From the Research
The next step for a patient with a dislodged pessary that appears as a radio-opaque object in the pelvis on abdominal X-ray (AXR) is to perform a vaginal examination and attempt removal of the pessary. This should be done carefully in the office or emergency department setting, using appropriate analgesia if needed, as suggested by general medical knowledge and principles of managing dislodged devices. If the pessary cannot be easily removed due to its position or patient discomfort, consider performing the removal under sedation or anesthesia. After removal, the vaginal tissue should be assessed for any erosion, ulceration, or infection that may have developed due to the dislodged pessary. Antibiotics such as metronidazole 500mg twice daily for 7 days may be necessary if infection is present, based on standard treatment protocols for infections in the pelvic area 1. The patient should then be reevaluated for pessary management - either fitting a new, more appropriate pessary or discussing alternative treatments for urogenital prolapse, considering the latest research on pessary sizing and management 2. The urgency of removal is based on the presence of symptoms such as pain, bleeding, or urinary retention. Prompt removal is important because a dislodged pessary can cause pressure necrosis, fistula formation, or infection if left in place for extended periods. Following removal and treatment of any complications, a comprehensive discussion about prolapse management options should occur, including pessary care education if continuing with pessary use, and considering the potential long-term impacts of different treatment options 3. Imaging modalities such as ultrasound, CT, or MRI may be useful in evaluating the extent of prolapse or complications, but the initial step should focus on the safe removal of the dislodged pessary and assessment of the patient's condition 4, 5.
Key considerations in managing this patient include:
- Prompt removal of the dislodged pessary to prevent further complications
- Assessment and treatment of any infections or tissue damage
- Reevaluation of pessary management and consideration of alternative treatments for urogenital prolapse
- Comprehensive patient education on pessary care and management options
- Potential use of imaging modalities to evaluate the extent of prolapse or complications, guided by the most recent and highest quality evidence available.