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
Hippocrates
 pomegranate
A.D.
 leg binding
 Astringents

David Scott Miller, MD

Contemporary Use of the Pessary
Obstetrics and Gynecology
Vol. 1, Chapter 39, January 1991

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Historical perspective
1500’s
 vaginal hysterectomy
 de Carpi--tied string around prolapsed uterus
1800’s
 uterine malposition
 Hodge
 Smith

 Risser

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 Uses of Pessaries
Genital Prolapse
 Uterine
 Vaginal
 Rectal
 Bladder
Urinary Stress Incontinence
Mixed Incontinence
Cervical Incompetence
Retrodisplacement

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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
Leading edge of Prolapse: Location Leading Edge of Prolapse:
Stage of the Most Distal Point of the
Anterior or Posterior Vaginal Wall
Location of Apex of Vagina or
Cervix
(any points Aa, Ap, Ba, Bp) (Value of Point C or D)
No prolapse: All points are 3 cm No prolapse: Apex of cervix is at a
0 above the hymen (value=-3) position above the hymen that
equals to or is within +/- 2 cm of
vaginal length (value </= (tvl-2))
All points are more than 1 cm
I above hymen (value<-1)

Maximal prolapse point protrudes

II to or beyond 1 cm above hymen
but not more than 1 cm below
hymen (value >-1 to <+1)
Maximal prolapse point protrudes
III beyond 1 cm above hymen but less
than 2 cm less than the total
vaginal length. (value >+1 but <+
(tvl-2))
Maximal prolapse point protrudes
IV 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:
 Cystocele
 Rectocele
 Enterocele

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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 Degree
 Lower back pain
 Pelvic Pressure and Heaviness
 Difficulty Controlling Urine and Stool
 Urinary Urgency

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Symptoms of Prolapse
3rd and 4th Degree Prolapse
 Blockage of Bladder Neck
 Urinary Retention
 Increased Urinary Stress Incontinence
 Palpable 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
1st and 2nd Degree
Prolapse
Ring with or without Support
Shaatz
Regula

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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 Support
Fitting and Removal
Posterior Fornix to the Pubic Notch
Insertion
 Fold and insert
 Make 1/4 turn
Proper Removal
 1/4 turn
 Feel for notch
 Fold and pull down

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 Ring with Support
Fitting 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 Support
Fitting and Removal
Posterior Fornix to the Pubic Notch
Insertion
 Fold and insert
 Make 1/4 turn

Removal
 1/4 turn
 feel for notch and fold
 and pull down

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 Shaatz
Fits 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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 Regula
Fitting 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 Procidentia
Donut
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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 Inflatoball
Fitting and Removal
Squeeze and insert
Pump until firm
Over inflation causes bulge
Secure tubing inside vaginal vault

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 Cube
For 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 Cord
Available with holes
 Bulk not suction

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 Cube
Fitting 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 Cube
Fitting 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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 Gellhorn
Fitting and Removal
Trimo San on leading edge
Hold parallel to introitus
Barber pole twist
Available with short stem
 Approximately ½ inch shorter

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 Pessaries
Urinary Stress
Incontinence
Urinary Stress Incontinence
and/or 1st and 2nd Degree
Prolapse
Incontinence Ring
Ring with (and without) Support and Knob
Incontinence Dish with and without Support
Hodge with and without Support
Hodge with and without Support and Knob
Gehrung with Knob
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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, MD
Professor of Female Urology and Void Dysfunction,
Baylor College of Medicine
Surgical Therapies Favored by Urologists – Sling
American 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 Ring
Fitting 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
junction
Increases
closure pressure
Stress
Incontinence.
Mild Prolapse.

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 Incontinence Dish
Fitting 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
Gehrung
Gehrung with Knob
Hodge with Support
Ring with Support and Knob
Ring with Support
Incontinence Dish with Support

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 Pessaries
Lever Pessaries
Incompetent Cervix
Retrodisplacement

Hodge with Support

Hodge without Support
Risser
Smith

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 Incompetent Cervix
Lever (Hodge) pessary
Secures the axis of the cervix in a
posterior plane
83% successful in several studies of
women at risk of premature cervical
dilation
Insert at 14 weeks; remove at 38
weeks
Cerclage 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 Pessary
Fitting 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 type
 Art - 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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 Pessary
Follow-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 San
 ½ applicator 3 times in 1st week
 Twice 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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 Pessary
Follow-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
growth
Lubricator
Unique Jel-Jector
applicator

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 Reimbursement
New 2001 Medicare Codes
 A4561 – Pessary Rubber , any type
 A4562 – Pessary Non-rubber, any type
 A4560 – Eliminated

Silicone Pessary Reimbursement:

Approx: $44.00
based on area of the country

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 Reimbursement
Change 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

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