Pelvic Organ Prolapse - Pessary Treatment - Springer Link

5 downloads 131 Views 912KB Size Report
cant uterine prolapse, especially if accompanied by anterior and posterior wall descent. A varia- tion of the doughnut pessary is the Inflatoball; this is made of ...
4.10 Pelvic Organ Prolapse - Pessary Treatment Jane A. Schulz and Elena Kwon

Key Message Pessary treatment of prolapse is one of the oldest remedies in medicine and is an important conservative treatment that is particularly valuable for the physically frail. Pessaries can be used for diagnosis and treatment of prolapse, for voiding dysfunction and urinary incontinence and for the management of incontinence or retention during pregnancy. The guidelines for pessaries and the role of the woman in taking care of her pessary is emphasized. The main types of pessary and the specific indications are reviewed - choice will depend on the type of prolapse and the vaginal anatomy. The success rate and the complications and their management are outlined. The role of pelvic floor exercises and supportive garments are reviewed. The importance of future randomized control trials and establishment of clinical guidelines is emphasized.

Introduction The lifetime risk for pelvic organ prolapse (POP) or incontinence surgery for a female by the age of 80 years old is 11.1%. Up to 30% of women will require repeat prolapse surgery, and up to 10%of women will require repeat continence surgery.I Treatment of prolapse depends on several factors, including the patient's wishes for management, the severity of prolapse and its symptoms, the woman's general health, and whether childbearing is completed. In the past, conservative treatment of prolapse has been reserved for those with

mild prolapse, those who are too frail or unwilling to have surgical management, or for those who wish to have more children. However, because evidence indicates that we still do not have good durability of prolapse repairs, and with women living longer, conservative management options must be considered for all as a method of treatment.

Historical Perspective Mechanical devices as a conservative management tool for POP have been used for many centuries. They were described as far back as the time of Hippocrates. Multiple variations have been described, such as pomegranates, bone, sea sponges, and various external braces (see Fig. 4.10.1). Other conservative methods included repositioning of the prolapse, leg binding, douching, herbal remedies, and the use of leeches. Pessaries gained popularity in the 1800s for the management of uterine retroversion. All were precursors to our current pessaries and were used very frequently because of the high surgical morbidity and mortality. However, with advances in anesthesia and surgical techniques, they fell out of favor. More recently, with newer pessaries, and a wide range of styles, the longer lifespan of women, and the realization of the impermanence of surgery, mechanical devices for POP are experiencing a rebirth in popularity of use. 2 Research in this area is still lacking. The recent Cochrane review of mechanical devices for POP in women found no eligible, completed, published

271

J.A. Schulz and E. Kwon

272

agement. Pessaries can also be used as a diagnostic tool. Examples of their use for diagnosis include whether pessary insertion corrects the patient's symptoms of prolapse, and whether associated symptoms such as voiding dysfunction and urinary incontinence are corrected by pessary insertion. Pessaries are believed to work by creating an artificial shelf of levator support to reduce the prolapse. Incontinence pessaries also work by elevating the bladder neck back to the normal anatomic position, and by some degree of obstructive effect on the urethra.' Pessaries need to be fitted by a health care professional. A nurse-run clinic for pessary fitting is a good option as a time- and cost-saving measure.' FIGURE 4.10.1. Cup and stem pessary with belt. (Source: Repro-

duced with permission from Milex Products Inc., Chicago, Illinois.)

or unpublished randomized controlled studies; therefore, no data collection or analysis was possible.'

Indications for Pessary Fitting Pessaries can be used for all types and all stages of POP.Pessaries can also be used for stress, urge, mixed, and overflow urinary incontinence. Although, historically, incontinence type pessa-

Types ofPelvic Organ Prolapse and Evaluation Conservative Management Options for POP

Pessaries An extensive range of mechanical devices has been described for the management of pelvic floor disorders, and they are listed in Chapter 3.4. Because these devices are often underutilized, they are covered separately in this chapter, where we will consider their use for specific indications of POP. These mechanical devices consist mainly of pessaries. Pessaries are primarily made of medical grade silicone covering surgical steel. The advantages of silicone are that it has a longer lifespan for use, it can be autoclaved, it does not absorb odors or secretions, and it is an inert material. Pessaries come in a wide range of shapes and sizes (Fig. 4.1O.2). They may be used to prevent prolapse from becoming worse, to decrease the frequency or severity of symptoms of prolapse, and to avert or delay surgical man-

FIGURE 4.10.2. Milex pessaries. (Source: Reproduced with per-

mission from Milex Products Inc.,Chicago, Illinois.)

4.10. Pelvic Organ Prolapse - Pessary Treatment ries have been used for stress urinary incontinence, there have been reports of success with urge incontinence in 64-67% of patients." Pessaries have been used for the diagnosis and management of latent stress urinary incontinence," Hextall et al. found stress incontinence was unmasked in 27% of women in their unit with prolapse that were being investigated with urodynamics." The use of a pessary before surgery is also useful to predict whether women will achieve relief of their prolapse symptoms, and whether urinary symptoms, such as urgency and voiding dysfunction, will resolve." Pessaries are a valu able tool for the management of the pregnant woman who has urinary incontinence, POP, or urinary retention secondary to uterine retroversion or incarceration. In pregnancy, the size of the pessary may have to be changed with advancing gestation. Hodge pessaries work best for uterine incarceration with associated voiding dysfunction. Once the pregnant uterus moves up out of the pelvis in the second trimester, symptoms often improve. There are few contraindications to pessary fitting. Active infections of the pelvis or vagina, such as vaginitis or pelvic inflammatory disease, preclude the use of a pessary until the infection has resolved. Allergies to the pessary are very uncommon, especially since now most are made of silicone. However, any allergic response to a vaginal pessary would be a contraindication to fitting. The only other caution is with patients who are not likely to be compliant with pessary care and follow-up; these patients should not be fitted with a device ."

273

inserted and tilted up behind the pubic symphysis (Fig. 4.1O.3). A fingerbreadth should fit between the pessary and the vaginal mucosa. Once the pessary has been fitted, the patient should walk around and exercise in the clinic to ensure it will not immediately fall out. It is necessary to ensure that patients are able to void and are given appropriate education before leaving the clinic with their new pessary. If possible, patients should be taught to remove, clean, and replace their pessaries themselves. If pessaries are difficult to remove, fishing wire or dental floss may be attached to the pessary to aid in removal. There are few guidelines for pessary removal and cleaning, and the recommendations that do exist are variable. Current Canadian practice advises any woman who is able to remove her own pessary to remove, wash, and replace it once per week. The patient is advised to wash the pessary in soap and warm water. If she cannot remove her pessary, she should have it removed, cleaned, and replaced every 3 months by a health care professional.' Similar guidelines are followed by family physicians and gynecologists." :" Women may have intercourse with their pessary in place; however, many elect to remove it .

Guidelines for Pessary Fitting An adequate amount of time should be allotted for pessary fitting. A clinical setting in a nurserun pessary clinic is ideal. In postmenopausal women, pretreatment with local estrogen therapy for at least 6 weeks is helpful to optimize successful fitting.' A postvoid residual should be checked before pessary fitting, as pessaries can cause obstruction of urinary flow. To fit a pessary, size the vaginal vault by examining the vagina with two fingers. Start with a covered ring pessary, or the appropriate design for the diagnosis. The pessary should be lubricated on the end and then

FIGURE 4.10.3. Pessary fitting. (Source: Reproduced with permission from Milex Products Inc., Chicago, Illinois.)

274

Proper pessary fitting may require trials of several styles and sizes. Difficulty with pessary fitting may arise if there is a large posterior wall defect, poor perineal body support, or a shortened vagina." Many pessaries rely on good perineal support to remain in place. Patients that have had prior radiation or multiple pelvic surgeries may also encounter difficulties with pessary fitting because of a scarred or shortened vagina.":" Peri- or postmenopausal women with significant vaginal atrophy may have significant discomfort when pessary fitting is attempted. In this situation, 4 to 6 weeks of local estrogen therapy is often helpful to increase the success rate of pessary fitting. "

Types ofPessaries Ring pessaries are the most widely available and most commonly used:" they are available in open and covered forms . The covered ring pessary has drainage holes to allow the vaginal secretions to escape; it is useful in patients that still have a uterus, to prevent the cervix from slipping through the ring. Open and covered ring pessaries are best used in POPQ stage I and II prolapse ." The Shaatz pessary is a stiffer circular pessary that is used when more support is required for management of the prolapse. Shaatz pessaries can be used if the rings fall out, or if there is still protrusion of the prolapse beyond a ring pessary. Doughnut pessaries are shaped like their namesake; they are used for more significant uterine prolapse, especially if accompanied by anterior and posterior wall descent. A variation of the doughnut pessary is the Inflatoball; this is made of latex and must be deflated daily for removal and cleaning. The Inflatoball pessary is used in patients with a narrow introitus but a capacious upper vagina. The Regula is a newer pessary for mild prolapse. Its unique bridgeshaped design helps to prevent expulsion." The Gellhorn, or stem, pessary is indicated for more advanced stage III or IV prolapse. It is often useful in reducing a complete procidentia or vaginal vault eversion. Like the other pessaries, the Gellhorn creates an artificial levator shelf, but also creates a suction to provide a little more support. The stem helps to prevent the pessary from shifting position. The Gellhorn is more dif-

J.A. Schulz and E. Kwon

ficult to remove, and cannot be used if a patient is sexually active, unless she is able to remove the pessary herself. To remove the Gellhorn, the suction must be broken at the dish of the device; occasionally, a Kelly clamp is requ ired to pull on the stem and assist with removal. The cube or tandem cube pessaries are used when other pessaries are unsuccessful, or when there is very poor pelvic tone . They work using suction to the vaginal walls, as all their sides are concave. Older cube pessaries did not have drainage holes and required daily removal and cleaning. However, newer versions do have some drainage holes that allow them to be left for up to a week. There is a string attached to the cube pessary; however, this is to assist with locating the pessary and is not for traction for removal. There are now a variety of lever pessaries that are all modifications of Hodge's original design from the 1860s.15 These include the Hodge, the Smith-Hodge, the Risser, and the Gehrung. The Hodge pessary has been used traditionally for uterine retroversion and incompetent cervix. Variations of this pessary are for variations in pubic arch anatomy. Traditionally, the Gehrung has been used for women with both a cystocele and rectocele, although it is sometimes difficult to keep this pessary in position." Incontinence pessaries are variations on the other forms of pessaries with an elevated knob to support the bladder neck. There are incontinence ring and dish pessaries, and now also incontinence versions of some of the lever pessaries. If a patient with prolapse develops stress incontinence after being fit with one of the other styles of pessaries, switching to an incontinence pessary may address both problems.

Success Rates with Pessaries The reported success rates for pessaries vary by diagnosis. Vierhout reported a 63% subjective improvement or cure rate with pessary use for stress urinary incontinence." In a prospective review by Clemons et al. of 100 women being fitted for a pessary for POP, 73% had a 2-week successful pessary-fitting trial. I? Of the group that had successful pessary fitting, almost all had complete resolution of their prolapse symptoms, 50% had improvement of their urinary symp-

4.10. Pelvic Organ Prolapse - Pessary Treatment

toms, and 92% were satisfied with their pessary. Dissatisfaction with pessary fitting was associated with occult stress incontinence. In a retrospective review of 1,216 women in a tertiary care gynecology unit, 86% of women were able to be fit with pessaries, and of these 71% were able to wear them successfully. Successful fit was achieved in 83% of patients with uterine prolapse, 82% of patients with cystocele, 69% of patients with vault prolapse/enterocele, and 66% of patients with cystocele/rectocele." There is some suggestion that the use of a pessary may prevent the progression of POP.IS However, there is still significant study required in this area.

275

ing or a change in discharge. If left untreated, they may progress to ulcers. In patients with a uterus still in place, other causes of abnormal vaginal bleeding must be ruled out. These areas may also become secondarily infected, leading to further tissue breakdown. Erosions occur in 2% to 8.9% of patients. v" They usually respond well to local estrogen therapy; addition of an antibiotic cream may also be required if secondary infection has occurred. Diligent pessary care and inspection of the vaginal tissues every 6 to 12 months helps to prevent erosions. Pessary size may also have to be adjusted to prevent further erosions from developing.

Fistulas Pessary Complications Overall pessary complications are uncommon and affect less than 10% of patients.Y

Vaginal Discharge Vaginal discharge is one of the more common complaints with pessary fitting. With insertion of a foreign body into the vagina, it is normal to see an increase in the vaginal discharge, especially if local estrogen treatment is also being used, such as in the postmenopausal population. However, if there is patient concern, or if there are other symptoms such as foul smell, bleeding, or pruritis, the discharge should be investigated. A vaginal examination and culture can be completed. If there is a yeast infection or bacterial vaginosis, the pessary should be left out for a week while the appropriate antibiotic or antifungal treatment is used. Concern about recurrent vaginal infections is a common patient concern. However, this is unusual; in the postmenopausal population this is best prevented with local estrogen use. The use of Trimosan cream, which is provided with the Milex pessaries, has been recommended to help decrease the amount of odor and discharge, although it has not been studied in clinical trials.":":"

Vaginal Erosions Erosions of the vaginal mucosa usually start as an area of redness or abrasion where the pessary is resting. They may present with vaginal bleed-

One of the keys to long-term pessary care is ensuring that the patient takes adequate precautions to prevent the more serious complications. Fistulas, although very rare, are among the most serious complications of neglected pessaries." They can be rectovaginal, vesicovaginal, or urethrovaginal. An impacted pessary can develop erosions that break down, or get infected, leading eventually to fistula. It is very important that pessaries are regularly removed, washed, and replaced, and that the vagina inspected for any signs of infection or erosion. In a cognitively impaired patient, it is imperative that a caregiver be committed to ensuring ongoing pessary care and cleaning.

Pelvic Floor Physiotherapy Pelvic floor prolapse is an anatomical defect associated with functional changes. These may include urinary incontinence (urge, stress, and overflow), defecatory dysfunction, and pelvic pressure. There is evidence that pelvic floor exercises are helpful for some of the resultant conditions and functional changes associated with POP. These include pelvic floor exercises and bladder retraining for urinary incontinence. i'r" However, for the direct treatment of pelvic floor prolapse as an anatomical defect, there is little documentation regarding the effect of pelvic floor physiotherapy." For mild prolapse there is a perceived benefit," however, more severe prolapse is unlikely to be corrected by exercises

J.A. Schulz and E. Kwon

276

alone. Defects such as stress urinary incontinence and POP have been associated with electromyographic changes that may represent either motor unit loss or failure of central activation," and this would certainly impact the potential success of pelvic floor therapy for these conditions. Randomized clinical trials, and the estab lishment of clinical and referral guidelines, are required in this area.

Fembrace26 For many centuries, conservative management of POP relied primarily on the use of pessaries and pelvic floor exercises. Since the marketing of a new V-brace" support garment in NewYorkin the fall of 2000, however, there exists an alternative for POP symptom relief in patients who cannot use a pessary for various reasons (Fig. 4.10.4). The Vbrace' garment is a panty with a padded double crotch and cross elastic straps that acts to reduce the symptoms of pelvic organ prolapse by providing support and pressure to the vaginal area. The creators of the V-brace" garment suggest that even women who use a pessary can alternate and also use the V-brace" every other day when not wearing the pessary, for ultimate relief of prolapse symptoms. The garment is also recommended for

FIGURE 4.10.4. The Fembrace support device for pelvic organ prolapse.

reducing varicose veins on the vulva, as well as for reducing hip, leg, or pelvic pain.

Other Alternatives Other options include the use of tight bicycle shorts as a perineal support in women that are unable to fit a pessary and unable to have surgery. Some women have used their contraceptive diaphragms or tampons to attempt to reduce their prolapse, or to provide relief for their urinary incontinence. However, a common complaint of women with moderate to severe prolapse is the inability to retain a tampon. Desperate patients that have come to our clinic have also described the use of sticky tape across the vaginal opening.

Summary Pelvic organ prolapse is a prevalent condition that impacts quality oflife. As women live longer, further research is needed to study conservative options to treat prolapse. Pessaries are currently the main conservative management tool. 27 Other options that exist include pelvic floor physiotherapy and the Fembrace support.

References 1. Deval B, Haab F. What's new in prolapse surgery? Curr Opin Urol. 2003; 13(4):315-323. 2. Davila GW. Vaginal prolapse: management with nonsurgical techniques. Postgrad Med. 1996; 99(4):171-81. 3. Adams E, Thomson A, Maher C, et al. Mechanical devices for pelvic organ prolapse in women (Cochrane Review). In: The Cochrane Library. Issue 2. Chichester, UK: John Wiley and Sons Ltd.; 2004. 4. Bhatia NN, Bergman A, Gunning JE. Urodynamic effects of a vaginal pessary in women with stress urinary incontinence. Am J Obstet Gynecol. 1983; 147(8): 876-884 . 5. Tam F, Schulz J, Flood CG, et al. Factors affecting the success of pessary fitting in a nurse-run clinic . Int Urogynecol J. 2000;11:S17. 6. Hanson L, Schulz JA, Flood CG, et al. Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient characteristics and factors contributing to success. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(2): 155-159. Epub 2005 Ju126.

4.10. Pelvic Organ Prolapse - Pessary Treatment

7. Wu V, Farrell SA, Baskett TF, et al. A simplified protocol for pessary management. Obstet Gynecol. 1997; 90(6): 990-994.

8. Liang CC, Chang YL, Chang SD, et al. Pessary test to predict postoperative urinary incontinence in women undergoing hysterectomy for prolapse. Obstet Gynecol. 2004; 104(4): 795-800. 9. Hextall A, Boos K, Cardozo L, et al. Videocystourethrography with a ring pessary in situ . A clinically useful preoperative investigation for cont inent women with urogenital prolapse ? Int Urogynecol J Pelvic Floor Dysfunct . 1998;9(4): 205-209. 10. Lazarou G, Scotti RJ, Mikhail MS, et al. Pessary

reduction and postoperative cure of retention in women with anterior vaginal wall prolapse. Int Urogynecol JPelvicFloor Dysfunct. 2004;15(3):175178. Epub 2004 Feb 14. 11. Clemons J, Aguilar V, Tillinghast T, et al. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol 2004; 190: 345-350. 12. Farrell SA, Singh B, Aldakhil 1. Continence pessaries in the management of urinary incontinence in women. J Obstet Gynaecol Can. 2004 Feb; 26(2): 113-117. 13. Pott-Grinstein E, Newcomer J. Gynecologists ' patterns of prescribing pessaries. J Repro Med 2001; 46(3): 205-208. 14. Milex (Chicago, Illinois). Website. http://www.

milexproducts.com/products/pessaries. Accessed January 1, 2005. 15. Miller D. Contemporary use of the pessary. In: Sciarra JJ, editor. Gynecology and Obstetrics: Clinical Gynecology. Vol 1. Philadelphia: Lippincott; 1999:1-13. 16. Vierhout ME, Lose G. Preventive vaginal and intra-urethral devices in the treatment of female urinary stress incontinence. Curr Opin Obstet Gynecol. 1997;9:325-328.

277 17. Clemons JL, Aguilar VC, Tillinghast TA, et al.

Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse . Am J Obstet Gynecol. 2004;190:1025-1029. 18. Handa VL, Jones M. Do pessaries prevent the pro gression of pelvic organ prolapse? Int Urogyne J. 2002;13:349-532. 19. Viera A, Lark ins-Pettigrew M. Practical use of the pessary. Am Fam Physician . 2000; 61(9): 27192726. 20. Chow S, LaSalle M, Rosenberg G. Urinary incon-

tinence secondary to a vaginal pessary. Urology. 1997;49(3):458-459. 21. Proceedings of the international consultation on

incontinence. Abrams P, Cardozo L, Khoury S, Wein A, editors. 2004. 22. Borello-France D, Burgio K. Nonsurgical treatment of urinary incontinence. Clin Obstet Gynecol. 2004;47(l):70-82 23. Wallace SA, Roe B, Williams K, et al. Bladder

training for urinary incontinence in adults . (Cochrane Review). In: The Cochrane Library. Issue 1. Chichester, UK: John Wiley and Sons Ltd.; 2004 . 24. Hagen S, Stark D, Cattermole D. A United

Kingdom-wide survey of physiotherapy practice in the treatment of pelvic organ prolapse . Physiotherapy. 2004;90:19-26. 25. Cundiff G, Addison A. Management of pelvic organ prolapse . Obstet Gynecol Clin N America. 1998;25(4):907-921. 26. Weidner A, Barber M, Visco A, et al. Pelvic muscle

electromyography oflevator ani and external anal sphincter in nulliparous women and women with pelvic floor dysfunction. Am J Obstet Gynecol. 2000;183:1390-1401. 27. Fembrace Support Garment. Advertisement. Website. http://www.fembrace.com/. Accessed 18 Aug 2004.