guideline no 411 vaginal pessary use

Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (837.05 KB, 13 trang )

Trang 1<div class="page_container" data-page="1">

It is the Society of Obstetrician and Gynaecologists of Canada (SOGC) policy to review the content 5 years after publication, at whichtime the document may be revised to reﬂect new evidence or the document may be archived.

No. 411, February 2021 (Replaces No. 294, July 2013)

Guideline No. 411: Vaginal Pessary Use

This clinical practice guideline was prepared by the authors andoverseen by the SOGC Urogynaecology Committee. It wasreviewed by the SOGC Family Practice Advisory Committee andapproved by the SOGC Guideline Management and OversightCommittee and the SOGC Board of Directors.

This clinical practice guideline supersedes technical update No.294, published in July 2013.

Marie-Andree Harvey, MD, MSc, Kingston, ONMarie-Claude Lemieux, MD, Montreal, QCMagali Robert, MD, MSc, Calgary, ABJane A. Schulz, MD, Edmonton, AB

SOGC Urogynaecology Committee (2019): Aisling Clancy,Laura Didomizio, Sinead Dufour, Roxana Geoffrion, DobrochnaGloberman, Maryse Larouche, Marie-Claude Lemieux, OlaMalabarey, Dante Pascali (co-chair), Marianne Pierce, Jens-ErikWalter, David Wilkie (co-chair), and Maria Wu

Disclosures: Statements were received from all authors. Norelationships or activities that could involve a conﬂict of interest

were declared. All authors have indicated that they meet thejournal’s requirements for authorship.

Keywords: pessaries; pelvic organ prolapse; urinaryincontinence; stress; vaginal discharge

Corresponding author: Marie-Andree Harvey,

RECOMMENDED CHANGES IN PRACTICE1. All women with pelvic organ prolapse or stress urinary

incontinence can be offered a pessary; most women can besuccessfullyﬁtted with a pessary.

2. While using a pessary, women should be followed withregular, thorough vaginal examinations to look forerosions, performed by a health care provider withspecialized training.

3. Although it is recommended that women take care of their ownpessary, if a woman is unable to remove and reinsert herpessary, this does not preclude pessary use.

KEY MESSAGES

1. Most women can be successfullyﬁtted with a pessary forpelvic organ prolapse or stress urinary incontinence.2. Serious complications are rare.

(En fran¸cais : Utilisation des pessaires)

The English document is the original version. In the event of any discrepancy between the English and French content, the English version prevails.

J Obstet Gynaecol Can 2021;43(2):255−266 2020 The Society of Obstetricians and Gynaecologists of Canada/LaSociété des obstétriciens et gynécologues du Canada. Published byElsevier Inc.

This document reﬂects emerging clinical and scientiﬁc advances as of the publication date and is subject to change. The information is not meantto dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however,that they adequately document any such amendments.

Informed consent: Everyone has the right and responsibility to make informed decisions about their care together with their health careproviders. In order to facilitate this, the SOGC recommends that health care providers provide patients with information and support that isevidence-based, culturally appropriate, and personalized.

Language and inclusivity: This document uses gendered language in order to facilitate plain-language writing but is meant to be inclusive of allindividuals, including those who do not identify as a woman/female. The SOGC recognizes and respects the rights of all people for whom theinformation in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages healthcare providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to applythese guidelines in a way that is sensitive to each person’s needs.

Copyright: The contents of this document, in whole or in part, cannot be reproduced in any form without prior written permission of the publisherof the Journal of Obstetrics and Gynaecology Canada.

</div>Trang 2<div class="page_container" data-page="2">

Objective: To review the use, care, andﬁtting of pessaries.

Target population: Women requiring the use of vaginal pessaries forpelvic organ prolapse and/or stress urinary incontinence. Use mayalso be indicated for women with certain pregnancy-related clinicalscenarios, including incarcerated uterus.

Options: Pessaries are an option for women presenting with prolapseand/or stress urinary incontinence. In addition, certain types ofpessaries can be considered for patients with cervical insufﬁciencyor incarcerated uterus.

Outcomes: Most women with prolapse or stress urinaryincontinence can be successfullyﬁtted with a pessary andexperience excellent symptom relief, high satisfaction rates, andminimal complications.

Beneﬁts, harms, and costs: Women with pelvic organ prolapse and/or stress urinary incontinence may choose to use a pessary tomanage their symptoms rather than surgery or while waiting forsurgery. Major complications have been seen only when pessariesare neglected. Minor complications such as vaginal discharge,odour, and erosions can usually be successfully treated.

Evidence: Medline was searched for relevant articles up to December2018. This is an update of the SOGC technical update published in2013, which was theﬁrst internationally published guidance on

pessary use. Subsequently, an Australian guideline on the use ofpessaries for the treatment of prolapse was published later in 2013.Validation methods: The authors rated the quality of evidence and

strength of recommendations using the approach of the CanadianTask Force on Preventive Health Care (Appendix A).

Intended audience: Gynaecologists, obstetricians, family physicians,physiotherapists, residents, and fellows.

SUMMARY STATEMENTS:

1. Most women can be successfullyﬁtted with a pessary to treat thesymptoms of pelvic organ prolapse or stress urinary incontinence(II-2).

2. Satisfaction rates for pessary use are very high (I).

3. Some vaginal pessaries may prevent recurrence of incarcerateduterus (III).

4. The role of pessaries speciﬁcally designed to prevent preterm labouris not yet elucidated (I).

5. Complications associated with pessary use are usually minor, withvaginal discharge being the most common problem (II-3).

6. Vaginal erosions can be treated with removal of the pessary andoptional vaginal estrogen supplementation (II-2).

1. Pessaries should be considered in all women presenting with some pelvic organ prolapse and/or stress urinary incontinence (I, A).

</div>Trang 3<div class="page_container" data-page="3">

T

his guideline reviews the evidence for the use of nal pessaries in pelvic organ prolapse (POP) andstress urinary incontinence, as well as in certain preg-nancy-related clinical scenarios, including incarcerateduterus and risk of premature labour related to cervicalinsufﬁciency. In the context of this guideline, the wordpessary is used in its most general deﬁnition, as anydevice worn inside the vagina to support the uterusand/or remedy a displacement. Many types of vaginaldevices, globally referred to as pessaries, will be discussedin this guideline.

POP occurs in up to 50% of parous women.1 Althoughoften asymptomatic, POP may present with symptoms ofbulging, pelvic pressure, and occasionally backache. It isoften associated with bladder, bowel, and sexual dysfunc-tion. Management options include pelvic ﬂoor exercises,2

expectant management, use of mechanical vaginal devices(pessaries), and surgical correction. The focus of this clini-cal practice guideline is to guide health care providers onthe use of pessaries.

A pessary is a device placed into the vagina to either port the prolapsing vaginal walls or provide urinary conti-nence. Pessaries provide immediate relief of symptomsand have the distinct advantage of being minimally inva-sive. In the past, pessaries were reserved for older patientsand/or those who were frail. However, they are an excel-lent option for the treatment of POP or stress urinaryincontinence for women of any age, including those whowish to preserve their child-bearing potential, those whoprefer a non-surgical intervention, and those seeking symp-tom relief while awaiting surgery. Currently, pessaries areexperiencing resurgence in popularity, with increased avail-ability.

sup-SUMMARY STATEMENT 1 ANDRECOMMENDATION 1

Pessaries are made of medical-grade silicone, which hasthe advantage of making the devices inert and less likelyto have an odour or cause an allergic reaction.3Ring pes-saries and incontinence ring pessaries also contain surgicalsteel to facilitate ﬂexion. Surgical steel is contained as wellin rarely used pessaries not discussed in this guideline,such as the Hodge, Risser, Smith, Gehrund, or Regulamodels.

Pessaries used for the treatment of POP can generally beclassiﬁed as either support pessaries or space-occupyingpessaries.4Support pessaries sit in the posterior fornix andgenerally rest above the pubic bone and/or pelvic ﬂoor.The most common types of support pessary are ring pes-saries (with or without diaphragm, Figure 1A) and theShaatz pessary (Figure 1B). Space-occupying pessariesinclude the cube (Figure 1C), Inﬂatoball (Figure 1D),and donut (Figure 1E) pessaries. The cube works bybringing the vaginal walls towards the midline, and theothers occupy a larger space than the introitus.4 Thespace-occupying pessaries are most often used for moresevere prolapse. The commonly used Gellhorn pessary(Figure 1F) works as a combination of these two meth-ods.4There are many other types of pessaries to addressspeciﬁc defects, but their use is seldom reported in theliterature.

Pessaries for incontinence are often designed as supportpessaries, with extra support provided anteriorly(Figure 2A) to support, elevate, and slightly constrict theurethra.5 Some pessaries are speciﬁcally designed to treatstress urinary incontinence: the incontinence ring(Figure 2B), the incontinence dish (Figure 2C), and Ure-sta pessary (Resilia Inc., Shediac, NB) (Figure 2D). If awoman develops stress incontinence after being ﬁttedwith a prolapse pessary, switching to an incontinencering or a pessary with a continence knob may bebeneﬁcial.3

Pessaries can be used for therapeutic or diagnostic poses. Therapeutically, pessaries are often used to relievesymptoms of POP6 (for which they are cost-effective7)and stress urinary incontinence. Women choosing a pes-sary for the treatment of POP are as likely to be satisﬁedand have improved pelvicﬂoor function as those selectingsurgery.8

pur-Diagnostically, pessaries can be used to provide ative evaluation of women with POP by unmaskinglatent stress incontinence9and information on postoper-ative voiding dysfunction.10,11 Occult urinary inconti-nence could be revealed during the use of a pessary orduring the performance of urodynamic testing with andwithout a pessary, although this method of evaluationmay be suboptimal.12 Although urodynamic testing haspoor sensitivity, its speciﬁcity is high (93%), andthe absence of occult incontinence has an excellent nega-tive predictive value (91%−98%) for postoperativecontinence.13,14

</div>Trang 4<div class="page_container" data-page="4">

preoper-Pessaries can also be used to temporarily treat symptomswhile the patient awaits surgery and to help in healingdependent vaginal ulcers that result from erosions due to alarge prolapse. They may also play a role in preventingPOP from progressing.

Pelvic Organ Prolapse

Women can be successfullyﬁtted with a pessary up to 75%of the time.15,16Symptoms of bulging are relieved in 70%

to 90% of women and symptoms of pressure are relievedin 29% to 49% of women,15,16thus improving quality oflife.17Most women who report successful pessary use at 4weeks continue to use a pessary at 5 years (Table 1).18

The most common pessary for POP is the ring pessary,followed by the Gellhorn, cube, and donut pessaries.16,19,20However, a randomized crossover trial found no differen-ces in patient satisfaction or symptom relief between theFigure 1. Support pessaries: (a) ring pessary with support, (b) Shaatz pessary, (c) cube pessary, (d) Inﬂatoball pessary, (e)donut pessary, (f) Gellhorn pessary

Reproduced with permission from CooperSurgical, Inc., Trumbull, CT

</div>Trang 5<div class="page_container" data-page="5">

ring and the Gellhorn pessaries.21 Ring pessaries may beopen or covered (also referred to as “with support” or“with diaphragm”) and are the most widely available andmost commonly used. The purpose of a covered ring pes-sary is to support the cervix and avoid genital incarcera-tion,22 while perforations allow the escape of vaginalsecretions. Ring pessaries, either open or covered, are bestused in POP quantiﬁcation stage I and II prolapse (mild tomoderate prolapse), although they often work well with a

more advanced degree of prolapse, provided there is anadequate perineal body to ensure the pessary is retained.3Ring pessaries also have the advantage of ease of insertionand removal.

If a ring pessary fails to remain in position or to relieveprolapse, a stiffer support pessary such as a Shaatz or Gell-horn, or a space-occupying pessary such as a cube ordonut, may be used. Cube pessaries have been successfullyused in severe prolapse. However, they can be prone toerosions and require frequent removal. Patients can learnto remove a cube pessary themselves.

Successful use of a pessary depends on both adequate ﬁtand patient satisfaction. The most common reasonswomen choose to use a pessary are to improve symptomssecondary to POP, such as bulging, and to improve activityand general health.5,23 Other symptoms that can beimproved with the use of a pessary include urinary urgencyand difﬁculty with bladder emptying or defecating.16,19

Contrary to common belief, sexual activity is not a reasonto avoid pessary use; dissatisfaction with sexual activitydoes not predict discontinuation of pessary use.19,24Pessary use may, in fact, enhance sexual activity andsatisfaction.25,26

Figure 2. Incontinence pessaries: (a) ring pessary with support and continence knob at 12 o’clock, (b) incontinence ring,(c) incontinence dish, (d) Uresta kit

Figures 2a−2creproduced with permission from CooperSurgical Inc., Trumbull, CT;Figure 2d reproduced with permission from Resilia Inc.

Table 1. Change in symptoms after pessaryﬁtting% of patients

Fernando et al.16b

Clemons et al.19

</div>Trang 6<div class="page_container" data-page="6">

SUMMARY STATEMENT 2

Predictors for unsuccessful ﬁtting include a short vagina(<6 cm),19,27a wide introitus (>4 ﬁngers’ breadth),19,27

aratio of genital hiatus to total vaginal length of >0.8,15

patient discomfort,15younger age (<65 years),15

history ofsmoking,15lower initial prolapse stage,15and previous vag-inal surgery.16,19,26,28−30The presence of a rectocele31withstress urinary incontinence30predicted unsuccessful ﬁt insome studies but not in others.15We did notﬁnd any stud-ies that evaluated provider factors associated with success-ful pessary use. Many women may need to try more thanone pessary type toﬁnd the one that works best for them.About one-third (29%32 to 35%33) of women required asecondﬁtting using a Gellhorn pessary because the initialﬁtting with a ring pessary failed. Some women may subse-quently try a donut or a Shaatz pessary, but this scenariohas not been described in the literature.

Factors that predict pessary discontinuation include rior wall prolapse,16,28,34younger age (<65 years),19urinaryincontinence,19 discomfort,29 and expulsion.17 However,women successfully ﬁtted with a pessary who had previ-ously undergone pelvic reconstructive surgery were morelikely to continue pessary use.30

poste-In many centres, a pessary ﬁtting is deemed successful ifthe patient is comfortable in clinic, is able to void, anddoes not experience uncomfortable descent or expulsionduring a Valsalva manoeuvre, which should be done whilethe patient is sitting on a toilet rather than lying on theexamination table. After the initialﬁtting visit, the patientmay require one or more subsequent visits to try other pes-saries of different sizes or models before an optimal pes-sary is found and the trial of pessary use is deemedsuccessful.

Urinary Incontinence

Some pessaries have been speciﬁcally designed to treatstress urinary incontinence. These include the ring pessarywith support and a continence knob (Figure 2A), theincontinence ring (Figure 2B), the incontinence dish(Figure 2C), and over-the-counter pessaries such as Uresta(Figure 2D) and Impressa (Poise, Kimberly-Clark)pessaries.

The ring and dish pessaries are designed to stabilize theurethra and increase urethral resistance. The rate of initialsuccessful ﬁtting varies between 60% and 92%,35,36

continued use drops to 55% by 6 months.37 By 1 year,overall continuation may be as low as 16%. However, thisﬁnding was from a study of an incontinence ring pessarywith diaphragm, in which most women stopped using thedevice owing to lack of efﬁcacy.38

In a retrospective chartreview of 100 women who had a pessary successfully ﬁt-ted, most with an incontinence ring, 59% were continentor mostly continent at 11 months.39Reasons for discontin-uation included persistent incontinence, pessary falling out,or pain and bleeding. One crossover study (published onlyin abstract form) that compared the incontinence ring withno treatment found that the incontinence ring was moreeffective for the management of stress urinary inconti-nence, signiﬁcantly decreasing the number of incontinenceepisodes and improving quality of life.40Eighty percent ofwomen saw an improvement in continence, and 20% werecompletely continent. However, there is insufﬁcient evi-dence to determine whether pessaries are better than otherdevices or treatments,41including pelvicﬂoor exercises.42

In addition to incontinence rings, other commercial vaginalpessaries for bladder neck support are available directly toconsumers and allow self-sizing, such as Uresta(Figure 2D) and Impressa (a single-use disposable, similarto a tampon) pessaries. Uresta and Impressa pessariescome in various sizes, and each has a “ﬁtting box” thatcontains the available sizes to allow patient self-sizing.Each size can then be purchased on its own.

Sixty-seven percent of patients randomly assigned to sta for bladder support showed a 50% reduction in urineloss on a pad test using a standardized,ﬁxed bladder vol-ume, compared with 22% of patients assigned to placebo43(a vaginal silastic ring placed in the cul-de-sac, similar torings used for estrogen supplementation, but unmedi-cated).

Ure-In a prospective before-and-after study of 62 women usingImpressa, 85% achieved a≥70% reduction in pad weight,with 92%“feeling that they were continent.” Quality of life(measured on the Incontinence Impact Questionnaire-7[IIQ-7] and Urogenital Distress Inventory-6 [UDI-6]scales) was statistically signiﬁcantly improved by the end ofa period of device use. Fitting was performed by thepatient, who chose the size that best balanced comfort andcontinence. Seventeen percent of the recruited womenwithdrew, about half owing to lack of interest and the otherhalf owing to adverse effects. Although nearly half ofwomen reported discomfort and one-quarter reportedspotting, only 7% discontinued the device because ofadverse effects.44,45

</div>Trang 7<div class="page_container" data-page="7">

POP and incontinence can occur during pregnancy. It isestimated that uterine prolapse occurs in 1 out of every13 000 to 15 000 pregnancies.46,47Prolapse is usually notedin theﬁrst trimester (and usually precedes the pregnancy)but can occur at any time.47,48If prolapse occurs before 12weeks gestation, it usually resolves by the end of the sec-ond trimester as the uterus enlarges and ascends into anintra-abdominal position, whereas, if POP develops duringpregnancy, it is more likely to resolve spontaneously post-partum.47 Women who develop POP during pregnancycan be ﬁtted with a pessary, although not alwayssuccessfully.3,49,50By 18 weeks, when the uterus lifts out ofthe pelvis, symptoms often resolve, and the pessary can bediscontinued. Pessaries that have been studied for thetreatment of POP in pregnancy include the donut, Hodge,ring, and Gellhorn pessaries. Fitting issues, particularlyexpulsion, appear to be a common concern, suggestingthat the use of a stiffer or space-occupying pessary may bebeneﬁcial.48

The use of an incontinence pessary in nancy has not yet been studied but is not contraindicated.

preg-During pregnancy, women can develop urinary retentiondue to an incarcerated uterus.51It has been suggested thatwomen with a retroverted uterus be examined routinely at12 to 13 weeks gestation to evaluate whether pessary place-ment is needed to prevent incarceration. This preventativeapproach has been used in subsequent pregnancies ofwomen with a history of incarceration. In cases of incarcer-ation, a pessary may be used to direct the cervix posteri-orly, which is thought to reduce recurrence of urinaryretention by resolving the acute anterior angulation of thecervix against the urethra.

SUMMARY STATEMENT 3

Pessaries have recently been used in pregnancy for anotherindication: preventing preterm labour. There are data onthe use of the Arabin pessary (Figure 3), placed around thecervix, to prevent premature delivery in singleton pregnan-cies.52Unfortunately, theﬁndings of these studies remaincontradictory.53−55In twin pregnancies, there is also con-ﬂicting evidence regarding the beneﬁt of pessaries for theprevention of preterm birth.56,57 Two meta-analyses, onein singleton and the other in twin pregnancies, did not sup-port the use of the Arabin pessary to lower the risk of pre-term labour and delivery.58,59 Therefore, the use of theArabin pessary to prevent preterm labour cannot be rec-ommended in situations in which alternative establishedtreatment is available, outside of a clinical trial.

SUMMARY STATEMENT 4

GUIDELINES FOR FITTING

Successful ﬁtting and continued use of a pessary dependon adequate patient education (online Appendix, supple-mentary handout 1). The woman or her caregiver mustcomply with pessary care instructions.60Physicians, as wellas other appropriately trained health care providers (e.g.,continence advisors, nurse practitioners, and pelvic healthphysiotherapists, in some provinces), can ﬁt a pessary inCanada. All professionals involved in ﬁtting pessariesshould have the skills and knowledge to insert a speculumand inspect thoroughly all parts of the vaginal vault todetermine the integrity of the mucosa.

Patient history−taking should include inquiring aboutsymptoms of prolapse, bladder and bowel dysfunction,and sexual activity. This should be followed by a compre-hensive pelvic examination, which consists of assessingvaginal mucosal health; evaluating the degree and compart-ment of prolapse, including genital hiatus and vaginallength; and measuring pelvicﬂoor strength. It is commonpractice to begin vaginal estrogen therapy in postmeno-pausal women to improve the health of the vaginal epithe-lium,3,4 but this therapy not essential.61 In fact, nocomparative studies have conﬁrmed that vaginal estrogentherapy helps in preventing or managing erosions, althoughit is widely believed that this therapy is helpful. Similarly, nodata were found on the effect of Replens (vaginal moistur-izer), hyaluronic acid, or other non-hormonal vaginal prep-arations on pessary use or related complications.

Figure 3. Arabin cervical cerclage pessary

Reproduced with permission from Dr. Arabin GmbH & Co. KG,Witten, Germany.

</div>Trang 8<div class="page_container" data-page="8">

For Pelvic Organ ProlapseSupport Pessaries

To determine the approximate size of the pessary, the iner should assess the width of the vaginal canal by separat-ing the two examiningﬁngers at the vault in a sagittal planeand estimating their separation distance. A ring pessary isusually the initial choice forﬁtting because it is easy to useand tends to be more comfortable than other types. Thepessary is folded, and the leading edge is lubricated. It isinserted by directing it towards the sacrum and allowing it tounfold above the pelvic ﬂoor, with the anterior edge justbehind the symphysis. Aﬁnger’s breadth should ﬁt betweenthe pessary edge and the symphysis anteriorly and betweenthe side of the pessary and the lateral vaginal wall. Afterplacement, the ring pessary should be rotated a quarter turnin either direction to prevent the foldable edge from beingplaced in front of the introitus, thus reducing the chance ofspontaneous expulsion. Once the pessary has been placed,the patient should walk around in the clinic and performactivities such as squatting and the Valsalva manoeuvre toconﬁrm the pessary will remain in place. The health careprovider should ensure that patients can void and are givenappropriate educational resources before leaving the clinic(online Appendix, supplementary handout 1). If obstructionis clinically suspected, a post-void residual urine test can beconducted to rule out that possibility. Dental ﬂoss can beattached to a pessary to aid in removing the pessary if it isdifﬁcult to reach.

exam-Space-Occupying Pessaries

A space-occupying pessary is the type most likely to besuccessful if the vaginal introitus exceeds the width of threeor four examining ﬁngers. A Shaatz pessary is ﬁtted simi-larly to a ring, with the convex portion placed anteriorly.Toﬁt a Gellhorn pessary, the disk should be folded, whenpossible, with the stem folded down towards the disk, forease of insertion. Once the pessary is in the vagina, thestem should be directed caudally (pointing out), so that aﬁnger can be passed between the disk and the vaginal side-wall. A cube pessary, owing to its unique square shape,need not be as large as the width of the vagina (as mea-sured with the examiningﬁngers spread apart) but shouldbe approximately half of that width. Inserting a cube pes-sary simply involves compressing the edge that is intro-duced into the vaginal opening and pushing it up and back.Donut pessaries must also be compressed for insertion.

For Stress Urinary Incontinence

An incontinence ring is ﬁtted by assessing the distancebetween the posterior cul-de-sac and the mid-urethra.Because the incontinence ring is moreﬂexible, it will adapt

to the shape of the vagina. The health care provider mustensure that the knob is centred underneath the mid-urethraand that the proximal ring is placed in the posterior cul-de-sac, rather than in front of the cervix in the anteriorfornix.62

A ring pessary with an incontinence knob (with or withouta membrane) is placed like a regular ring, but, once the pes-sary has opened, the knob will face the sidewall. The pes-sary must thus be rotated a quarter-turn to place the knobunder the mid-urethra.62

PESSARY CARE AND FOLLOW-UP

After a successfulﬁtting, the woman should be seen againwithin 2 to 4 weeks to see whether she is satisﬁed. If possi-ble, further instruction on removing the pessary and pes-sary care should be given.3 The need for instruction isdetermined by evaluating comfort, pessary retention, con-venience, and relief of symptoms. Commonly, another sizeor style of pessary may be tried if the patient is dissatisﬁed.Although there are no clear guidelines for pessary care,health care providers should advise women who can per-form self-care to remove the pessary weekly to monthly,according to their preference, and to wash it with mildsoapy water or water alone. Women unable to performself-care should initially attend follow-up at 3-month inter-vals. Pessary care is typically performed by a health careprofessional for Gellhorn, cube, and donut pessaries. Fol-low-up intervals recommended by the manufacturers arenot evidence-based or consistent with common practiceand therefore are not considered standard of care.63Some pessaries may be difﬁcult to remove. The Gellhornpessary can be removed using a ring forceps (clamped onthe tip of the stem) or packing self-closing forceps (withone end introduced in the stem’s channel) to apply outwardtraction, then using one ﬁnger to break the suction andfold the round disk along the stem. To remove the cubepessary, the seal must be broken by sweeping a ﬁngeraround the pessary, and, here again, sponge forceps canhelp with traction. A cube pessary requires removal andcleaning more often than every 3 months owing to agreater amount of discharge that can become trappedwithin the cups (although the cube is available with drain-age holes or holes can be created using a 4-mm punchbiopsy). The frequency of required cleaning for a cube pes-sary varies by patient, from as often as every few days toevery few weeks.

Once removed, the pessary should be washed using mildsoapy water or water alone. The perforations of the Gellhorn

</div>Trang 9<div class="page_container" data-page="9">

and Shaatz are best cleaned with a cytobrush or a small cottonswab. The vaginal epithelium should then be inspected forerosions or ulcerations, with special attention paid to the pos-terior and lateral fornices of the vagina. This is best accom-plished using a large cotton swab to displace the cervix in thecontralateral direction. The size, location, and depth of anyerosions should be noted and documented.

If no complications arise, and particularly when the patientcan perform self-care, the interval between visits can beincreased to 6 months or 1 year.36Women can be sexuallyactive with the ring or Shaatz pessary in place if theychoose. A cube, donut, or Gellhorn pessary generally mustbe removed before intercourse.

SEXUALITY AND PESSARY USE

In a study of new pessary users, sexual function has beenshown to remain unchanged, as assessed using validatedquestionnaires.64 Although a ring pessary is said to becompatible with intercourse, most women choose toremove it before sex.64

Complication rates vary, which likely reﬂects differences inreporting. Hanson et al.26reported a low complication rate of11% among 1216 women. Common complications includederosions (9%) and vaginal infections (2.5%).26Theseﬁndingsare in contrast to those of a study by Bai et al.,65who reportedthat 73% of women had complications, including bleeding,erosions, or foul odour. Despite this high rate of complica-tions, over 70% of women reported being satisﬁed with thepessary and wanted to continue using it,65 thus suggestingthat these complications are minor. Of 187 women offeredpessaries, 151 continued to use one at 1 month, and 130 werestill using one at 5 years.18 Most complications were seenwithin 6 months of insertion and included pain (13; 5.3%),bleeding or excoriations (3; 1.2%), and constipation (3;1.2%). It was rare for complications to develop after 6months of use.18

Infection and Discharge

Vaginal discharge is a common experience among pessaryusers. It can be caused by a physiological response to fric-tion of the pessary on the vaginal mucosa, by bacterial vag-inosis, or by yeast infections. A study comparing womenusing pessaries with women waiting for surgery found that,although women using a pessary more often have vaginaldischarge, there was no difference in vaginal ﬂora or rateof bacterial vaginitis.69This contrasts with the ﬁndings ofAlnaif and Drutz,70who showed that, in matched women,

pessary users had a higher rate of diagnosed bacterial nosis than non-users (32% vs. 10%). Indications for bacte-rial vaginosis testing and treatment should be the same forpessary users as for non-users.

vagi-Bacterial vaginosis can cause malodourous vaginal charge, which can be bothersome but is not related toan ulcer.66,69The use of estrogen cream does not appearto have a protective effect against bacterial vaginosis.66However, more frequent pessary removal can reduce therisk of bacterial vaginosis. The use of Trimo-San vaginalgel (CooperSurgical Inc., Trumbull, CT) has not beenshown to affect discharge.71 Often, simple reassurancethat discharge is physiological may be sufﬁcient. Other-wise, accepted treatments for bacterial vaginosis areeffective.72 Yeast infections can be treated in conven-tional ways. Removing the pessary for the duration oftreatment is often recommended, although there is noevidence that this makes a difference. Gellhorn pessariesare associated with increased vaginal discharge21; thus,changing to another type of pessary may reduce thissymptom.

dis-SUMMARY STATEMENT 5

Local pressure from the pessary can lead to focal larization. This can result in excoriations, erosions, ulcers,and/or granulation tissue. Reported rates range from 2%to 9%.8,10Devascularization may present as vaginal bleed-ing, odour, or increased discharge, which is typicallybrown. A primary indicator of devascularization is thepresence of a strong odour upon removal of the pessary.When strong odour is detected during routine pessarycare, careful examination of the vagina should be per-formed, often facilitated by using large swabs to push thecervix and sidewalls apart.

devascu-Other causes of vaginal bleeding in pessary users cannot beexcluded. Endometrial sampling or ulcer biopsy may beindicated if bleeding persists.

There is no consensus on optimal care for tion. The standard therapy consists of pessary removal fora period of at least 2 weeks.63,66 For ongoing problems,more frequent visits and a change in pessary type or sizemay be required. There is no consensus about whetherchanging to a smaller or larger pessary would be most ben-eﬁcial.63

devasculariza-Some physicians apply silver nitrate to treat theerosion; however, no studies have assessed the effective-ness of silver nitrate in the management of erosion. If the

</div>Trang 10<div class="page_container" data-page="10">

pessary is not removed, there is a continuing risk ofﬁstuladevelopment despite the management of erosion with sil-ver nitrate. Douching with sucralfate 10% suspension twicedaily has been reported to help with recalcitrantulcerations.67

In a study involving 130 women, erosions were seen sively in those who were postmenopausal (27% of all post-menopausal women) at 1-year follow-up of pessary use.68Vaginal estrogen therapy in postmenopausal women hasnot been shown to affect complication rates; however,there is a trend towards decreased complications with con-tinued use.66 Although no randomized controlled trialshave been performed to conﬁrm this trend, estrogen ther-apy is often advised when erosions have been identiﬁed(e.g., one 10 mg estradiol tablet or 0.5−1 g conjugatedequine estrogen cream nightly for 2 weeks then twice perweek, or one estradiol vaginal ring every 3 months).26However, erosions may also resolve without local estrogentherapy.66 A consensus study reported that 75% of care-givers routinely prescribe estrogen therapy with pessaryuse.63

exclu-Vaginal microﬂora have been suspected as a possible logical factor for the development of erosions. However, astudy of pessary wearers found that the microﬂora ofwomen who developed erosions did not differ from thatof women who did not develop erosions.69

etio-SUMMARY STATEMENT 6

Other Complications

Most complications occur in the ﬁrst 4 weeks of pessaryuse and include expulsion of the pessary (16.3%), pain anddiscomfort (5.3%), and constipation (1.2%); these compli-cations rarely persist, according to a study that evaluatedthem over 5 years of use.18

Dislodgment is a common reason for discontinuing the useof a pessary. This is best prevented by avoiding constipa-tion and straining in general. In a large cohort, the mechan-ical complication rate over 9 years was reported as 5%.Unfortunately, the termmechanical complications was not fur-ther deﬁned or explored.73

Major Complications

Major complications are uncommon with pessary use.However, erosions can progress to ulcers or ﬁstulae. In acohort of pessary users from a large Medicare database,ﬁstulae did not appear until 2 years after placement; by9 years the reported rate was 3%.73Many case reports of

major complications have been published, including covaginal ﬁstulae, bowel ﬁstulae, and incarcerated pessa-ries.74 Of those, 91% involved pessaries that had beenneglected. Vaginal or cervical cancer is rarely associatedwith a neglected pessary but should be considered in thepresence of an ulcer that is not healing.75These risks high-light the importance of continued and diligent pessary carefollow-up. Overall, complications tend to be minor withthe use of a pessary, but diligent follow-up is required toensure that minor issues do not progress to more seriouscomplications.

Pessaries have high success and low complication rates forthe treatment of both POP and stress urinary incontinence.When successfully ﬁtted, they are associated with highpatient satisfaction. Consequently, they should be consid-ered ﬁrst-line treatment for all women presenting withthese indications.

GUIDELINE TOOLKIT

SOGC members can visit the Guideline Resource Kit page on sogc.org toﬁnd complementary tools and resour-ces and to participate in accredited continuing professionaldevelopment activities.

1.Swift SE. The distribution of pelvic organ support in a population of femalesubjects seen for routine gynecologic health care. Am J Obstet Gynecol2000;183:277–85.

2.Braekken IH, Majida M, Engh ME, et al. Can pelvicﬂoor muscle trainingreverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol 2010;203. 170e1−7.

3.Schulz JA, Kwon E, et al. Pelvic organ prolapse - pessary treatment. In:Baessler K SB, Burgio KL, Moore KH, et al, editors. Pelvicﬂoor re-education: principles and practice, London: Springer-Verlag LondonLimited; 2008. p. 271–7.

4.Trowbridge ER, Fenner DE. Practicalities and pitfalls of pessaries in olderwomen. Clin Obstet Gynecol 2007;50:709–19.

5.Komesu YM, Ketai LH, Rogers RG, et al. Restoration of continence bypessaries: magnetic resonance imaging assessment of mechanism of action.Am J Obstet Gynecol 2008;198. 563 e1−6.

6.Patel M, Mellen C, O’Sullivan DM, et al. Impact of pessary use on prolapsesymptoms, quality of life, and body image. Am J Obstet Gynecol 2010;202.499 e1−4.

7.Hullﬁsh KL, Trowbridge ER, Stukenborg GJ. Treatment strategies forpelvic organ prolapse: a cost-effectiveness analysis. Int Urogynecol J2011;22:507–15.

</div>

guideline no 411 vaginal pessary use

Guideline No. 411: Vaginal Pessary Use

T

Tài liệu liên quan

Tài liệu bạn tìm kiếm đã sẵn sàng tải về