Tanaz R. Ferzandi
History of present illness
A 50-year-old postmenopausal woman presents to an urgent care clinic due to new-onset urinary incontinence following placement of a pessary for uterine prolapse. She recently went to her primary gynecologist in her hometown for a routine annual visit. At that time she reported a three-year history of a worsening “vaginal bulge” and was found to have grade 3 uterine prolapse per the Baden–Walker assessment scale [1]. A pessary was inserted and the patient noted relief of her pressure symptoms and improvement in constipation, but then shortly thereafter began noticing bothersome symptoms of urinary leakage, which was not an issue prior to the place- ment of her pessary. She now has complaints of urinary leak- age with cough, sneeze and when she tried to attend an exercise class. She has mild overactive bladder symptoms and nocturia, but she is not as bothered by these issues. She has no other medical problems and has had no prior surgeries.
Physical examination
General appearance:Well-developed woman in no acute distress
Vital signs:
Pulse: 67 beats/min
Blood pressure: 130/60 mmHg Respiratory rate: 16 breaths/min BMI: 24 kg/m2
Abdomen:Soft, nontender, nondistended, no palpable masses
Pelvic:
Normal external vulvar and vaginal tissue without any visible lesions
Vulvar atrophy is noted
#5 Ring with support pessary removed (Fig. 82.1) Negative empty supine stress test
Post-void residual is obtained with a straight catheter for 25 cc
Speculum exam: Atrophy noted, but no erosions or lesions
With maximum valsalva, the genital hiatus is 4 cm and the cervix is distal to the hymen by 2 cm. Both the anterior wall and posterior wall of the vagina protrude to but not beyond the hymenal ring (stage III pelvic organ prolapse or grade 3 uterine prolapse)
Bimanual exam: Uterus is normal sized, midline, and no adnexal masses appreciated
Rectovaginal exam: Fascial defect palpated along the posterior vagina, normal external
Anal sphincter tone and strength: No masses in the rectal vault
Laboratory studies:Urine dipstick is negative for leukesterase, nitrites, and blood
How would you manage this patient?
This patient has new-onset stress urinary incontinence that was unmasked with the reduction of her prolapse with the pessary.
Given the type of pessary that the patient had inserted, another
# 5 Ring with Support and Knob (Fig. 82.2) was inserted. The patient was offered surgical management of her prolapse, but she opted to continue with the new pessary given her lifestyle and that she was overall content with its use. She was instructed on how to insert, clean and replace her pessary. She was also prescribed vaginal estrogen cream (1 g per vagina, at night, 3 times weekly) to treat the vaginal atrophy. She returned to the clinic in a week to check on her symptoms and to assure
Fig. 82.1 Ring with Support.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
that the pessary was comfortable. She reported a 50% improve- ment in her incontinence symptoms and was pleased with the results as a means for conservative management of her prolapse.
Pelvic organ prolapse
Pelvic organ prolapse is common but the exact prevalence is difficult to ascertain due to many reasons, including the manner in which the studies were conducted, type of classifi- cation system used to quantify the prolapse, and the likelihood that many women do not report or seek help for the condition.
Pessaries are an excellent method of treatment for many patients, especially in those who desire to avoid surgery, and pessaries have been in use for centuries. In fact, Hippocrates (fifth century BC) commented on the use of a half pomegran- ate dipped in wine to reduce prolapse. Modern pessaries are made of inert silicone and come in several varieties [2].
To determine the right candidate for a pessary, multiple factors need to be assessed on an individual basis. This includes whether the patient has healthy vaginal epithelium, the ability of the patient to return for routine pessary exams, need for vaginal estrogen, current sexual function, ability to empty the bladder efficiently, and whether a patient might want to remove and insert the pessary herself. It is recom- mended to have the patient come in for afitting, and the pelvic organ prolapse quantification assessment can guide selection of a pessary [1]. The most commonly used pessaries are the Ring and Gellhorn (Fig. 82.3). The Gellhorn is usually reserved for those patients with more advanced prolapse and those who are no longer sexually active due to the difficulty associated with removal. After fitting the patient for a pessary, it is recommended she takes some time in the examination room and performs various maneuvers such as bending, squatting,
or jumping to ensure a comfortablefit and appropriate size. If the pessary is the correct size, it should be very comfortable to the patient. The patient is then asked to use the bathroom to assure that she can void, and simulate having a bowel move- ment (i.e. valsalva) to ascertain if they will expel the pessary.
The patient then returns one week later to assess overall function and for a speculum examination to assess the health of the vaginal tissue. In postmenopausal women, we highly recommend concomitant use of a vaginal estrogen cream or ring (the latter serves us very well as we can insert the ring for patients who might have difficulty self-administering the cream, and it will coincide with return visits, as we can replace the ring for them). For patients who use the ring, we place it proximal to the pessary. Patients present every three months to have the pessary removed, cleaned and the vaginal tissue inspected. It is very important to use a speculum and assess not only the lateral walls, but to rotate the speculum and inspect the anterior and posterior walls of the vagina for erosions/abrasions. If such are seen, we then proceed with a“pessary holiday” by having the patient discontinue use of the pessary for a period of time, usually one to three months, depending on extent of damage to the vaginal epithelium, to allow the vaginal epithelium to heal. More liberal use of the vaginal estrogen cream is advised during this time to promote healing. The patient then returns for an examination at the end of this period to ensure proper healing before reinitiating pessary use.
In patients who have concurrent incontinence, or present with such after placement of a pessary, we recommend usage of an incontinence ring pessary or one that has a“knob.”The knob is placed anteriorly behind the pubic bone to help with
Fig. 82.2 Ring with Knob and Support.
Fig. 82.3 Gellhorn.
stabilization of the hypermobile urethra. It is difficult to assess to what degree the knob is efficacious, but it’s a viable option to help prevent incontinence. In fact, we often warn patients that they might have leakage after the placement of a pessary due to occult incontinence. Symptoms of leakage are often thwarted by the acute angulation of the urethra caused by the prolapse.
It is thought that reduction of the prolapse with a pessary unmasks stress urinary incontinence since the angle of the urethra returns to a more normal plane. During the exam, the patient may also be evaluated with an“empty supine stress test.”This is a simple and inexpensive method to diagnose for stress urinary incontinence and potential intrinsic sphincter deficiency. With the patient having voided earlier, and while she’s in the dorsal lithotomy position, she is asked to cough. If she leaks, it is diagnostic of stress urinary incontinence with 98% positive predictive value [3]. For women who present with incontinence following a pessary placement it is also important to consider other causes of incontinence including urinary tract infections and urinary retention with overflow incontin- ence. For the patient above, she was evaluated for each of these with a urinalysis and a post-void residual urine assessment, respectively.
Long-term outcomes with pessary use were addressed in a couple of studies. The majority of patients who trial a pessary utilized it for over 5 years, with only minor complications (pain/discomfort 6.9%, excoriation or bleeding 3.2%, disim- paction or constipation 2%) [4]. In another retrospective study, over 14% had continuation of use over 14 years [5].
With regards to counseling for patients who might want to get
information regarding progression of prolapse, a recent study monitored 64 women (median follow-up 16 months) who chose expectant management by sequential pelvic organ pro- lapse quantification system (POP-Q) examinations. They noted that a change in leading edge greater than or equal to 2 cm was significant, and the leading edge ranged from–1.5 to +7 cm. Most of the women were stage II or III prolapse. No change in leading edge was found in 78%, while 19% had progression, and 3% had regression. On multivariate analysis, no variables were associated with change. In this study, 63% of women were satisfied and chose to continue with observation, while 38% chose a pessary or surgery [6].
Key teaching points
A pessary is an excellent method of treatment for pelvic organ prolapse, especially in those who desire to avoid surgery.
The most commonly used pessaries are the Ring and Gellhorn.
In patients who have concurrent incontinence, or present with such after placement of a pessary, the use of an incontinence ring pessary or one that has a“knob”may be beneficial.
For women who present with incontinence following a pessary placement it is also important to consider other causes of incontinence, including urinary tract infections and urinary retention with overflow incontinence.
References
1. American College of Obstetricians and Gynecologists. Pelvic organ prolapse.
Practice Bulletin, No. 85.Obstet Gynecol 2007;110:717–29.
2. Oliver R, Thakar R, Sultan AH. The history and usage of the vaginal pessary:
a review.Eur J Obstet Gynecol Reprod Biol2011;156:125–30.
3. Lobel RW, Sand PK. The empty supine stress test as a predictor of intrinsic urethral sphincter dysfunction.Obstet Gynecol1996;88(1):128–32.
4. Lone F, Thakar R, Sultan AH, Karamalis G. A 5-year prospective study of vaginal pessary use for pelvic organ prolapse.Int J Gynecol Obstet 2011;114:56–9.
5. Sarma S, Ying T, Moore K. Long-term vaginal ring pessary use:
discontinuation rates and adverse events.BJOG2009;116:1715–21.
6. Gilchrist AS, Campbell W, Steele H, et al.
Outcomes of observation as therapy for pelvic organ prolapse: A study in the natural history of pelvic organ prolapse.
Neurourol Urodyn2013;32(4):383–6.
Case 82: Incontinence in a 50-year-old woman after pessary placement