[Safety and acceptance of self application of cubic pessaries and urethral ring pessaries]

OBJECTIVE

Flexible cubic and ring pessaries with a suburethral thickening are devices for the treatment of genital prolapse and urinary stress incontinence. Threads attached to the pessary enable overnight self-removal and self-application. Little is known about the safety and women's acceptance of these devices.

METHODS

Eighteen women (age 36-85 years), 9 of them with failed surgery, tried this therapy (cubic pessary n = 6; ring pessary n = 12). The size of the pessary was chosen clinically. All patients were seen after a week and then monthly.

RESULTS

All women showed up after 1 week. Twelve of 18 women felt comfortable with these devices at that time. During follow-up, 5/18 women wanted surgical therapy within the first 2 months, 3/18 refused the device later, 1/18 was lost to follow-up and 9/18 patients continued pessary therapy for a mean duration of 11 months. During 107 treatment months, only 2 mild complications were observed without the need to intervention (mild vaginal erosion, spotting).

CONCLUSIONS

Pessary therapy is safe but has a dropout rate of approximately 50%. It can be an efficient alternative method in motivated women.

Self-reported uterine prolapse in a resettlement colony of north India

The aims of this study are to estimate the prevalence of self-reported uterine prolapse and to determine the treatment-seeking behavior of the respondents. Participants of this study are married women of Dadu Majra colony, Chandigarh, India, January-February, 1996. A house-to-house screening of the women was done by a nursing student utilizing a checklist of indicator symptoms of uterine prolapse. All women reporting such symptoms were interviewed further. Among the 2,990 women surveyed, 227 (7.6%) reported symptoms of uterine prolapse. Of the 227 women with self-reported uterine prolapse, 128 (57%) had not taken any treatment, 28 went to a traditional birth attendant (TBA), and 47 (21%) consulted a doctor. Thirty-eight women were advised to have an operation, but only eight complied. Other treatments used by small numbers of women included the use of a ring pessary or alcohol-soaked swab and heel pressure technique. Reasons for non-consultation included shyness (80; 63%), lack of cooperation by the husband, lack of time (80; 63%) and lack of money (74; 58%). The prevalence of prolapse was significantly higher in women with higher parity. More than 7% of the women reported symptoms of uterine prolapse.

Review of vaginal pessaries

Pessaries have been used to treat pelvic organ prolapse throughout history, although with advances in the field of anesthesia and in surgical technique during the past century, pessary use declined. Current indications for pessary use include women awaiting definitive surgical repair, treatment for an unsuccessful surgical repair, treatment for women who are not surgical candidates, and for those who prefer medical management. In addition pessary use is gaining popularity among women with stress urinary incontinence, as well as in younger women interested in maintaining child bearing capabilities. Neonatal pelvic organ prolapse has also been treated successfully with pessaries. Many physicians have limited experience with pessary selection and fitting. This review article attempts to provide a basic overview of pessary selection and management.

Antimicrobial mesh versus vaginal wall sling: a comparative outcomes analysis

PURPOSE

We prospectively compared transvaginal antimicrobial mesh (MycroMesh*) and anterior vaginal wall slings using an outcomes analysis.

MATERIALS AND METHODS

Between August 1997 and November 1998 we implanted transvaginal slings in 40 consecutive women randomized to a synthetic mesh (20) or vaginal wall (20) group. All patients had documented stress urinary incontinence on preoperative urodynamics. We prospectively compared postoperative outcomes data obtained from pelvic examinations, cough stress test, cotton swab test and validated patient questionnaires using a visual analog scale.

RESULTS

Complete followup was available in all patients. Mean followup was 22 months (range 12 to 27). Stress incontinence was cured in 95% of the mesh and 70% of the vaginal wall group, and pelvic prolapse was cured in 100% and 95%, respectively. Transient de novo urge incontinence was noted in 12.5% of the mesh and 14.3% of the vaginal wall group. Mean postoperative cotton swab angle during Valsalva's maneuver was 20 and 45 degrees for the mesh and vaginal wall groups, respectively. The incidence of urinary retention and tissue erosion was 0% for both groups. The satisfaction rate was 100% and 80% for the mesh and vaginal wall groups, respectively.

CONCLUSIONS

The antimicrobial MycroMesh sling was superior to the vaginal wall sling for correction of stress incontinence and pelvic prolapse with comparatively low morbidity.

A survey of pessary use by members of the American urogynecologic society

OBJECTIVE

To describe trends in pessary use for pelvic organ prolapse.

METHODS

An anonymous survey administered to the membership of the American Urogynecologic Society covered indications, management, and choice of pessary for specific support defects.

RESULTS

The response rate was 48% (359 of 748). Two hundred fifty surveys were received at the scientific meeting and 109 were returned by mail. Seventy-seven percent used pessaries as first-line therapy for prolapse, while 12% reserved pessaries for women who were not surgical candidates. With respect to specific support defects, 89% used a pessary for anterior defects, 60% for posterior defects, 74% for apical defects, and 76% for complete procidentia. Twenty-two percent used the same pessary, usually a ring pessary, for all support defects. In the 78% who tailored the pessary to the defect, support pessaries were more common for anterior (ring) and apical defects (ring), while space-filling pessaries were more common for posterior defects (donut) and complete procidentia (Gellhorn). Less than half considered a prior hysterectomy or sexual activity contraindications for a pessary, while 64% considered hypoestrogenism a contraindication. Forty-four percent used a different pessary for women with a prior hysterectomy and 59% for women with a weak pelvic diaphragm. Ninety-two percent of physicians believed that pessaries relieve symptoms associated with pelvic organ prolapse, while 48% felt that pessaries also had therapeutic benefit in addition to relieving symptoms.

CONCLUSION

While there are identifiable trends in pessary use, there is no clear consensus regarding the indications for support pessaries compared with space-filling pessaries, or the use of a single pessary for all support defects compared with tailoring the pessary to the specific defect. Randomized clinical trials are needed to define optimal pessary use.

Obstetrical emergencies

This article discusses different techniques that can be used in the diagnosis and treatment of obstetrical emergencies. Female reproductive emergencies commonly encountered by small animal practitioners include pyometra, dystocia, cesarean section, mastitis, eclampsia, uterine torsion, and uterine prolapse. A thorough knowledge of normal and abnormal reproductive behavior will aid the emergency veterinarian in successfully managing such cases. Timely diagnosis and treatment of these emergencies will often give a good outcome.

Practical use of the pessary

The pessary is an effective tool in the management of a number of gynecologic problems. The pessary is most commonly used in the management of pelvic support defects such as cystocele and rectocele. Pessaries can also be used in the treatment of stress urinary incontinence. The wide variety of pessary styles may cause confusion for physicians during the initial selection of the pessary. However, an understanding of the different styles and their uses will enable physicians to make an appropriate choice. Complications can be minimized with simple vaginal hygiene and regular follow-up visits.

Continuous ambulatory peritoneal dialysis and uterovaginal prolapse

It has been estimated that 50% of parous women have some degree of genital tract prolapse and that 10–20% of these cause symptoms. Approximately 20% of women on gynaecological waiting lists for major surgery have prolapse and this rises to 60% of elderly women undergoing major gynaecological surgery (Cardozo, 1995). As the condition is very common it is extraordinary that there is so much uncertainty regarding the natural history of genital tract prolapse.

[Genital prolapse]

The prevalence of genital prolapse in women is unknown. The development of prolapse is dependent on the pelvic floor muscles and connective tissue. Risk factors are vaginal birth, obstipation, high abdominal pressure and surgical procedures. Preventive measures are discussed. The classification of prolapse is somewhat difficult. Conservative treatment with pessaries and pelvic floor muscle exercises and various surgical procedures are discussed.

Intravesical foreign body and vesicovaginal fistula: a rare complication of a neglected pessary

A silicone Gellhorn pessary, 3 inches in diameter, neglected for several years in an elderly woman, eroded through the anterior vaginal wall, ultimately to lie entirely within the bladder. General anesthesia and bilateral deep full-length Schuchardt's incisions were required to remove it. A Latzko procedure was done at a later date to close the large vesicovaginal fistula; similar Schuhardt's incisions were again used.

[Present views on treatment of genital prolapse]

The uterine and vaginal descent create multidisciplinary issue. Its consequences interfere in gynaecology, urology, geriatrics, general medicine and psychiatry. Collateral symptomatology, pathology of the anatomy, diagnostics, both conservative therapy and surgery are discussed. The author mentions the abdominal and vaginal approach, being most experienced with the latter. Prevention is seen shortening of the labour stress, reduction of chronic elevation of the intraabdominal pressure and use of hormonal replacement therapy in the menopause.

Treatment of vaginal vault prolapse with abdominal sacral colpopexy using prolene mesh

BACKGROUND

We report our experience on abdominal sacral colpopexy (CSP) with a prolene mesh in women with vaginal vault prolapse.

METHODS

From 1994 to 1997 15 patients (average 57 years), underwent CSP. All patients suffered from a serious vaginal vault prolapse. Eight of them also had a uterine prolapse. Seven patients had already been operated for hysterectomy (5 vaginal, 2 abdominal). Four of them had already been operated for urinary incontinence: (3 Raz, 1 Burch). In 6 cases we have a colposuspension according to Burch associated with CSP. Average follow-up was 15 months.

RESULTS

All the patients have carried a bladder catheter for 4-12 days (average 5 days). The patients who were sexually active have begun having normal sexual intercourse again. Neither relapses of the treated prolapses, no infections or rejections of the prosthesis have been verified. In 1 patient pollakiuria insensitive to anticholinergics has persisted. Four patients have complained of hypogastric "sense of weight", without any clinical evidence of pathology.

CONCLUSION

Our survey confirms the information and the good result of this technique in the treatment of the total vaginal dome prolapse, also in comparison with our operations for sacrospinosous ligament fixation. This kind of treatment through the vagina, is not always possible, above all after hysterectomy with a very short vagina.

Urosepsis associated with vaginal pessary use

Conservative management of genital prolapse in older women uses vaginal pessaries. Infectious complications of these devices, attributable in some instances to poor routine maintenance, are uncommonly reported. We present 2 cases of genitourinary sepsis associated with unsuspected pessary use and discuss the spectrum of complications reported with these appliances.

Management of pelvic organ prolapse

The wide variety of available pessaries permits rather precise choice of pessary to meet a given patient's needs. Different approaches are reviewed. A paradigm for choosing a surgical repair based on the fascial and muscular support defects, as well as the functional demands and limitations of the patient is presented.

[Analysis of subjective effect, acceptance and costs of conservative treatment of prolapse and incontinence in women]

A renaissance of conservative treatment for urinary incontinence and descensus is taking place presently in the German speaking area for pre-surgical improvement of tissue quality as well as for long-term-treatment replacing or postponing surgery. Modern pessaries (shape and material), a more intense and pathophysiological well-founded physiotherapy as well as the support of treatment by electrostimulation and its completion by adequate hormone substitution lead to a successful conservative treatment. "Gesundheitsstrukturreform" (reformatory measures of the German Public Health System), "Fallpauschalen" (flat-rate tariff of treatment by the case) and "Praxisbudgets" (budgets for out-clinic-treatment by the case, also a form of flat-rate tariff) lead to a restriction in prescribing necessary conservative treatment or preventive measures. Assigning the patient to surgical treatment is therefore in large parts favoured (treatment costs are then charged to clinic budgets). On the basis of the presented exemplary cost analysis completed by data on subjective effectiveness, acceptance and evaluation of efforts for patient and doctor we want to show that it is not either method that has to be considered in the treatment but both. Besides we have to treat the patient sequentially-conservative treatment in most cases first, especially in younger women. Conservative treatment thereby offers the possibility to delay or postpone surgery, a very meaningful option offered regarding the relatively poor results of surgery especially in cases of recurrent disease.

Alternatives to hysterectomy for benign conditions

Hysterectomy is the second most commonly performed major operation in the United States. Approximately one in three women will have this operation, resulting in 590,000 procedures per year. The most common indications for hysterectomy are leiomyomata uteri, abnormal uterine bleeding, endometriosis, pelvic pain, and pelvic organ prolapse. Although hysterectomy is an appropriate therapeutic option for some women with these conditions, in many instances less radical alternatives may be offered. Leiomyomata may be managed expectantly if symptoms are not bothersome; for women with troubling leiomyomata symptoms, alternatives to hysterectomy include: endoscopic removal or destruction of myomas, arterial embolization, or hormonal therapy to inhibit or modify bleeding. Endometriosis and abnormal uterine bleeding of leiomyomata are both amenable to hormonal therapy. Pelvic pain is most effectively approached with a thorough evaluation (particularly for nongynecologic illness), with specific therapy directed at the cause of the pain. Pelvic organ prolapse may respond symptomatically to pelvic floor exercises, or to the use of a pessary. After alternatives to removal of the uterus are discussed, the informed woman may decide that hysterectomy is the option best suited to her. It is unusual for hysterectomy to be her only option.

Pelvic prolapse: diagnosing and treating uterine and vaginal vault prolapse

Uterine prolapse is often associated with a concomitant rectocele, cystocele, and/or an enterocele. Moderate degrees of prolapse are often associated with a feeling of pelvic heaviness or fullness or low back pain. The symptoms usually worsen with exertion and ease with bed rest. In severe prolapse, the cervix may descend outside the vaginal introitus, and patients may complain that a "mass" is protruding from the vagina. Bleeding from mucosal ulcerations or from the cervical os may occur due to rubbing of the prolapsed tissue against the patient's clothing. The commonly associated problems of cystoceles and rectoceles may lead the patient to complain of difficulty voiding, recurrent urinary infections, and/or "splinting" to defecate. Mild cases of uterine prolapse do not require therapy unless the patient is symptomatic; in most cases of second- or third-degree prolapse, however, patients may be quite uncomfortable and desire therapy. Nonsurgical options, such as a pessary, are usually tried first if the patient desires conservative therapy. Operative repair for uterine prolapse is usually approached vaginally if the uterus is small. An abdominal approach may be preferred if the uterus is large or if the woman has had multiple previous pelvic procedures or has extensive endometriosis or other processes that may obliterate the cul-de-sac. In either approach, the uterosacral and cardinal ligaments must be carefully ligated and tied together, and the cul-de-sac must be obliterated to reduce the risk of subsequent enterocele and to properly suspend the vaginal vault.

A simplified protocol for pessary management

OBJECTIVE

To evaluate a simplified protocol for pessary management.

METHODS

Women with symptomatic pelvic organ prolapse who opted for pessaries were enrolled in a prospective simplified protocol for pessary management. After the initial pessary fitting, they were seen at 2 weeks for reexamination and thereafter at 3- to 6-month intervals.

RESULTS

One hundred ten women (mean age 65 years) were enrolled, and 81 (74%) of them were fitted successfully with a pessary. Life-table analysis showed that 66% of those who used a pessary for more than 1 month were still users after 12 months and 53% were still users after 36 months. The severity of pelvic prolapse did not predict the likelihood of pessary failure except in cases of complete vaginal eversion. Patients complaining of stress incontinence were less likely to have a successful pessary fitting and more likely to opt for surgery. Current hormone use and substantial perineal support do not predict greater likelihood of pessary fitting success. No serious complications from using the pessary were observed in the study sample.

CONCLUSION

Stringent guidelines calling for frequent pelvic examinations during pessary use can be relaxed safely. Pessaries can be offered as a safe long-term option for the management of pelvic prolapse.