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1/1/2018

Complications of Pessary Use

Pessary devices have been used for a number of indications including pelvic organ prolapse, urinary incontinence, preterm labor, and cervical insufficiency. They are considered a safe and reasonable long-term option for patients who either do not wish to undergo surgery or may be poor candidates for surgery. There are currently around 20 different pessary types in use worldwide. They are generally made of silicone, rubber, or plastic (Polyvinyl-Chloride [PVC] or Polythene). Medical grade silicone has superior properties including long durability and tolerance of repeated cleanings. Silicone pessaries do not absorb vaginal secretions or odors and are hypoallergenic.

Minor complications are common and occur with all types of pessaries. Pessaries alter vaginal flora, often producing a thin, watery, physiologic discharge. This discharge does not need to be treated unless there is itching, burning, or odor. Superficial vaginal mucosal erosion is the most frequently reported complication and may result in foul odor and purulent discharge. Erosion can usually be managed by removing the pessary until the erosion is healed. If untreated, continued pressure of the pessary on the erosion may lead to local ulcerations, infections, and rarely, fistulas. Risk factors for erosion include continuous long-term use and placement of an ill-fitting pessary.

Other minor complications include vaginal discomfort or pain, bleeding, constipation, or material allergy. Some of these complications can be avoided by careful pessary fitting. A successful fit occurs when the biggest pessary is comfortably retained upright with walking, coughing, or squatting without patient discomfort or obstruction of bladder or bowel emptying. Women with genital atrophy may benefit from a short course of topical estrogen treatment before or after pessary placement.  Additionally, using topical estrogen with the pessary could decrease the incidence of bacterial vaginosis, but whether it helps reduce other complications has not been convincingly demonstrated.

Some types of pessary shapes and materials are associated with more serious complications, usually in a setting of neglect, for example, nursing homes residents or patients with dementia. Vesicovaginal fistulas have been associated with the Gellhorn or shelf design pessaries. Rectovaginal fistulas have a higher association with rubber or PVC pessaries when compared with polythene pessaries. A neglected pessary can also lead to fecal impaction, bowel fistula, hydronephrosis, and urosepsis. Some small case series correlated long term use of pessaries with very rare occurrences of primary vaginal cancer, with postulated mechanistic pathways including chronic inflammation in the setting of viral infection or inducement of metaplastic changes that progress to dysplasia and cancer.

Overall, pessaries remain a safe, viable and important non-surgical treatment option for many patients. Complications are generally minor. More serious complications can occur and are more frequent with improper care and certain device designs and materials. Frequent removal and cleaning of the pessary as well as periodic vaginal examinations can minimize complications.

Further Reading:

Abdulaziz M, Stothers L, Lazare D, Macnab A. An integrative review and severity classification of complications related to pessary use in the treatment of female pelvic organ prolapse. Can Urol Assoc J. 2015 May-Jun;9(5-6):E400-6. doi: 10.5489/cuaj.2783.

Ai F, Wang Y, Wang J, et al; Effect of estrogen on vaginal complications of pessary use: a systematic review and meta-analysis. Climacteric. 2022 Jun 13:1-10. doi: 10.1080/13697137.2022.2079973. Epub ahead of print. PMID: 35695119.

 

Initial approval January 2018. Reaffirmed July 2019. Reaffirmed March 2021. Revised September 2022.

 

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