Contemporary Use of the Pessary
David Scott Miller
Table Of Contents
David Scott Miller, MD
The anatomy of the human female pelvis reflects two divergent evolutionary forces. A rigid, narrow platform is necessary for efficient bipedal locomotion, whereas a wide, flexible outlet is needed to accommodate the delivery of a well-developed neonate for propagation of the species. The compromise is a rigid, wide pelvic outlet with the abdominal contents restrained and contained by barriers of fascia and muscle that are stretched and often torn during birth, resulting in the defects of uterine prolapse and procidentia, rectocele, and cystocele. In an attempt to correct these deformities and alleviate the accompanying suffering, pessaries have been developed and refined over the centuries. In this chapter, the development of pessaries, the types of devices in common use, and their indications, management, complications, and contraindications are discussed.
The Egyptians were the first to describe prolapse of the genital organs. The pessary was a known treatment.1 The word pessary frequently appears in both Greek and Latin literature, but in most instances it refers to a mechanical device in no way like the modern one. It usually meant a tampon, a ball of wool or lint soaked in drugs. However, Hippocrates mentioned the use of half of a pomegranate to be introduced into the vagina in instances of prolapse. Soranus likewise suggested the use of this fruit as a pessary and reports that Diocles was in the habit of supporting a prolapsed uterus by the introduction of half of a pomegranate previously treated with vinegar.2 Aurelius Cornelius Celsus (27 B.C.-A.D. 50) wrote of the use of pessaries in De Medicina.3 A bronze cone-shaped vaginal pessary with a perforated circular plate at its widest end was found at Pompeii. Supposedly, a band was attached to these openings and tied around the body to keep the device in place.2
About A.D. 326, Oribasius discussed pessaries, which he considered singularly useful for diseases of the uterus. There were three types of tampons: the emollient, the astringent, and the aperient. The astringent tampons were used for prolapse and were made of drug-saturated pledgets of cotton tied to string. These were placed snugly against the cervix.2
Paulas Aegina around A.D. 600 was touted as the first male midwife. He also used astringent pessaries made of wool dipped in medicine; he applied these to the mouth of the womb to restrain the female discharge, contract the womb when it was open, and impel it upward when it was prolapsed.3
Trotula, the wife of Joannes Platearious, was the first recorded female practitioner of gynecology around A.D. 1050. She originated the use of a ball pessary that was made of strips of linen and filled the vagina in cases of prolapse.1 To complete the therapy, a T binder was applied. Caspar Stromayr of Lindau, Germany, recommended in 1559 that a sponge tightly rolled and bound with string, dipped in wax, and covered with oil or butter be substituted for a pomegranate as a pessary4 (Fig. 1 and Fig. 2).
Ambrose Pare, late in the 16th century, devised ingenious oval-shaped pessaries of hammered brass and waxed cork for uterine prolapse. He made an apparatus of gold, silver, or brass that was kept in place by a belt around the waist. He also designed pear-shaped and ring pessaries5 (Fig. 3). William Harvey was an exponent of the conservative school that treated prolapse with pessaries, replacement, and other such means unless carcinoma was present, when surgery was occasionally suggested. In his book, Anatomical Exercitations Concerning the Generation of Living Creatures (1653), he reported an enlarging and completely prolapsed uterus that contained a dead fetus.3
Hendrik Van Roonhuyse, born in 1622, was particularly interested in the diseases of women and made a remarkable contribution to 17th century gynecology when in 1663 he published Heelkonstige Aanmerkkingen Betreffende de Grebrecken der Vrouwen. This book often has been referred to as the first textbook on operative gynecology. Van Roonhuyse discussed the etiology and treatment of prolapse. An accepted procedure for treatment of prolapse was the use of cork with a hole in it to allow passage of discharges, plus wax pessaries or cork dipped in wax. He described one of the first complications and its resolution—his removal of one of these putrefied wax pessaries that had obstructed a patient's lochia.3 As noted in 1684 by Thomas Willis, “When at any time a sickness happens in a woman's body of an unusual manner so that its cause lies hid, and the curatory indication is altogether uncertain, presently we accuse the evil influence of the womb.”6
By the late 1700s, Thomas Simson, Professor of Medicine at the University of St. Andrew (Scotland), devised a metal spring that kept a cork ball pessary in place. Most pessaries had string attachments to facilitate removal. In instances of extensive perineal lacerations, pessaries were kept in place by T binders. These devices proved very unsatisfactory because friction injured the labia. 2 Conversely, John Leake had no use for pessaries, believing that rest and astringent applications were in every repect preferable to the use of those painful and indelicate instruments called pessaries. He advocated the use of sponges as pessaries to avoid vaginal wall injuries, which he noticed resulted from pessaries made of hard material. He extracted a pessary from the rectum of a patient at St. Thomas' Hospital.2 Mòrgagni recorded the autopsy of a woman with a pessary in situ.2 To avoid such complications, Jean Juville in 1783 introduced a soft rubber pessary. In devising this new type of pessary, Juville stated that it facilitated introduction by the patient. Juville's pessary resembled the contraceptive cup currently used. In the center of the cup was a perforated gold tip to permit the escape of cervical secretions. When he first introduced this new device, Juville was unable to state whether rubber was injurious to the vaginal tissue. Jean Astruc stated that the pessary had the same effect as a truss for a rupture. He believed that if the pessary were worn long enough and the patient grew fat, a cure would follow.2
Gynecologic faddism enjoyed its heyday throughout most of the 19th century. During the early decades, most of the ills of womankind were attributed to inflammations of the uterus. Toward the middle years, these views were supplanted by the Galenic doctrine that displacements of that organ were the principal cause of women's complaints. The pessary school of gynecology began to flourish. It was said that fortunes were to be made by two groups of gynecologists—those who inserted pessaries and those who removed them.7,8
Goodyear's discovery of the vulcanization of rubber was a boon to the purveyors and wearers of pessaries and greatly enhanced the popularity of the devices. Hugh Lenox Hodge, Professor of Gynecology at the University of Pennsylvania, was dissatisfied with the shapes of the existing pessaries. He set out to design a new one using Goodyear's newly patented material. The lever pessary was designed especially for cases of uterine retroversion. Hodge explained in 1860:
Albert Smith of Philadelphia later narrowed the anterior portion and widened the posterior end of the Hodge pessary.6
With the advent of asepsis and anesthesia, gynecologists' fascination with pessaries abated as uterine support deficiencies were addressed by surgery. Pessaries were used mainly for inoperable patients or as temporizing measures. Little progress was made in the development of new devices. Minor changes typically were made to existing pessaries and a new eponym attached. The most significant advance in the art and science of pessaries was the replacement of hard rubber by polystyrene plastics in the 1950s and recently by silicone-based materials.11
More than 200 different types of pessaries have been invented, but only a few are currently in clinical use.
The ring pessary in its modern version appears similar to a contraceptive diaphragm (Fig. 5I and Fig. 5J). It is useful in first- and second-degree uterine prolapse. The ring with the support membrane is beneficial for a mild cystocele accompanying the prolapse. This pessary is fitted like a contraceptive diaphragm. The length of the vaginal canal can be measured with the examining finger and the size of pessary approximated. The ring pessary is folded so that the arc points downward and is directed past the cervix into the posterior fornix.
The lever pessaries are variations on the design by Hodge.9 They are intended to treat uterine retroversion by posteriorly displacing the cervix and anteverting the uterus.11,12 The Smith pessary has a narrower anterior limb for application in a patient with a narrow pubic arch (Fig. 5A). The somewhat broader anterior limb of the Hodge pessary prevents the pessary from turning and precludes pressure on the urethra (Fig. 5B and Fig. 5C). The Risser pessary is a further modification, for an even flatter pubic arch13 (Fig. 5E). Although originally designed to treat uterine retroversion, these devices currently are used for the treatment of an incompetent cervix in pregnancy, for mild uterine prolapse with retroversion, and as a diagnostic maneuver in evaluation of patients with large cystoceles or urinary stress incontinence. The pessary is inserted by first manually elevating a retrodisplaced uterus. The pessary is then folded and pushed into the vagina by the index finger, pressing on the posterior bar until it is behind the cervix, with the anterior bar behind the pubic notch14 (Fig. 6 and Fig. 7).
The Gehrung pessary provides support in cases of cystocele and rectocele (Fig. 5D). It provides support to the anterior vaginal wall, with its lateral bars resting on the levator sling. These bars tend to flatten out a rectocele. Because of its unusual shape, most practitioners are unfamiliar with it and have difficulty inserting it. However, insertion is easily accomplished by introducing the lateral bars of the pessary over the perineum completely into the vagina while the device is on its side (Fig. 8). The pessary is then rotated so that the curved bars point with their convexity toward the anterior wall of the vagina14 (Fig. 9 and Fig. 10).
The Gellhorn pessary provides support of a third-degree uterine prolapse or procidentia (Fig. 5N, Fig. 5L, Fig. 5M, Fig. 5N, Fig. 5O and Fig. 5P).15 The cervix rests behind the flat base of the pessary, and the stem prevents turning the support within the vagina, making it possible to keep even a large prolapse in place by means of a comparatively small pessary. It requires a relatively capacious vagina so that the base is broad enough to rest above the levators. It is inserted by turning the disk portion parallel to the introitus; then the base is rotated over the perineal body and into position16 (Fig. 11).
Probably the most popular pessary in the past was the doughnut pessary and its modifications. It is simply a doughnut-shaped ring that is solid or can be inflated by a bulb and valve assembly (Fig. 5Q and Fig. 5R). It works by occluding the upper vagina to support a uterine prolapse. To remain in place, the mass of the inflated pessary must be greater than the defect in the levator sling. The Inflatoball pessary can be removed easily and replaced by a patient for vaginal hygiene.
An effective pessary in patients with third-degree prolapse—especially very elderly patients with complete procidentia, rectocele, or cystocele—is the cube pessary (Fig. 5K). On each of the six sides of the cube are suction cups that adhere to the vaginal walls. A cube pessary is often useful in a very elderly patient with significant atrophy and complete prolapse.17,18 However, this pessary is difficult for a patient to remove and thus requires close monitoring. It is inserted by merely compressing the cube and placing it as high up in the vagina as possible.
Neonatal Uterine Prolapse
Neonatal uterine prolapse is a rare condition. 19,20,21,22 Most cases occur in association with meningomyelocele or other defects of the central nervous system. It typically occurs during the first few days of life, presenting as a mass at the introitus. Satisfactory treatment has been reported using 1- to 2-cm doughnut-shaped pessaries constructed from small Penrose drains. These devices were applied for days to months and then removed. Prolapse did not recur.20,21,22,23
Prolapse in Pregnancy
Two hundred fifty-six cases of uterine prolapse during pregnancy have been reported, including eight patients who died of septicemia or uterine rupture.24,25,26,27,28 Fortunately, no fatalities have been reported since 1925. It occurs in multiparous patients who have noted a degree of pre-existent uterine prolapse that is often asymptomatic. However, the weight of the gravid uterus causes the uterine prolapse to descend farther. If prolapse is not treated early, the cervix becomes ulcerated and infected and undergoes hypertrophy to the extent that it continues to prolapse even as the uterus rises out of the pelvis. Complications have varied from minor cervical ulcerations and infection to uterine rupture with fetal and maternal fatalities. In their review of the literature, Piver and Spezia recommend prompt treatment with bed rest in Trendelenburg's position to reduce edema and allow reduction of the uterus. The infected cervix can be treated with local antiseptics. After reduction is accomplished, a large doughnut or lever pessary should be inserted and left in place until the onset of labor.24 Theirs and subsequent case reports of patients treated with pessaries have shown an excellent maternal and fetal outcome.24,25,26,27,28
Retrodisplacement of the uterus in early pregnancy occurs in 15% of pregnancies. It almost always is self-limited because the enlarging uterus rises into the abdomen. Incarceration occurs rarely when a retroverted pregnant uterus becomes entrapped in the sacral hollow, probably as a result of adhesions or endometriosis. The uterus presses against the rectum and fails to rise into the abdomen as it enlarges. Patients present after 12 weeks of gestation with pain and urinary and rectal complaints. Examination shows a posterior cul-de-sac mass with the cervix rotated anteriorly high up in the vagina behind the pubic symphysis, impinging on the bladder trigone.29 Gibbons and Paley reported that patients who were treated with uterine repositioning and pessary support before 15 weeks did well but that those beyond that gestation aborted despite treatment.30 The appropriate lever pessary, typically the Hodge, displaces the cervix posteriorly, anteverting the uterus and allowing it to rise out of the pelvis (see Fig. 4). It has been used successfully to treat mobilized incarceration and to prevent recurrences in subsequent pregnancies.30,31
Incompetent Cervix with Premature Labor
The diagnosis of incompetent cervical os as a cause of midtrimester pregnancy loss is difficult to document. Nonetheless, in this country, it usually is treated with an invasive surgical procedure fraught with well-described complications. The use of the pessary as a nonsurgical alternative to cervical cerclage is well reported but has not yet been accepted in the United States. Cross, of the Rotunda Hospital in Dublin, was the first to report the use of Bakelite ring pessaries in 13 patients with a history of only seven term deliveries in 54 pregnancies (13%) before treatment. After application of the pessary, the patients delivered 11 of 13 viable infants (85%).32 In the United States, Vitsky studied 21 patients with a pregnancy history of only 23% viable deliveries; this improved to 87% with the use of a Smith pessary.33,34,35 Oster and Javert later reported a similar experience in 29 patients using the Hodge pessary.36,37 Multiple European reports have confirmed these findings.38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53 In the United States, the Hodge pessary has been used successfully to treat cervical incompetence due to defective connective tissue in Ehlers-Danlos syndrome.54 The incompetent cervix points anteriorly in the axis of the vagina (Fig. 12). The lever pessary directs the cervix to point posteriorly, as in a normal pregnancy. Direct pressure on the cervical os is reduced and brought to bear on the lower uterine segment.36 Although a randomized prospective placebo-controlled study evaluating pessaries for the treatment of incompetent cervical os has yet to be accomplished, a randomized prospective study comparing cervical cerclage versus the Mayer ring pessary showed no difference in the efficacies of these treatments.50 A controlled study recently showed no increase in pathologic vaginal flora or puerperal febrile morbidity in patients who had a pessary in place during pregnancy versus a control group.47,49 It has never been shown that any treatment method affects the subsequent pregnancy outcome of women who have recurrent pregnancy losses.55,56,57,58 This recently was confirmed by Harger, who found that these patients had a 70% to 80% chance of a viable pregnancy regardless of whether a defect was identified or treated.59 In fact, two prospective randomized studies failed to show any significant advantage of cervical cerclage over no treatment in this group of patients.60,61 Further study of this problem clearly is required. Pending clarification, a pessary is certainly a less invasive treatment option.
Stress Urinary Incontinence
In the modern therapy of stress urinary incontinence, pessaries originally were used merely as platforms for electrodes to stimulate the pudendal nerve to strengthen pelvic muscles—an involuntary Kegel exercise.62,63 Richardson and colleagues elucidated the mechanism of paradoxical continence in patients with significant uterovaginal prolapse (procidentia).64 Using a doughnut pessary to replace the prolapse, the patients became incontinent. Urethrovesical pressure dynamic studies showed that the mechanism of continence in significant uterovaginal prolapse was urethral obstruction. Reducing the prolapse with a doughnut pessary could differentiate patients who also require urethrovesical neck suspension as part of their surgical treatment.64,65,66 The “doughnut” pessary merely replaces a prolapsed uterus but offers no support to the proximal urethra. The lever pessaries are applied behind the pubic arch and support the proximal urethra. Using detailed urodynamic studies, Bhatia and colleagues showed that Smith and Hodge pessaries promoted consistent and significant increases in urethral functional length and closing pressure without causing obstruction. These pessaries restored continence by stabilizing the urethra and urethrovesical junction to allow proper pressure transmission and actively increasing urethral resistance to the escape of urine under resting and stressful conditions. They proposed the use of the lever pessary as a simple prognostic test to identify patients with stress urinary incontinence that would benefit from urethrovesical neck suspension procedures.67,68,69,70 A recent study showed that a Hodge pessary with support was successful in preventing incontinence in exercising women.71 Lever pessaries are effective nonsurgical and nonpharmacologic options for the elderly woman with stress incontinence.72,73,74
Surgery, the most effective long-term therapy for uterovaginal prolapse, often cannot be immediately undertaken because of complications of the prolapse or underlying medical problems.15,75 Typical examples are patients who have procidentia and have developed cervical or vaginal decubiti surrounded by inflamed edematous but atrophic vaginal mucosa. This inflammation and ulceration make the necessary surgical maneuvers difficult and obviously increase the risk of local infection. Reduction of the prolapse and retention with an appropriately fitted pessary allow the inflammation to subside and ulcers to heal. A temporizing pessary allows for better vaginal hygiene than a vaginal pack. The application of systemic or topical estrogens in patients without contraindications promotes healing, matures vaginal epithelium, and subjectively improves surgical planes. Rarely, uterovaginal prolapse causes ureteral obstruction and hydronephrosis, and patients may present with flank pain and uremia. Pessary application has been shown to relieve obstruction and improve renal function so that patients can undergo surgical correction.76,77,78 The most common indication for the temporizing use of pessaries is to alleviate the suffering of a patient while she awaits medical and anesthesia clearance for surgery. Such use illustrates to the patient the relief she might expect from the operation.15
Poor Operative Risk Patients
The most common use for pessaries in modern gynecology has been for the treatment of press continence uterovaginal prolapse in patients deemed to be a poor risk for a vaginal procedure.72,73,74,79,80,81,82,83 The advent of modern monitoring and regional anesthesia techniques should limit the number of these patients. If necessary, colpocleisis can be done under local anesthesia; because it is in this group of patients—the aged, the frail, and the disabled—that the complications of a pessary are most often encountered. These patients, deemed to have a limited life expectancy, often live long enough to develop embedment, incarceration, and, rarely, fistulization of their poorly fitted, infrequently monitored, or forgotten pessaries.64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94 However, with proper care as outlined subsequently, uterovaginal deformities can be supported and suffering alleviated by pessaries in this poor-risk group.
Selecting a Pessary
Selecting the most appropriate pessary requires an understanding of the devices and their indications.79,80 However, the pessary should be fitted to the patient. Different devices often are used to treat the same process in different patients. Those with uterine prolapse should be fitted first with a ring. The Gellhorn is also useful if the patient has an intact perineal body.15 If results are less than satisfactory, the doughnut or cube may be used in patients with complete procidentia or poor perineal bodies. Stress urinary incontinence with or without prolapse is best approached with one of the lever pessaries. Symptomatic cystocele and rectocele are well supported by the Gehrung pessary. Prolapse of the vagina after hysterectomy usually is best treated with a doughnut or cube pessary.
Most pessaries currently on the market are made of inert polystyrene plastics or silicone rubber.11 Only these inert materials should be used. Old Bakelite or hard rubber pessaries should be discarded.
Fitting a Pessary
In general, the largest pessary that a patient can comfortably accommodate should be fitted. Ring and lever pessaries should fit snugly behind the pubic symphysis and posterior to the cervix. As when fitting a contraceptive diaphragm, the examiner's finger should easily pass between the vagina and the circumference of the pessary. After the pessary has been inserted, separate the labia; have the patient perform a Valsalva's maneuver. A properly fitted pessary descends to where the lower bar is visible and then ascends with relaxation.13 The patient should be able to stand, sit, squat, urinate, and defecate comfortably without dislodging the device. Coitus is possible with the ring, lever, and Gehrung pessaries in place.13,79,80
Physicians must consider a patient as being under their active care as long as she wears the device. The patient and her family should be instructed about the management plan with the pessary. After placement of the pessary, the patient should return in 1 week for re-evaluation consisting of palpation of the pessary in place; removing it; inspecting the vagina for excoriation, laceration, or ulceration; cleaning and inspecting the pessary; and refitting it. These maneuvers should occur subsequently at 1 month and then every 3 months. Although most pessaries are made of inert materials, they still are foreign bodies, and physicians placing a pessary must assume responsibility for it and assure themselves of the patient's continued follow-up. More dexterous and highly motivated patients may remove the pessary at night and replace it on arising. This usually can be accomplished only by women in early pregnancy or those awaiting corrective surgery. A patient who is a poor operative risk is likely to wear the pessary for the rest of her life and usually is not capable of removing and replacing the device. Thus, a physician must assume responsibility for maintaining the device with adequate follow-up to avoid complications. Patients without contraindications should be treated with systemic or topical estrogen therapy, which matures the vaginal epithelium, increases the pliability of submucosal connective tissue, and improves perineal muscular tone. These patients often require resizing of their pessaries.
The most common complaint of patients wearing pessaries is an increase in vaginal discharge and odor. Cytologic atypia in the form of severe inflammatory changes and prominent superficial maturation of squamous cells, atypical metaplasia, on a background of superficial squamous maturation have been reported on vaginal cytology.95 These complaints usually are resolved by proper sizing and fitting of the pessary and the use of estrogen therapy. Dilute vinegar or hydrogen peroxide douches also provide relief. Poorly fitted or neglected pessaries can ulcerate the walls of the vagina or become embedded.86 Ulceration should be managed by pessary removal with treatment of any infection and topical sucralfate, a basic aluminum salt of sucrose octasulfate that binds preferentially to ulcerated areas and promotes healing.96 General anesthesia and surgical procedures have been required to remove embedded pessaries.84,86,87,88,91,93 In the heyday of pessaries, a pessariotome was used to fracture and extract these devices, thus obviating the advantage of pessaries in patients who are supposedly poor operative risks. Incarceration can occur when the cervix and uterus or intestines herniate through the center of a poorly fitted ring pessary and become strangulated.85,93 Patients with embedded or incarcerated pessaries sometimes can have them removed on an outpatient basis, using improved vaginal hygienic measures and topical estrogens to mature epithelium and diminish inflammation.89 Surprisingly, fistula formation secondary to pessaries is quite unusual.2,86,90,93 Uncontrolled studies of vaginal cancer implicated pessaries as an etiologic factor.86,97 This cause has not been confirmed in population-based studies.98,99 Because physical contact or irritation has never been shown to cause any cancer, the possible relationship between pessaries and vaginal cancer may have been due to the composition of the devices rather than their mere presence.
The contraindications to pessary placement include primary vaginitis, active pelvic inflammatory disease, endometriosis, a noncompliant patient, and lack of assured follow-up.