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Pessaries

19 December, 2018

 

We Pelvic Health Physios have a number of closed Facebook groups we belong to, where questions are asked and journal articles are disseminated about Women’s Health. This is great for us to network and learn from each other and if there are problematic patients who we are struggling with, we can throw the question out to the group and get some help. Recently there have been some more questions about pessaries.

Q: Any advice as to how to dispel the belief from some doctors – GPs, Obs and Gynaes and urogynaecologists -that pessaries are just for old ladies and not to be offered to young women to help them manage their prolapse?

Now this is an important issue to address and problem solve. Pessaries do come with some problems (eg. vaginal wall erosion, infection, the forgotten pessary, that a pessary just can’t stay in) but they can be life-transforming for a woman who is paralysed with terror about moving, let alone exercising, with her prolapse. Once we have fitted a pessary we give an extensive handout to the patient describing the precautions and problems that can occur; we ask the patient to sign that they understand they should get a new pessary every 12 months if they are wearing the pessary all the time; sign that they understand that they require a speculum check of the vagina from their GP or specialist doctor every 12 months to check for vaginal erosion; that they should be on vaginal oestrogen where possible to help plump up the tissues once menopausal and immediately remove the pessary if there is blood or smelly discharge or pain. The patients are taught self-management which is empowering for the patient. Then we say: “Go and exercise with gay abandon”.

Why wouldn’t there be a trend for doctors to encourage this wonderful, wonderful strategy?

Some gynaes have told us:‘It was glossed over in their training”.So it isn’t their go-to strategyAnd I can understand this. If you are training to be a surgeon it makes sense to concentrate on the complexities of surgery and that may fill virtually the whole training rather than the relatively less complex pessary fitting.

The belief was probably held by the trainer that pessaries were for old women (who were not sexually active and because of their age or other medical conditions were inoperable) so that information (some may say myth) was handed onto the next generation of doctors (surgeons).

It’s expensive to provide a pessary service. The cost of carrying the stock is huge. The purchase of the steriliser is a big outlay. Running the steriliser is expensive with a yearly service costing anything from $500 to $1500.

The biggest cost though is the time it takes to fit a pessary. It takes time because we have fitting kits and the patients get to go for a walk (with a fitting kit pessary in) to make sure the pessary doesn’t dislodge. My staff get to have 1 hour 15 minutes to do this – because we want to do it properly – and this is an impossible amount of time for a specialist to allocate I would imagine.

But we are in new times now- when surgical repairs are being researched more and those results (between 30-80% failure rate especially if there is levator avulsion / vaginal ballooning from a vaginal birth trauma) are being pondered; where a history of 10 years or more of vaginal mesh drama (many say catastrophe) has made the humble pessary start to make a comeback – after all pessaries have been around since the days of Hippocrates (you can read about it in this earlier blog I wrote)

I have been fitting pessaries since 2010 and keeping a register of them since 2011. I have had other staff who fit pessaries start working with me since 2015. We have recorded 470 patients in our register and so there maybe over 500 women who have had a pessary fitted (I had a year where I am not sure how many I fitted).

Some of those women have definitely gone on to have surgery.

Some of them will have stopped using their pessaries for different reasons.

But many of them have had their lives transformed.

There are now many other Pelvic Health Physios who are fitting pessaries – to female farmers in Dubbo, to weight lifters in Sydney, to runners in Perth -far and wide across the country. There are a lot of happy women thanks to their pessary.

Do they shout it from the rooftops?

Well some do, but most don’t. It’s like everything we Pelvic Health Physios do – it’s personal, private and most women keep their successes to themselves – which is entirely right. But sadly it means that the word is more difficult to get out to other women and many women are not knowing that a pessary is a valid, conservative option to try, in the plethora of conservative strategies that a Pelvic Health Physio can offer a woman who has prolapse (and other pelvic floor dysfunction), before surgery.

 

Dr Chris Barry   Dr Trish Neumann 

  

Taryn Hallum   Natalie McConochie 

The history of pessary fitting in Australia goes back to a lecture we had at the Continence Foundation of Australia’s National Conference in 2009 (I think) from a nurse practitioner from Canada who runs a pessary clinic in Canada and had done so successfully for 15 years. Dr Trish Neumann, a specialist Pelvic Health physio from Adelaide, was inspired to start a collaboration with Dr Chris Barry, a urogynaecologist in Adelaide, to come up with guidelines for pessary fitting by physiotherapists. There was months of hard work that was put in by that Committee (which also had another great Nurse Practitioner on it – Donna Coates) and soon the Pessary  Guidelines were born and Trish ran the first pessary workshop in 2010 which I attended. For the last 7 years, another great Pelvic Health Physio and Educator, Taryn Hallum (Women’s Health Training Institute) along with Natalie McConachie, has trained many more physios to fit pessaries.

This is truly spectacular. Thousands of women have been helped now as a result of this one lecture by Lesley Hanson.

Lesley Hanson

My point?

The physio in the Facebook group was asking how to talk to doctors about offering pessaries as an option for a woman with prolapse? How to educate the doctors that there are many physios who can fit pessaries?

My suggestion is share this far and wide.

Talk about pessaries on social media. We can talk about this stuff now. Vaginas, vulvas, prolapse, incontinence, constipation.

We are not in the Victorian times. Let’s stop being prim and proper about this. Disseminate information.

It. Changes. Women’s. Lives. 

 

6 Comments
  1. Dear Ms. Croft: Thanks for your interesting and very helpful post regarding pessaries. I have had one since 2015 and my Massachusetts gynecologist never mentioned changing it once per year. I have now moved to Florida and due to an irritation, my new gynecologist removed the pessary in October, 2018, established an Estrace regimen, and after the irritation was gone fitted me with a smaller pessary. I have experienced no irritation or problems since. However, she did not mention changing it every year either. After reading your recommendation about how important that is, I would like to ask my gynecologist to change it next year and wonder if you would mind sharing the specific reason(s) it is so important. Is it bacteria buildup on the pessary material? Many thanks for any additional information you can share,Florida Pessary user.

    • Hi and thanks for your comments
      You must have a rigid plastic pessary in as opposed to a silicone self managing pessary. These are usually checked (in Australia at least) every 6 months and taken out, washed and reinserted once the speculum check is completed. The silicone once deteriorate (at a microscopic level)- they often look fine to the naked eye but the plastic ones don’t need changing. But you would usually be checked in Australis every 6 months.

  2. Kathleen Nelson permalink

    Some women expel pessaries right away…and I tried 3 kinds. Is there any other alternative?

    • Kathleen yes that’s definitely an issue- actually getting a pessary to hold – there’s no guarantee that it will work. But there are many types of pessary- all I can say is keep persevering

  3. Great article Sue. A question I have often pondered and what an eloquent answer. I would love to be able to share with my patients some pessary success stories but alas they are usually behind closed doors and other health professionals are slow to get on board with them.

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