Once you have removed the pessary and inspected the vagina, irrigate and cleanse the vagina with a mild solution of betadine or hydrogen peroxide. Insert a lubricated 20-cc syringe into the vagina (10 cc for a small introitus) and irrigate until clear (usually 40 cc to 60 cc). Be sure to document the type and amount of solution used.

Clean the pessary in soap and water and reinsert it. You may need to switch to a larger size since the vagina may stretch with the pessary in place. If a larger-sized ring is not effective, try a different type. A Gellhorn with drainage holes is often a good second choice.

Advise patients to call you if they experience any vaginal bleeding. It is imperative to carefully assess the source, since pessary placement may interfere with signs of endometrial hyperplasia. The pessary may irritate the friable atrophic vagina. If erosion or abrasions to the vaginal epithelium occur, remove the pessary for 1 to 2 weeks and allow the area to heal. Schedule a follow-up visit for 1 to 3 months later.

Most women are very satisfied with their pessaries and experience no complications that would deter them. Still, some women decided to discontinue using a pessary. The most common reasons are listed in Table 5.

A Precautionary Note
It is imperative that you maintain a list of all of your patients with pessaries, along with a schedule for their follow-up care. Since many women with pessaries are elderly, their physical or mental status may change suddenly. A woman may have a stroke or require hospitalization. The staff there may have no idea that she has a pessary in place. A forgotten pessary can be dangerous if it isn't cleaned for a long time.⁷ It can erode into the bladder or become impacted in the vagina. A pessary should not be used in a woman who is unable to care for herself. If a patient has a condition such as Alzheimer's disease, her caregivers need to know that the pessary is in place and follow the requirements for maintenance.

Reimbursement
Pessaries are now directly reimbursed by Medicare, which pays between $44 and $53 for each. The actual fitting procedure (CPT code 57160) is reimbursed at an average of $59 for the session. If a lot of time is spent at the fitting session, a level II visit (99213 to 99215 for an established patient, or 99293 to 99295 for a new patient) can be billed based on time and counseling. The follow-up visits can be billed as a level 99213 or 99214, depending on the complexity of the visit. If vaginal irrigation is performed, it can be billed as 57150 but cannot be billed along with an E and M visit unless there is a separate diagnosis and modifier 25 is used. When assessment of vaginal atrophism is performed, a level II visit (usually 99213) can be added to the procedure code, again with the separate diagnosis of vaginal atrophism and use of modifier 25.

The Test of Time
Many baby boomers are entering their postmenopausal years, a time when problems of pelvic support and urinary incontinence are more likely to occur. The vaginal pessary offers women an excellent choice as a short-term adjunct while deciding about surgery, as a diagnostic modality to decide on the type and effectiveness of surgery, or as a long-term solution to urinary incontinence without surgery. The pessary offers women a chance to lead normal lives unencumbered by the burden of incontinence.

Helen Carcio is a women's health nurse practitioner at Pioneer Women's Health in Greenfield, Mass., where she specializes in the treatment of incontinence, infertility, vulvovaginitis and menopause. She created and operates two continence treatment centers, one at Pioneer Women's Health and another at Grace Urological in Brattleboro, Vt. Carcio, who is a member of the ADVANCE for Nurse Practitioners editorial advisory board, is also an adjunct graduate nursing professor at the University of Massachusetts and is nearing completion of her PhD.  

References
1. Deger RB, Menzin AW, Mikuta JJ. The vaginal pessary: past and present. Postgraduate Obstetrics & Gynecology. 1993;13(18):1125-1129.

2. Emge LA, Durfee RB. Pelvic organ prolapse: four thousand years of treatment. Clin Obstet Gynecol. 1966;9:997.

3. Bergman A, Bhatia NN. The pessary test in women with urinary incontinence. Obstet Gynecol. 1985;65:220.

4. Sulak PJ, Kuehl TJ, Shull BL. Vaginal pessaries and their use in pelvic relaxation. Journal of Reproductive Medicine. 1993;38:12.

5. Vierea A, Larkins-Pettigrew M. Practical use of the pessary. Am Fam Physician. 2000;61:2719.

6. Miller DS. Contemporary use of the pessary. In: Sciarra JJ, Droegemueller W, eds. Gynecology and Obstetrics. Philadelphia, Pa.: J.B. Lippincott; 1992:1-12.