What are the recommendations for using a pessary in a patient with renal parenchymal disease, obstructing kidney stone, possible cancerous pelvic masses, and pelvic organ prolapse?

Management of Pessary in Complex Clinical Context

Immediate Priority: Address Obstructing Kidney Stone First

In a patient with renal parenchymal disease, obstructing kidney stone, possible cancerous pelvic masses, and pelvic organ prolapse, you must urgently drain the collecting system if there is any suspicion of infection, then address the stone before considering pessary management. 1

Critical First Steps for Obstructing Stone

• Emergently drain the collecting system with percutaneous nephrostomy (PCN) or ureteral stent if obstruction is present with suspected infection, as infected obstructed systems have compromised antibiotic delivery and require immediate drainage 1
• Percutaneous nephrostomy may have higher technical success rates than retrograde stenting when obstruction involves the ureterovesical junction or is caused by extrinsic compression from pelvic masses 1
• After stabilization, definitive stone treatment should follow based on stone size and location per standard protocols 1

Evaluation of Renal Parenchymal Disease

• Perform comprehensive workup including serum creatinine, eGFR, urinalysis with microscopy looking for dysmorphic RBCs (>80% suggests glomerular disease), red cell casts, and 24-hour urine protein quantification 2
• Refer to nephrology if proteinuria >1,000 mg/24 hours, dysmorphic RBCs, cellular casts, or renal insufficiency are present, as these indicate medical renal disease requiring concurrent evaluation alongside urologic assessment 1, 2
• Risk-based urologic evaluation should still be performed even when medical renal disease is suspected, as coexistent urologic pathology may be present 1

Evaluation of Pelvic Masses Before Pessary Placement

Imaging and Malignancy Assessment

• Obtain high-quality cross-sectional imaging with CT or MRI to characterize any pelvic masses and assess for malignancy before considering pessary placement 1
• For renal masses specifically, apply Bosniak classification: Bosniak III-IV lesions (≥50% malignancy risk) require surgical intervention, not conservative management 3
• Evaluate gynecologic masses with appropriate physical examination and imaging to rule out malignant etiology 1

Impact on Urinary Obstruction

• If pelvic masses are causing bilateral hydronephrosis and hydroureter, PCN placement may be necessary but careful patient selection is critical - those most likely to benefit have reasonable treatment options for their malignancy 1
• In advanced pelvic malignancies with poor prognosis, PCN may offer little benefit as performance status and survival are frequently poor, and the procedure carries significant morbidity including risk of pyelonephritis 1

Pessary Management for Pelvic Organ Prolapse

When Pessary Can Be Considered

Pessary should only be considered after addressing the obstructing stone, evaluating renal function, and ruling out or treating malignant pelvic masses. 1, 4

• Pessaries are appropriate for symptomatic prolapse when surgery is not desired or medically contraindicated 4, 5
• Up to 77% of clinicians use pessaries as first-line management for prolapse 6
• Patient satisfaction with pessaries is high when properly fitted and managed 7

Specific Considerations in This Clinical Context

• Attention to malignancy risk factors should guide decisions about whether to pursue prolapse treatment when non-obstructing conditions like prolapse are present alongside hematuria 1
• Pelvic organ prolapse itself may not merit immediate treatment if it is non-obstructing, and clinicians must use careful judgment with shared decision-making 1
• Pessaries combined with pelvic floor muscle training probably improve prolapse symptoms and quality of life more than PFMT alone (RR 2.15,95% CI 1.58-2.94) 5

Pessary Selection and Follow-up

• Trial and error with different pessary types (ring vs. Gellhorn) is appropriate as both show similar effectiveness in approximately 60% of women 6
• Regular follow-up is essential - vaginal erosions, impaction, and migration can occur, particularly if check-ups are delayed 8
• Local estrogen therapy should be used to prevent vaginal erosions 8
• Patient education on self-management and early detection of complications is critical 8

Absolute Contraindications in This Case

• Do not place a pessary if active infection is present with the obstructing stone 1
• Delay pessary fitting until malignant pelvic masses are definitively ruled out or treated, as management priorities differ significantly 1
• Pessaries may increase risk of adverse events including abnormal vaginal bleeding and voiding difficulty, which could complicate the clinical picture in a patient with existing renal and urologic pathology 5

Clinical Algorithm Summary

1. Immediate: Drain obstructed kidney if infection suspected (PCN or stent) 1
2. Urgent: Treat obstructing stone definitively per size/location 1
3. Concurrent: Nephrology referral for renal parenchymal disease evaluation 1, 2
4. Before pessary: Complete imaging and evaluation of pelvic masses for malignancy 1
5. Only after above resolved: Consider pessary for symptomatic prolapse with proper fitting, local estrogen, and close follow-up 4, 5, 8