Author Corrected: 19th Sep 2013, Accepted for Publication: 8th Nov 2013
Introduction
Pessaries are the standard nonsurgical treatment for Pelvic Organ Prolapse [1] .Throughout history various vaginal devices and materials for prolapse have been described including cloth, wood, wax, metal, ivory, bone, sponge and cork [1]. Now pessaries are usually made of silicone or inert plastic and they are safe and simple to manage [1]. Pessary is indicated in a woman who is unfit for sugery or is a high risk for surgery on account of some medical disorders [2]. It is indicated in a young woman planning a pregnancy, during early pregnancy, puerperium and temporary use while clearing infection and decubitus ulcer [2]. A pessary does not cure prolapse, it merely holds up the tissues [3]. Survey demonstrates that 87% to 98% of gynaecologists and/or urogynecologists prescribe pessaries in their practice [4]. Of all the pessaries the two most commonly used and studied devices are the ring and Gellhorn pessaries [1]. A patient must be an active particiant in the treatment decision to use a pessary. Its success will depend upon her ability to care for the pessary either alone or with the assistance of a caretaker and her willingness and availability to come for subsequent evaluations [1].Serious complications such as erosions into adjacent organs are rare with proper use and usually result only after years of neglect [1].
Case report
A 65 year old woman came to our OPD with history of something inserted for uterine prolapse 30 years ago and willing for the definitive treatment now. She didn’t had any complaint of foul smelling discharge or blood stained discharge or any difficulty in urination and defecation. She was Para [7] and all deliveries were conducted at home by dais. Her last childbirth was 35 years back. She didn’t have any medical disorder. There was history of tubectomy around 35 years back. On examination patient was fairly built and there was no pallor. On per speculum examination a white colour pessary was seen which on both lateral sides was covered by vaginal epithelium. On examining further a loop like structure was formed by the vaginal epithelium over the lateral ends of pessary. After due fitness, patient was taken under short general anaesthesia for removal of the pessary. The vaginal outgrowths were cut by cautery on either side and the pessary was easily removed. There was raw area left but no active bleeding. Patient was sent home with antibiotics for 5 days and called after 15 days for vaginal hysterectomy. On examination there was very small raw area left and the rest healed. Patient underwent Vaginal hysterectomy with Pelvic floor repair and was discharged on postoperative day [7].
Fig 1: Pessary is visible during examination
Fig 2: Cauterization to remove epithelial lining
Fig 3: After cutting vaginal band pessary was removed
Discussion
Vaginal pessaries are devices of varying composition (rubber, clear plastic, silicone, or soft plastic with internal mouldable steel reinforcement) that serve to reposition and support prolapse genitourinary organs [5]. Now-a-days ring pessary made of inert plastic or silicone is the most commonly used pessary. Two broad categories of pessary exist: support and space-filling pessaries. The supportive pessaries were defined as those derived by a spring mechanism(ring, Gehrung, lever-type pessaries) that rests in the posterior fornix and against the posterior aspect of the symphysis pubis. Space filling pessaries were defined as supported by the creation of suction between the pessary and the vaginal walls (eg. Cube) or by providing a diameter larger than the genital hiatus (Donut, Inflatoball, Shaatz) or by both mechanism (Gellhorn) [4]
Although surgery is the definitive treatment for severe uterine prolapse, pessaries can give satisfactory results in women who wish or need to avoid surgery [6]. Various complications have been reported due to forgotten pessaries. Most commonly a discharge and odor develop with continued wearing of a vaginal pessary [4]. In a study by Ainaif and Drutz [7] bacterial vaginosis was found four times more commonly in pessary users. Mucosal abrasions and erosions of the vagina and/or cervix are more common with cube and Gellhorn pessaries [4]. They are also more likely in patients who do not remove and reinsert their own pessary, as well as women with untreated vaginal atrophy. Many serious complications like vesicovaginal fistula [ 8], rectovaginal fistula [9], Intestinal obstruction [10], small bowel prolapse and incarceration [11], hydronephrosis and urosepsis [12,13] and vaginal cancer [14] have been reported but are rare and have been noticed in cases of neglected or forgotten pessaries.
Funding: Nil, Conflict of interest: Nil
Permission from IRB: Yes
References
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