Entrapment of vaginal ring pessary: A Case report and review of the literature

Abstract

The use of vaginal pessaries for symptomatic pelvic organ prolapse (POP) is well established. Recently pessaries have been offered routinely as a first-line treatment option for symptomatic POP, and in patients with medical comorbidity, those who are unfit for surgical intervention, and young women who still wish to bear children. The favourable physical and chemical properties of silicone have made pessaries safer to use for the treatment of POP. Complications associated with neglected pessaries are well documented, and it is probable that complications are rare when pessary care is regular. We present a case of partial encapsulation of a ring pessary despite regular follow-up at a tertiary urogynaecological unit, and review the literature pertaining to early entrapment of vaginal ring pessaries. A variety of pessaries are available, but it is evident from the literature that the ring pessary is the most common type prescribed, regardless of compartmental defect. Although the early literature commonly reserved their use for patients who declined surgery, were unfit for surgery or required interim relief while awaiting surgery, and for young women who wanted to fall pregnant, their use as first-line treatment for symptomatic pelvic organ prolapse (POP) is currently common clinical practice among gynaecologists and allied health clinicians (nurses and physiotherapists). S Afr J Obstet Gynaecol[1-4] Using a variety of questionnaires, several studies have demonstrated both a statistically and clinically significant improvement in prolapse, urinary and bowel sympotoms, sexual activity, and general quality of life. [5][6][7][8] Handa and Jones [9] reported a significant improvement in stage of prolapse (p=0.045) in a small group of 19 women who were fitted with a ring pessary for at least 1 year, and Matsubara and Ohki [10] reported correction/reversal of uterine prolapse in six women 42 months after removal of the ring pessary, suggesting a therapeutic effect.Major complications associated with neglected ring pessaries, such as fistulas (vesicovaginal, rectovaginal), vaginal vault perforation, pessary incarceration, urosepsis and pessary entrapment/ embedment, are well noted in the literature.[11] Lone et al. [3] reported an overall minor complication rate of 12.1% (pain/discomfort, excoriation/bleeding, disimpaction/constipation) in symptomatic patients followed up over a 5-year period. Entrapment, also frequently referred to as embedment, is a common complication reported mainly with neglected and forgotten ring pessaries. We present a case of a ring pessary entrapped in a band of vaginal tissue despite frequent pessary care at a tertiary urogynaecology clinic. Case reportA 64-year-old woman, para 7, gravida 7, presented to the urogynaecology clinic for her routine 3 -6-monthly pessary review visit. She had no current complaints and was satisfied using the ring pessary as a treatment option for symptomatic POP. On clinical examination the clinician failed to remove the ring pessary, which was retained.The patient ...