Transcript The New Age of Pessaries

THE VAGINAL PESSARY
A Practical Approach to the
Management of Pessaries
Helen A. Carcio, NP, MS, MEd
Director, Health & Continence Institute
[email protected]
THE VAGINAL PESSARY
A Thing of Beauty!
WHY CONSIDER THE PESSARY?
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Demand for treatment of POP or UI is projected
to grow by 45% in the next 30 years
Viable alternative to new “high tech” surgeries
 Very effective, low-risk of complications
Equally beneficial for both POP or UI
Satisfaction rate is high – 72-92% report
symptom relief
Prevents problems that occur if left untreated
 Loss of women from the work force
 Increased use of incontinence products
 Increased admission to assisted care facilities
 Emotional toll
PURPOSES
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Supports the vaginal musculature/bladder base in
physiologic alignment
Can provide a permanent solution to incontinence
in women unable or unwilling to have surgical
correction
May improve a prolapse or prevent one from
worsening
May uncover the presence of any hidden
incontinence related to a marked cystocele
Provides a diagnostic means of predicting which
patients would be helped with surgical correction
ADVANTAGES
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Uro-gynecology
 Reduces the symptoms of incontinence
 Supports and corrects retro-displacement of
the uterus in early pregnancy
 Relieves the discomfort of a pelvic organ
prolapse
Pelvic Floor Rehabilitation
 Repositions pelvic structures during pelvic floor
rehabilitation
 Promotes muscle re-education & strengthening
PESSARY CAN SUPPORT A POP
A. Cystocele
B. Rectocele
C. Enterocele
CAUSES OF PROLAPSE
Constipation
 Exercise
 Pregnancy and Childbirth
 Abnormal collagen/connective tissue
 Hormonal factors
 Previous pelvic surgery
NOTE: The pessary works very well but some
behavior modification to decrease causes
is also essential.
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STRESS INCONTINECE: Causes
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Weakened pelvic floor musculature
Intrinsic sphincter deficiency
Increased intraabdominal pressure
Reduced strength of urethral sphincter
NOTE: The pessary ring with knob increases
the closing pressure of the urethra
URGE INCONTINENCE: Causes
Overactive bladder
 Detrusor hyperreflexia
 Cystocele
Note: Pessary works very well to lift and
support a cystocele to allow the bladder to
empty more completely
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WHY WOMEN WON’T DISCUSS
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Consider incontinence or prolapse a normal part
of aging
Fear it is associated with some sort of cancer
Fear institutionalization
Are able to rely on self-management regimes
Feel associated shame and embarrassment
PCP’s fail to inquire about it
Are unaware of conservative treatments
(pessary)
Have had a friend/relative with a pessary and do
not want to be “old like her”
MULTIFACETED APPROACH
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The pessary works very well to relieve symptoms
related to incontinence and POP
Pelvic floor rehabilitation helps stabilize
musculature around pessary
Behavior modification helps reduce episodes of
urgency, frequency, and incontinence
Medications help reduce bladder contractions and
nourish the vaginal mucosa
Combination strategies result in a dramatic
improvement in symptoms
HISTORICAL PERSPECTIVES
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Appears in both Latin
and Greek literature
Many different types
of materials and
shapes
Over 2000 used
throughout history
Fell into disfavor 1020 years ago
Today offers a viable
alternative to surgery
PESSARY FEATURES
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Silicone – FDA approved
 Non-toxic, medical-grade silicone
 Biologically inert - does not absorb vaginal odor
 Pliable
 Can be autoclaved or soaked in Cidex
A few pessaries are made of latex rubber
 Must assess and document any latex allergy
Available in a variety of sizes and shapes
 The outside diameter is measured in inches
with a range of one to four inches
CONSIDERATIONS PRIOR
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Possibility of other
gynecological care and
procedures
Ability of the woman
to manage the
pessary
Extent of sexual
activity
Sexual activity
GYN care
Women’s dexterity
SEXUAL ACTIVITY
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Intercourse is possible
with pessaries that are
not vaginally occlusive
Must have the dexterity
and know-how to insert
and remove as
necessary
Note: Always ask about
sexual activity – never
assume
CONTRAINDICATIONS
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Severe untreated vaginal atrophism
Vaginal bleeding of unknown origin
Pelvic inflammatory disease
Abnormal pap smear
Dementia without possibility of
dependable follow-up care
Expected non-compliance with follow-up
EMOTIONAL BARRIER
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May initially view the pessary as a “foreign
object” which they want no part of
Must begin the “comfort” process
 Allow to handle the pessary
 Talk to other women who have one
Need to understand the proper care
Explain that the properly fitted pessary
should not be felt
It will soon become their “best friend”
THE LEARNING CURVE
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Insertion technique requires patience and
practice
May initially feel insecure about which types to
use since there are so many to choose from
There are a variety of pessaries that could work
for any given condition; on the other hand………
There are a variety of conditions where a pessary
will not fit correctly or correct the problem
Use should progress from the simple to the
complex
The majority of urogynecologists use the ring
with support and knob
THE EVALUATION
Pelvic Examination
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Determine the extent of the
pelvic support problem
Assess degree of incontinence
 Simple CMG
Rule out any pathology
 Pap smear
 Wet mount
Assess estrogen status
 Wet mount
 Vaginal pH
PELVIC ORGAN PROLAPSE
QUANTIFICATION EXAM
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Measures the descent of the anterior, apical
and/or posterior portions of the vagina
Records vaginal length and width of the introitus.
Uses centimeters with reference to the hymen
when performing the Valsalva
Negative numbers: Distance above the hymen
Positive numbers: Distance of prolpase
protruding beyond hymen
May simply grade the prolapse from 1 to 3
PATIENT PREPARATION
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Advise woman to arrive with her rectum
as empty as possible
Have her void immediately prior to fitting
Reinforce the “trial & error” nature of
pessary fitting
Allow woman to examine and hold pessary
prior to insertion
The fitting process itself maybe a little
uncomfortable
SOME THOUGHTS
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No need to recreate pelvic anatomy…want
to just keep inside
Don’t memorize which pessary to use with
which condition; start with the simple ring
Some possible predictors of pessary
failure
 Short vaginal length
 Wide introitus
 Posterior-wall defects
 Patients who desire surgery
SUPPORT PESSARIES
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Start with a trial of a support pessary
Most women will do well with the ring
with knob. Additionally, the membrane will
support any prolapse
The next few slides will show the insertion
and removal technique using the ring
since it would be impossible to outline all
the pessaries
THE RING with KNOB
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Often referred to as
the “incontinence
ring” since it works so
well for stress
incontinence
Available with
membrane to support
prolapse
Has holes for drainage
Knob applies pressure
to the urethra against
the pubic bone
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Very easy to insert
and remove
SPACE FILLING PESSARIES
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If unsuccessful, progress to space-filling
pessaries (donut, cube)
 More difficult to insert and remove
 Usually require provider assistance for
cleaning
 May have to be removed more often due
to drainage issues
 Work well in women who have both a
cystocele and rectocele
THE FITTING – “TRIAL & ERROR”
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There are many different sizes and shapes of
pessaries to fit the many different sizes and
shapes of a woman’s vagina
The examiner should become comfortable with
a single pessary and then progress to others
Must educate the woman that it may take a
series of visits to ensure an adequate fit
Pessary should be large enough for its
designed function but small enough to prevent
any discomfort
LUBRICATION
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Avoid lubricating the pessary itself
Mix Xylocaine gel (50-50) with lubricant
Generously lubricate the vaginal introitus
with non-dominant hand
Grasp pessary with the non-lubricated
hand in order to keep a firm hold
As an alternative may lubricate the
leading edge of the pessary
FITTING A PESSARY
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The pubic bone is an important landmark.
 The pessary should fit snugly behind it.
 There is less chance of expulsion if thus anchored
Uterine Prolapse (if present)
 Insert two fingers in the vagina to push any
uterine prolapse back into place
 Place opposite hand on abdomen and push on
the fundus (if present) to hold in place
 Reduce any cystocele or rectocele prior to fitting
Put in largest size that will fit comfortably, or
simply tuck a smaller pessary well behind the
pubic bone
TEST PRIOR TO FITTING
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Insert two fingers into the vagina
Extend fingers to either side of the vaginal
fornices
Keep fingers extended and pull through
introitus
If you must close your fingers to get them
out a pessary will probably be retained
MEASURING THE WIDTH
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Insert first two fingers
of dominant hand
deep to the posterior
fornix
Approximate size by
using the fingers to
determine the width
Spread fingers wide to
measure
Remove fingers and
compare to pessary
sample or fitting kit
FITTING KIT
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Bioteque Fitting Kit
 Attractive package
 Contains 6 rings
 Approximates
proper fit
 Useful for fitting
most round
pessaries
 Actual fit will vary
with the type of
pessary inserted
MEASURING THE LENGTH
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Reinsert fingers
deep into the
posterior fornix
Make note of where
the hand comes
into contact with
the pubic bone
Compare to
pessary.
I
d
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n
INSERTION TECHNIQUE
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Remove and compare width to pessary
sample
Fold the chosen pessary at the notches with
concavity facing downward
Separate the labia minor posteriorly at the
introitus with the non-dominant hand
Hold folded pessary firmly and insert through
the introitus by curving it posteriorly
INSERTION TECHNIQUE
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Slide it into the vagina, and curve posteriorly
Release and allow to spring open to its
normal shape
Push deep into the vaginal vault
Tuck securely behind pubic bone anteriorly
and under the cervix (if present) posteriorly
INSERTION
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Should be able to sweep the tip of one
finger around the pessary
Insert a finger tip into one of the larger
holes and rotate the pessary until the
knob is behind the pubic bone, at the level
of the urethra
This helps to stabilize the urethrovesicular
junction
Assess comfort
FITTING – SOME THOUGHTS
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Can be tricky – want to fit with the smallest
pessary that can be easily inserted but can also
come out with the least amount of difficulty
Many women with incontinence have had a
hysterectomy, and have no cervix to act as an
anchor
When the support pessary is placed properly, it
will take up redundant vaginal tissue, forming a
sling that will support and elevate the uterus
and flatten and support a cystocele
POST-FITTING
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Separate labia to observe introitus
Note any visible pessary or prolapse
Ask the woman to bear down (Valsalva) while
observing for any descent
Inquire if woman feels pessary
Ask to walk around room, sit up and down
Have her stand in front of you with her legs
spread (explain that it may feel awkward for
her).
POST-FITTING
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Allow her to hold onto your shoulders for
stability.
Reach into the vagina and ask her to bear down.
Note any descent of the pessary.
Separate labia and observe for any visible POP or
pessary
Assist to bathroom to assess ability to urinate
Reassess upon return
Inquire as to comfort
FINAL CHECK
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Reinforce that she may experience some
discomfort for a day or two until the pessary
“settles in”
Inform that some of the discomfort may be from
the fitting process and not from the pessary
Advise to call should urination or defecation
become difficult
Remember this is a NEW experience for her.
Acknowledge that.
VAGINAL ESTROGEN
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The majority of older women with a pessary need
vaginal estrogen
The Estring works nicely since it also needs to be
changed every 3 months
Estrogen use keeps the vagina healthy and
eliminates the need for regular douching
Estrogen thickens the layer of the vaginal mucosa
allowing for more support of the pelvic organs.
Monitor estrogen status using pH paper to test
for alkalinity
FIRST FOLLOW-UP VISIT
 Individualized. Most elderly women prefer to
have their clinicians responsible for the care
 Need to return within 1-3 days of pessary fitting
 Return earlier
 Should pessary become uncomfortable
 If urination or a bowel movement is difficult
 If pessary falls out or becomes displaced
RETURN VISIT
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Recheck the size – may go smaller or
larger
Ask about any change in elimination
pattern
Observe for a vaginal tissue reaction such
as discharge, irritation, odor, or ulceration
Determine if there has been any
improvement in symptoms
 May uncover the presence of “hidden”
incontinence
SUBSEQUENT VISIT
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Return in one month, and gradually lengthen
to every 2 to 3 months
Instruct the woman to return earlier if any
odor, discomfort, or abnormal discharge
Reinforce that proper follow-up is important
since most women have limited sensation in
the vagina and may not be physically aware
of any ulcerations
A list should be kept of pessary users and
their expected date of return
REMOVAL: General Considerations
What goes in must come out!
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Removal is much more difficult than
insertion since the pessary cannot be
folded easily for withdrawal
Lubricate introitus well with non-dominant
hand, keeping the other hand dry
Sweep fingers around pessary to loosen
the pessary and to break mucosal seal
REMOVAL
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If hard to remove - simply grasp and pull
with dominant hand, guiding and
collapsing the pessary with the other
Upon removal, observe the pessary for
any signs of discoloration, discharge, or
odor. Some discoloration is normal
Perform a speculum examination to
determine the presence of any erosion
Note the estrogen status of the vagina
PESSARY REMOVER
Able to hook pessary for easier withdrawal
REASSURANCE AND SUPPORT
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Pessary use is a whole new experience for
a woman
Allow her time to express any concerns or
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questions
Reassure her that most women soon
become very comfortable with the idea of
a pessary
COMMON SIZES
Type of Pessary
Size
Ring with support
#1-4
(2.00-2.75 inches)
Ring w/ Knob,
Gehrung, and Cube
#2-5
(2.25-3.00 inches)
Donut
#1-4
(2.25- 3.00 inches)
Gellhorn
#3-6
(2.25- 3.00 inches)
REASONS FOR DISCONTINUING
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Inconvenient to use
Inadequate relief of symptoms *
Uncomfortable *
Elected for surgery
Unable to remain in place *
Difficulty urinating or having a bowel
movement *
Incontinence increased *
•A DIFFERENT size or shape pessary should be offered
COMPLICATIONS
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Increase in vaginal discharge
Odor
Cytologic atypia
Ulcerations
Pelvic discomfort
Incarceration
 Scar/granulation tissue may form around
pessary
Complications are rare in the properly fitted and
well maintained pessary
SELF CARE VS. OFFICE VISIT
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Assess desire and ability of the woman to care for
her own pessary
The woman must feel comfortable touching own
genitals
Allow a woman 10 to 15 minutes to practice
insertion and removal on her own. Leave handwashing materials at her disposal
Prior use of diaphragm increases the likelihood of
a woman’s ability to care for her own pessary
Observe dexterity
Evaluate compliance issues and ability to perform
self-care
PRECAUTIONARY NOTE
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Must maintain a list of all patients with
pessaries
List times of follow-up care
Do not use in a woman who cannot care
for herself or come in for routine care
Any caregiver needs to know the
requirements for follow-up care
 Women should wear a medic alert bracelet
 See www.medids.com/phorm/phorm.php to
order
DESCRIPTION OF VARIOUS
TYPES OF PESSARIES
DONUT
The Donut Hole
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Description: soft silicone,
donut shaped. (gives a
whole new meaning to the
donut!)
Indications:
 Occludes upper vagina
and supports a uterine
prolapse
 Useful for cystocele or
rectocele
 Good for prolapse of the
vagina after a
hysterectomy
 Adequate integrity of
the introitus is
necessary for the
pessary to remain in
place
DONUT: Insertion
Separate vagina with
nondominant hand and
press down on the
perineum.
Compress the donut – it is
somewhat rigid so does
not compress easily.
Hold the pessary parallel
to the introitus and
push past the introitus,
into the vagina.
Sweep fingers around the
donut to feel smooth
sides well within the
vagina.
Downward pressure on the perineum
DONUT: Removal
Insert fingers into the
vagina to grasp the hole
in the center of the
donut.
Compress the donut using
the thumb and middle
finger and bring them
parallel to introitus.
Gently pull down and out
of the introitus.
DONUT: A New Technique
The donut is round and smooth
and if it easily slips in, it just
as easily can slip out.
It is relatively soft and can be
compressed somewhat but
often not enough.
Deflation: Using a 20 cc syringe
and large gauge needle,
puncture the donut and
remove as much air as
possible to compress it
further.
Insert as instructed.
Next, insert needle in donut to
re-inflate. This technique
actually works very well.
Note: this technique is not
recommended by the
manufacturer since the
integrity of the pessary is not
guaranteed once it has been
punctured.
CUBE
Indications: Third-degree
prolapse, cystocele or
rectocele, with or without
good vaginal tone.
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Drainage holes
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Description: Each side of the cube has
concave suction cups that adhere to the
vaginal walls, helping to restore anatomical 
support to the pelvic organs.
Often this is the only
satisfactory support for
women with a complete
prolapse, complicated by a
cystourethrocele.
Excellent for vaginal wall
prolapse in that it keeps the
vaginal wall from collapsing
from its six pressure points.
Maybe used by an athlete and
removed after exercise.
Mucosa molds to the
concavities creating a
negative pressure
CUBE
Some thoughts:
If changed by the woman,
removal requires high
motivation with good
dexterity.
Needs to be changed often
since the cube completely
fills the vagina and blocks
off drainage. Cube has
holes that work well for
days to weeks but will
eventually become
clogged.
The longer it is left in place
the more complete the
suction and the more
difficult removal.
CUBE: Insertion
Spread the labia with the nondominant hand.
Compress the cube and hold
parallel to the introitus and
insert the corner through the
vaginal opening.
Basically, the cube needs to be
pushed through the opening.
The tail should be oriented
toward the vaginal opening.
Once behind the pubic bone,
push as high in the vagina as
possible.
Note compression of cube
CUBE: Removal
Removal may be difficult
because of the suction the
cube has created.
Attempt to break the suction
on all sides before removal
by sliding fingers around
the cube.
Do not pull on the tail to
remove.
Compress cube and pull out
through the introitus
If unable to remove, insert 5
mL of lidocaine jelly into
the vagina and sweep
around cube as much as
possible to dispel the jelly.
Visualize the pessary by
spreading the labia as
wide as possible with the
non-dominate hand.
Grasp the corner of the
pessary with a ring forceps
Apply gentle traction and pull
down and out, assisting
the removal with the
opposite hand.
INCONTINENCE DISH
Membrane support
The knob
Description: Dishshaped pessary with
holes to allow for
drainage. The flexible
membrane of the dish
supports and elevates
a mild cystocele.
Indications: SUI in
conjunction with a 1st
or 2nd degree
prolapse, or a mild
cystocele.
DISH: Insertion
Compress the side of the dish
with the knob at the apex.
Spread the labia with the
non-dominant hand
Lubricate the presenting edge
of the knob
Insert into the vagina while
folded
DISH: Proper Fit
The dish fits securely in
the vagina supporting
the uterus and
bladder anteriorly
Note: the knob supports
the urethra to
decrease any
incontinence.
The Knob
DISH: Removal
Perform a pelvic examination to assess the position
of the dish. Note the location of the knob
Grasp flexible dish with dominant hand and pull
toward introitus
Spread labia with opposite hand
Pull down and out of vagina
SHAATZ
Description:
A circular pessary with
holes for drainage of
secretions.
Indications: For the
support of a first or
mild second-degree
prolapse.
SHAATZ: Insertion
Measure the length of the
vaginal canal against the
examining finger. Mark
with thumb. Compare to
pessary.
Lubricate the tip.
Bend pessary in half at the
notches.
Insert the ring into the
posterior fornix (and
behind the cervix if
present)
Spread the labia with the
non-dominant hand. Place
superior to the introitus.
Release and allow it to open
to its normal shape.
Fold the ring in half so that
the leading edge of the
formed crescent points in
a downward direction
Tuck behind pubic bone.
Give pessary a quarter turn
to secure in place
SHAATZ
Presenting edge pointed downward
Position without uterus
GEHRUNG
Description:
U-shaped device that provides
support to the anterior
vaginal wall. The arms or
heels rest flat on the vaginal
floor
It avoids pressure on the rectum
while supporting the anterior
wall
Arclike – malleable-can be
shaped to suit the shape of
the vagina
Shape can be expanded once
inserted, a distinct advantage
Creates a “bladder bridge”
Heel
Arch
May be underutilized
GEHRUNG: Insertion
Perform a normal pelvic
examination
Fold with the arch convexity
oriented upward, with both
heels parallel to the pelvic
floor, left heel first.
Hold device on its side, and
insert the lateral bar over the
introitus and insert into the
vagina.
When in the vagina, push one
heel back and the other
forward to complete a 90degree rotation, so that the
convex curved portion lies
against the anterior wall.
Once inside the vagina the heels
can be spread further apart to
decrease chance of expulsion.
Left Heel
GEHRUNG: Proper Placement
The back of the arch should
be positioned over the
cervix if present, in the
anterior fornix, and the
front of the arch, behind
the symphasis pubis.
Both heels should be resting
on the bottom of the pelvic
floor with the arch and
cross-support forming a
bridge to raise the bladder.
Heels on pelvic floor
GELLHORN
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Holes for drainage
Description: Most commonly
used pessary for uterine
prolapse, also helpful with
SUI. Fits superiorly and
anteriorly.
Indications: Provides
support for third-degree
uterine prolapse and
procidentia.
Provides less support for a
rectocele since there is less
support of the posterior
segment.
A CLOSER LOOK
Hole for irrigation
Knob
Holes for drainage
Area to grasp for
removal
Disk
Note: the knob is flexible enough to be folded
back against the disc for insertion.
GELLHORN: Other Thoughts
Base is large enough to
support the tissue
proximal to it.
Concave shape provides an
anchor, helping to
prevent spontaneous
expulsion.
Should the gellhorn
become displaced
downward during a hard
bowel movement, the
woman can simply push
the knob back inside.
Stem fills the vagina
preventing it from turning.
May be difficult to insert in
women with a narrow
introitus
It is the hardest pessary to
remove, other pessaries
for similar conditions
should be tried first.
Can work VERY well!
GELLHORN: Insertion
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Grasp gellhorn with non-lubricated hand and
bend the stem portion against the disc.
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Insert sidewise with the disc portion held parallel
to the long axis of the introitus.
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Apply downward pressure to the perineum with
the opposite hand, being careful to avoid the
urethral opening.
Insert the pessary using a cork-screw motion
until the disc lies transversally in the vagina.
Once the disc lies within the vagina, push
posteriorly until the end of the stem slips within
the orifice
Position
With a Uterus
Gellhorn in position
Without a Uterus
GELLHORN: Removal

Using the non-dominant hand, reach inside the vagina to grasp the
knob. Loop 2nd and 3rd fingers around the bulb of the knob.

Pull toward thumb and grasp with thumb and fingers. Pull
laterally.

With the dominant hand, reach deep inside the vagina and slide
fingers behind the edge of the disc to release the suction.

Turn the disc so that it is nearly parallel with the introitus.

Pull both hands together as the gellhorn is bent toward itself.

Pull downward on the perineum to ease the pessary out of the
vagina.

Removal can be very difficult as the loose vaginal tissue can
collapse in front of the arc of the base, making it hard to break the
suction.
An Advance Removal Technique
For a difficult removal, slip an instrument such as a
tenaculum through the introitus and grasp the knob of the
gellhorn
Pull down and out while the other hand reaches behind the
arc to release the suction of the disc
Collapse together and remove
May also try flushing water through the hole in the knob with
a syringe in order to break the seal
HODGE
Description:
The anterior notch prevents
urethral impingement and
obstruction.
Available with support for the
bladder in patients with
stress incontinence.
If properly fitted sexual
intercourse is possible
Notch
Support for
cystocele
Malleable
HODGE
Indication:
Uterine retroversion to
reposition the cervix and
uterus
Incompetent cervix in
pregnancy.
Mild uterine prolapse with
retroversion
Diagnostic evaluation of
patients with large cystocele
or SUI – demonstrated
support of the anterior
vagina.
Provide support to the proximal
urethra, promoting increase
in urethral function length
and closing pressure without
causing obstruction.
Useful for SUI
HODGE: Insertion
Manually elevate a
retrodisplaced uterus if
present.
Fold the device along the long
axis, with the curved end
oriented toward the
introitus.
Push into the vagina using the
index finger, advancing the
posterior bar into the
posterior vaginal fornix.
Keep pressure on the posterior
bar during insertion, sliding
it underneath the cervix.
Anchor the anterior bar under
the symphysis pubis.
.
MAR-LANDS Pessary
Unique flexible support
Description: Soft, round disc
with unique flexible
support for the urethra
Indications:
For control of SUI or a first or
mild second-degree
prolapse
Unique concept
Membrane with holes for drainage
MAR-LANDS: Insertion
Fold the pessary so that the back ring of the pessary
(opposite the supportive sling) collapses the membrane
sling.
Insert the leading edge of the cresent through the introitus in
a downward direction.
Push below the cervix (if present) into the posterior fornix.
Release to normal shape.
Position so the membrane portion is positioned to support the
bladder.
RING - with and without support
Description:
Round flexible ring.
Helps support the urethra and
bladder neck.
Membrane provides additional
support for a cystocele.
Support
Indications:
Useful for a first or mild
second-degree uterine
prolapse associated with a
mild cystocele.
Note: Instructions for use of the ring with knob are in Part 1
RING
Commonly used
Simple to fit, insert and
remove
Easily managed by the
patient
Recommended for use in the
women who is sexually
active since it can easily
be inserted and removed,
or may remain in place
during intercourse (as
compared to the size of a
diaphragm.)
Comes in an oval size to give
more fitting options in a
deep vagina.
If cystocele or rectocele is present
use ring with support
RING: Insertion
Measure the length of the vaginal
canal against the examining
finger. Mark with thumb.
Compare to pessary.
(May also use the fitting kit)
Bend pessary in half at the
notches.
Spread the labia with the nondominant hand place superior
to the introitus.
Fold the ring in half so that the
leading edge of the formed
crescent points in a downward
direction
Lubricate the tip.
Insert the ring into the posterior
fornix
Release and allow to spring open
Tuck behind pubic bone
Give a quarter turn to secure
in place
RING: Removal
Perform a normal pelvic
examination to assess
the position of the
pessary.
If this is not possible, grasp
2nd and 3rd finger and
rotate parallel to introitus.
Palpate the indentations
and rotate to bring into
position.
Pull gently and evenly to
remove.
Note any odor or discharge
on pessary.
Attempt to fold in half.
Perform speculum
examination to observe for
any ulcerations.
TEAMWORK


Front desk
 Maintains list of
pessary users
 Arranges routine
care and cleaning
Triage
 Answers questions
and concerns
MORE INFORMATION





You can find updated information at
www.hc-institute.com or www.bioteque.com
Consider establishing a Bladder Health Center to
enhance your pessary program, with an
estimated revenue of over $250,000 per year
Information on courses available on the
hc-institute web-site
Email Helen Carcio at [email protected]
with any questions
This slide presentation is copyrighted and is the
sole property of the Health & Continence Institute
in partnership with Bioteque