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The forgotten pessary

10 November, 2019

I love pessaries for prolapse management. I wear a pessary for my own prolapse (perhaps oversharing a bit there) and fitting pessaries have been a great adjunct to all the other things (pelvic floor muscle training, engaging your PF muscles prior to increases in intra-abdominal pressure, lifestyle changes, excellent bowel management -correct position, defaecation dynamics and a Goldilocks consistency bowel motion – not too soft, not too hard, but just right) that we pelvic health physios teach to patients to empower them to keep everything where it should be while they are exercising or to support their prolapse.

There has been an explosion of talk on social media about pessaries in recent times. The beauty of that is that whereas only a couple of years ago barely anyone nobody knew what a pessary was, now every patient who has prolapse seems to have read about them already and they are asking would a pessary help them? The problem with that is that sometimes the girls who may benefit most from wearing a pessary, because they have suffered a serious muscle injury at childbirth (called levator avulsion), are the ones who can be difficult to fit with a pessary because of that significant injury, but it is definitely worth trying.

Illustration showing a levator avulsion injury

It can take multiple attempts with different styles/sizes of pessaries and this can be frustrating and disappointing for the patients. Persistence and perseverance is important with pessaries. Sometimes if you wear one type of pessary for a while and you are doing all those treatment strategies I outlined above, the prolapse can actually improve sufficiently to then mean a less bulky pessary or smaller sized pessary can be fitted.

But a warning: Pessaries need to be taken seriously.

There are rules that need to be adhered to. You need to follow the instructions of your treating pelvic health physiotherapist.

  • These include regularly taking the pessary out to rest the vaginal tissue if you have been fitted with a silicone self-managing pessary. The length of time depends on the type of pessary and the status of the patient’s vaginal tissue. For some women it may be every night; others every second night; some every seven nights and for the Gynaecologic pessary – they have just received TGA approval to be left in for 28 days before needing removal.
  • The pessary needs to be washed once it is removed in a liquid soap and dried and stored in some type of plastic container with a lid while it is out (we have had a spate recently of dogs discovering the pessary on a side table and chewing it to bits – which is definitely not good for the dog if they ingest it and is an expensive toy for the dog).
  • The pessary must be replaced every 12 months (this is the manufacturer’s advice and must be followed).
  • If the patient has self-referred rather than being sent by a medical practitioner, they need to see their GP for a speculum check and bi-manual examination as soon as possible after being fitted with a pessary and return yearly to their GP for a speculum check.
  • They must return for an appointment with their treating physio at between 2 weeks to 4 weeks after fitting to make sure all is going well and then yearly to get their replacement pessary and a check of their muscles, bowels, bladder function and general exercise programme.
  • It is important to continue with all the conservative strategies as mentioned above (especially pelvic floor muscle training and the knack so you maintain good strength in your muscles, especially if you eventually have to have surgery).
  • While it can be normal that the pessary causes increased vaginal discharge, you must visit your GP if there is bloody discharge (obviously not if it is a period) or smelly discharge as there may be an infection (bacterial vaginosis).
  • If you are menopausal you should discuss the use of local oestrogen with your GP as the risk of vaginal tissue erosion is increased with a pessary (which is why you require a regular yearly speculum check with your GP or a gynaecologist or urogynaecologist).
  • At our practice we get you to read our instruction sheet explaining all about the pessary and with all the above precautions and then get you to sign the form saying you understand about some critical factors (the new pessary 12 monthly, the speculum check 12 monthly and seeing your GP if there is blood or smelly discharge) and you will stick to those rules.
  • We also keep a log of all pessaries that we fit at the practice. We now attempt to audit the log every year to help our patients remember to come back and to remember to get a new one yearly. This is why you may get a call from our secretaries prompting you to return as there can be some significant issues if you don’t.

When a pessary fits well, it can be very easy to forget about it and it is for this reason that I have written this blog. The forgotten pessary is concerning. This is one reason why a patient who has dementia can only be fitted with a pessary if they have a designated carer who is taking them to a doctor 4-6 monthly for a pessary check, removal, wash, speculum check and re-insertion. This type of pessary is a PVC one (rigid pessary) and can stay in for longer periods of time and not usually removed by the patient (some younger women are able to self-manage a rigid pessary themselves and therefore it can be taken out and washed in a similar manner to the silicone ones).

Lately some incidents with pessaries have prompted me to write this blog.

The first one involves a lady who had her first pessary fitted in 2011 and who returned in 2014 for her next replacement one (but still had her old one at home). She unfortunately went on for the next few years using the pessary, not taking it in and out as often as she should have and forgetting about the important rules (this was before we instituted a regular audit). Sometime in these ensuing years this lady has found the original pessary and thought she didn’t have a pessary in and put this pessary in. Recently the patient rang up needing an urgent appointment because she felt uncomfortable and thought her pessary was no longer holding her prolapse, as she had heaviness, discomfort and drag. I was overseas at the time and despite there being other physios at my practice who could see her, she elected to wait for me to return. By the time I saw her, she no longer had the severe discomfort but definitely knew she needed a new pessary so arrived at the appointment.

After a chat about her history (and then a reminder about how important it was in future to definitely come yearly to get a new pessary), I examined her and found she actually had two pessaries in. The drag and heaviness she had experienced was probably an episode of bacterial vaginosis, which her body had been able to sort out itself (well done body), because those symptoms had completely resolved. We were both pretty shocked and I made her an urgent appointment at her GP who performed a speculum check and thank goodness gave her the all clear. This can so easily happen because a good fitting pessary can’t be felt and is too easily forgotten sometimes! I told her that I would like to write a blog about this because it would be a good learning blog for other patients and she consented to me telling this story.

The second event was a GP rang asking me to see a patient who had a cube pessary in, which had been fitted by a doctor, but the patient had not been removing it at all, had not returned for a new one and it was now disintegrating. The GP removed the pessary, the lady is starting on local oestrogen and then in a few weeks time she will be coming to be fitted for a new pessary and perhaps a different type of pessary from a cube.

So the moral of the story?

Take your pessary seriously.

Be vigilant about the rules.

Be aware of how long you have had your pessary in and how long you have owned it.

See the practitioner who inserted the pessary yearly for renewal and a revision of all the important conservative strategies and have a yearly speculum check with your GP or specialist.

Put reminders in your phone and a good idea can even be gradually moving the date of your renewal closer towards your birthday so you can more easily remember it if that is a problem for you.

And here are some reminders of what a pessary may allow you to do exercise wise.

Sue hiking at The Matterhorn Paradise Glacier Trail 2019

  

Yoga class at my old studio  Jane Cannan finishing her first marathon

Photos kindly supplied by Nadine Brown, Pelvic Health Physio who loves boxing

 

 

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