NONSURGICAL TREATMENT OF VAGINAL PROLAPSE: DEVICES FOR PROLAPSE AND INCONTINENCE

Chapter 58 NONSURGICAL TREATMENT OF VAGINAL PROLAPSE: DEVICES FOR PROLAPSE AND INCONTINENCE



Peggy A. Norton



NONSURGICAL TREATMENT OF VAGINAL PROLAPSE


Surgery for pelvic floor disorders such as stress urinary incontinence and pelvic organ prolapse (POP) is aimed at restoring or improving the function of the pelvic organs. By its nature, such functional surgery cannot be guaranteed to restore continence and support to its original state. Up to one third of surgeries for pelvic floor disorders fail.1 Given these facts, many women are interested in nonsurgical options for vaginal prolapse that offer less risk and expense. Once fitted, patients are immediately aware of whether the device is comfortable and whether it is effective in treating the condition. Although use of these devices should not be viewed as a permanent solution for prolapse, many women successfully use them for many years without much bother. Such devices are widely available but require some professional intervention to determine correct use and fit, similar to fitting a contraceptive diaphragm. Little has been published on the use of vaginal devices for prolapse, possibly because there is no industry support for (or profit from) conducting properly controlled clinical trials.



Indications for Pessary Use


Indications for a pessary in the management of POP include patient desire for nonsurgical management of the condition. Traditionally, this group of patients has included those few women who are unable to undergo surgical management because of medical problems. But there are many women who might be interested in a pessary, because it manages the prolapse without the need to undergo surgery. In our practice, pessaries are used successfully in women who cannot take time off for surgery, such as mothers with small children at home and women with busy careers outside the home.


Willingness to use a vaginal device may be cultural, especially in areas where contraceptive diaphragms are used. Prashar and colleagues2 found that only a fifth of 104 women who presented to a community continence clinic in Australia felt very comfortable about inserting a device into the vagina (and half felt uncomfortable). In our practice at the University of Utah, most women who are believed to be good candidates for a pessary trial are readily fitted and can demonstrate removal and replacement of the device. Clemons and colleagues3 successfully fitted three-quarters of patients with POP with a pessary. It has even been suggested that use of a pessary longer than 1 year may have some therapeutic effect, in that a minority of users have an improvement in prolapse stage.4



Patient Selection


In addition to a patient’s interest in nonsurgical management, there are physical factors that favor use of a pessary. The best clinical situation is an anterior and/or apical defect (cystocele, uterine prolapse, vaginal vault prolapse) in a woman with adequate vaginal capacity, a narrow pubic arch, and good pelvic floor strength. This is because the ventral edge of a pessary is held behind the pubic rami, and a wide arch would allow extrusion of the device. Likewise, the dorsal edge of the pessary is braced by the pelvic floor muscles. In the absence of these factors, one must consider the use of pessaries that utilize suction or inflation (see later discussion). An isolated posterior wall defect (rectocele) is more difficult to manage with a pessary, because the force vectors act to extrude the pessary. If the vaginal capacity is reduced after surgery, a narrower pessary may be needed (e.g., oval, Hodge, cube). Other reported risk factors for pessary failure include a shortened vagina and a wide levator hiatus.3



Selection of a Pessary


Vaginal pessaries have been used for many centuries, but improvements in materials and design have increased the usefulness of these devices for prolapse. Most are made of silicone (latex-free), are flexible to allow easier placement and removal, and should last for several years with proper care. Sources for vaginal pessaries are listed in Table 58-1.


Table 58-1 Sources for Vaginal Pessaries


















Web Site Address Description
http://www.milexproducts.com/products/pessaries Milex Products Online Catalog?? Source for many continence devices, including continence dish, rings, other pessaries with knobs, and so on.
http://www.urology.coloplast.com/pelvic-organ-prolapse/evacare Patient information source for EvaCare continence devices
EvaCare formerly prod. by Mentor, not Coloplast; Mentor bought DesChutes incontinence line in 2000, maybe sold it now?; site has only breast info & press releases re these items. www.urology.coloplast.com/bladder-control/incontinence-women/index.htm?? including continence dish. Source for intravaginal continence devices.
http://www.augs.org Web site for the American Urogynecologic Society, with sites for members and patients. For bladder diaries and bladder retraining, click on information for women, diagnostic and treatment information on overactive bladder/urge incontinence. Information on pelvic floor muscle training (Kegel exercises) is also available.


Supportive Pessaries


Supportive pessaries (which depend on some levator muscle support to stay in place) include the Gehrung, Hodge, and Schatz designs, as well as rings and ovals with support. Although individual practices may vary, flexible ring pessaries and Gelhorn pessaries are used most commonly. Members of the American Urogynecologic Society (AUGS) were surveyed by Cundiff and colleagues,5 and more than three quarters of respondents reported that they tailored the pessary to the defect. A ring pessary was more common for anterior and apical defects, a Gelhorn was more common for large Stage III and IV prolapse, and a donut pessary was used for posterior defects. Twenty-two percent of respondents used the same pessary, usually a ring pessary, for all support defects. One questionnaire study of gynecologists reported that ring and donut pessaries were the types most commonly used.6 In a tertiary referral practice in Texas, Sulak and colleagues7 used a Gelhorn pessary in 96 of 107 women with symptomatic POP. Because many of the women desiring pessary use have stage II prolapse, the pessary we use most at the University of Utah is the ring with support in sizes 3 and 4 (size refers to diameter in centimeters.)


Supportive pessaries are the easiest pessaries to use because they fold to a smaller dimension for insertion. Many of them, because they are similar to a contraceptive diaphragm, permit coitus while wearing the device. Perhaps because they are easier to manage, supportive pessaries may not be sufficient to support large prolapses. Pessaries are easiest to insert lying down, easiest to remove standing up, and may require digital bracing per vaginum during bowel movements. Some women have difficulty removing the pessary, and in the past some pessaries came with removal strings that became malodorous over time. Instead, we recommend tying a strand of dental floss around the ring, so that the pessary can be pulled out by the floss, and renewing the floss each time.



Space-Occupying Pessaries


Space-occupying pessaries include the cube, donut, Gelhorn, and inflatoball. These pessaries are more difficult to insert and remove, but they work in situations in which other devices would be extruded: with larger prolapse, poor pelvic floor strength, or wider pubic arch. Of these, we use the donut and the Gelhorn with the most frequency. The donut is simply pushed into the vagina quickly, and it is easiest to use in women without significant atrophy or scarring. The Gelhorn is held by the knob, aligned along an almost vertical axis (but sparing the urethra) and rapidly inserted, then adjusted so that the knob faces the introitus or posterior distal vagina. We have not found that pinching the flexible disk of the Gelhorn makes much difference to the relative discomfort with which this pessary is placed. To remove the Gelhorn, an index finger should be inserted to break the slight suction seal of the disk in the vagina, and the thumb and index finger of the other hand may grasp and pull the knob. Occasionally, we use a ring forceps to grasp the knob and bring it to the introitus. Although insertion and removal of the Gelhorn sounds daunting, it is a highly successful pessary for large prolapses, and with practice this pessary is inserted and removed on a regular basis in many patients. The cube has a relative suction effect and may be effective in cases of lax vaginal walls, but it generates significant discharge and in our experience is more prone to excoriation and ulceration than other pessaries. The inflatoball is pumped up with a small bulb and is similarly prone to excoriation unless care is taken.



Care and Long-Term Use of a Vaginal Pessary

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Jun 4, 2016 | Posted by in ABDOMINAL MEDICINE | Comments Off on NONSURGICAL TREATMENT OF VAGINAL PROLAPSE: DEVICES FOR PROLAPSE AND INCONTINENCE

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