Contemporary Use of the Pessary

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Contemporary Use of the Pessary

Indications - Fitting Instructions

Milex Products, Inc.Chicago, Illinois 60634-1403

Copyright August 2002 All Rights Reserved

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Outline

Historical perspective

Prevalence of prolapse

Staging

Types of pessaries

Practical care of the pessary

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Historical perspective

Hippocratespomegranate

A.D. leg binding Astringents

David Scott Miller, MDContemporary Use of the PessaryObstetrics and GynecologyVol. 1, Chapter 39, January 1991

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Historical perspective

1500’svaginal hysterectomy

de Carpi--tied string around prolapsed uterus

1800’suterine malposition

HodgeSmithRisser

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Uses of Pessaries

Genital Prolapse Uterine Vaginal Rectal Bladder

Urinary Stress IncontinenceMixed IncontinenceCervical IncompetenceRetrodisplacement

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Diagnostic Use of Pessaries

Dynamic testing – illustrates urethral and bladder function

Predictor of Bladder Function After Pelvic Surgery???

Linda Brubaker, Rush Medical College

Now Professor and Fellowship Director

Female Pelvic Medicine and Reconstructive Surgery

Loyola University Medical Center, Chicago, IL)

Poster Presentation, October 1996, New Orleans

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Types of Prolapse

Uterine

Vaginal

Cystocele

Rectocele

Enterocele

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Nine Measurement Points for Pelvic Organ Prolapse Quantification (POP-Q)

Aa Position of distal anterior vaginal wall, 3cm proximal to the external urethral meatus

Ba The most distal portion of the remaining anterior vaginal

wall above point AaPoint at anterior vaginal

C The most distal edge of the cervix or vaginal cuff

D The position of the posterior fornix

Bp, Ap The most distal position of the posterior vagina; wall above point Ap

gH The genital hiatus

pb The perineal body

tvl The total vaginal length

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Ordinal Staging of Pelvic Organ Prolapse

StageLeading edge of Prolapse: Location of the Most Distal Point of the Anterior or Posterior Vaginal Wall

(any points Aa, Ap, Ba, Bp)

Leading Edge of Prolapse: Location of Apex of Vagina or Cervix

(Value of Point C or D)

0No prolapse: All points are 3 cm above the hymen (value=-3)

No prolapse: Apex of cervix is at a position above the hymen that equals to or is within +/- 2 cm of vaginal length (value </= (tvl-2))

IAll points are more than 1 cm above hymen (value<-1)

IIMaximal prolapse point protrudes to or beyond 1 cm above hymen but not more than 1 cm below hymen (value >-1 to <+1)

IIIMaximal prolapse point protrudes beyond 1 cm above hymen but less than 2 cm less than the total vaginal length. (value >+1 but <+(tvl-2))

IVMaximal prolapse point protrudes the length of the vagina (2 cm) beyond the hymen. Complete eversion of the vagina +/- cervix ([value >/= + [tvl-2])

tvl=total vaginal length

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Vaginal Prolapse

Anterior or Posterior Wall Prolapse

Results in:CystoceleRectoceleEnterocele

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Cystocele

Prolapse of Bladder and Anterior Vaginal Wall

Incomplete Emptying of Bladder

Can Cause UTI

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Rectocele

Prolapse of Rectum and Posterior Vaginal Wall

Incomplete Rectal Emptying

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Enterocele

Herniation of Small Bowel into Upper Posterior Vaginal Wall

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Symptoms of Prolapse

1st and 2nd DegreeLower back painPelvic Pressure and HeavinessDifficulty Controlling Urine and StoolUrinary Urgency

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Symptoms of Prolapse

3rd and 4th Degree ProlapseBlockage of Bladder NeckUrinary Retention Increased Urinary Stress IncontinencePalpable Prolapse Incomplete Emptying of Bowels

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Risk Factors - Prolapse

Childbirth

Repetitive Bearing Down

Heavy Lifting or Coughing

Family History of Prolapse

Hysterectomy

Pelvic Surgery or Trauma

Menopause – Endopelvic facia failure

Obesity

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Advantages of Silicone Pessaries

Silicone has longer use-Life

Silicone can be autoclaved

Silicone does not absorb secretions and odors

Silicone is an inert material

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Uses of Pessaries

Uterine Prolapse

Procidentia

Cystocele, Rectocele, Urethrocele

Urinary Stress Incontinence

Incompetent Cervix

Retroverted Uterus

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Pessaries for Uterine Prolapse

Ring with or without Support

Shaatz

Regula

11stst and 2 and 2ndnd Degree Degree ProlapseProlapse

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Ring without Support

1st and 2nd degree prolapse

Posterior Fornix to the Pubic Notch

Fitting

Removal

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Ring without SupportFitting and Removal

Posterior Fornix to the Pubic Notch

Insertion Fold and insert Make 1/4 turn

Proper Removal1/4 turnFeel for notchFold and pull down

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Ring with SupportFitting and Removal

1st and 2nd degree

prolapse complicated

by mild cystocele

Posterior Fornix to the

Pubic Notch

Fitting

Removal

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Ring with SupportFitting and Removal

Posterior Fornix to the Pubic Notch InsertionFold and insertMake 1/4 turn

Removal1/4 turn feel for notch and foldand pull down

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ShaatzFits between the Levator Ani Muscles

Fold and insert

Removal - pull down with exam finger and remove

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Regula

Unique design helps prevent expulsion

Legs spread with pressure on arch

Indicated for 1st and 2nd degree uterine prolapse

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RegulaFitting and Removal

Fold pessary by bringing heels together to insert and remove

Arch is positioned so prolapse rests behind arch

Flanging of heels helps prevent expulsion

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Pessaries for Uterine Prolapse

3rd and Complete ProcidentiaDonut

Cube

Gellhorn

Inflatoball

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Donut

The Donut pessary is very effective for 3rd degree prolapse.

The Donut fits by filling the Vaginal Vault and supporting the prolapse.

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Inflatoball

The Inflatoball pessary works well for 3rd degree prolapse.

This pessary is latex rubber.

Must remove daily.

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InflatoballFitting and Removal

Squeeze and insert

Pump until firm

Over inflation causes bulge

Secure tubing inside vaginal vault

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CubeFor 3rd degree prolapse when all others will not be retained.Maintained by suction – can cause vaginal erosion if not removed as directed.Do Not Pull on CordAvailable with holes Bulk not suction

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CubeFitting and Removal

Squeeze and insert

Break suction

Compress to remove

Remove daily. May cause vaginal erosion if not removed

as directed.

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Tandem-Cube

Last Resort

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Tandem CubeFitting and Removal

Trimo San on leading edge

Larger size pessary inserted first

Held by suction

Remove daily. May cause vaginal erosion if not

removed as directed.

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Gellhorn

Three Designs: Silicone Flexible Silicone 95% Rigid

Levator Ani Muscles

Cervix rests behind disk portion of pessary

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GellhornFitting and Removal

Trimo San on leading edge

Hold parallel to introitus

Barber pole twist

Available with short stemApproximately ½ inch shorter

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Pessaries Urinary Stress Incontinence

Incontinence RingRing with (and without) Support and KnobIncontinence Dish with and without SupportHodge with and without SupportHodge with and without Support and KnobGehrung with Knob

Urinary Stress Urinary Stress Incontinence and/or 1Incontinence and/or 1stst

and 2and 2ndnd Degree Prolapse Degree Prolapse

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A Word about Mixed Incontinence

Best treated by first correcting the anatomical deficiencies causing the SUI.

The same anatomic deficiencies causing the SUI are often creating the urgency too.

Treat the SUI first – 70 percent cure rate for both SUI and Urge.

Rodney Appell, MDProfessor of Female Urology and Void Dysfunction, Baylor College of MedicineSurgical Therapies Favored by Urologists – SlingAmerican Urology Association Annual Meeting,June 2001 Anaheim, Ca

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Why Treat Mixed Incontinence with Pessaries?

Pessary is good diagnostic tool – urodynamic studies costly.

Incontinence pessaries manually support and stabilize the urethrovesical junction which the vaginal sling repair does surgically

Limiting the use of drugs for mixed incontinence saves the patient money and avoids side effects (dry mouth, constipation, etc.) and serious drug interactions.

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Incontinence Ring

Stabilizes urethrovesical junction

Increases closure pressure

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Incontinence RingFitting and Removal

Posterior Fornix to the Pubic Notch.

This pessary is effective for a patient who may have incontinence during exercise.

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Ring with Support and Knob

Stabilizes urethrovesical junction

Supports a mild uterine prolapse complicated by a mild cystocele.

Increases closure pressure

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Incontinence Dish

Stabilizes urethrovesical junctionIncreases closure pressureStress Incontinence. Mild Prolapse.

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Incontinence DishFitting and Removal

Posterior Fornix to the Pubic Notch.

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Incontinence Dish with Support

Urinary Incontinence with 1st to 2nd degree prolapse complicated by a mild cystocele

Increases closure pressure

Stabilizes urethrovesical junction

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Gehrung with Knob

The Gehrung supports a cystocele and thins out a rectocele.

The knob stabilizes urethrovesical junction

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Pessaries Cystocele and Rectocele

GehrungGehrung with KnobHodge with SupportRing with Support and KnobRing with SupportIncontinence Dish with Support

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Pessaries Lever Pessaries

Hodge with Support

Hodge without Support

Risser

Smith

Incompetent Cervix Incompetent Cervix RetrodisplacementRetrodisplacement

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Incompetent CervixLever (Hodge) pessarySecures the axis of the cervix in a posterior plane83% successful in several studies of women at risk of premature cervical dilationInsert at 14 weeks; remove at 38 weeksCerclage reinforcement – in conjunction with cerclage.

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Other Lever Pessaries

Hodge with Knob

Hodge with Support and Knob

Smith

Risser

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Lever PessaryFitting and Removal

Trimo San on leading edge

Must remove before MRI or X-ray

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Patient Education and Counseling

Discuss Condition

Risk Factors

Choice of Pessary

Follow-Up Care

Sexual Activity

Need to Change Pessary size or typeArt - Not a science

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Pessary Fitting

Determine type of prolapse and severity

Decide on pessary

Digital exam to size

Finger against pessary to size

Have patient bear down

Stand, sit, walk, use toilet

Re-examine patient in erect position to check if pessary “shifts”

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PessaryFollow-Up Care

Return in 24 hours for 1st exam

Return within 3 days for re-exam

Return every 4-6 weeks

Cube, Inflatoball – remove daily

Trimo San½ applicator 3 times in 1st weekTwice a week thereafter

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Pessaries and MRIs

Remove prior to procedure

Metal cord Incontinence Ring Smith Risser Hodge – with or without Support Hodge – with or without Support and Knob Gehrung Gehrung with Knob Regula Ring – check for dimples (Old Metal Style Had No Dimples)

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PessaryFollow-Up Care Exam

Remove

Clean pessary

Vaginal exam

Re-insert if no contraindications

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Trimo San

pH to healthy vagina – helps prevent odor-causing bacteria growthLubricatorUnique Jel-Jector applicator

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Reimbursement

New 2001 Medicare CodesA4561 – Pessary Rubber , any typeA4562 – Pessary Non-rubber, any typeA4560 – Eliminated

Silicone Pessary Reimbursement:

Approx: $44.00

based on area of the country

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ReimbursementChange in Jurisdiction

Effective January 1, 2002, jurisdiction for claims processing changes from the DMERC (Durable Medical Equipment Regional Carriers) to the local Medicare intermediary (local carrier).

Program Memorandum Carriers, August 22, 2001

Department of Health and Human Services

Centers for Medicare and Medicaid Services