Potentially dangerous complication of an ineffective shelf pessary

Abstract

A 76-year-old lady attended clinic for routine change of shelf pessary. Her current shelf pessary was size 17 and had been inserted 4 months previously. On inspection there was a procidentia; the pessary was¯ush to the posterior vaginal wall with the uterus prolapsing anteriorly. T he`hook' had perforated through the posterior vaginal wall which had closed about it. Rectal examination revealed the end to be 5 cm within, tenting the mucosa and pointing upwards. Thus the pessary had rotated transversely through 180°and coronally through 90°. The hook was on the verge of perforating the rectum com pletely and urgent arrangem ent for removal under anaesthesia was m ade.Six years previously she had declined surgery for ® rst degree prolapse. Increasing sizes of ring pessary (from 80 mm to 95 mm) were required. One year later she agreed to surgery for what had become a procidentia. A further year later she was admitted for operatio n, but an E C G revealed a rec ent myo card ial infarction. As her ring pessary was working well at that time, long-term conservative m anagement was considered appropriate. M atters worsened and 2 years later a size 16 shelf pessary was inserted but failed after 6 m onths. Finally a size 17 shelf pessary was inserted 4 m onths prior to the index visit.At operation the shelf pessary was removed with artery forceps. A buttonhole defect was left in the posterior vaginal wa ll. N o other vaginal or rectal trauma was seen.She went home the next m orning and is currently being man aged w ith dinoestrol cream an d vaginal packing in the community. An anaesthetic assessment is awaite d. DiscussionVaginal wall erosion by pessaries is reported, but is usually associated with prolonged, uninterrupted use, or with a pessary that is too large (D avila, 1996). H owever, this pessary had room to rotate in two planes and had been in place for 4 m onths.The last report of a similar com plication of shelf pessary was in 1961 (Russell). That patient had rectoand vesico-vaginal ® stulae having neglected a pessary for 18 years. She required extensive surgery and died 8 m onths later.Periodic review does not preclude this complication as seen in our case, and another whereby a ring pessary eroded through the vault in a hysterectomised patient causing small bowel incarceration requiring resection (Ott et al., 1993). She had been followed up periodically with no evidence of erosion prior to presentation.It is not only neglect or a tight ® t that can m ake vaginal pessaries dangerous. The problems caused often necessitate m ajor surgery. Elderly patients tolerate vaginal surgery well, although avoidance of surgery may be desirable in the debilitated.

An integrative review and severity classification of complications related to pessary use in the treatment of female pelvic organ prolapse

“…Thirteen papers discussed complications related to pessary size. [20][21][22][23][24][25][26][27][28][29][30][31] By combining the data in both case reports and case studies, we found that the most frequent complications were: vaginal discharge, bleeding, vesicovaginal fistula, erosion, ulceration, and foul odor (Table 1). We graded the reported complications using the Clavien-Dindo classification (Table 3).…”

“…31 Recommendations associated with this literature stress the need for proper sizing and performance of periodic examination. 28,43 Vaginal flora are affected by pessary use. Many patients have a physiologic watery discharge; this finding is not considered an infectious process unless accompanied by other symptoms (e.g., itching, burning, or foul odor).…”