Pessaries for Treatment of Uterine Prolapse and Pelvic Relaxation


Uterine prolapse is just what it sounds like: the uterus drops down into the vagina, and in severe cases, outside the vagina. It occurs from injury to the fascia, which is the tissue that supports and holds up the uterus. Weakening of the ligaments that support the uterus and loss of pelvic floor musculature also contribute to the loss of the normal uterine position.

Women who have uterine prolapse frequently have other organs that are displaced due to weak pelvic tissues. A cystocele results when a prolapsed bladder bulges through the vaginal roof; a rectocele occurs when the rectum bulges through the vaginal floor.

Who gets a Prolapsed Uterus?

Vaginal deliveries, particularly if the labor is long and the baby large, are the greatest risk factor for pelvic relaxation. It's not the only risk factor, since most women who deliver vaginally don't end up with uterine prolapse. Family history seems to be a major factor. Tissue that is prone to damage is an inherited tendency and it is not unusual for a woman with uterine prolapse to mention that her mother and grandmother had the same problem. Take a genetic predisposition, add a nine pound baby and three hours of pushing, and something is going to give. Once the tissue is damaged, it never completely regains its strength and elasticity; the effects of gravity and age then compound the problem.

Smoking is also a major risk factor. Smokers have poor tissue in general and chronic coughing weakens tissue even further. Long-distance runners may also have a greater propensity for prolapse. The running probably doesn't cause the weakened tissue; it just makes an already tenuous situation worse from the constant pounding.

Incidence is directly related to age, and since women are living longer, increasing numbers of women are destined to suffer from uterine prolapse. It is not unusual for women with only a slight prolapse to be unaware of the problem until they go through menopause. Vaginal and pelvic tissues depend on estrogen to maintain their strength and elasticity. The decline of estrogen, which occurs at menopause, can result in a sudden worsening of symptoms, particularly if a woman chooses not to take hormone therapy. Many women who stop postmenopausal estrogen replacement find that pelvic organ prolapse is far more bothersome than the hot flashes.

How do you know if you have a prolapse?

Symptoms are generally related to the degree of the prolapse—in other words, how far the uterus has dropped. In a first-degree prolapse, the uterus is only slightly lower than its normal position, and most women are totally unaware that something has shifted unless their gynecologist points it out. A further drop creates a second-degree prolapse, which is the point when some women become aware that something is not quite right. Still, many women with a second-degree prolapse have no symptoms. By the time the uterus drops low enough for the vagina to be completely filled and the cervix reaches the opening of the vagina (third-degree prolapse), most women are definitely aware there is a problem. When the uterus has dropped outside the vagina (a fourth-degree prolapse), this generally prompts an emergency room visit.

The most common symptom that someone reports is the feeling that "something is falling down," which is not surprising since that is exactly what has happened. Nine times out of ten, a women correctly diagnosis her own prolapse before any doctor lays eyes on her. Many women, in addition to constant pressure, actually feel a mass or bulge at the vaginal opening. A quick look in the mirror (a hand mirror with a long handle works really well) and you can see something pink bulging out. Low back pain and discomfort during intercourse are common. If the cervix is outside the vaginal opening, there may also be bleeding, discharge, and pain. In severe cases, there may be an inability to have a bowel movement or urinate.

Does Anything Prevent It From Happening?

Avoiding vaginal delivery is not necessarily the most practical way to prevent prolapse, but it is the best way to avoid prolapse. Women who have never been pregnant almost never have a significant prolapse. Women who labor but ultimately end up with a cesarean section are at less risk than if they had delivered vaginally, but still at some risk.

Treatment Options

Once the damage is done, what options are available to treat uterine prolapse?

Today, vaginal or laparoscopic hysterectomy is the standard treatment for symptomatic uterine prolapse. The details of vaginal hysterectomy for prolapse are discussed in chapter 11 along with associated surgical procedures for cystocele and rectocele. Sometimes, depending on other needed procedures, an abdominal approach is also appropriate.

Non-surgical Treatment of Uterine Prolapse
Non-surgical options are available and useful in the treatment of uterine prolapse. They are the most appropriate if the condition is not severe, or if a woman is a poor surgical candidate. Some women simply want to avoid surgery or need to delay surgery until a more convenient time. In 1870, the recommended non-surgical treatment for prolapse was application of leeches to the vulva or cervix. It is unclear if the uterus was "scared" back where it belonged, or if the woman told her doctor things had improved to avoid further "treatment".

There is no question that estrogen can improve pelvic relaxation. It's well established that vaginal tissues and supporting structures depend on estrogen for their strength and elasticity. Women in low estrogen states (menopause, breastfeeding moms) often are the most symptomatic. The use of estrogen in the form of pills, vaginal rings, patches, or vaginal creams will often improve a mild prolapse such that no other treatment is needed. Severe prolapse (third- or fourth-degree) will rarely respond to estrogen therapy alone, but can be useful as an adjunct to other therapy.

Menopausal women who are scheduled for surgery will have a better result if they are pretreated with estrogen for at least a few weeks before surgery. The tissue is much easier to work with and will be more supportive. Often, gynecologists will recommend continuing the use of vaginal estrogen creams after surgery to maintain surgical results, particularly if the vaginal tissues are dry and thin.

Every woman who has ever had a problem with incontinence or prolapse has been instructed in the fine art of Kegel and other pelvic muscle exercises.

Picture a hammock that has been used for too long. If someone lies in an old hammock, his or her bottom sinks through the middle. Even if the fabric on the sides of the hammock is strong and supportive, the middle is still loose. Now picture a cystocele, which is the bladder bulging through the roof (the hammock) of the vagina. Kegel exercises can strengthen the sides, but not the middle. The only way to strengthen the middle is by surgically repairing the loose area using stronger tissue. Kegels help in mild cases of incontinence, but are not particularly worthwhile in severe cases or to improve prolapse.

Pessaries are not new. In fact, devices placed temporarily in the vagina to lift up the uterus have been around long before modern medicine. There is documentation of a Roman medicated pessary as early as AD 30. Modern pessaries can be left in place for up to three months at a time with interval physician visits for cleaning and replacement. Younger women are usually able to clean and replace their pessaries themselves, allowing for less frequent visits.

In the past, pessaries were often recommended for women who were felt to be poor surgical risks due to age or chronic illness. Pessary use is far less frequent in recent years, since improved surgical and anesthetic techniques have made surgery a safer, more reasonable option for older and sicker patients. There are still some situations in which a pessary is useful and appropriate.

Some women simply don't want to go through surgery and are willing to live with the inconvenience—and limited relief—of a pessary. Some women are so elderly or sick that surgical intervention would be dangerous or inappropriate. If young women with symptomatic prolapse desire more children, a pessary is a good option to alleviate symptoms until her family is complete and she is ready for definitive surgery. Some women with slight prolapse are only symptomatic at certain times, such as when they are playing golf or tennis, and find a pessary useful to use on an as-needed basis.

Short-term pessary use is appropriate for women to make them more comfortable if a planned surgery needs to be delayed. Women with post-partum prolapse are good candidates for a pessary. Given time (and return of normal estrogen levels), the situation will likely improve. Some women are even advised to wear pessaries during pregnancy to elevate an uncomfortable, prolapsed enlarged uterus.

There are multiple types of pessaries and finding the right pessary, in the right size, is the key to success. Many women have a miserable pessary experience and feel that they were not good candidates, when, in fact, the pessary was the wrong type or did not fit properly.

There are rings, rings with a rubber support (much like a diaphragm), cubes, donut shapes, and inflatable balls. The type of pessary is dependent on the degree of prolapse and presence of other pelvic defects, such as a cystocele or rectocele. Each type of device comes in multiple sizes. If the wrong size is used, If the wrong size is used, problems such as pain, vaginal ulceration, infection, or inability to urinate or have a bowel movement can result. The pessary also will not stay in its correct position, holding up the uterus, if the fit is wrong. If the pessary fits properly, complications are rare. Fitting takes time, and before a woman leaves her doctor's office with a new pessary, it is imperative that she walk around, urinate, bear down, and then have the placement rechecked to make sure that slippage has not occurred. It is not unusual to require multiple fittings to get it right. Within one week of placement, a return visit is required in order to make sure that the pessary is not rubbing or pressing on the vaginal wall, which can cause bleeding, ulceration, and infection down the road. Sometimes, a good fit—which supports the uterus, stays in, and is comfortable—is impossible, despite multiple attempts with different shapes and sizes.

Once the correct pessary is in place, most women can be taught to take out and replace it for cleaning. Some women are unable or unwilling to do this, in which case they must return at least every three months for cleaning and examination.

Most women that are motivated to use a pessary do well and are generally satisfied with the device, at least in the short term. One study showed that approximately 50 percent of women fitted for a pessary were still using it and satisfied sixteen months later.

Why would someone not be satisfied? The discharge, for one. Women who are unable to clean and replace their pessary themselves frequently have a malodorous, watery discharge. Even women who are fastidious about cleaning and replacing their pessary report a chronic odor and discharge. Pessaries also interfere with intercourse for women who are sexually active. Sometimes a pessary makes incontinence worse due to displacement of the urethra. Most women who are dissatisfied simply find the pessary to be inconvenient and inadequate.

Fitting a pessary is often better done by an experienced (translation: older) gynecologist. A newly trained gynecologist may be great for innovative, high-tech laparoscopic or hysteroscopic procedures, but may have not had a lot of experience with good old-fashioned pessaries. If your gynecologist only has one type of pessary in his or her office, that's probably an indication that it's not his or her forte.




Does it make sense to wait it out?
Surgical treatment should never be considered in a woman with prolapse who recently had a baby. Tissues damaged during childbirth, once given the chance to heal, often improve. Many women panic when they discover that, in addition to all the other new surprises that come with motherhood, they are unable to make it to the bathroom without losing urine. Before running out and buying diapers in both newborn and adult sizes, it is important not to overreact. A symptomatic prolapse in the first few weeks after delivery, especially in breastfeeding moms who have lower than normal estrogen levels, is not an indication of a long-term problem. There is always improvement after nursing is concluded and hormones return to pre-pregnancy levels. Often, the problem completely resolves.

If a woman already has normal estrogen levels, and has eliminated smoking and high-impact exercise from her routine, further spontaneous improvement is unlikely. What nobody can predict is: will it get worse? Therein lies the difficulty. Many women can endure the situation as it is, but are worried that, as the years go on, their prolapse will progress to an intolerable point. They will then be in the position of needing surgery when they are much older and potentially too sick to undergo an operation safely. The vision of lying in a nursing home with diapers and a pessary is one scenario most people would like to avoid, but it is difficult to predict which women with moderate prolapse will ultimately end up with a severe prolapse. Another reason some women opt to do surgery before they absolutely need it is that pelvic reconstructive surgery, like a face lift, holds up better if it is done with younger, more elastic tissue.

Having said that, expectant management is appropriate if symptoms are tolerable and as long as the uterus is not actually hanging outside the vagina. Once that happens, treatment is no longer elective. Cervical and uterine tissue, when exposed to air, dries out, breaks down, bleeds, and over time becomes macerated and potentially infected. That situation is potentially life-threatening and requires immediate surgery.

Women who choose to wait it out in hopes that things won't get worse should be seen at regular intervals to ensure that the situation is not deteriorating. Most women, though, know when something has changed.

(Excerpt from The Essential Guide to Hysterectomy)