Pessary Fitting 101

University of New Mexico, Health Sciences Center Division of Urogynecology November 7th, 2012

Pessaries Useful Practical Safe Inexpensive Easy

History

Beeswax Fruits Vegetables Rubber Silicone

Basic Points

NORMALIZE HOPE HUMOR

Which Pessary?

Comfortable Relieves symptoms Retained with Valsalva Easiest for self-care

Which Pessary? Prolapse?

Incontinence? Both?

Pessary Style/Size Pessary Chart

Styles Sizing (whole #, mm, inches)

RING WITH SUPPORT

RING

Shaatz

Long or Short Stem Gelhorn

INCONTINENCE RING

INCONTINENCE DISH

INCONTINENCE DISH WITH SUPPORT

Pessary 1st Visit S. Initial History problem, dx, goals pregnancies, births, work, surgeries partner, family, community hearing, vision, dementia HTN, DM, obesity, arthritis, depression

Pessary 1st Visit O. Physical and mental state

Mobility Prolapse (POP-Q) Vaginal architecture Atrophy

List of pessaries tried

Pessary Fitting  Genital Hiatus?  Vaginal length and width?

 Apex?  Retropubic notch?

Pessary Fitting Trial and Error Select pessary style Select 3 sizes

Office Trial Hula Hop Valsalva Void

Criteria for Success

Comfortable Symptom Relief Retained with Valsalva Easiest for self-care

Checking Position

Office Trial Self-care

Patient needs to demonstrate placement and removal before going home with pessary.

Self-Care Safety Good candidates Patient education Written instructions Clinic phone # Follow-up

Pessary 1st Visit A. 1. POP

2. UI 3. Atrophy 4. Pessary Fitting Placement/ Pt. Ed.

Pessary 1st Visit P. Dispense/Order Rx F/U Referral

Follow-Up

1-4 weeks after placement Then: Assisted care: 4-12 weeks Self care: 6-12 months

Questions at Follow-Up Effectiveness Satisfaction Changes in health Mental status

Questions at Follow-Up Bleeding Malodorous discharge Pain Problems with bowel or bladder Problems with removal or insertion Frequency of cleaning pessary Vaginal atrophy and E cream use

Follow-Up Visit S. Changes in health/family Satisfaction/problems with pessary

Follow-Up Visit S. Bleeding Malodorous discharge Pain Problems with bowel or bladder

Follow-Up Visit S. Frequency of removal and cleaning Use of Estrogen cream Use of douche

Follow-up Visit O. physical and mental status integretity of skin remove and clean pessary speculum exam: bleeding, abrasions, atrophy, malodorous discharge replace pessary with E cream

Follow-Up Visit A.

1. POP 2. UI 3. Atrophy 4. Malodorous d/c and irrigation 5. Pessary F/U and Patient Education

Pessary Follow-Up Visit  P.

1. Return… 2. Rx…. 3. Referral

Pessary Challenges

Challenging Fittings  Atrophy  Altered architecture

 Pain  Large genital hiatus  Mobility challenges  Posterior prolapse

Atrophy  Pain  Bleeding

 Abrasions

Strategies for Atrophy  Vaginal estrogen cream  Vaginal estrogen ring  Apricot kernel oil  Water based lubricants

Malodor  Acetic acid/water douche

 Metronidazole gel  Boric acid suppositories  Hydrogen peroxide douche  Iodine swab

Vaginal discharge  Patient description  Inspect and evaluate

 Treat infection  Pessary care routine  Alter plan of care

Discomfort  Good history  Evaluate pessary

position  Re-evaluate pessary size/style  Bimanual exam

Vaginal bleeding  Good history  Evaluate pessary position, size

 Estrogen status  Thorough inspection of vagina  Bimanual exam  Pap history, Endometrial Biopsy

Abrasions  Bleeding  Speculum exam

 Document  Treat  Follow-up

Altered mental status  Assurance for follow-up  Inform other caregivers

 History from caregivers  Patience  Distraction

Pessary not helpful  Expulsion  Slipping

 Prolapse around pessary  Persistent or New Incontinence

When to quit  Inability to return for care  Poor symptom control

 Patient dissatisfaction  Patient opts for other treatment

Test Q. Did Cleopatra wear a pessary?

1. Probably 2. No

Test Q. How common is symptomatic prolapse in post-menopausal women?

1. Very 2. Not at all

Test Q. How common is incontinence in all ages of women? 1. Very 2. Not at all

Test Q. Are most pessaries made out of nonreactive silicone? 1. Yes 2. No

Test Q. Can most women with prolapse be successfully fitted with a pessary? 1. Yes 2. No

Test Q. Is the ring with support the most commonly used pessary for prolapse? 1. Yes 2. No

Test Q. Can a ring with support be used for stress incontinence? 1. Yes 2. No

Test Q. Can most women be taught to manage a pessary by themselves? 1. Yes 2. No

Test Q. Are soap and water effective in

cleaning a pessary? 1.Yes 2. No

Test Q. Is a pessary (usually) comfortable?

1. Yes 2. No

Test Q. Is it okay to have sex while wearing a pessary?

1.Yes 2. No

Test Q. How important is clinic follow-up?

1.Very 2. Not at all