Setting up a Vaginal Pessary Service within a Physio Clinic By - PowerPoint PPT Presentation

Setting up a Vaginal Pessary Service within a Physio Clinic By Liana Johnson

Historical Overview – Vaginal pessary use dates back to 5 th century. – A variety of materials have been used as pessaries: – Pomegranites

Crocodile Dung

Porcelin, Metal, Sea sponges

and potatoes A patient reported a two-week history of a vine growing from her vagina. On physical examination it was discovered that she did have a vine growing out of her vagina, about six inches in length. A pelvic exam revealed a mass which was easily removed from the vaginal vault, vine still attached. Upon extraction, the patient reported that her uterus had been falling out and that she “put a potato in there to hold it up” and subsequently forgot about it.

Clients who would benefit from this service – Ante and Post Natal clients presenting with POP – Symptomatic POP (bother over 4/10) – Women awaiting vaginal surgery – POP +Urinary incontinence – Women too high risk for vaginal surgery – Intermittent use for exercise or or physical occupation – Failed vaginal surgery – Women who prefer conservative management

Do Pessaries Work? What is the Evidence! – Pessaries are a safe and effective treatment option for POP (Sitavarin et al 2009) – Significant decrease in Genital Hiatus size after 3mths pessary use (Jones et al 2008) – Vaginal pessaries are effective in alleviating POP symptoms. (Fernando et al 2006) – A Cochrane Review (2013)found only one RCT on efficacy of pessaries in POP. This study showed a 60% efficacy rate but was methodological flawed.

Contraindications to pessary use – Vaginal infection – Severe erosion and ulceration of vaginal walls – Allergy to silicone or latex – Failure to adhere to follow-up – Pelvic Cancer associated with POP symptoms – Non compliance – Vaginal mesh

Compliance – Pessaries manage symptoms. – Pessaries are not a long term solution for most pts – Patient needs a significant Bother factor. – Education is essential. – Willingness to use vaginal oestrogen if post menopausal – Success rates vary bet 41-71%. 62% with advanced POP and 53% over 3 years, (Jones etal2010)

Factors predisposing to a less successful fitting – Short vaginal length <6cm – Wide vaginal introitus >4 fingers – Post vaginal prolapse surgery – Severe posterior vaginal prolapse – Severe SUI – Weak PFM’s – Avulsion of puborectalis at pubic symphysis

Education Equipment needed to set up a Pessary Service - Written information - Pelvic diagrams - Models - Selection of pessaries for patient to feel

Pessary Station

Equipment needed for Pessary Service – Pessary Station should ideally be set up beside a sink – Pessary fitting sets – Selection of most commonly used pessaries – Bottle of Clinidet solution – Plastic container to soak fitting pessaries before autoclaving – Medical Sterilization bags – Container to place washed and bagged pessaries ready for autoclave System for autoclaving pessaries – – Pessary Autoclave Record book

Pessary Fitting Set

Follow up Document – Patients details eg Bradma – Description of prolapse, pessary (size, make and shape) – Statement asking for pelvic examination to exclude serious pathology – List options for management – List options for vaginal oestrogen use – 3 copies of this document are made (notes, patient, GP/specialist) – Patient details are put on clinic pessary data base

Patient Pessary Pathway – Initial Consultation- pessary is mentioned as a management option (unless pt referred specifically for pessary fitting eg specialist, PF physio) – Review consultation- Education phase- tampon, models, pessary intro – Pessary fitting session- pessary in situ for 7 days – Informed consent – Review 7days later to teach self management and discuss follow up – Continued follow up individualized with patient

Pessary Fitting – Sizing- vaginal width and length – Most common sizes are 2,3,4 – Most commonly used pessaries are ring and ring support – Ask patient to empty bladder before fitting pessary Use fitting set pessaries to determine correct size – – Should be able to comfortably fit 1 finger either side of pessary – Ask patient to stand, squat and cough – View position of pessary in standing – Replace fitting pessary with permanent pessary

Self- Management – It is advisable if possible for patients to self-manage ring pessaries – Special care must be taken when removing specialized pessaries – It is not advisable to self manage Gellhorn pessaries – Nightly or twice weekly removal is recommended – The pessary is removed in lying or standing(with one foot on a stool) – Finger slides inside vagina, hooks over pessary and draws pessary out Pessary is washed and stored in a snap lock bag – – To replace: fold pessary, put lubrication on top of fold and slide in – Use finger to push pessary as high as possible and slightly twist

Most Common Complications – Vaginal infection/thrush – Pain in vagina due to pessary slipping – Difficulty emptying bladder /bowel (ask patient to empty bladder before leaving clinic. Could also do bladder scan) – Vaginal rubbing /ulceration – Increase in urinary incontinence

Serious less common complications – Bacterial vaginosis – Cervical incarceration – Impacted pessaries causing vesicovaginal fistulae or rectovaginal fistulae

Avoiding serious complications – Appropriate sizing and fitting – Use of vaginal oestrogen when necessary – Careful follow up

Frequently asked questions – Can I use my pessary when menstruating? – Can I have intercourse with my pessary in? – Can I do high impact exercise now I have a pessary? – Can I use a pessary if I am pregnant? – Can I continue to use a my Stims machine with my pessary in?

Ring and ring support pessaries- most common-1 st degree uterine/ mild cystocele

Oval with or with out support, 1 st uterine/mild cystocele-inhibits rotation in women with PH vaginal surgery

Gellhorn short/long stem- cystocele/rectocele 2-3 rd degree uterine

Dish with knob +/- supp- cystocele/rectocele,2-3 rd uterine,SUI

Donut & Cube – cystocele/rectocele, 2-3 rd degree uterine- women with large introitus

Marland +/-supp- cystocele/rectocele,2- 3 rd degree uterine, SUI

Dish +/-support- cystocele/rectocele, 2-3 rd degree uterine, SUI

Where To From Here – There is a need for more RCT’s to be conducted – Pessary courses to upskill clinicians – Mentoring and brainstorming between clinicians – Updated education material for patients to become more informed – Upskilling of GP’s to enable easy removal of pessaries and speculum follow up for patients

Was it worth it – A resounding YES – Pessary fitting is a service that has been an educational journey for us as clinicians, has increased our skill base, extended our scope of practice and benefitted many of the women we see with debilitating vagina prolapse. – Please feel free to contact me if you have any questions or thoughts regarding pessaries Liana Johnson 9724 9755 – Acknowledgements : Pessary Guidelines 2012. Sayco