Pessaries for Genital Prolapse

Use of vaginal devices for prolapse reduction and administration of chemicals is documented as early as the Egyptian civilization. Written documentation of efforts to reduce genital prolapse with vaginal objects dates back as far back as the fifth century. Modernization of the pessary came with the discovery of vulcanization of rubber and a better understanding of female anatomy. Since then, multiple modifications in pessary design and material selection for manufacture have been made.4

Advances in gynecologic surgery and anesthesia over the last several decades have reduced the need for pessary usage in the treatment of prolapse and incontinence. However, the recent increase in the elderly population requiring conservative treatment of prolapse and incontinence has led to a resurgence of pessary use.5 In addition, there remains a very acceptable role for therapeutic use of a vaginal pessary in the premenopausal patient. In a recent survey administered to members of the American Urogy-necologic Society, 77% of the respondents used pessaries as a first-line therapy for prolapse, and only 12% reserved pessaries for women who were not surgical candidates. In addition, 92% of the physicians surveyed believed that pessaries relieved symptoms associated with pelvic organ pro-

Figure 8-1.1. Gellhorn pessary. (Reprinted with the permission of The Cleveland Clinic Foundation.)

lapse, and 48% believed they had a therapeutic benefit in addition to relieving the symptoms.6

In a simple prospective protocol for pessary management, patients with symptomatic pelvic prolapse were given the option of pessary use versus surgery or expectant management. If the vaginal pessary was chosen as the method of treatment, the patient was fitted with a ring pessary or a pessary that could be retained without difficulty. The patient then followed up at scheduled intervals to evaluate pessary effectiveness. Sixty-six percent of those who used a pessary for more than 1 month remained users after 12 months. Fifty-three percent of the patients continued to wear the pessary after 36 months.7 A retrospective series of 107 patients who were fit with a Gellhorn, cube, or ring pessary for symptomatic vaginal prolapse for various indications including medically unfit for surgery, awaiting surgery, or desired conservative management, confirmed that at least 50% of the women continued use of their pessary without complications at follow-up.8 Of those who continued pessary use, 20% were patients who initially desired surgery but later declined because of satisfaction with the vaginal pessary (Figure 8-1.1).

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