Contraindications to Pessary

Although the pessary can be a valuable tool in the treatment of genital prolapse, there are certain patients for whom pessary use may be considered contraindicated.

• Severe atrophic tissues

• Erosive ulcerative changes in the vaginal mucosa

• Undiagnosed vaginal bleeding

• Undiagnosed vaginal discharge

• Vaginal or cervical cancer

• Noncompliance in follow-up

• Impaired mental capacity

At our center, pessaries are frequently used as first-line therapy for prolapse and incontinence. For advanced degrees of prolapse, our most commonly used pessary is the Gellhorn, which is available with either a short or long stem depending on the patient's vaginal length. Cube pessaries should only be used with extreme caution in women who will be compliant with follow-up, as the suctioned adherence to the vaginal sidewalls may lead to significant mucosal erosions and ulcerations. Shaatz pessaries are also used in patients with advanced prolapse, but may be more difficult to remove, because of the absence of the stem.

For those elderly women with severe genital prolapse as well as SUI who cannot or do not want surgery, a pessary may be placed and a bulking agent such as collagen used to treat the incontinence. Many women who wear pessaries for SUI or prolapse eventually become frustrated with the efforts required for safe pessary use, and opt for surgical management. Some women will postoperatively use a pessary upon return to increased physical activity to help provide additional support to the pelvic floor and reduce the risk of prolapse recurrence.

Cost issues must also be considered. In many cases, reimbursement by insurance companies does not cover the entire cost of a pessary. Additionally, no optimal distribution systems through pharmacies or durable medical supply houses exist. The physician is thus typically at financial risk when fitting pessaries.

Motivated patients who wish to avoid surgical therapy are the optimal candidates for vaginal pessary use. Although several limiting factors may arise, including difficulty with insertion and removal, interference with sexual activity, pelvic discomfort, and associated vaginal discharge, vaginal devices are a valuable conservative option for the treatment of prolapse.

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