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Vaginal Pessaries for the Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse
ulcerations or abrasions, as well as use of a sulfa-based cream to
Figure 1: Vaginal Prolapse
decrease discharge and odour. Little evidence exists to support the
timing or use of these interventions. Contraindications to the use of a
Factors associated with successful
fitting and continued use include
women aged 65 years or older,
patients treated with local or systemic
hormone replacement therapy
and sexual activity.
pessary are rare: women who cannot care for their pessary and are
unable to return for care should not have a pessary placed, and
active infection of the pelvis or vagina precludes pessary use until the
infection is resolved.
Treatment of Stress Urinary Incontinence
Although expert opinion supports offering pessaries as first-line
treatment for pelvic organ prolapse and stress incontinence,
16,17
only
two randomised trials have compared different kinds of pessaries or
pessary with other or no treatment. The first trial compared a
Hodge pessary with a super-tampon or no device, and found that
exercising women lost less urine with either the Hodge pessary or the
tampon in place.
18
A more recent trial concluded that both the ring
Prolapse of the anterior apical and posterior vagina. With permission of R Rogers.
and Gellhorn pessary were equally effective in treating prolapse, urge
Figure 2: Types of Pessaries
and obstructive urinary symptoms, but found no improvement in stress
incontinence symptoms.
9
ABCD
How Successful Are Pessaries in the Treatment of
Stress Incontinence?
Few studies have evaluated women with only stress
incontinence, and have also included women with overactive
EF G
bladder symptoms and pelvic organ prolapse. Treatment of
stress incontinence symptoms in patients who also have significant
pelvic organ prolapse is complicated by ‘hidden’ or de novo
incontinence. With reduction of severe prolapse, women may
experience more incontinence than they did with the prolapse
Upper row = pessaries for incontinence. A: incontinence ring; B: incontinence ring with
unreduced because the urethra is no longer kinked. De novo stress support; C: incontinence dish; D: incontinence dish with support. Lower row = pessaries for
incontinence after pessary placement has been reported as a reason
prolapse. E: ring; F: ring with support; G: Gellhorn.
for pessary discontinuation.
19
symptoms after four months of use, although urge symptoms and
In a prospective cohort study of 72 women, stress incontinence voiding function improved.
20
symptoms improved in 45% fitted with a pessary; however, in
that same cohort, 21% of women without incontinence at
baseline reported new incontinence symptoms after the pessary was
With reduction of severe prolapse,
placed.
8
Although de novo stress incontinence was associated with
women may experience more
patient dissatisfaction in this study, only 36% of the women with
incontinence had symptoms severe enough that they discontinued
incontinence than they did with the
pessary use.
8
prolapse unreduced because the
urethra is no longer kinked.
In a randomised trial comparing Gellhorn with ring pessaries,
stress symptoms did not improve in either treatment group.
The authors attributed the lack of change to the ‘unmasking’ of Retrospective studies report higher success rates for treatment of stress
hidden incontinence in women with significant pelvic organ incontinence, ranging from 52 to 94%.
6,7,10,19
These findings support the
prolapse.
9
In another cohort study, 97 women who used pessaries to use of pessaries for the treatment of urinary complaints in general (and
treat stress incontinence symptoms found no change in stress in particular urge and obstructive voiding), but further studies of
EUROPEAN GENITO-URINARY DISEASE 2007 37