European Journal of Obstetrics & Gynecology and Reproductive Biology
ReviewThe history and usage of the vaginal pessary: a review
Introduction
Pelvic organ prolapse (POP) and its treatment have had a variable course through the annals of history. Over many centuries, various civilisations such as the ancient Egyptians, Chinese, Indians and through to the Christian and modern eras, have propagated their own unique medications and potions for treatment of prolapse. Scripts from the Kahun papyrus from ancient Egypt, 2000 years before the birth of Christ, advocated standing the patient over an assortment of burning ingredients to force the prolapsed organs back into the pelvis [1]. Substances including mould, fermented beer and manure have been advocated either for application on the prolapsed organs or for consumption by the patient to treat prolapse. In later periods, Hippocrates advocated succusion, where the patient was tipped head down and shaken to return the prolapsing organs into the pelvis with the aid of gravity. One of the earliest ‘pessaries’ used was placement of half a pomegranate in the vagina, as described by the Greek physician called Polybus [2]. Other methods described include a linen tampon soaked with astringent vinegar and a piece of beef as advocated by Soranus, another Greek physician. It was only later in the sixteenth century that the first purpose-made device to be used as a pessary, as opposed to naturally occurring objects, was described. Ambrose Paré created oval shaped pessaries, followed by C. Bauhin (1588) and William Fabry of Hilden in (1592) who devised pessaries of various shapes ranging from oval to globular, to fit differing vaginal proportions. The word ‘pessary’ comes from a Greek word ‘pessós’ meaning an oval stone used in a checkers-like game. Oval stones were inserted into the uteruses of saddle camels using a hollow tube, to prevent conception during long desert voyages. This practice was widespread in both Arabia and Turkey and would have translated to apply to all intrauterine devices.
Surgical procedures such as hysterectomy were considered only when the uterus became gangrenous in chronic procidentia, as the absence of effective anaesthetic techniques and surgical sterility resulted in high mortality and morbidity. Reliance on mechanical methods for prolapse reduction decreased with the advent of modern surgical techniques, anaesthesia and asepsis. While it has been established indisputably that either the removal or the repositioning of the prolapsed organs is ideal treatment for relief of symptoms, there is no consensus of opinion on the usage of pessaries. Considering the history of the pessary there is a paucity of scientifically reliable information about their usage. Nearly one hundred years after the first review [2] questions still abound as to the type of pessary to be used, the long-term effectiveness and whether pessary usage affects the progression or regression of POP.
In this review we aim to address the indications for pessary usage and also the evidence for their effectiveness in affording symptom relief.
Section snippets
Methods
An electronic search of Medline from 1966 to 2010 was done. Keywords used were pelvic organ prolapse; pelvic floor dysfunction; vaginal pessary and urinary incontinence. The citations which were not available online were identified by hand-searching. Textbooks are also quoted where relevant.
Pelvic organ prolapse
Support and repositioning of prolapse of pelvic organs is the commonest indication for vaginal pessary usage [3], [4]. The aim of mechanical treatment in the management of POP is to prevent worsening of the prolapse [5], decrease the frequency and severity of prolapse symptoms and to avert or delay the need for surgery [6]. The reported success rate of pessary use is between 56 and 89% at two to three months [7], [8], [9] while Komesu et al. [10] reported a success rate of 56% at 6–12 months
Types of pessaries
Of the multitude of pessaries described, currently only approximately 20 models remain in general use (Fig. 1) [23]. Modern pessaries are made of inert silicone-coated rubber and hence can be used in patients allergic to latex. Vaginal pessaries can be broadly divided into two types: support pessaries and space filling pessaries (Table 1).
Patient assessment and pessary insertion
The cardinal point of patient assessment is the suitability of the particular patient for the particular pessary, taking into account the sexual activity, type and degree of prolapse, ability of the patient to self-manage or attend follow-up. One of the major factors to consider is the ability of the patient to attend for follow-up examinations, alone or with a carer.
At the initial visit it is recommended that the patient be examined in the recumbent as well as the standing position, during
Pessary maintenance and follow-up
There is no consensus on the follow-up regimen as it can vary widely depending on the patient's ability to remove and self-insert, the integrity of the vaginal epithelium, and complications. The patient must be informed of the symptoms of potential complications and should be advised to be aware of any change in her voiding pattern. Although there is no consensus on the duration, periodic vaginal inspections are recommended. Any frank ulceration or vaginal excoriation should prompt
Effectiveness of pessary usage
Pessaries have been shown to be largely successful for the remission of most of the symptoms attributable to POP.
Predictors of success
Komesu et al. [10] established that prolapse symptom improvement best predicted continued pessary use. They used the short form of the Pelvic Floor Disorders Impact Questionnaire (PFDI-20), in which lower scores represent fewer symptoms, and a prolapse score that fell to 50% of baseline at two months best predicted continued use. Patient choice has an impact on pessary usage. It has been shown that older patients are more likely to retain a pessary [8]. Additionally, it was shown that patients
Complications of usage
Common complications are bleeding, vaginal excoriations, ulcerations and impactions in the vagina, while rare complications include actinomycosis and bacterial vaginosis. Vaginal ulcerations and excoriations can be treated effectively by vaginal estrogen application. An estradiol-17 ring (placed behind the pessary) has also been shown to be effective. Neglected pessaries present with more serious complications, namely fistula formation and peritonitis. Erosion into the bowel or bladder and
Conclusion
Based on available evidence, it appears that pessaries are a viable option for women with prolapse and incontinence and should be offered as an alternative to surgical correction to all suitable women. A recent Cochrane review did not identify any randomized controlled trials on which treatment with pessaries can be based and research in this area needs to be encouraged [6].
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