Small bowel prolapse and incarceration caused by a vaginal ring pessary

Abstract

A 72-year-old woman was seen in the emergency room with a 2-h history of acute abdominal pain and transvaginal prolapse of the bowel, which had developed immediately after a strong fit of coughing. The patient had undergone transvaginal hysterectomy and colpoperineoplasty 10 years previously for vaginouterine prolapse. A soft rubber vaginal ring pessary of 5.5 cm diameter had been inserted 5 years later because the woman had developed a recurrent rectocystocele but had refused further operation. Periodic follow-up examinations had always been unremarkable.On clinical examination bowel loops were visible, protruding externally from the vagina (Figure I ). The blood pressure was 200/130mmHg and the heart rate 88 beats/min. The abdomen was tender with no guarding and bowel sounds were decreased. The white blood cell count was slightly raised at 12.5 x 10y/l. Plain abdominal radiography showed distended small bowel loops but no air-fluid levels.At emergency laparotomy, exploration of the pelvis revealed perforation of the vaginal stump and incarceration of the terminal ileum into the vaginal pessary. A 45-cm segment of ischaemic bowel was removed, and end-to-end ileoileal anastomosis performed. The vagina was stabilized by fixation to remnants of the sacrouterine and round ligaments, and the vaginal defect was closed.The patient had an uneventful postoperative course and was discharged on day 11. DiscussionThere is agreement that definitive treatment of genital prolapse should consist of extirpative or reconstructive surgery, because this is well tolerated even in elderly patients'. Vaginal supportive devices should be restricted to patients who refuse or are awaiting operation, since their use is frequently associated Intestinal obstruction caused by a vaginal pessary is a clinical rarity. A literature review of this complication revealed two reports of compression ileus but not a single instance of incarceration and transvaginal bowel prolapse. Seling and Lindenfelser3 described a patient in whom a retrovaginal small bowel loop was compressed by a ring pessary; a similar case was reported by Lukowski4. In the present patient, intestinal obstruction and bowel prolapse resulted from perforation of the vaginal stump and incarceration into the ring of the pessary. This was clearly related to the preceding hysterectomy, since the uterus with its fixation in the pelvis acts as a barrier between the abdominal cavity and vagina.

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).…”

“…39 Several reports implicated pessaries as a causal mechanism for both vaginal and cervical cancer. 25 Chronic inflammation in association with viral infections has been suggested to predispose patients to such cancers as the tumours appeared at the site of pessary placement. 50 It has been proposed that wearing a vaginal ring or cup-and-stem pessary for a long time may cause cancer of the vagina, ulcerative vaginitis, or fistulae.…”

Potentially dangerous complication of an ineffective shelf pessary

“…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.…”

Neglected vaginal pessary

“…[3][4][5] Rare instances of bowel incarceration through a ring pessary and even cancer of vagina have been reported. 6,7 Vaginal pessary may improve the quality of life but command proper care in elderly patients. Literature lacks adequate consensus on cleanliness or replacement protocols.…”