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1
Contemporary Use of the Pessary
Indications - Fitting Instructions
Milex Products, Inc.Chicago, Illinois 60634-1403
Copyright August 2002 All Rights Reserved
2
Outline
Historical perspective
Prevalence of prolapse
Staging
Types of pessaries
Practical care of the pessary
3
Historical perspective
Hippocratespomegranate
A.D. leg binding Astringents
David Scott Miller, MDContemporary Use of the PessaryObstetrics and GynecologyVol. 1, Chapter 39, January 1991
4
Historical perspective
1500’svaginal hysterectomy
de Carpi--tied string around prolapsed uterus
1800’suterine malposition
HodgeSmithRisser
5
Uses of Pessaries
Genital Prolapse Uterine Vaginal Rectal Bladder
Urinary Stress IncontinenceMixed IncontinenceCervical IncompetenceRetrodisplacement
6
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
7
Types of Prolapse
Uterine
Vaginal
Cystocele
Rectocele
Enterocele
8
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
9
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
10
Vaginal Prolapse
Anterior or Posterior Wall Prolapse
Results in:CystoceleRectoceleEnterocele
11
Cystocele
Prolapse of Bladder and Anterior Vaginal Wall
Incomplete Emptying of Bladder
Can Cause UTI
12
Rectocele
Prolapse of Rectum and Posterior Vaginal Wall
Incomplete Rectal Emptying
13
Enterocele
Herniation of Small Bowel into Upper Posterior Vaginal Wall
14
Symptoms of Prolapse
1st and 2nd DegreeLower back painPelvic Pressure and HeavinessDifficulty Controlling Urine and StoolUrinary Urgency
15
Symptoms of Prolapse
3rd and 4th Degree ProlapseBlockage of Bladder NeckUrinary Retention Increased Urinary Stress IncontinencePalpable Prolapse Incomplete Emptying of Bowels
16
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
17
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
18
Uses of Pessaries
Uterine Prolapse
Procidentia
Cystocele, Rectocele, Urethrocele
Urinary Stress Incontinence
Incompetent Cervix
Retroverted Uterus
19
Pessaries for Uterine Prolapse
Ring with or without Support
Shaatz
Regula
11stst and 2 and 2ndnd Degree Degree ProlapseProlapse
20
Ring without Support
1st and 2nd degree prolapse
Posterior Fornix to the Pubic Notch
Fitting
Removal
21
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
22
Ring with SupportFitting and Removal
1st and 2nd degree
prolapse complicated
by mild cystocele
Posterior Fornix to the
Pubic Notch
Fitting
Removal
23
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
24
ShaatzFits between the Levator Ani Muscles
Fold and insert
Removal - pull down with exam finger and remove
25
Regula
Unique design helps prevent expulsion
Legs spread with pressure on arch
Indicated for 1st and 2nd degree uterine prolapse
26
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
27
Pessaries for Uterine Prolapse
3rd and Complete ProcidentiaDonut
Cube
Gellhorn
Inflatoball
28
Donut
The Donut pessary is very effective for 3rd degree prolapse.
The Donut fits by filling the Vaginal Vault and supporting the prolapse.
29
Inflatoball
The Inflatoball pessary works well for 3rd degree prolapse.
This pessary is latex rubber.
Must remove daily.
30
InflatoballFitting and Removal
Squeeze and insert
Pump until firm
Over inflation causes bulge
Secure tubing inside vaginal vault
31
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
32
CubeFitting and Removal
Squeeze and insert
Break suction
Compress to remove
Remove daily. May cause vaginal erosion if not removed
as directed.
33
Tandem-Cube
Last Resort
34
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.
35
Gellhorn
Three Designs: Silicone Flexible Silicone 95% Rigid
Levator Ani Muscles
Cervix rests behind disk portion of pessary
36
GellhornFitting and Removal
Trimo San on leading edge
Hold parallel to introitus
Barber pole twist
Available with short stemApproximately ½ inch shorter
37
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
38
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
39
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.
40
Incontinence Ring
Stabilizes urethrovesical junction
Increases closure pressure
41
Incontinence RingFitting and Removal
Posterior Fornix to the Pubic Notch.
This pessary is effective for a patient who may have incontinence during exercise.
42
Ring with Support and Knob
Stabilizes urethrovesical junction
Supports a mild uterine prolapse complicated by a mild cystocele.
Increases closure pressure
43
Incontinence Dish
Stabilizes urethrovesical junctionIncreases closure pressureStress Incontinence. Mild Prolapse.
44
Incontinence DishFitting and Removal
Posterior Fornix to the Pubic Notch.
45
Incontinence Dish with Support
Urinary Incontinence with 1st to 2nd degree prolapse complicated by a mild cystocele
Increases closure pressure
Stabilizes urethrovesical junction
46
Gehrung with Knob
The Gehrung supports a cystocele and thins out a rectocele.
The knob stabilizes urethrovesical junction
47
Pessaries Cystocele and Rectocele
GehrungGehrung with KnobHodge with SupportRing with Support and KnobRing with SupportIncontinence Dish with Support
48
Pessaries Lever Pessaries
Hodge with Support
Hodge without Support
Risser
Smith
Incompetent Cervix Incompetent Cervix RetrodisplacementRetrodisplacement
49
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.
50
Other Lever Pessaries
Hodge with Knob
Hodge with Support and Knob
Smith
Risser
51
Lever PessaryFitting and Removal
Trimo San on leading edge
Must remove before MRI or X-ray
52
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
53
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”
54
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
55
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)
56
PessaryFollow-Up Care Exam
Remove
Clean pessary
Vaginal exam
Re-insert if no contraindications
57
Trimo San
pH to healthy vagina – helps prevent odor-causing bacteria growthLubricatorUnique Jel-Jector applicator
58
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
59
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