Pessaries are an underutilised for prolapse, here are some tips for a successful outcome.

The first known pessary for treating pelvic floor prolapses was a pomegranate soaked in vinegar, according to Hippocrates. Fortunately, we’ve come a long way since then but Monash Health based urogynaecologist, Dr Mugdha Kulkarni, says pelvic floor dysfunction is still a neglected area of women’s health.

Approximately 50% of women who’ve given birth have some type of prolapse and one in five of those will need treatment. That figure, however, may be even higher since many women don’t seek treatment at all.

“Our society often doesn’t talk about pelvic floor dysfunction. So, there are a lot of women out there with prolapse, urinary incontinence, and unfortunately, they just live with it because they think it’s a part of ageing. They’re not aware that something can be done and quality of life can be significantly improved,” she says.

Once identified and staged, there are various options that can help with prolapses.

“We always try and start off with conservative treatment, which would involve lifestyle modification. So, if it is someone who’s experiencing bladder symptoms, and if they’re drinking too much fluid or caffeinated drinks, then we will try and modify those things. Weight loss is also something that helps with symptoms,” Dr Kulkarni says.

One option that is often neglected but can be effective is pelvic floor physiotherapy.

“Pelvic floor muscle training has shown to improve symptoms and sometimes stage of the prolapse as well,” she adds.

The next step is a pessary, a removable device that can sit in the vagina for 4-6 months.

Unlike the pomegranate of old, Dr Kulkarni says today’s models are usually made of silicone. There are different shapes and sizes and some can remain in while having sex while others will need to be removed, so the one you choose will depend on the symptoms and the woman’s lifestyle.

“Pessaries can be loosely categorised as supportive or space occupying. A supportive pessary would be something that’s something simple, like a ring, whereas a space occupying one would be a cube or Gellhorn”. The Gellhorn is circular, but with a stem that helps stabilise it.

Pessaries need to be individually fitted, she says, because if it’s too large it could cause pain and discomfort and if it’s too small it could fall out. They can be fitted by physiotherapists and GPs who’ve been trained to fit them, or by gynaecologists, but they aren’t suitable for all women.

“Sometimes a person just can’t be fitted as it’s uncomfortable or falls out. And the risks for this is when the vaginal length is short— which can happen if they’ve had a previous prolapse surgery or a hysterectomy— or if the vaginal opening is very wide and the muscles around the vagina are weak and there’s no support there.”

Good candidates for pessaries include women who:

• want to avoid or delay surgery
• have medical problems that need to be optimised prior to surgery
• are very elderly or frail and can’t have surgery
• find the prolapse is not bothersome enough to have surgery, but experience problems during certain activities like playing sport. In that instance, they could manage the pessary themselves.

When it comes to long term complications, Dr Kulkarni says in some cases, pessaries may cause ulceration due to constant irritation on the vaginal mucosa, especially on the posterior fornix. One of the symptoms is vaginal bleeding or discharge. This can be managed by leaving the pessary out for a few weeks and sometimes with vaginal oestrogen cream.

Other complications can include discomfort if the pessary isn’t placed correctly, and infection. Pessaries can be used for the long-term management of prolapse, but they need to be assessed by a doctor or nurse every six months or so for a check-up. As a result, she says studies show that long-term compliance beyond five years is low – around 15%.

If pessaries don’t work or cause complications another alternative is to consider surgery. Type of surgery will often depend on the stage and type of the prolapse.

“Surgery depends on the type of prolapse, the stage, the desire for uterine preservation for various reasons, and then the route of surgery— whether it’s vaginal, or minimally invasive like laparoscopic or robotic.

Prolapse basics

Pelvic organ prolapse can impact on women’s quality of life by causing symptoms including:

• urinary incontinence
• urinary frequency
• urinary urgency
• a heavy or dragging feeling in the pelvic floor
• difficulty in passing urine or faeces
• difficulty with sex

Sometimes there may be multiple symptoms.

“If the bowel is involved, women may complain of difficulty moving of the bowel or sensation of incomplete emptying. They may also need to digitate, so press inside the vaginal wall, to actually achieve complete emptying. So, lots of symptoms at the same time, which can affect your physical, mental and sexual quality of life.”

Beyond having given birth, other common causes of prolapse are:

• anything that increases intra-abdominal pressure such as chronic coughing or lifting heavy weights.
• being overweight
• inherited conditions that can affect your connective tissue such as Marfan Syndrome or Ehler Danlos Syndrome.

Dr Kulkarni says a prolapse is basically a hernia of the pelvic organs through the vaginal wall. This can include the uterus, the bowel, or the bladder. Women can also experience prolapse of the vaginal vault following a hysterectomy (removal of uterus).”

“It often happens because of weakness of the ligaments or the fascia, which is like the network of supporting tissue between the vagina and the surrounding organs. When it becomes weakened, that’s when you get pelvic organ prolapse,” she adds.

To hear more on this topic, listen to Dr Kulkarni’s recent Healthed podcast here.

Recommended resources:

• Urogynaecological Society of Australasia
• Continence Foundation of Australia
• International Urogynaecology Association