A 77-year-old female (F) who wears a pessary is experiencing difficulties with bowel movements (BM)?

From the Guidelines

A 77-year-old female wearing a pessary and experiencing difficulty with bowel movements should have her pessary temporarily removed if possible and start a bowel management regimen with a gradual increase in fiber intake and an osmotic agent like polyethylene glycol or milk of magnesia, as recommended by the American Gastroenterological Association 1. The patient's constipation is likely related to the pessary's pressure on the rectum, and removing it can help alleviate this issue.

• Implementing a bowel management regimen with a gradual increase in fiber intake, as recommended by the American Gastroenterological Association 1, can help improve bowel movements.
• Using an osmotic agent like polyethylene glycol (17g daily) or milk of magnesia (1 oz twice daily) can also help soften stool and improve bowel movements, with an approximate daily cost of $1 or less 1.
• If symptoms do not respond to these measures, considering a newer agent like lubiprostone or linaclotide, or biofeedback therapy, which improves symptoms in more than 70% of patients with defecatory disorders 1, may be necessary. The pessary may need adjustment by the healthcare provider to reduce pressure on the rectum while still providing pelvic support.
• Regular pessary care and periodic removal can help prevent this complication, and the patient should be advised to follow a bowel training program and manage diarrhea and constipation with diet and medications if necessary, as part of a stepwise approach for management of defecatory disorders 1.

From the FDA Drug Label

Uses Relieves occasional constipation (irregularity) Generally causes bowel movement in 6 to 12 hours The patient, a 77-year-old female wearing a pessary, is experiencing issues with bowel movements.

• The senna (PO) drug label indicates it is used to relieve occasional constipation.
• It generally causes bowel movement in 6 to 12 hours. The use of senna (PO) may help the patient have a bowel movement, potentially alleviating her issues with bowel movements 2.

From the Research

Bowel Movement Issues with Pessary Use

• A study published in 2014 3 found that women with prolapse who used a pessary reported significant improvements in bowel-related symptoms and quality of life after 12 months of use.
• However, another study from 2016 4 suggests that polyethylene glycol (PEG) with or without electrolytes is an effective treatment for functional constipation, which may be a contributing factor to bowel movement issues.

Treatment Options for Constipation

• A 2016 study 5 compared the effectiveness of PEG 3350 and docusate sodium versus docusate sodium alone after urogynecologic surgery, and found that PEG 3350 did not significantly reduce time to first bowel movement.
• A 2010 study 6 found that the use of senna with docusate decreased time to first bowel movement after pelvic reconstructive surgery compared to placebo.
• However, a 2021 review 7 suggests that docusate may not be effective for constipation in older adults, and that other treatments such as psyllium and sennosides may be more effective.

Potential Solutions

• Consider using polyethylene glycol (PEG) with or without electrolytes to treat functional constipation, as suggested by the 2016 study 4.
• The use of senna with docusate may also be effective in decreasing time to first bowel movement, as found in the 2010 study 6.
• However, the effectiveness of docusate alone is questionable, and other treatments may be more effective, as suggested by the 2021 review 7.