Chapter 19: Pessaries for Treatment of Pelvic Organ Prolapse and Urinary Incontinence

INTRODUCTION

Pessaries offer a safe, nonsurgical option for the treatment of urinary incontinence and pelvic organ prolapse. The concept of pessaries for the treatment of prolapse is not a new one. The pessary dates back thousands of years, prior to the days of Hippocrates, and innumerable varieties have been available over the last 200 years. One of the earliest “pessaries” used was placement of half a pomegranate in the vagina, as described by a Greek physician called Polybus.¹ Other methods described include a linen tampon soaked with astringent vinegar or a piece of beef as advocated by Soranus, another Greek physician. It was only in the 16th century that a device was made specifically to be used as a pessary, as opposed to using naturally occurring objects.

Since the 20th century, considerable refinements have been made of existing pessaries. At present, pessaries are generally made from inert plastic or silicone and can be used in patients allergic to latex.² Although it is not possible to establish a global perspective of the full extent of pessary use, a survey of the members of the American Urogynecologic Society showed that 75% of surgeon members used pessaries as first-line therapy for pelvic organ prolapse. No clear consensus emerged regarding the type of pessary used or their indications for use by these surgeons.³ In the United Kingdom, a recent postal survey demonstrated that 87% of consultants (physicians) use vaginal pessaries for management of POP.⁴

INDICATIONS FOR USE

Clinicians primarily opt for vaginal pessaries as a treatment option for those with comorbid medical conditions, those who still wish to bear children, as interim relief prior to surgery, and for those who prefer nonsurgical treatment.⁵ However, a recent study has shown that when pessaries are offered to patients with symptomatic pelvic organ prolapse,⁶ nearly two-thirds of women choose a pessary rather than surgery as initial management. Furthermore, a case–control study comparing women who chose pessaries with those who underwent surgery one year after their respective treatment found no difference in prolapse symptoms, bladder, bowel, or sexual function between groups.⁷ Although traditionally thought of as treatment only for women deemed unfit for surgery or infirm, pessaries should be considered a viable treatment option for the majority of women in the initial management of pelvic organ prolapse and stress incontinence.

Pelvic Organ Prolapse

Pelvic organ prolapse is the most common indication for pessary use.^3,8 The aim of treatment in the management of POP is to decrease the frequency and severity of prolapse symptoms and to avert or delay the need for surgery.⁹ Pessary use may prevent worsening of the prolapse as demonstrated in a small retrospective review of patients using pessaries for the treatment of POP.¹⁰ Pessary use success rates, defined as continued pessary use of women who ...