A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence and to treat pelvic organ prolapse to maintain the location of organs in the pelvic region. It can also be used to administer medications locally in the vagina or as a method of contraception.
Early use of pessaries dates back to the ancient Egyptians, as they described using pessaries to treat pelvic organ prolapse. The term ‘pessary’ itself, is derived from the Ancient Greek word ‘pessós’, meaning round stone used for games. The earliest documented pessaries were natural products. For example, Greek physicians, Hippocrates and Soranus, described inserting half of a pomegranate into the vagina to treat prolapse. It was not until the 16th century that the first purpose-made pessaries were made. For instance, in the late 1500s, Ambroise Paré was described as making oval pessaries from hammered brass and waxed cork. Nowadays, pessaries are generally made from medical grade silicone.
POP (pelvic organ prolapse)
POP occurrence is cited to occur in 30-50% of parous women.(1,2,3)
three main types occur:
- A cystocele, where the bladder (or urethra) deviates into the vagina,
- A rectocele, where the rectum deviates into the vagina and
- A uterine prolapse, where the uterus (cervix) deviates into the vagina.
I purposefully use the word ‘deviate’ as the web of connective tissue supporting the pelvic organs can become stiff in response to injury and cause altered orientation of organs. It is not only a vertical movement that can happen but a shift into any direction. Addressing these restrictions, especially in the post partum population can significantly affect prolapse presentation.
Let’s review THE VAGINA:
Length of a normal vagina (7-10 cm) from the hymen to the posterior fornix.
The size varies with age, estrogen level, number of deliveries, genetics.
It is inclined posteriorly, from the vestibule to the cervix.
The anterior wall is about 3 cm shorter than the posterior wall because of the position of the cervix.
The folds on the walls are called rugae of the vagina and they contribute to its elasticity.
The mucosa is covered with a layer of erectile and muscular tissue.
Quite vascularized, irrigated by the vaginal artery and innervated by the pudendal nerve
Normal PH of the vagina is 3.8-4.5
(according to John De Lancey)
In the distal third of the vagina, the vaginal walls attach to the structures around the paracolpium without the paracolpium itself. Anteriorly, the vaginal wall fuses the urethra and attaches on the tendinous arch of the pelvic fascia.
Posteriorly, the vagina fuses at the perineal body (that is maintained at the ischial pubic rami by the perineal membrane. ) And laterally, it is attached directly on the LA (levator ani)
Damage to the distal third of the vagina causes a urethrocystocele or a rectocele.
If the posterior vaginal wall is stretched, and if the rectovaginal fascia is torn or damaged, it might not be able to prevent the rectum from moving forward and a rectocele could form.
A large rectocele could mask stress urinary incontinence.
Uterocele: We can see or touch the cervix during the vaginal exam
Evaluation of the patient in standing position is important to evaluate the degree of prolapse.
POP is most often related to once- off trauma or repeated strain to the pelvic structures overwhelming muscular and connective tissue support. Examples of the former include prolonged 2nd stage in labour and vaginal birth with surgical assistance from forceps or episiotomy. Cumulative trauma such as breath- holding, repeated heavy lifting with a poor technique, straining when having a bowl movement/constipation and persistent coughing are all common culprits.
Other risk factors include parity (slows down after 2 babies), age, family history of POP and obesity
Presenting complaints include a sense of heaviness or bulging, ‘sitting’ on an egg, the sense of a tampon falling out, delayed initiation of voiding or altered stream and, occasionally back ache.
29% women who have had a 1st surgery will have a second one Beck RP 1983,
50% women with SUI have a POP (anterior) Jackson S et al 1997
Caucasian women (5,4-11%) are more affected by POP than Black and Asian women (0.6-2%).