Posts Tagged ‘pessary’

Femicushion: Conservative Management Of Pelvic Organ Prolapse

July 1, 2017

Andrew Siegel MD  7/1/17

Medical trivia: Did you know that July 1 is the transitional day in which medical students become interns, interns become residents, residents become fellows, and residents and fellows become attending physicians? It is typically a day of mass confusion in the hospital. For this reason, it is always better to be treated in June than July!

Pelvic organ prolapse (POP) is a common female condition due to weakened pelvic anatomical support.  It results in one or more of the pelvic organs falling into the vaginal space, and at times, outside of the vaginal opening.  Several of my previous entries have covered the topic of POP and its treatment:

Introduction to POP

More about POP

A pessary is an internal device available in different sizes and shapes that is placed within the vagina to keep the fallen pelvic organ in its proper anatomical position. I reviewed pessaries in a previous blog entry: The basics of pessaries

Today’s entry is on Femicushion, a newly available soft cushion that functions as an external pessary, which offers the advantage of not needing to be positioned deeply within the vagina as is a standard pessary.  This device is ideal for women who cannot or do not want to have surgery for their POP and are not thrilled with the concept of wearing an internal pessary.

femicushion posicionado

The Femicushion is composed of washable, medical-grade silicon and is available in three sizes based upon the anatomy of the vaginal opening.

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After the POP is “reduced” (the prolapsed pelvic organ is pushed back into its normal anatomical position), the appropriately sized Femicushion is placed just within the vaginal opening. Its presence prevents the fallen pelvic organ from descending outside the vaginal opening.

IMG_1397

Once in place, it is maintained in proper position with a special pad with Velcro that is attached to adjustable undergarments (all washable):

Femicushion

The Femicushion is designed to be worn during the day and removed at night. It is washed upon removal, to be worn the following day.

The Femicushion causes less complications than an internal pessary, since it is external and is removed and cleaned on a daily basis, reducing the risk for vaginitis and bleeding. Furthermore, it eliminates forgetting to remember the presence of the internal pessary that can give rise to erosions and other serious medical issues.

Dr. Sophia Souto and colleagues performed a pilot study of the Femicushion concluding that it is an effective means of alleviating POP symptoms and improving the quality of life of women suffering with POP.  Dr. Souto was kind enough to send me all of the images used in today’s entry.  For an excellent reference on the topic, see the following article published by Dr. Souto et al: Femicushion: A new pessary generation – pilot study for safety and efficacy.  Pelviperineology 2016: 35: 44-47

The Femicushion device can be purchased online at the Urology Health Store: Use “Urology 10” code for 10% discount and free shipping.

http://www.UrologyHealthStore.com

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com  

 

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Pessaries To Treat Pelvic Organ Prolapse: What You Need To Know

April 15, 2017

Andrew Siegel MD    4 /15 /17

A pessary is a vaginal insert that is used to help provide pelvic support in women with vaginal prolapse of the urogenital organs, a.k.a. pelvic organ prolapse (POP). Pessaries are available in a variety of sizes and shapes and when positioned in place within the vagina, function as “struts” to help keep the prolapsing pelvic organ(s) in proper anatomical position. They are ideal for older patients who have medical issues that preclude surgical treatment and for women who opt for non-surgical management.  Pessaries need to be removed periodically in order to clean them.  Some are designed to permit sexual intercourse.

A Few Words on POP

POP is a common condition in which there is weakness of the pelvic muscles and connective tissues that provide pelvic support, allowing one or more of the pelvic organs to move from their normal positions into the potential space of the vaginal canal and, at its most severe degree, outside the vaginal opening. POP is an important issue in women’s health, with an increasing prevalence correlating with extended longevity. Two-thirds of women who have delivered children vaginally have anatomical evidence of POP (although many are not symptomatic) and 10-20% will need to undergo a corrective surgical procedure. The true prevalence of POP is not known because of the large number of women who do not seek medical care for the problem.

POP is not life threatening, but can be a distressing and disruptive problem that negatively impacts quality of life. Despite how common an issue it is, many women are reluctant to seek help because they are too embarrassed to discuss it with anyone or have the misconception that there are no treatment options available or fear that surgery will be the only solution.

POP may involve any pelvic organ including the urinary, intestinal and gynecological tracts. The bladder is the organ that is most commonly involved in POP. POP can vary from minimal descent—causing few, if any, symptoms—to major descent—in which one or more of the pelvic organs prolapse outside the vagina at all times, causing significant symptoms. The degree of descent varies with position and activity level, increasing with the upright position and/or exertion and decreasing with lying down and resting, as is the case for any hernia.

POP can give cause a variety of symptoms, depending on which organ is involved and the extent of the prolapse.  The most common complaints are the following: a vaginal bulge or lump, the perception that one’s insides are falling outside, and vaginal “pressure.”  Because POP often causes vaginal looseness in addition to one or more organs falling into the space of the vaginal canal, sexual complaints are common, including painful intercourse, altered sexual feeling and difficulty achieving orgasm as well as less partner satisfaction.

3 Options to Manage POP

  1. Conservative
  2. Pessaries
  3. Surgery (Pelvic Reconstruction) 

Conservative treatment options for POP include pelvic floor muscle training (for details on pelvic muscle training for POP see http://www.TheKegelFix.com), modification of activities that promote the POP (heavy lifting and high impact exercises), management of constipation and other circumstances that increase abdominal pressure, weight loss, smoking cessation and consideration for hormone replacement, since estrogen replacement can increase tissue integrity and suppleness.

Pessary Basics

A pessary is a non-surgical option for treating POP, used with the goal of improving quality of life, body image, and bladder, bowel and sexual function. Pessaries are made of soft and pliable hypoallergenic plastic or silicone and can successfully alleviate symptoms of POP in 85% of those who use them.  About 50% or so of women who trial pessaries continue to use them for the long term, with discontinuation typically occurring in those who cannot retain the pessary, those experiencing discomfort or pain, those who desire surgery, and those who are incapable of inserting and removing them.

It is important to know that pessaries are not successful in all women with POP.  They tend to fail in women with significantly enlarged vaginal openings, in which case the pessary can fall out with effort and exertion. Factors associated with a higher risk for failure are younger age, obesity, and weak pelvic floor muscles.

For Whom is a Pessary Appropriate?

  • Older women who are not candidates for surgery
  • Anyone who desires non-surgical management of their POP
  • For those who need to delay surgery, wish to defer surgery or simply desire to trial one prior to surgery

1-Pessary Image

Image Above: A Potpourri of Pessaries

What Types of Pessaries Are Available?

For Mild-Moderate POP

The ring pessary (7:00 position of image above) is the simplest and most commonly used pessary that has the least side effects.  It is widely employed because of its ease of insertion, good vaginal fit and allowance for sexual intercourse without removing it.  A variation of the ring pessary is one with central support. The oval pessary is a variation of the ring used in narrow vaginas.  The Shaatz pessary (4:00 position of image above) is another variation. The incontinence dish pessary (5:00 position of image above) is used for stress urinary incontinence and mild POP.  A variation of this comes with a central support.

For Moderate-Severe POP

The Gellhorn pessary (3:00 position of image above) is used for greater degrees of POP than the pessaries described in the paragraph above, which are typically used for mild-moderate POP.  It tends to produce the greatest degree of vaginal discharge because of its shape.   The Hodge pessary has wires that can be manually shaped to fit the nuances of one’s anatomy. The Gehrung pessary (10:00 position of image above) also has wires that allow it to be manually shaped.  The donut pessary (center position of image above) is soft allowing it to be compressed for insertion, even with its bulk.  The cube pessary (9:00 position of image above) comes with a tie to help with its removal.

What Are Side Effects Of Pessaries?

The most common side effects are vaginal discharge and vaginitis (vaginal irritation or infection).  Occasionally, vaginal ulcerations can occur because of abrasive contact of the pessary with the delicate lining of the vagina.

How Does One Get Fitted For A Pessary?

A pelvic exam is performed prior to the fitting in order to help determine the proper size and type.  A properly fitted pessary should be large enough to function optimally, but not so large that it causes pressure or discomfort. It should be possible to insert a finger between the pessary’s outer rim and the wall of the vagina.

Usually a ring pessary (size 2, 3, or 4) is initially trialled.  It comes in 9 sizes, ranging from 2.00-4.00 in 0.25 increments.  If unsuccessful, a Gellhorn (size 2, 2.25, 2.5, or 2.75), cube or other model is utilized, depending upon particular circumstances. The largest pessary that is comfortable is placed and the patient is asked to walk and strain to ensure that it remains in proper position.  Motivated patients can be taught how to remove, clean and reinsert it. Typically, removal is done once weekly prior to sleeping, with reinsertion the following morning.  For the less motivated patient, the gynecologist can remove, clean and replace the device every three months or so.

Bottom Line: Pessaries are a non-surgical alternative to help provide pelvic support in women with pelvic organ prolapse.  They are available in a variety of sizes and shapes and need to be fitted and sized to the particulars of one’s anatomy.  They fold and compress to facilitate insertion and removal.  They are ideal for older patients who have medical issues that preclude surgical treatment.  If pessaries fail to improve the POP or cannot be retained or are poorly tolerated, a surgical procedure–pelvic reconstruction–can be performed to remedy the problem.  

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com 

Even More About Pelvic Prolapse: Diagnosis & Treatment

October 29, 2016

Andrew Siegel MD 10/29/2016

Note: This is the final entry in a 3-part series about pelvic organ prolapse.

 How is POP diagnosed and evaluated?

The diagnosis of POP can usually be made by listening to the patient’s narrative: The typical complaint is “Doc, I’ve got a bulge coming out of my vagina when I stand up or strain and at times I need to push it back in.”

After listening to the patient’s history of the problem, the next step is a pelvic examination in stirrups.  However, the problem with an exam in this position is that this is NOT the position in which POP typically manifests itself, since POP is a problem that is provoked by standing and exertion. For this reason, the exam must be performed with the patient straining forcefully enough to demonstrate the POP at its fullest extent.

A pelvic examination involves observation, a speculum exam, passage of a small catheter into the bladder and a digital exam. Each region of potential prolapse through the vagina—roof, apex, and floor—must be examined independently.

box

A useful analogy is to think of the vagina as an open box (see above), with the vaginal lips represented by the open flaps of the box.  A cystocele (bladder prolapse) occurs when there is weakness of the roof of the box, a rectocele (rectal prolapse) when there is weakness of the floor of the box, and uterine prolapse or enterocele (intestinal prolapse) when there is weakness of the deep inner wall of the box.

Inspection will determine tissue health and the presence of a vaginal bulge with straining. After menopause, typical changes include thinning of the vaginal skin, redness, irritation, etc. The ridges and folds within the vagina that are typical in younger women tend to disappear after menopause.

Useful analogy: The normal vulva is shut like a closed clam. POP often causes the vaginal lips to gape like an open clam.

Since the vagina has top and bottom walls and since the bulge-like appearance of POP of the bladder or rectum look virtually identical—like a red rubber ball—it is imperative to use a speculum to sort out which organ is prolapsing and determine its extent. A one-bladed speculum is used to pull down the bottom wall of the vagina to observe the top wall for the presence of urethral hypermobility and cystocele, and likewise, to pull up the top wall to inspect for the presence of rectocele and perineal laxity. To examine for uterine prolapse and enterocele, both top and bottom walls must be pulled up and down, respectively, using two single-blade specula. Once the speculum is placed, the patient is asked to strain vigorously and comparisons are made between the extent of POP resting and straining, since prolapse is dynamic and will change with position and activity.

 

exam-relaxed

Image above shows vaginal exam at rest (mild prolapse)

exam-minor-strain

Image above shows vaginal exam with straining (moderate prolapse)

exam-full-streain

Image above shows vaginal exam with more straining (more severe prolapse)

After the patient has emptied her bladder, a small catheter (a narrow hollow tube) is passed into the bladder to determine how much urine remains in the bladder, to submit a urine culture in the event that urinalysis suggests a urinary infection and to determine urethral angulation. With the catheter in place, the angle that the urethra makes with the horizontal is measured. The catheter is typically parallel with the horizontal at rest. The patient is asked to strain and the angulation is again measured, recording the change in urethral angulation that occurs between resting and straining. Urethral angulation with straining (hypermobility) is a sign of loss of urethral support, which often causes stress urinary incontinence (leakage with cough, strain and exercise).

Finally, a digital examination is performed to assess vaginal tone and pelvic muscle strength. A bimanual exam (combined internal and external exam in which the pelvic organs are felt between vaginal and external examining fingers) is done to check for the presence of pelvic masses. On pelvic exam it is usually fairly obvious whether or not a woman has had vaginal deliveries. With exception, the pelvic support and tone of the vagina in a woman who has not delivered vaginally can usually be described as “high and tight,” whereas support in a woman who has had multiple vaginal deliveries is generally “lower and looser.”

Depending upon circumstances, tests to further evaluate POP may be used, including an endoscopic inspection of the lining of the bladder and urethra (cystoscopy), sophisticated functional tests of bladder storage and emptying (urodynamics) and, on occasion, imaging tests (bladder fluoroscopy or pelvic MRI).

cystogram-normal

Image above is x-ray of bladder showing oval-shaped well-supported normal bladder.

cd-cystocele

                    Image above is x-ray of bladder showing tennis-racquet shaped bladder,                          which is high-grade cystocele.

How is POP treated?

First off, it is important to know that POP is a common condition and does not always need to be treated, particularly when it is minor and not causing symptoms that affect one’s quality of life.

There are three general options of managing POP: conservative; pessary and surgery (pelvic reconstruction).

Conservative treatment options for POP include pelvic floor muscle training Kegel); modification of activities that promote the POP (heavy lifting and high impact exercises); management of constipation and other circumstances that increase abdominal pressure; weight loss; smoking cessation; and consideration for hormone replacement since estrogen replacement can increase tissue integrity and suppleness.

A pessary is a mechanical device available in a variety of sizes and shapes that is inserted into the vagina where it acts as “strut” to help provide pelvic support.

512px-pessaries

Image above is an assortment of pessaries (Thank you Wikipedia, public domain)

The side effects of a pessary are vaginal infection and discharge, the inability to retain the pessary in proper position and stress urinary incontinence caused by the “unmasking” of the incontinence that occurs when the prolapsed bladder is splinted back into position by the pessary. Pessaries need to be removed periodically in order to clean them. Some are designed to permit sexual intercourse.

Studies comparing the use of pessaries with pelvic floor training in managing women with advanced POP have shown that both can significantly improve symptoms; however, pelvic floor muscle training has been shown to be more effective, specifically for bladder POP.

PFM Training (PFMT)

PFMT is useful under the circumstances of mild-moderate POP, for those who cannot or do not want to have surgery and for those whose minimal symptoms do not warrant more aggressive options. The goal of PFMT is to increase the strength, tone and endurance of the pelvic muscles that play a key role in the support of the pelvic organs. Weak pelvic muscles can be strengthened; however, if POP is due to connective tissue damage, PFMT will not remedy the injury, but will strengthen the pelvic muscles that can help compensate for the connective tissue impairment. PFMT is most effective in women with lesser degrees of POP and chances are that if your POP is moderate-severe, PFMT will be less effective. However, if not cured, the POP can still be improved, and that might be sufficient for you.

Numerous scientific studies have demonstrated the benefits of PFMT for POP, including improved pelvic muscle strength, pelvic support and a reduction in the severity and symptoms of POP. Improvements in pelvic support via PFMT are most notable with bladder POP as opposed to rectal or uterine POP. PFMT is also capable of preventing POP from developing when applied to a healthy female population without POP.

In symptomatic advanced POP, surgery is often necessary, particularly when quality of life has been significantly impacted. There are a number of considerations that go into the decision-making process regarding the specifics of the surgical procedure (pelvic reconstruction) to improve/cure the problem. These factors include which organ or organs are prolapsed; the extent and severity of the POP; the desire to have children in the future; the desire to be sexually active; age; and, if the POP involves a cystocele, the specific type of cystocele (since there are different approaches depending on the type). Surgery to repair POP can be performed vaginally or abdominally (open, laparoscopic or robotic), and can be done with or without mesh (synthetic netting or other biological materials used to reinforce the repair). The goal of surgery is restoration of normal anatomy with preservation of vaginal length, width and axis and improvement in symptoms with optimization of bladder, bowel and sexual function.

More than 300,000 surgical procedures for repair of POP are performed annually in the United States. An estimated 10-20% of women will undergo an operation for POP over the course of their lifetime.

Dr. Arnold Kegel—the gynecologist responsible for popularizing pelvic floor exercises—believed that surgical procedures for female incontinence and pelvic relaxation are facilitated by pre-operative and post-operative pelvic floor exercises. Like cardiac rehabilitation after cardiac surgery and physical rehabilitation after orthopedic procedures, PFMT after pelvic reconstruction surgery can help minimize recurrences. Pre-operative PFMT—as advocated by Kegel—can sometimes improve pelvic support to an extent such that surgery will not be necessary. At the very least, proficiency of the PFM learned pre-operatively (before surgical incisions are made and pelvic anatomy is altered) will make the process of post-operative rehabilitation that much easier.

Useful resource: Sherrie Palm is an advocate, champion and crusader for women’s pelvic health who has made great strides with respect to POP awareness, guidance and support. She is founder and director of the Association for Pelvic Organ Prolapse Support and author of “Pelvic Organ Prolapse: The Silent Epidemic.” Visit PelvicOrganProlapseSupport.org.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro. Area and Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.  The book was written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.