In this episode of PodMD, minimally invasive gynaecologist Dr Deb Karmakar will be discussing the topic of pessary management of prolapse. We discuss the symptoms of prolapse, treatment options and development, warning signs to look out for and more.
- Transcript
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
This podcast is brought to you by DPM Financial Services.
DPM is a specialist medical financial advice firm that aims to empower doctors of Australia to make the right financial decisions and achieve their financial goals.Today I’d like to welcome to the PodMd studio Dr Deb Karmakar.
Dr Karmakar is a Melbourne-based Minimally Invasive Gynaecologist with a special interest in Urogynaecology. With over 18 years of experience across India, the UK, and Australia, he provides expert care for complex gynaecological and pelvic floor conditions.
After graduating from the University of Kolkata, Dr. Karmakar completed his Obstetrics and Gynaecology training at AIIMS, New Delhi—one of India’s premier institutions. He then pursued advanced subspecialty training in Urogynaecology and Minimally Invasive Surgery in the UK before moving to Australia where he did further advanced subspecialty training in Urogynaecology. He has been a recognised specialist since 2018, following further training at Mercy Hospital for Women, Melbourne. Dr Karmakar’s private practice is based primarily in Melbourne, and he also provides services in regional Victoria. He holds a public appointment at Mercy Hospital for Women and an academic position at the University of Melbourne, where he completed a PhD in applications of artificial intelligence to obstetrics and gynaecology.
Today, we’ll be discussing the topic of Pessary Management of Prolapse. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Deb, thanks for talking with us on Pod MD today.
The topic of today’s discussion is pessary management of prolapse. Deb, can you describe for our listeners what prolapse is?
Deb: Thanks. From A gynecological perspective, prolapse would imply vaginal prolapse, where the pelvic floor muscles and connective tissues no longer support the bladder, uterus, or the top of the vagina, or the bowel as firmly as it should. So one of these organs, through their respective compartments, bulges into the vagina. It is fairly common. Up to 40% of women will experience symptoms through their lifetime, but usually it’s not dangerous. We try to treat the person’s symptoms and goals because the degree seen on clinical examination may not match how much it affects the person. In a lot of ways, it’s very similar to a hernia.
How would a patient with prolapse typically present?
Deb: The symptoms can be varied however, the classic description of symptom is a vaginal bulge or the feeling that something is coming down, often with heaviness or dragging, that gets worse after standing, lifting, and typically later in the day. There may also be incomplete bladder emptying, leakage problems, recurrent urinary tract infections, constipation. difficulty emptying the bowels, the need to support or reduce the bulge, which is described often as splinting, or discomfort or obstruction with sex. Some women have visible prolapse but no symptoms at all.
And what are the risks or efficacy of the conditions?
Deb: Thankfully, it’s a usually benign condition, and it’s typically not life-threatening. In fact, in many people, it might remain stable, but it can substantially affect activity, exercise, intimacy, confidence, and quality of life domains. For instance, bladder effects include leakage or incomplete emptying. Bowel effects include obstructed defecation or the need to splint, as we discussed before. An advanced prolapse can cause ulcerations and, very uncommonly, complete urinary retention or upper urinary tract obstruction, leading to hydronephrosis and kidney damage. Conversely, many women with anatomical prolapse might not have any bother. So in most cases, our treatment strategies should be driven not by stage alone.
And what are some of the treatment options?
Deb: Yeah, I think we’ve got a wide variety of options, and it’s usually a good idea to progress step by step. So some people might choose to have a period of watchful expectancy, and we can just observe. And it’s reasonable as long as they don’t have any of those red flag things, such as bladder not emptying completely or significantly, or hydronephrosis, where the renal pelvises are getting swollen up. So in some cases, some people will choose to have just a period of observation. Commonly, if they want to do something about it, we would recommend they see a pelvic floor physio. And a good way of accessing that is to get a primary access care plan from the GP so that they get a bit of Medicare rebate. There is some evidence that if the prolapse is grade 3 or beyond, a pelvic floor physio may not be as efficacious, but it never hurts to try. And in many cases, the patients will see some benefit from it. And obviously, the third option is what we’re going to focus a bit more in detail today is a pessary. And if any of those options are not working or not suitable for the patient or it’s not preferable for the patient for a variety of reasons, then we also have surgical management options. So aside of all of this, it is also very important to address aggravating factors. So for example, anything that is putting strain on the pelvis, for instance, chronic constipation, chronic cough, higher body mass index, and repeated heavy lifting because they will increase the intra-abdominal pressure and they can aggravate the prolapse. The UK NICE guidelines recommend at least 16 weeks of supervised pelvic floor muscle training for symptomatic prolapse. Here, the contextual bit is that it has to be supervised. We can educate the patients about their Kegel exercises, But what research has consistently shown is that little bit of biofeedback coming from a professional, like a pelvic floor physio, will lead to much better results. And in terms of the pessaries, there’s two different types of pessaries. One is the common one, which is more accessible in the community. These are called ring pessaries. So they work by providing support. So they’re inserted in the vagina and they help in kind of replacing the pelvic organs in their anatomical location. However, in some patients, especially if it’s a multi-compartment or severe prolapse, a more space-occupying type of pessary might be needed, and the common ones we use are Gelhorn or Cube. Typically, the latter space-occupying pessaries have been administered by specialists, but it’s really refreshing to see many physios now in the community have started providing the options of Gelhorn or Cube pessaries so that the treatment can be initiated in the community. And again, they have to be tweaked as per the patient’s situation. For instance, a space-occupying pessary is typically not suitable in a patient who’s sexually active because removing it in and out before sexual intercourse can be challenging. However, there are patients who can use a cue pessary and they can self-manage and they can take it out before intercourse and they do quite well. So while there is some general guidance that ring pessaries are better for sexually active patients, it’s always not the case. We also find that in patients who have had hysterectomy or if they have a very enlarged vaginal entrance, for example, if they’ve had instrumental birth where there is some element of pelvic floor trauma, the ring pessaries may not be retained adequately in those patients. The space-occupying ones like Cube or Gelhorn are a better option if they are suitable for the patient. And obviously, if the patients continue to have bothersome symptoms or the pessary is not quite the right fit, where it keeps falling out, or if it’s too big, where it’s causing obstruction of the bladder or bowel, or if it’s leading to complications, which we will discuss in a little bit, then obviously we’ll have to start talking about surgical options.
Has there been any developments in treatment in the last years, or are there any in trials or development now?
Deb: I think the whole perspective around pessary has changed in the positive direction, thanks to some very large studies that have been published in reputed journals. And the evidence is that by far, majority of the patients can be deemed suitable for pessary management. And so from a medical perspective, the suitability is well evidence-based. When it comes to preference, that’s a slightly different issue. For instance, there was this big study published in JAMA authored by Wonder Ward and colleagues. When they looked at patients and they split them into patients who used pessary as their first-line strategy versus surgery as the first line option, 76% of women assigned to a pessary first strategy reported feeling very much better compared to 82% with surgery and the difference was not significant. So in simpler words, whether the patients chose surgery first or operation first, their outcomes was, the patient reported outcomes were similar. And also in a subsequent study published in the Lancet e-clinical medicine, which is called the Topsy trial, with this whole paradigm shift now being towards self-management, where the patient can take out the pessary every few days or every few weeks, give it a rinse and put it back. It gives the patients a… a significant sense of choice and autonomy. And they have found that with self-management strategies in the TOPSI trial, the risk of complications was 17% versus 22%, where their care was more clinic-based. So even in my own practice, I can definitely see that I have shifted from a more clinic-based approach versus a more community-based or a self-managed approach. Because the pessary has to be removed and rinsed at least every six months so that it doesn’t cause pressure changes or lead to infections or ulcers. But ideally, if we can, if the women can remove it more frequently, so every few days or every few weeks, then the outcomes do tend to be a bit better.
Are there any warning signs a GP or their patient can look out for?
Deb: Yeah, so With this one, what is closely tied in is that because the pessary is a foreign body object, and there is a risk of pressure ulcers or decubitus ulcers, and just being a foreign body, it does increase the risk of vaginitis and colonization of bacteria and urinary tract infections. So any bleeding typically is a red flag. A little bit of a small amount of discharge is normal. So routinely all patients with pessary management should have vaginal estrogen prescribed to them. If there are contraindications to it, they can use alternative non-hormonal lubricants. For instance, Replens is a common brand name. However, estrogen does seem to be better in preventing all of these pressure or foreign body complications. So any bleeding, any new discharge that is more than what the patient usually experiences, or complete obstruction in emptying the bladder or bowel or severe pain, those are the big red flags and they need urgent referral to a specialist. In the initial setting of pessary fitting, a more common problem is the patient might be satisfied with the passive fit in clinic, they go home and in a few hours they land up in urinary retention, even though they might be emptying the bladder completely normally in clinic. So we do have to warn them that urinary retention can happen maybe a few hours later or in one or two days, even though initially they might be passing their urine normally. And so they have to report straight away to a hospital emergency because they will need to have a catheter put in.
And what is the likelihood of recurrence of the condition?
Deb: I think this is more contextual, depending on the actual management. If we are doing pessary management for prolapse, and usually the patients are counseled that it might take two or three attempts where we find the right shape or size of pessary. And eventually, when we find the right fit, most patients would be suitable for ongoing management. In fact, some of my patients have used pessary lifelong, as long as… the minimum, at a minimum every six to nine months, someone’s removed their pessary, looked at the vaginal tissues, made sure that there is no, you know, complications going on. They can continue it. The recurrences would be more when there is a sudden change in their prolapse or body configuration. So sometimes we have patients who’ve been managing well with a pessary and all of a sudden they have a major illness or for some reason, for instance, they have an intra-abdominal condition, so like ascites, so the abdominal pressure has increased. So the pessary that was working before fine stops working. So I had a patient recently who had… a long-term pessary, and then she had major surgery, hepatobiliary surgery, and lost a lot of weight, so her body configuration changed. So the pessary was not a good relative fit for her anymore. So then the pessary stopped working. Otherwise, so those are the few situations where the pessaries might stop working. And obviously, if this was a very progressive kind of prolapse, where initially the pessary might work, and as the prolapse becomes worse, then the pessaries will stop working. So that’s a slightly common situation. When it comes to surgery, the evidence has to be looked at very carefully. A lot of our traditional gynecology textbooks have quoted recurrence rates of around 25 to 33%. In fact, the RANSCOP guidelines also note reoperation rates up to 25%. But if you look at the literature more carefully, especially the long follow-up studies, the large registries from US and Scandinavia, We find that if the surgical planning was done diligently and all the compartments of prolapse, so the anterior compartment for the bladder, the central compartment for the uterus, or the top of the vagina and the posterior compartment for the bowel, were addressed appropriately at the time of index surgery by an appropriately trained surgeon, the reoperation rate should really not be more than 10 to 15%. And that is how I tend to guide my patients as well. So there is a bit of nuance around the evidence. And even in patients who will report some degree of recurrence with their prolapse after surgery, most women will have meaningful symptom relief. So we always try to hear the pre-op counseling is very important. So we try to tell patients that, okay, these are the symptoms you have. For instance, if someone’s had got bulge symptoms and bladder symptoms, we have to be realistic and say, look, your bladder symptoms may or may not improve, but your bulge symptoms should improve. And so setting the expectation correctly is very important. And then a lot of patients, if they have recurrent symptoms, they don’t usually need an operation. And then framing the prolapse as a condition where there is a defect in the support structures and there is a risk of, some element of recurrence does help in setting those expectations and hence leads to better outcomes for patients.
When should a GP refer their patients?
Deb: It’s really when the patient is bothered and wants a specialist. opinion. The other situation sometimes where the patients might not have symptoms, but the GP is what it is at the time of taking a cervical screening test, they’ve noticed a prolapse and they would refer, but usually it is driven by symptoms or if there are other conditions, for example, the patient is unable to empty their bladder very well or a renal tract ultrasound for some other reason has shown a raised post-void residue in the bladder. or if someone’s experiencing recurrent urinary tract infections, obstructed defecation, or if someone’s had surgery before they are experiencing recurrence. The other thing that has come through recent studies is that in a lot of women with pelvic pain, it could be the prolapse that is sensitizing their pelvic nerves. So while it is good to investigate for other conditions, such as endometriosis or adenomyosis, In a lot of women, if they have, for instance, a stage 2 prolapse, that might be sensitizing the pelvic floor. So it’s worthwhile considering that. And obviously, there are more urgent reasons to refer if an ultrasound has shown hydronephrosis or the prolapse is visibly sort of hanging out. I’m sorry, I will pause, and then I’ll rephrase it. So obviously, if there are more urgent indications, such as hydronephrosis, or there is an irreducible or ulcerated prolapse, which is quite rare, or there is a concern about pelvic mass or malignancy that is pushing on the pelvic organs and causing prolapse, those are the other triggers for referral.
And in terms of managing expectations for patients, what advice would you give a patient when they’re being fitted for a pessary?
Deb: Yeah, my strategy is usually to phrase this as a chronic health condition. So it is best to look for incremental gains. unless obviously someone’s going straight for surgery, which is a different situation. In a lot of the cases, especially with physiotherapy and pessary management, it is a bit of a process. and a period of trial and error. So if the expectation is set at the start, okay, you will have this pessary trial, but you will still need to do pelvic floor physio because the pessary will give you good biofeedback by staying there and you will have incremental gains from the physio with the pessary being in. I think they tend to have a little bit more trust in that whole process of waiting and trying conservative options. And then usually I tell them that any pain or significant discomfort or obstruction of bladder or bowel is not normal. So if any of those things are happening, best not to wait. It should be a pessary fitting and pessary trialling should be a relatively comfortable experience. If there is a significant amount of discomfort or pain, it just means that this is not the right size or shape of the pessary. And obviously, as we mentioned before, sexual activity is an important consideration. So the whole guidance around how to manage the pessary around sexual intercourse. So a lot of patients with ring pessary can have sex with the ring staying in, or they might want to take it out. But typically patients with a cube or a gel horn pessary, if they want to be sexually active, they will have to be very well-trained in self-managing it. So in a lot of older patients, the other consideration is if they’ve got arthritis of their finger joints, then that becomes a barrier for self-managing a space-occupying pessary. So all of those considerations have to be teased out at the start of the pessary trial.
And can a pessary be used long-term or what follow-up is needed?
Deb: So I will pause the recording here, Rowena. This was mostly covered in the previous question, so we can remove the question 10. I realized that I went a bit off script and to address some of the other questions I’ve covered this.
Okay, no problem. Was that the six months part that you were talking about it being in for six months? Yeah, okay, no problem.
Deb: Oh, I think we can, if that’s okay. you can maybe we can make question 10 as is there anything else specific you wanted to cover and because with the follow-up I did miss something and maybe I can put that in here.
Okay yeah no problem so is there any is there anything else specific um regarding pessaries that you wanted to address is that a good?
Deb: Yes yeah yes can you tell me when I can answer yeah all right.
Okay, we’ll start recording again, Rob. And question 10 is, is there anything specific regarding pessaries you’d like to address, Deb?
Deb: Yes, the 4 week, the 4 to 6 week mark is a very critical time after a right fit for pessary has been found, and as that is the trigger point for us to do the first really careful look to make sure those early complications with pressure changes are not happening. And once that four to six week mark is satisfactory, then a clinician-led check can happen less frequently, as we discussed earlier, every six to nine months, with or without patient self-managing in between.
Perfect. Well, thank you very much for your time today in the PodMD studio. To sum up for us, could you please identify the three key take-home messages from today’s podcast on pessary management of prolapse?
Deb: Thanks. The first take-home message, I think, is that prolapse is a common condition. Thankfully, it’s benign, but it does lead to a lot of body image and distress in a lot of patients. So it’s useful for us to treat the symptoms and the patient goals and not the examination stage findings. The second take-home message, I think, is that a well-fitted pessary is an effective reversible option at any stage, but it is good to set the expectation at the start that the fitting may take more than one attempt. And the third is that there is a lot of evidence now from several studies that if self-management is supported, then it leads to more reliable follow-up and less complications.
Thanks again for your time and the insights you’ve provided, Deb. It’s been great to have you in the PodMD studio.
Deb: Thank you.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
