K
Popli, P Ranka and K Toop
James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW
E-mail: kiran_popli@hotmail.com
SMJ 2006 53(1): 60
Abstract
Although
corrective surgery is the definitive treatment for uterine-vaginal prolapse,
vaginal pessaries are often used as a non-invasive alternative in the elderly,
in women who are at high risk for medical complications with surgery and in
women who wish to avoid surgery. Complications can occur with use of these
pessaries but are usually rare. We present a case of an impacted shelf pessary,
which required a midline episiotomy and incision of the band of vaginal tissue
under general anaesthesia for its removal.
Keywords: vaginal pessary, complications, entrapment
Case Report
A 92-year-old woman attended the Gynaecology outpatient clinic with complaints of blood stained discharge per vaginum for last two-three weeks. She had a size 10 shelf pessary inserted about nine months ago for utero-vaginal prolapse and had not attended for her follow-up appointment at six months. She was partially deaf and suffered from dementia and peripheral vascular disease. Her carer, who had first noticed the discharge, was accompanying her. On examination, the introitus barely admitted two fingers and the prolapse appeared to be well supported with the pessary. The vaginal tissues were extremely atrophic and bled to touch. A transabdominal ultrasound was performed which showed a thin endometrium measuring 3mm. This ruled out any endometrial cause of postmenopausal bleeding and was reassuring for the patient. Estrogen cream was applied locally and removal of the shelf pessary was attempted in the clinic. However the procedure was extremely painful for her and the pessary could not be removed. In order to prevent complications from the retained pessary, she was booked for its removal under anaesthesia.
On
examination in theatre, the shelf pessary was found embedded in a band of
vaginal tissue posteriorly. A midline episiotomy was given and the vaginal
incision was extended upwards to incise the band of vaginal tissue. The stem of
the pessary was caught with a sponge holder and a finger was inserted in the
space between the posterior edge of the diaphragm of the pessary and the vaginal
wall. With continuous traction on the stem, the suction between the pessary and
the vaginal walls was broken and the pessary removed. After removal of the
pessary, no descent of the cervix was noticed even when it was pulled with a
vulsellum. Perhaps the fibrosis within the vaginal walls was preventing the
prolapse. Hysterectomy was not required and only colporrhaphy was performed
leading to further narrowing of the introitus.
Discussion
Vaginal
pessaries are commonly used for management of utero-vaginal prolapse in the
elderly, in women who are at high risk for medical complications with surgery
and in women who wish to avoid surgery. Pessaries are available in different
shapes, sizes and material but in the UK, ring and shelf pessaries are most
popular. Usually the ring pessary is tried first and shelf pessary is reserved for cases where the ring is unable
to provide symptom relief and falls off consistently.
Although
rare, serious complications can occur with use of these pessaries. These
complications are more likely to occur in the elderly women, in whom the
pessaries are neglected and not well cared for. The chronic irritation with the
pessaries then easily leads to erosion of the hypoestrogenic vaginal walls.
Cases of vesico-vaginal fistulas,1, 2, 3 recto-vaginal fistulas,4
cervical entrapment,5 and bowel evisceration6 have all
been reported in the literature following their use.
To
minimise and prevent these complications it is recommended that the clinicians
undertaking care of such women should have adequate training in selection,
insertion and removal of these pessaries. The patients should be followed up
every 4-6 months and any history of pain, discomfort, discharge or bleeding per
vaginum noted at each visit. The pessary should be removed and vaginal mucosa
examined for any areas of erosion. If erosion is noticed, the pessary should be
kept out and estrogen cream should be applied locally for 3-4 weeks. In most of
the cases, this leads to epithelial healing and the pessary can then be
reinserted.
In
the case presented above, irritation of atrophic vaginal tissues leading to
ulceration, re-epithelialisation and fibrosis was the probable cause for
entrapment of the pessary. The
patient was supposed to get the pessary replaced six months after insertion.
However, she did not attend for the appointment. It is possible that the
entrapment of the pessary could have been prevented if she had been seen
earlier.
Conclusion
This
case highlights the importance of follow-up of patients fitted with a vaginal
pessary.
The majority of serious complications with the pessaries occur in elderly and
demented patients, who are lost to follow-up or miss appointments. We recommend
that these patients should be actively pursued by closely liasing with their
General Practitioner if they fail to attend for any reason. Alternative
surgical therapies should also be discussed again with these patients.
References
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into rectum. Ann R C S Eng 2004; 86:18-19.
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