Although the pessary can initially be effective in reduction of the prolapse, with further weakening of the pelvic floor caused by continued progression of pelvic floor neuropathy as well as an increase in the vaginal hiatus, or decreased vaginal hiatus diameter due to levator muscle hypertrophy the size and type of pessary may need to be changed. Pessary size may also need to be changed over time because of patient weight loss. For those patients who are able to easily remove and place the pessary themselves, follow-up with the clinician should occur every 6 months to assure proper fit and placement. Following is a list of recommended care procedures; the patient who cannot self-care for the pessary must be seen by the clinician on a regular basis. Pessary care recommendations should be followed closely for safe long-term use.
• Remove at least two nights per week
• Leave out overnight
• Insert 1 to 2g of estrogen cream during the night while pessary is out
• Wash pessary with soap and water
• Reinsert using water-soluble lubricant
• Report any unusual discharge, bleeding, or discomfort
• Report any changes in bladder or bowel function
• Have pelvic examination every 6 to 12 months
For those unable to provide self-care, we recommend scheduled office visits for pessary care every 6 to 12 weeks. Patients must be encouraged to use intravaginal estrogen cream regularly to help prevent vaginal ulceration from foreign-body use within the vagina. This is especially true in the postmenopausal patient. Some pessaries that are used, such as the Gellhorn, may be difficult for the patient to remove herself. This can be facilitated by attaching a string (dental floss or suture) to the pessary. For those patients who are sexually active, the pessary may either be removed or left in place provided there is no discomfort to either the patient or her partner.
Many young patients with prolapse believe that pessaries are designed for the elderly women with prolapse, dissuading them from considering their use. Young women of reproductive age are often ideal candidates for pessary treatment of prolapse, as well as SUI. However, most women of reproductive age desire surgical correction of their prolapse, and they may use a vaginal pessary only to relieve the symptoms of genital prolapse until the desired time to undergo surgical treatment. Other ideal candidates include those:
• Of reproductive age
• Comfortable with genital contact (i.e., tampon user)
• With adequate manual dexterity
• Compliant with safe usage recommendations
• With a well-estrogenized vagina
• With an unscarred vagina
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