbent (related to
odor and secretions), biologically
inert, non-allergenic, non-carcino-
genic, and washable, and can generally be sterilized using an autoclave, boiling water, or a cold sterilization product (Cooper Surgical,
2008; Personalmed, 2012).
Support pessaries are experiencing a renaissance and are currently recommended as a first-line,
low-risk treatment option for a variety of prolapse-related symptoms
(ACOG, 2007; Clemons, Aquilar,
Sokol, Jackson, & Myers, 2004).
However, to provide satisfactory
Urologic Nursing Editorial Board Statements of Disclosure
In accordance with ANCC-COA governing rules Urologic Nursing Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for
this offering are published below.
Susanne A. Quallich, ANP-BC, NP-C, CUNP, disclosed that she is on the Consultants’
Bureau for Coloplast.
All other Urologic Nursing Editorial Board members reported no actual or potential
conflict of interest in relation to this continuing nursing education activity.
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
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Table 1.
Pessary Indications
Relief of prolapse symptoms
Convenience in scheduling surgery
Surgical avoidance
Diagnostic tool, as in identifying occult stress incontinence
Prediction tool to clarify likely surgical outcomes
Prevention of future increasing prolapse and related morbidity
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
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PESSARIES
Pessaries are a low-risk option
for treatment of pelvic floor disorders with few absolute contraindications. Typically, providers are
advised to use caution if pessary
candidates have an active vaginal
infection, persisting vaginal erosion or ulceration, or severe vaginal atrophy (Weber & Richter,
2005). In addition, non-compliance with follow up can be problematic because it may result in
late recognition of complications;
therefore, providers are advised to
weigh risks, family support, and
alternative options carefully
before providing pessaries to
women with dementia or other
conditions that may lead to irregular follow up or pessary neglect
(Weber & Richter, 2005). Common
indications for the use of support
pessaries include relief of symptoms, avoidance of surgery, diagnosis and surgical outcome prediction, and prevention (see
Table 1).
Symptoms of pelvic organ
prolapse (POP) may include
pelvic pressure, vaginal bulge,
irritative voiding symptoms, urinary incontinence (UI), fecal
incontinence, dyspareunia, constipation, and difficulty emptying
both the bladder and bowels.
Many trials have reported significant improvement of common
symptoms, including urinary urgency and frequency, and urgency
UI; vaginal bulge; pelvic and
abdominal heaviness and pressure; incomplete or difficult
bowel emptying; flatal incontinence; and fecal urgency and
incontinence (Barber, Walters,
Cundiff, & the PESSRI Trial
Group, 2006; Clemons, Aguilar,
Tillinghast, Jackson, & Myers,
2004a; Fernando, Thakar, Sultan,
Shah, & Jones, 2006; Komesu et
al., 2007, 2008). Improved bladder
emptying subsequent to reduction
of POP and urethral obstruction
may prevent many causes of
ongoing morbidity or mortality,
including recurrent urinary tract
infection, acute urinary retention,
and renal injury (Micha et al.,
2008). Both stress and mixed
UI were improved with pessary
use in approximately 50% of
women in two separate trials
(Donnelly, Powell-Morgan, Olsen,
& Nygaard, 2004; Richter et al.,
2010). Additionally, overall body
image improves in many successful pessary users (Patel, Mellen,
O’Sullivan, & LaSala, 2010).
Other areas of symptomrelief related to pessary use have
been less well studied. For example, women with a vaginal bulge
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Pessary Indications
Symptom Improvement
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care, health care providers must
effectively evaluate pelvic symptoms and related health attitudes;
assess vaginal size, shape, and
support; select a comfortable and
effective pessary; and provide
health education and appropriate
follow up. This article addresses
basic information essential to prescribing pessaries to women,
including an overview of current
patterns of clinical use, a review
of existing evidence, and suggestions for ongoing research.
can develop epithelial ulceration
due to dryness and friction on
clothing. The risk of infection
and hemorrhage can be effectively treated in a plan of careful follow up and pessary use to
enhance healing.
In addition to symptom
improvement, use of support
pessaries can help women meet
their health improvement goals.
In one study, women who
achieved their own pre-determined treatment goals (improved
bladder control, increased comfort with physical activity, decreased prolapse symptoms)
were more likely to be satisfied
and continue pessary use as compared with women who did not
meet their treatment goals
(Komesu et al., 2008). Helping
patients set realistic goals for
treatment outcomes based on
current evidence will help
women meet their treatment
goals and encourage continued
pessary use.
While a majority of women
may note symptom relief with
pessary use, some women cannot
be successfully fitted, and others
may experience burdensome
new symptoms during a pessary
trial. New symptoms can include
de novo problems with bowel
and bladder emptying, discomfort, pressure, or pain; increases
in vaginal discharge or odor, or
new onset stress UI due to
unkinking of an otherwise inadequately
supported
urethra
(Bump, Fantl, & Hurt, 1988). In
one study, the most common risk
factors for dissatisfaction related
to pessary use included de novo
stress incontinence, a pre-existing strong desire for surgical
repair, and more advanced prolapse (where the leading edge of
the prolapse is halfway beyond
the hymen or more) (Clemons,
Aguilar, Tillinghast et al., 2004b).
Potential distress may be reduced if women considering pessary use are aware of common
uses, benefits, and potential risks
prior to their initial pessary fitting.
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Surgical Avoidance or
Scheduling Convenience
Conservative management
with a pessary, either on a temporary or long-term basis, may be
the optimum choice for many
women for a variety of reasons.
Although evidence is sparse,
clinical examples of indications
include fear of surgery or anesthesia, significant co-morbidities
that preclude surgery, or prior
failed surgery with resultant
higher risk of poor surgical outcome. Temporary use of a support pessary may improve comfort for women delaying surgery
due to career or family priorities,
or for women who have been
advised to defer vaginal reconstruction until child bearing is
completed.
Diagnostic Assessment
And Prediction of Surgical
Outcomes
A pessary trial can provide
an opportunity to explore likely
symptom improvement or the
potential for onset of new
adverse effects, and help women
develop realistic expectations
during pre-operative treatment
planning. In a classic study,
researchers used a trial with a
lever pessary to successfully
predict surgical cure of stress
incontinence via retropubic urethropexy. In this trial, 24 of 26
women with stress UI became
continent with a supine stress
test after pessary insertion, and
all patients remained continent
after a retropubic urethropexy
was performed (Bhatia &
Bergman, 1985). In another
study, de novo stress incontinence, which can occur when an
otherwise deficient urethra is
straightened during repair of the
prolapsed anterior compartment, was shown to be a major
reason for post-treatment dissatisfaction (Clemons, Aguilar,
Tillinghast et al., 2004a).
Post-surgical expectations
have also been explored with
women reporting two common
symptoms often attributed to
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POP – lower abdominal pressure
and low back pain (Heit,
Culligan, Rosenquist, & Shott,
2002). In that study, participantrated symptom severity using
visual analog scales, (n = 152)
was compared with objective
prolapse determination and
demonstrated no significant
association. Therefore, because
prolapse may not be the cause of
some symptoms, a pessary trial
can play a role in clarifying
treatment expectations during
pre-operative decision-making.
Pessaries have also been
useful in predicting successful
outcomes in cases of pre-operative elevated post-void residual
(PVR) due to urethral obstruction. A retrospective chart
review of women with pre-operative PVR greater than 100 cc (n
= 24) found that pessary use normalized PVR in 75% (n = 19) of
the women, with only one
woman subsequently experiencing elevated PVR three months
post-operatively. A trial pessary
reduction was found to be a reliable tool in predicting improvement in urinary retention
(Lazarou, Scotti, Mikhail, Zhou,
& Powers, 2004).
Prevention of Progressive
Prolapse
Emerging evidence also suggests a potential preventive role
for pessaries. Handa and Jones
(2002) observed a significant
improvement in stage of POP in
19 women following one year of
successful pessary use, suggesting a therapeutic effect associated with the use of a supportive
pessary. In addition, in an observational cohort study of women
using pessaries for three months
(n = 90), measurement of the genital hiatus decreased, leading the
authors to postulate that pessary
use allows recovery of the levator
ani muscles (Jones et al., 2008).
In another small case series (n =
6), prolapse regressed to normal
after a median duration of pessary use of 27.5 months and
remained resolved for a median
of 42.0 months of follow up
(Matsubara & Ohki, 2010).
Whether this observed prolapse
improvement is due to temporary
physiologic tissue response to
reduced strain and/or has potential long-term preventive ramifications is currently unclear.
Pessary Selection
Modern silicone pessaries
come in a variety of shapes and
sizes; therefore, selection is primarily determined by the
lifestyle of the potential wearer,
as well as findings on physical
examination. Both providers and
patients are likely to benefit if
pessary success could be predicted because counseling would be
improved, time would be saved,
and needless discomfort would
be eliminated; however, predictive parameters for pessary
choice and fitting success have
proven difficult to quantify
(Cundiff et al., 2007). For that
reason, expert opinion from clinical observation continues to
inform both patient and pessary
selection and is included here for
the potential benefit of novice
providers.
Patient-Specific Factors
Several recent studies concluded that the majority of
women can be successfully fitted
with a pessary, with POP-reduction success rates ranging from
63% to 86% (Clemons, Aguilar,
Tillinghast et al., 2004b; Hanson,
Schulz, Flood, Cooley, & Tam,
2006; Maito, Quam, Craig,
Danner, & Rogers, 2006; Mutone,
Terry, Hale, & Benson, 2005;
Nyguyen & Jones, 2005; Wu,
Farrell, Baskett, & Flowerdew,
1997). However, specific factors
that might predict successful fitting have not been consistently
identified. Some studies have
suggested that patient satisfaction is higher in women who are
older, have had no prior pelvic
surgery (including hysterectomy), have higher parity or less
severe prolapse, and have no UI
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Figure 1.
Pessary Shapes
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options. The pessary can be removed for intercourse either by
the woman or her partner. If she
prefers leaving the pessary in
place, some styles (for example,
Ring pessaries) are more likely to
be comfortable for both partners
during intercourse. However,
there is little research to assess this
specifically, and clinical reports
from individual couples vary
greatly. Overall, sexual function
has been shown to improve with
pessary use, including frequency
and satisfaction (Fernando et al.,
2006), desire, orgasm, and lubrication (Kuhn, Bapst, Stadlmayr, Vits,
& Mueller, 2009). Additionally,
one study found sexually active
women were more likely to continue pessary use compared to
women who were not sexually
active (Brincat, Kenton, Fitzgerald,
& Brubaker, 2004). Overall, pessary use may be acceptable to
many sexually active women.
Pessary-Related Factors
Many pessary styles and
sizes are available, and new
styles continue to be designed.
Figure 1 displays a variety of current pessaries. While successfully fitted pessaries offer a high
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
likelihood of symptom and quality-of-life improvement for most
users, no specific shape of pessary is best for all women. In one
crossover study comparing two
different pessaries (Ring and
Gellhorn), both shapes were
effective for the majority of
women and significantly improved urinary, bowel, and prolapse symptoms (n = 134, mean
age 61 years, median prolapse
Stage 3 – descent halfway
beyond the hymen, satisfaction
rates – Ring 80%, Gellhorn 76%)
(Cundiff et al., 2007).
Because no quantitative measures have been identified to
direct pessary choice and fitting,
providers must continue to rely
on manufacturer guidelines,
expert opinion, product availability, clinical judgment, and
provider or patient preferences
when choosing initial pessary
shape and style.
One way to conceptualize
support pessary options is to categorize them by their functional
design. Using that paradigm,
flexible silicone pessaries fall
into three categories: those that
need some support from the
woman’s own introital integrity
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PESSARIES
Note: The large variety of pessary shapes can be categorized as pessaries that
require significant introital support (top row), pessaries that are relatively selfsupporting (seond row), and pessaries with an incontinence support (third row).
ON
(Maito et al., 2006; Nyguyen &
Jones, 2005; Wu et al., 1997).
Hanson et al. (2006) assessed the
importance of estrogen therapy
to successful pessary fitting,
reporting that women using vaginal estrogen, with or without systemic hormone replacement therapy (HRT), had higher fitting success compared to both systemiconly and non-HRT users. Maito
et al. (2006) reported presence of
mild posterior compartment prolapse as a positive predictor of
fitting success, and history of a
prior prolapse procedure or hysterectomy as negative predictors.
Clemons, Aguilar, Tillinghast et
al. (2004b) also found a shortened vaginal length (≤ 6 cm) and
wide genital hiatus (4 fingerbreadths) to be predictive of
unsuccessful pessary fitting.
Other researchers have reported
no significant predictive value
regarding age, weight, vaginal
length, size of genital hiatus,
compartment of prolapse, stage
of prolapse, or hormone use
(Maito et al., 2006; Mutone et al.,
2005; Nyguyen & Jones, 2005;
Wu et al., 1997). Because of this
lack of consistent predictors, a
pessary trial may be appropriate
for any woman seeking treatment
for prolapse-related symptoms
(ACOG, 2007; Clemons, Aguilar,
Sokol et al., 2004).
Factors related to patient
preference, lifestyle, and ability
may guide pessary choice. For
example, some pessaries may be
easier to self-remove and selfinsert. This may affect choice
related to patient comfort with
self-touch, interest in performing
self-care, and desire to have vaginal intercourse. Clinical experience suggests that arthritis,
mobility impairment, and obesity may limit successful self-care,
even in very motivated women.
Women who are not doing selfcare will need to wear their pessary continuously between the
periodic office visits for removal
and cleaning.
With the appropriate pessary,
a sexually active woman has a few
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to stay in place (basic support pessaries), pessaries
with concavities that make them relatively selfretaining (self-retaining pessaries), and pessaries
with additional urethral support designed to
improve stress incontinence (incontinence pessaries). Use of these classifications to guide initial
choice is summarized in Table 2.
In the authors’ experience, pessaries retained by
introital integrity can be folded or deflated to ease
insertion through the introitus. Examples include
the Ring (see Figure 2), Donut (see Figure 3), and
Inflatable Donut (see Figure 4), and the Shaatz and
lever pessaries (not pictured separately). Those that
have a relatively slim profile and fit along the length
of the vaginal shaft, such as the Ring pessary, are
most likely to be comfortable when left in place during vaginal intercourse. Others, such as Donut pessaries, which are sometimes referred to as space-filling pessaries because they occupy more of the vaginal width, may preclude intercourse when in situ.
Pessaries designed to easily fold or deflate may also
be most amenable to self-insertion and removal.
In contrast, self-retaining pessaries are generally concave in shape. The vaginal walls conform to
these areas, allowing the pessaries to stay in place in
women with minimal or no introital strength. These
include the Gellhorn (see Figure 5) and Cube pessaries (see Figure 6). These are traditionally considered more likely to support advanced POP but may
also increase the risk of mechanical injury to the
vaginal epithelium. They may also be more difficult
for both the patient and provider to remove and reinsert. Incontinence pessaries include a knob that fits
behind the pubic symphysis, supporting the urethra
during times of increased abdominal pressure to
diminish stress incontinence (see Figure 7).
Although the topic is not well studied, when a
pessary is worn over time (longer than 24 hours),
Table 2.
Sample Simple Pessary Selection Guide Based
on a Woman’s Planned Coital Activity
and Introital Integrity
Introital Integrity
Present
Introital Laxity
Present
Sexual Activity
Planned
Ring*
Oval
Lever Pessary*
Inflatable Donut
Cube
Acoital
Donut
Gellhorn
Cube
Figure 2.
Ring and Ring with Support Membrane
Note: Note the hinge bends at the notch in the left pessary
and at the finger-sized holes of the right pessary. This pessary
is folded at the hinge for insertion and removal.
Figure 3.
Donut Pessary
Note: Some clinicians aid insertion and removal by carefully
deflating the Donut using a needle and syringe, inserting it, and
then re-inflating the pessary once it is in place and viceversa.
Figure 4.
Inflatable Donut Pessary
Note: If stress incontinence increases or continues with pessary use, an incontinence pessary can be used,* but coitally
active women will need to be able to do self-care.
*Pessaries that have a stress urinary incontinence support
option.
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Figure 5.
Gellhorn Short and Long-Stem Pessaries
Figure 6.
Cube Pessaries
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presence of drainage holes should
allow continuous drainage of normal vaginal epithelial shedding
and discharge. Retained discharge
may act as a medium for bacterial
overgrowth, increasing infection
risk, and/or odor. For this reason,
pessary styles with optional
drainage holes (such as Cube pes-
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
total vaginal length were less likely to be successfully fitted (Nager
et al., 2009). Thus, pessary fitting
remains an art, with some reliance
on trial and error.
Pessary Fitting
Because there has been little
success in identifying objective
evidence to improve pessary
choice, new providers must rely
on expert opinion and mentorship. Pessary manufacturers provide recommendations to help the
novice match pessary styles with
patient findings (Bioteque of
America, 2011). Successful fitting
also depends on clinician experience and training. Few nursing or
medical programs spend time
teaching pessary use (PottGrinstein & Newcomer, 2001).
However, with a sound general
background of women’s health
care, even in the absence of optimal mentorship, clinicians can
educate themselves to become
competent and safe providers of
this low-risk intervention.
The goal of fitting is to find a
pessary that improves the target
pelvic floor symptoms, is comfortable for the patient, is retained
during activity and toileting, and
does not obstruct voiding or defecation, or cause vaginal irritation.
Suggestions for improving fitting
outcomes are listed in Table 3.
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PESSARIES
Note: Examples include, top row:
Incontinence Dish (with and without
support); middle row: Marland (with
and without support); bottom row left:
Ring with support membrane and
incontinence knob; bottom right:
Incontinence Ring.
saries) are typically preferred
whenever possible.
Providers often prefer to use a
limited selection of available pessaries. For example, in a survey of
urogynecologists, the majority
reported using Ring pessaries for
anterior and apical defects, spacefilling pessaries (such as a Donut)
for women who have introital
integrity and posterior defects, and
self-retaining pessaries (such as the
Gellhorn) for severe prolapse
(Cundiff, Weidner, Visco, Bump, &
Addison, 2000). General gynecologists reportedly also used Ring pessaries most frequently, deeming
them easiest to use, with Gellhorn
pessaries used most commonly for
advanced prolapse (Pott-Grinstein
& Newcomer, 2001). The latter
respondents rated Donut pessaries
the least easy to wear and Gellhorn
pessaries most difficult to remove.
Generally, providers’ choice of
styles of pessary to stock and fit
appears to be based on the individual’s training, experience, and
product availability.
Pessary size selection is also
currently guided by experience
because no specific vaginal measures have predicted successful fit.
In one study, Pelvic Organ
Prolapse Quantification (POP-Q),
parameters were tested as a potential objective predictor but were
not found to predict pessary size;
however, women with a shorter
ON
Figure 7.
Incontinence Pessaries
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Table 3.
Pessary Selection and Fitting Tips
Assess for and treat causes of vaginal tenderness prior to fitting (infection, lesions,
or tension myalgia).
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Familiarize the woman with the pessary before fitting (let her see, feel, and fold it; use
visual aids, such as pelvic models or charts, to show how it will stay in her vagina).
Fitting will be more comfortable if the woman has an empty bladder and bowel;
however, to test for stress incontinence, fitting with the bladder full will facilitate
assessment. If the bowel is full and cannot be emptied voluntarily, an enema onsite
or rescheduling the appointment may be most helpful.
Autoclavable fitting kits are available, but keeping a small stock of silicone pessaries
in commonly used sizes and shapes may offer a more true-to-life fitting experience.
Fitting comfort may be improved for women who are very apprehensive or sensitive
by the use of lidocaine gel applied to the introitus 5 minutes before fitting. If genital
tissue is very atrophic or non-elastic, several weeks of topical estrogen therapy prior
to fitting may be optimal.
Refitting may be necessary after weight loss or weight gain, any period of temporary
removal, or during long-term use if atrophic tissue change continues (increased
stenosis or decreased support).
During post-fitting pessary testing, placement of a urine receptacle (“Hat”) in the
commode will ease retrieval if the pessary is expelled. Otherwise, instruct the woman
not to flush the pessary into the plumbing system.
A pessary that is comfortable and retained except during bowel movements may be
a success if the woman chooses to either remove the pessary for defecation or
support it digitally during evacuation.
If the pessary is easily expelled, try a larger size or different style. If the pessary is
uncomfortable or the patient feels pressure, try a smaller size or different style.
Successfully sized, the pessary should be comfortable; women often say, “I can’t
even tell it’s there!”
Make sure a system is in place to identify missed pessary follow-up visits to avoid
potential problems related to pessary neglect.
Figure 8.
Illustration of Digital Measurement of the Vagina, a Potential Aid to
Initial Pessary Choice
Notes: Line A: The vaginal length from posterior symphysis to apex or posterior
fornix can be useful for sizing Ring and Donut pessaries, or the length of a Gellhorn
neck. Line B: The vaginal width at the apex can be useful when considering the
diameter of the Gellhorn dish. Line C: The diameter of the introitus and vaginal shaft
can help in making an initial Cube choice.
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Although definitive measurements have not been identified to
aid size and style choice, experienced providers typically note
several digital measurements and
assess pelvic muscle tone and
support during pelvic examination (see Figure 8). These determinations can help the provider
develop a mental image of the
vaginal size, shape, and support.
The initial pessary attempt can
then be made using the pessary
that fits this visual image. Table 4
lists suggested steps in pessary fitting based on clinical experience
and expert opinion.
The average number of pessaries tried during a successful
pessary fitting is two to three, typically at a single session; however,
up to two follow-up fitting sessions have been reported prior to
successful fitting (Jones et al.,
2008; Komesu et al., 2007; Maito
et al., 2006; Robert & Mainprize,
2002; Wu et al., 1997). Women
unable to retain a pessary at an
initial fitting are less likely to be
successful at subsequent fittings
(Maito et al., 2006), but persistence may pay off. Clemons,
Aguilar, Tillinghast et al. (2004b)
found 22 of 49 women who could
not be fit at the first visit were successfully fit on the second visit. In
that study, a Gellhorn pessary was
more likely to require refitting
than a Ring, suggesting Ring pessaries are easier for providers to
size correctly. For women who prefer pessary treatment but have difficulty retaining any single pessary,
occasional use of double pessaries,
including a Donut with Gellhorn
or double Ring, has been reported
(Myers, LaSala, & Murphy, 1998;
Singh & Reid, 2002).
Prior to fitting, women should
be informed that the risk of a pessary trial is minimal, while the
potential symptom-relief can be
great. It may be helpful to be optimistic, normalizing the fitting situation, while informing the woman
prior to fitting that an appropriate
pessary may not be identified.
Clinicians also need to remember
that successful fitting after three or
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Table 4.
Steps to Pessary Fitting
1. Review treatment goals and expectations.
2. Ask the woman to empty her bladder and bowels.
3. Ask the woman to assume Semi-Fowler position, a position that is generally
comfortable and offers her a view of the fitting if desired.
4. Gently replace any vault eversion or procidentia prior to sizing.
6. Select the appropriate stocked pessary or fitting kit model, and clean it with
soap, rinsing well with water.
7. Apply additional water-based lubricant to the leading edge of the pessary if
needed.
10. Ask the woman to stand, move about the examination room, and simulate
activities she would normally do (walking, bending to pick up objects on the
floor, changing from standing to sitting) and report any discomfort.
11. Ask the woman to sit on the toilet, void, and Valsalva gently, simulating
defecation. For actual defecation, it may be helpful for her to support the
pessary digitally.
12. If the fitting is successful to this point, review expectations and schedule a
return visit. If the pessary is expelled or uncomfortable, start the fitting process
again.
13. Whether or not the fitting is successful, document any shape and size of
pessary used to avoid repeat attempts at subsequent visits.
four attempts is less likely. To aid
understanding of current pessary
choices, the following sections
look more specifically at commonly used pessary options.
Insertion and Removal of
Specific Pessaries for Women
With Introital Support
Ring with and without support membrane. The Ring pessary and Ring with support membrane (see Figure 2) are common
first-line choices for most types
of POP. They typically include a
rigid, hinged nylon ring that fits
into the length of the vagina, pro-
viding support for the anterior,
posterior, and apical walls. The
optional support membrane may
add additional support if anterior
or posterior compartment prolapse are present (such as cystocele or rectocele). The position of
the hinge is marked either by
notches in a Ring or finger-sized
holes in the Ring with support
membrane. To retain this type of
pessary, the introitus and/or
pelvic floor must provide enough
support to contain the pessary.
Ring pessaries tend to be easiest for both clinicians and
patients to use. Many women are
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
121
PESSARIES
9. To check initial fit, ask the woman to Valsalva and cough (in lithotomy and
standing postions) – the correct pessary should be comfortable and may
advance toward the introitus with pressure and recede with relaxation, but it
should not pass through the introitus. The examiner should be able to gently
rock the pessary in place, demonstrating that it is not pressing too tightly on the
vaginal walls.
ON
8. Insert the pessary, applying pressure gently toward the posterior vaginal wall
and/or obliquely (at 11:00 and 5:00 positions related to the introitus) in the
largest diameter, avoiding pressure on the sensitive urethra.
SPECIAL SERIES
5. After amply applying water-based lubricant to the vaginal introitus, digitally
assess vaginal size, shape, and support, and for any relative contraindications
to the fitting (pain with palpation, vaginal infection or lesions, full rectum).
able to remove and replace a Ring
pessary without difficulty. Even
when a Ring pessary is in place,
coitus may be comfortable for
both partners. Ring pessaries with
or without support are also available with a urethral support knob
for the treatment of stress UI.
To fit a Ring pessary, the vagina is measured digitally or with a
vaginal measuring instrument to
assess the depth, obtaining a general idea of the shape and size of
the intra-vaginal space (see Figure
8). To insert the pessary, lubrication of the vagina or a hinged edge
of the pessary and not the gloved
exam fingers will facilitate a grip
on the folded pessary. The pessary
is folded in half at the hinge and
inserted through the introital
opening, while applying gentle
downward posterior or perineal
pressure to avoid the sensitive
urethral area. Once inside the
vagina, the pessary will open
spontaneously. This pessary follows the length of the vagina,
from loosely behind the symphysis to the vaginal apex or posterior fornix. A Ring pessary can be
rotated 90 degrees while in-place,
which may help prevent spontaneous expulsion by placing the
hinge transversely to the introitus.
A well-fit Ring pessary will stay
in place without applying undue
pressure on the sidewalls, apex,
or introitus, and will not be
noticeable by the patient. If the
woman describes discomfort from
the pessary fitting too near the
introitus during movement, it is
either too large or there is insufficient introital support to hold the
pessary in place. Removal and
digital re-sizing may suggest
whether a larger or smaller pessary may work better. If two or
three tries are not effective, a selfretaining pessary, such as a
Gellhorn or Cube, may be a better
option.
To remove a Ring pessary,
lubricate the introitus, put an
examining finger through the finger-size hole or at a hinge notch,
rotate the pessary to bring the
hinge anteriorally to the introi-
SPECIAL SERIES
ON
PESSARIES
SERIES
tus, and gently pull downward,
diagonally, and out. The vaginal
walls will help to fold the pessary as it exits. Atrophic or
scarred tissue may fissure at the
posterior fornix with removal.
Increased lubrication, moisturization, or estrogenation may
ease future use. The most common sizes of Ring pessary are 2
through 5 (whole numbers).
Donut and Inflatable-Donut
pessaries. If a Ring pessary is not
successful, but there is some
introital support, a Donut or
Inflatable-Donut pessary may be an
option (see Figures 3 and 4). Donut
pessaries are essentially thicker
Rings and may fill a vagina
enlarged by loss of elasticity more
completely; however, these pessaries are in more complete contact
with the vaginal epithelium, which
may increase the risk of mechanical tissue injury or discharge production and retention. Some
women may be able to remove and
replace traditional Donut pessaries
themselves, but comfortable vaginal intercourse is unlikely. Inflatable Donut pessaries, which are a
silicone variation of an older latex
inflatable pessary called the Inflatoball, have a stem and valve for
inflation and deflation like a balloon, and are designed to be inserted and removed at frequent intervals (within 48 hours). Manufacturer instructions should be
reviewed before attempting to autoclave Donut pessaries because of
their air-filled core.
During fitting, digital examination is used to assess both the
depth and width of the vagina.
Introital stretching and discomfort
is more likely with a traditional
Donut, and with either type, adequate lubrication is essential.
With firm digital pressure, a traditional Donut pessary may be compressed somewhat to slip through
the introitus more comfortably.
Additionally, some Donut pessaries can be deflated using a needle and syringe to remove air.
After pessary insertion, it can then
be re-inflated by carefully inserting the needle into the Donut and
122
injecting air with the syringe. All
Donut pessaries are typically fit
either like a Ring pessary – along
the length of the vagina – or may
stay in place if fitted snugly into
the circumference of the vaginal
apex with appropriate intrinsic
support.
To remove a traditional Donut
pessary, the introitus is lubricated,
and with the examination finger
in the Donut center, the pessary is
pulled gently downward at a diagonal angle. Some Donut pessaries
can be carefully deflated in situ
using a needle and syringe to ease
removal, and the Inflatable Donut
pessary should also be deflated
prior to removal.
Other support pessaries require introital integrity, with indications based on clinical experience. They include the Oval
(which may be useful with a narrow vaginal width); the Hodge and
Smith Lever pessary (which may
be more comfortable in women
with a narrow vaginal introitus);
the Gehrung Arch (which may be
effective in women who have an
isolated anterior or posterior wall
prolapse), and the Shaatz (which is
a disc, similar to the Ring, but may
offer firmer support). Fitting for
these pessaries is very similar to fitting of the Ring pessary. Manufacturers typically include fitting
instructions with each pessary. If
these types of pessaries cannot be
retained, a self-retaining pessary
may be appropriate.
Insertion and Removal
Of Self-Retaining Pessaries
Gellhorn. The flexible Gellhorn
pessary is an option in women who
cannot retain Ring or similar pessaries due to introital laxity (see
Figure 5). The shape of the
Gellhorn pessary allows the lateral vaginal walls to in-fold under
the top dish, while the concave
dish itself may create a suctionlike action against the proximal
vagina, facilitating pessary retention. The stem of the Gellhorn follows the shaft of the vagina, maintaining correct alignment. The
option of two different stem
lengths (short and long) allows
optimal fitting even in women
with a shortened vagina, such as
post-hysterectomy
women.
Although the ability of the
Gellhorn to be somewhat selfretaining can be a considerable
advantage, it also makes this pessary more difficult for clinicians
and patients to remove. In addition, the Gellhorn pessary may be
more likely to cause mechanical
trauma to the vaginal tissue. As
with other pessaries, Gellhorn fitting involves measurement of the
vagina, in this case, assessing both
the diameter of the introitus and
the apex to approximate the correct size of the dish and of the
vaginal length to determine
whether a long or short neck is
appropriate (see Figure 8).
To insert the flexible Gellhorn,
the stem can be bent down to the
dish and the dish folded, with the
edge of the dish inserted first. The
pessary is then corkscrewed gently
down toward the perineum to
avoid the urethra, then upward to
bring the dish perpendicular to
the vaginal vault. The pessary can
then be pushed gently upward
using the index finger on the knob
at the end of the neck, placing the
dish into the vaginal apex. The
woman can then bear down as an
initial assessment of the likelihood of retention. If two to three
adjustments in the size of the pessary do not work, a Cube pessary
may be an option.
Removal of a flexible Gellhorn
is generally achieved by lubricating the introitus, pulling the knob
at the end of the pessary neck gently downward (toward the introitus) and laterally (toward a thigh),
and using the index finger to hook
and bend down the edge of the
dish. When the knob cannot be
easily grasped, a carefully placed
tenaculum or ring forceps may be
helpful to assist removal. Gellhorn
pessaries are sized in quarter-inch
intervals by the dish diameter,
with common sizes generally ranging from 1.75 to 3 inches.
Cube. The Cube pessary can
also be considered self-retaining
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
SERIES
Although the evidence base
for pessary use has been building
in recent years, much of practice
continues to be based predominantly on expert-opinion. Practicing providers may fill some of
these gaps through their own
observations and inventiveness,
as well as in formal clinical trials
in their own practice. Nurses
involved in pessary care may be
interested in studying ways to
improve patient satisfaction and
experience. Questions may include looking at changes in sexual function; testing appropriate
pre-trial, goal-setting models;
comparing methods of providing
information about pessary options
for individuals and lay groups;
and evaluating symptom relief
when pessaries are used in con-
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
Conclusion
Support pessaries are an
important option for treatment of
many pelvic floor symptoms.
Currently, providers new to the
field continue to learn pessary
indications, selection, and fitting
strategies from a relatively small
evidence base, and occasionally,
from conflicting expert opinion.
This article has summarized basic
concepts related to initiating pessary use. Other articles in this
series will discuss pessary follow
up and business strategies.
References
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PESSARIES
Incontinence pessaries help
stabilize the urethra and the urethral vesicle junction to prevent
Suggestions for Future Research
junction with other modalities,
such as anticholinergic medications or urethral bulking agents.
Expert opinion regarding indications for specific pessary types
should be tested in additional
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ON
Incontinence Pessary Options
leakage during times of increased
abdominal pressure. Options
include the Incontinence Ring or
Dish, which are similar to regular
Ring pessaries but offer less vaginal support; and standard Ring,
Arch (Gehrung), or Lever (SmithHodge) pessaries with an optional
incontinence support knob. Most
of these pessaries are fitted similarly to a standard Ring pessary.
While some women use incontinence pessaries only during exercise, others use them continuously. Generally, the incontinence
knob pessaries are fitted more
snugly behind the symphysis,
beneath the urethra. A pessary
that is too loose will not decrease
stress UI and may rotate in the
vagina. Too much pressure may
cause discomfort, epithelial injury, and urinary retention. If the
woman plans to use the pessary
only intermittently or during
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pessaries are typically fitted with
an empty bladder, fitting an
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with a full bladder may facilitate
testing of both stress UI treatment
during exercise and voiding adequacy.
SPECIAL SERIES
(see Figure 6). Compared to a
Gellhorn pessary, a smaller size
can be used; however, Cube use
may also result in mechanical tissue injury. Cube pessaries are
held in place because the concavities in the six sides allow vaginal
tissue to conform to the pessary
shape. Because large amounts of
epithelium are in contact with the
pessary, drainage holes are important to allow desquamated cells
and vaginal discharge to drain.
The Cube is designed for self-care,
but like the Gellhorn, some
women and providers find it difficult to remove due to the suction.
Softness and compressibility of
the silicone used vary by manufacturer. Softer Cubes can be easier to insert, but firmer devices
may be more likely to be retained,
and choice is typically based on
provider experience. The Cube
pessary can be placed at different
depths in the vagina, which may
offer an advantage when a woman
has an isolated or site-specific
prolapse.
Size is estimated by digitally
measuring the diameter of the
vaginal shaft and vault. To insert,
lubricate the pessary and introitus,
compress the pessary, part the
introitus gently, and insert the pessary to the depth that best corrects
the bulge and is most comfortable
for the patient. Commonly used
sizes range from 1 to 4.
To remove, lubricate the introitus, apply gentle traction on
the pessary cord to stabilize and
bring the device toward the introitus, and then insert the tip of the
index finger up above the Cube to
release it and pull it gently out of
the vagina. Pulling too hard on the
cord alone will break the cord. If
removal is difficult, a tenaculum,
ring forceps, pessary remover or
crochet hook, or dental tape tied
through several holes can be used
to facilitate bringing the Cube to
the introitus.
SPECIAL SERIES
ON
PESSARIES
SERIES
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UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3

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