Pessary


A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage, and pelvic organ prolapse to maintain the location of organs in the pelvic region. It can also be used to administer medications locally in the vagina or as a method of contraception. Pessaries come in different shapes and sizes, so individuals can be fitted for them by health care professionals. Depending on the circumstance and indication, individuals may also purchase pessaries over the counter without seeking help from a health care professional. Some side effects may occur if pessaries are not sized properly or regularly maintained, but with the appropriate care, pessaries are generally safe and well tolerated.
Early use of pessaries dates back to the ancient Egyptians, as they described using pessaries to treat pelvic organ prolapse. The term 'pessary' itself, derived from the Ancient Greek word 'pessós,' meaning round stone used for games. Pessaries are even mentioned in the oldest surviving copy of the Greek medical text, Hippocratic Oath, as something that physicians should never administer for the purposes of an abortion: "Similarly I will not give to a woman a pessary to cause abortion." The earliest documented pessaries were natural products. For example, Greek physicians, Hippocrates and Soranus, described inserting half of a pomegranate into the vagina to treat prolapse. It was not until the 16th century that the first purpose-made pessaries were made. For instance, in the late 1500s Ambrose Paré was described as making oval shaped pessaries from hammered brass and waxed cork. Pessaries used today, are generally well tolerated and made from silicon.

Types of pessaries

Therapeutic pessaries

A therapeutic pessary is a medical device similar to the outer ring of a diaphragm. Therapeutic pessaries are used to support the uterus, vagina, bladder, or rectum. Pessaries are most commonly used for pelvic organ prolapse and considered a good treatment option for women who need or desire non-surgical management or future pregnancy. It is used to treat prolapse of uterine, vaginal wall, bladder, rectum, or small bowel. It is also used to treat stress urinary incontinence.
There are different types of pessaries but most of them are made out of silicone—a harmless and durable material. Pessaries are mainly categorized into two types, supporting pessaries and space-occupying pessaries. Support pessaries function by supporting the prolapse and space-occupying pessaries by filling the vaginal space.
Ring with Support Pessary
Ring pessaries are the supporting type. These are often used as a first-line treatment and used for earlier stage prolapse since patients can easily insert and remove them on their own without a doctor's help. These can be easily folded in half for insertion.
Gellhorn Pessary
Gellhorn pessaries are the supporting and space-occupying pessaries. These resemble the shape of a mushroom and are used for more advanced pelvic organ prolapse. These are less preferred than ring with support pessary due to difficulty with self-removal and insertion.
Marland Pessary
Marland pessaries are the support pessaries. These are used to treat pelvic organ prolapse as well as stress urinary incontinence. These pessaries have a ring at their base and a wedge-shaped ridge on one side. Although these pessaries are less likely to fall out than standard ring with support pessaries, patients find it difficult to insert or remove them on their own.
Donut Pessary
Donut pessaries are the space-filling pessaries. These are used for more advanced pelvic organ prolapse including cystocele or rectocele as well as a second or third-degree uterine prolapse. Due to its shape and size, it is one of the hardest ones to insert and remove.
Cube Pessary
Cube pessaries are space-filling pessaries in the shape of a cube that are available in 7 sizes. The pessary is inserted into the vagina and kept in place by the suction of its 6 surfaces to the vaginal wall. Cube pessaries must be removed before sexual intercourse and replaced daily. Cube pessaries are generally used as a last resort only if the patient cannot retain any other pessaries. This is due to undesirable side effects such as vaginal discharge and erosion of the vaginal wall. In order to remove the cube pessary, the suction must be broken by grasping the device.
Gehrung Pessary
A gehrung pessary a space-filling pessary that is similar to the Gellhorn pessary. It is a silicone device that placed into the vagina and used for second or third degree uterine prolapse. These do contain metal and should be removed prior to any MRI, ultrasound or X-rays. They can also be used to help with stress urinary incontinence such as urine leaks during exercising, or coughing. These types of pessaries need to be fitted by a health care professional to ensure proper size. Once placed it should not move when standing, sitting, or squatting. It should cleaned with mild soap and warm water every day or two.
Hodge Pessary
These pessaries are rarely used.
The Cerclage Pessary is used to treat pregnant women with cervical incompetence in order to support the cervix and turn it backward towards the sacrum. It may be indicated in pregnancies with a history of premature labor, multiple pregnancies or mothers who are exposed to physical strain. It may also be indicated in pregnant women suffering from prolapse of the genital organs.
The pessary can be placed temporarily or permanently, and must be fitted by a physician, physician assistant, midwife, or advanced practice nurse. Some pessaries can be worn during intercourse.

Pharmaceutical pessaries

Treating vaginal yeast infections are one of the most common uses of pharmaceutical pessaries. They are also known as vaginal suppositories in which are inserted into the vagina and are designed to dissolve at body temperature. They usually contain a single use antifungal agent such as clotrimazole. Oral antifungal agents are also available.
Pessaries can also be used in a similar way to help induce labor for women who have overdue expected delivery dates or who experience premature rupture of membranes. Prostaglandins are usually the medication used in these kinds of pessaries in order to relax the cervix and promote contractions.
According to Pliny the Elder, pessaries were used as birth control in ancient times.

Occlusive pessaries

Occlusive pessaries are most commonly used for contraception. Also known as a contraceptive cap, they work similar to a diaphragm as a barrier form of contraception. It is inserted into the vagina and blocks sperm from entering to the uterus through the cervix. The cap must be used in conjunction with a spermicide in order to be effective in preventing pregnancy. When used correctly the cap is thought to be 92-96% effective. These caps are reusable but come in different sizes. It is recommended for anyone attempting this from of contraception to be fitted for the correct size by a trained health care professional.

Stem pessary

The stem pessary, a type of occlusive pessary, was an early form of the cervical cap. Shaped like a dome, it covered the cervix, and a central rod or "stem" entered the uterus through the os, to hold it in place.

Side effects and complications

When pessaries are used correctly, they are tolerated well for pelvic organ prolapse or stress urinary incontinence. However, pessaries are still a foreign device that is inserted into the vagina, so side effects can occur. Some more common side effects may occur, including vaginal discharge and odor. Vaginal discharge and odor may be associated with bacterial vaginosis, characterized by an overgrowth of naturally occurring bacteria in the vagina. These symptoms can be treated with the appropriate medications. More serious side effects include fistula formation between the vagina and rectum or the vagina and bladder, or erosion of the vaginal wall. Fistula formation is rare, but erosion of the vaginal wall occurs more frequently. Low estrogen production can also increase the risk of vaginal wall thinning. For individuals with pessaries that are not fitted for them, herniations of the cervix and uterus can occur through the opening of the pessary. This can lead to tissue necrosis in the cervix and uterus. To prevent these side effects, individuals can be fitted properly for their pessaries and undergo routine follow-up visits with their health care professionals to ensure the individual has the correct pessary size and no other complications. In addition, those with an increased risk of vaginal wall thinning can be prescribed estrogen to prevent erosion and prevent these serious complications.
If pessaries are not used properly or not maintained periodically, more serious complications can occur. For example, the pessary can become embedded into the vagina, which makes it harder to remove. Estrogen can decrease the inflammation of the vaginal walls and promote skin cells in the vagina to mature, so use of estrogen cream can allow removal of the pessary more easily. In rare cases, pessaries would need to be removed through surgical procedures.
Other complications can occur if individuals have characteristics that exclude them from this method of therapy. Some contraindications to pessary use include current infections in the pelvis or vagina, or allergies to the material of the pessary. In addition, individuals should not be fitted for a pessary if they are less likely to properly maintain their pessary.