The Vaginal Pessary

First published October 2004.

The baby boomers are aging and sagging. As a result, stress incontinence is becoming more prevalent in this age group. Stress incontinence is the involuntary loss of urine at inappropriate times. Simply put, it occurs when pressure in the bladder exceeds the intraurethral pressure necessary to retain urine. A major cause of stress incontinence is the loss of anatomic support for the urethra, bladder and urethrovesical junction. This loss of support allows displacement of the urethrovesicular junction and, as intra-abdominal pressures increase during physical activities, urine loss occurs.

Although surgery is an option, many women are interested in a more conservative approach to the management of pelvic floor and bladder dysfunction. Use of the vaginal support pessary offers such an alternative, but it is often overlooked because of patient and provider discomfort with its application. Pessaries can be extremely effective at restoring continence. They stabilize the urethra and urethrovesical junction to allow proper pressure transmission, which increases urethral resistance and helps overcome the forces of abdominal pressure.¹

Background
Pessary use is not widespread for two reasons: Women are reluctant to use a pessary because they are not familiar with it, and providers are reluctant to recommend a pessary because they don't know how to fit it properly. Table 1 outlines other common deterrents.

Pessary fitting is more art than science. It requires technical skill, and although education and background information are certainly needed, proficient management requires hands-on practice. Beginning learners may have to persevere through some fumbling inefficiencies to complete the learning curve, but it is short-lived. The process involves trial and error on the part of both patient and provider. You are already equipped with some beginning skills if you know how to fit a diaphragm. The same principles can be applied to fitting pessaries.

History
The vaginal pessary was first used thousands of years ago as a treatment for pelvic prolapse.² Figure 1 shows examples of early versions of the device. Cleopatra is believed to have been treated for prolapse with the vaginal application of a ball soaked in an astringent. Other treatments for prolapse involved even more fascinating approaches. The simplest is probably the use of the pomegranate as a pessary, while a more bizarre strategy is the suspension of a woman by her feet so that she could be shaken until the bladder returned to its proper position. Fortunately, the use of vaginal pessaries has been refined in the last century. Today's pessaries allow easier insertion and removal with greater efficacy, all of which make them more acceptable to providers and patients.

Role of the Modern Pessary
Today's pessary has many applications. It can be used as a temporary measure for relief of symptoms while a patient delays urologic surgery until a more opportune time, or until she decides whether to have surgery at all. It can also be used as a permanent alternative to surgery, particularly in elderly women who want to avoid surgical risks. The proper management of a pessary is less expensive and safer than its surgical alternative.

The pessary can also be used as a diagnostic aid to predict which patients will be helped by surgical correction. If realignment of the pelvic organs to the normal anatomical position provides relief of symptoms, there is an increased likelihood that surgical correction will be successful.³ Additionally, use of a pessary may uncover a hidden incontinence problem that would require further urethrovesical neck suspension as part of the surgical treatment. It may be that prolapse had provided continence because the abnormal angle of the bladder neck (resulting from the prolapse) caused a kink that obstructed the urethra.

The pessary also has expanding uses in obstetrics. For example, it resolves an incompetent cervix by relieving pressure on the cervix and repositioning the weight of the growing fetus a strategy that can help prevent miscarriage. It may also help hasten postpartum involution and retroversion.

Physiologic Considerations
The pelvic floor is comprised of two muscle groups, the levator ani and the ischiococcygeous. The levator group is made up of the puborectalis, pubococcygeus and iliococcygeus. These muscles form the "sling" that supports the pelvic floor. They play a critical role in maintaining both urinary and fecal continence and stabilize the joints of the pelvis. The pessary supports these muscle groups and places pelvic organs in close alignment to their proper anatomic position. It also helps patients who are undergoing pelvic floor rehabilitation by repositioning pelvic structures to enhance muscle strengthening. The goal is to promote continence by stabilizing the bladder base.

Stress incontinence is often associated with a cystocele, which occurs when the tissues between the bladder and vagina weaken, leading to herniation of the bladder. This herniation causes a bulge in the anterior vaginal wall. If the cystocele descends into the vaginal space, the bladder may have to empty uphill, causing urinary retention and urgency. Overactive bladder may occur. Atrophism causes further thinning of the vaginal wall separating the bladder anteriorly and the rectum posteriorly, weakening the support even more. Pessaries work well in the treatment of urinary incontinence by compressing the urethra against the upper posterior portion of the symphasis pubis, elevating and stabilizing the bladder neck. This increases outflow resistance and may correct the angle between the bladder and the urethra.

Pessary Features
The pessary is an FDA-approved medical device that is inserted into the vagina to treat a variety of urogynecologic conditions. Most pessaries are made of a non-toxic, medical-grade silicone. The silicone is pliable, making the pessary comfortable to wear. Pessaries do not absorb vaginal secretions or odors. They are biologically inert, rarely causing allergic reactions. Pessaries used for fitting purposes can be autoclaved, boiled or soaked in Cidex. The pessary is safe and is not associated with an increased risk of cancer.

Pessaries are available in many sizes and shapes, and are designed to support various anatomical defects (Figure 2). The pessary's outside diameter is measured in inches, with a range from 1 inch to 4 inches. At least three companies manufacture pessaries: Bioteque, Mentor and Milex. You can order the devices from each company's sales representatives or Web site (www.bioteque.com, www.milexproducts.com, www.mentorcorp.com). Pessaries typically include instructional sheets with recommendations for use and fitting instructions for each specific pessary. Table 2 outlines indications for selection.