The Potential of Pessaries

Mentioning the word ‘pessary’ as a treatment option for pelvic organ prolapse (POP) usually brings about the inevitable ‘what’s a pessary?’ query. The use of pessaries to treat female POP dates back to before Hippocrates when honey, hot oil and fumes were used along with various sizes of pomegranates to stem organ descent. Today’s pessaries are more user friendly, made of non-reactive silicone and come in a range of types and sizes.  How few realise the rate of POP in childbearing women is 50% and maybe even higher as not all women seek help when symptoms appear.

The use of pessaries in Australia is gaining more traction as continence nurses and women’s health physiotherapists attend evidenced based practical workshops. Gynaecologists traditionally complete their pessary traineeship as part of the 4-5 year training.  They typically fit pessaries for older women who are unsuitable for surgery or waiting for surgery, post partum mums or when specifically requested.

Women who’ve given birth with interventions or tearing have a higher risk of developing POP (lower risk with an elective caesarean birth). Some women are able to remodel their collagen with high quality type 1-collagen fibres and avoid prolapse following childbirth. Research shows women with POP have a higher concentration of weaker type 3 -collagen fibres in pelvic floor muscles and supports. They also have more varicose veins, abdominal striae, and joint hyper-mobility and are prone to hernias. These conditions should be ‘red flags’ signalling an increased risk of future POP in postpartum mums. Abdominal muscle separations, umbilical hernias, incontinence and back pain are also associated with POP in menopausal women.

Possible uses for pessaries

  • During pregnancy for women with pelvic heaviness, pelvic girdle pain, incompetent cervix and women at risk of pre term birth due to a shortened cervix and with a multiple pregnancy.
  • Pelvic organ support to promote repair following tears, the use of forceps or suction during birth. Most new mums have ongoing physical demands with home activities and lifting boisterous toddlers.
  • Women with chronic chest disease or allergic sneezing – again most important post partum and after menopause.
  • Those in the military or whose work is physically demanding (nurses, factory and child care workers).
  • Sports women with regular increases of intra abdominal pressure.
  • Runners who return to running soon after childbirth or surgery (despite advice to the contrary).
  • Childbearing women of all ages who attend gyms and challenging exercise classes.
  • Those who fail repair surgery (30%).

The likelihood of a successful fitting is reduced with

  • Prior hysterectomy or POP surgery
  • Wide vaginal opening
  • Short vaginal length
  • Severe posterior vaginal wall prolapse
  • Prior stress incontinence

Women who are unsuitable for a pessary include those with

  • Active vaginal infection
  • Pelvic inflammatory disease
  • Undiagnosed vaginal bleeding
  • Not willing to attend follow up sessions

Every prolapse is different and pessary retention is affected by

  • Scarring from previous surgery
  • Lack of perineal support (area between the back of the vagina and the anus)
  • Weak or detached levator ani muscles. The pessary requires a muscular base of support from underneath to be retained
  • The shape of the vagina – a large posterior vaginal wall prolapse can make pessary retention difficult
  • When mesh has been surgically implanted, a pessary should not be used as it promotes vaginal wall mesh erosion
  • The presence of a large pelvic mass (or several) contributes to POP and may be missed as a possible cause

Lifetime advice to prevent POP progression  

  • Resolve constipation issues. When dietary changes and bulking agents are not sufficient, osmotic agents (eg. Movicol) are added for strain free emptying.
  • Look at nutritional support for muscles and collagen especially with IBS and autoimmune deficiencies.
  • Stop heavy lifting!
  • Maintain a healthy weight to reduce pressure on the pelvic organs and muscles.
  • Quit smoking (smokers have poorer tissue quality).
  • Improve your posture to switch on pelvic floor and core muscles – they switch off when slumping.
  • Stop sitting so much – walk, climb stairs, move and stretch.
  • Take action – keep the levators (PFMs) strong to support the genital and levator hiatus and prevent pelvic organ descent. http://www.fysioterapeuten.no/fys/xp/pub/mx/filer/1210_Cap_525987.pdf
  • Resolve allergic sneezing/coughing early.
  • Local vaginal oestrogen when combined with PFXs improves early stage prolapse. Hormonal changes with menopause leave women more prone to POP.
  • Think twice about how you exercise. Women with ‘red flag’ signs and weaker type 3 collagen are advised to avoid heavy training with martial arts, jumping and landing sports, kick boxing, power lifting and challenging gym routines.
  • Follow the pelvic friendly exercise guidelines set out below.

Not all women are interested in the option of using a pessary and may opt for surgical prolapse repair. An anatomically correct surgical fixation doesn’t always guarantee long lasting results. Most surgery has a limited life and repeat/further procedures are common with both mesh fixation and tissue repair. Surgery has no guarantees against developing other problems (mesh erosion, painful sex, further prolapse, bladder urgency). The lifestyle advice above applies equally to women who undergo POP surgical repair.

For women who are suitable candidates and happy to manage their pessary and return for regular 3 – 4 monthly checks, this is an ideal first choice treatment.  Suitable women of varying ages and occupations find pessary support relieves their symptoms and prevents POP progression. When combined with effective PFM strength exercises (for weak muscles) studies show a narrowing of the levator hiatus (a wider hiatus is associated with organ descent).

Do pessaries have a role in supporting pelvic organs in professional sports women, regular exercisers, manual workers and those with chest disease, multiple pregnancies, recently given birth or with early symptoms of POP? Maybe women with ‘red flag’ signs for POP should be advised of their potential risk and offered a pessary as a preventive treatment measure. Only using pessaries after the vaginal walls have herniated is not realising the full potential of this silicone device. Visit a specialist or women’s health physio to determine your risk and present POP status. My book, Hold It Mama, contains a section on self-assessment of POP for women who feel comfortable with self-examination.

If you’re in the UK a new supplier has a large range of pessaries available for POP control during pregnancy through to senior years.

http://candgmedicare.com/products/pessaries-for-prolapse

Michelle’s story

The following story by Michelle on how she is dealing with giving up her favourite sport due to pelvic organ prolapse is a timely read for women who engage in high level sporting activities.

http://pelvicfloor.wordpress.com/2012/10/08/329

 

Mary O'Dwyer
Women's Health Physiotherapist
Oct 2012