What are the requisites for using pessaries (intrauterine devices) in treating procidentia (uterine prolapse)?

Requisites for Pessary Use in Procidentia (Complete Uterine Prolapse)

Pessaries are appropriate for procidentia when patients are not surgical candidates, decline surgery, or desire less invasive management, though they serve primarily as symptom relief rather than definitive treatment. 1

Primary Indications for Pessary Use in Procidentia

The key requisites for offering pessary therapy include:

• Symptomatic pelvic organ prolapse (procidentia) where the patient experiences bothersome symptoms affecting quality of life 2, 3
• Patient preference for non-surgical management over definitive surgical repair 1, 2
• Medical contraindications to surgery including poor surgical candidacy due to comorbidities, advanced age, or anesthetic risk 2, 4, 5
• Temporary management while awaiting definitive surgical repair 4
• Failed previous surgical repair requiring alternative management 4
• Desire to preserve childbearing capacity in younger women 4, 5

Clinical Assessment Requirements

Before pessary fitting, evaluate the following:

• Degree of patient bother from prolapse symptoms, as treatment decisions should align with symptom impact on quality of life 1
• Vaginal tissue quality and estrogenization status - 64% of urogynecologists consider hypoestrogenism a relative contraindication requiring pre-treatment with vaginal estrogen 3, 6
• Pelvic diaphragm strength - 59% of specialists use different pessary types for patients with weak pelvic floor support 3
• Prior hysterectomy status - 44% of practitioners modify pessary selection for post-hysterectomy anatomy 3
• Sexual activity status - less than half consider this a contraindication, but it influences pessary type selection 3

Pessary Selection for Complete Procidentia

For complete procidentia specifically, space-filling pessaries are preferred over support pessaries:

• 76% of urogynecologists use pessaries for complete procidentia 3
• Gellhorn pessary is the most commonly selected space-filling device for complete prolapse 3
• Donut pessaries are alternative space-filling options for severe prolapse 3
• Ring pessaries (support type) are less commonly used for complete procidentia compared to other prolapse types 3

Management Protocol Requirements

Successful pessary use requires:

• Trial-and-error fitting approach as evidence for optimal selection remains incomplete 2
• Patient education on self-management including insertion, removal, and cleaning techniques 2, 5
• Regular follow-up schedule to monitor for complications 2, 5
• Vaginal estrogen therapy when hypoestrogenism is present to improve tissue quality and prevent complications 6
• Monitoring for complications including vaginal erosion, discharge, bleeding, or incarceration 5, 6

Common Pitfalls to Avoid

• Do not assume pessaries provide therapeutic benefit beyond symptom relief - only 48% of specialists believe pessaries offer more than symptomatic management 3
• Do not neglect vaginal estrogen preparation in hypoestrogenic patients, as this significantly reduces complication risk 6
• Do not allow prolonged intervals without follow-up - incarcerated pessaries can occur with inadequate monitoring and require estrogen cream application for safe removal 6
• Do not use the same pessary type for all prolapse types - 78% of specialists tailor pessary selection to the specific defect, with space-filling types preferred for procidentia 3

Patient Satisfaction and Efficacy

• 92% of physicians report that pessaries effectively relieve prolapse symptoms 3
• Patient satisfaction rates are high when proper fitting and management protocols are followed 2
• Long-term pessary use is safe and effective for appropriately selected patients 5
• Serious side effects are infrequent with proper monitoring 5