Chapter 53: Pessary Insertion

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You know, when you think about a garden hose that's just been totally kinked up for a while, you don't really know what's going on further down the line.

Right.

The water just stopped completely.

Exactly.

But the second you unkink that hose,

suddenly you might discover like a hidden leak that you had absolutely no idea was even there just simply because the pressure was blocked.

Yeah, that's such a great way to look at it because when anatomy shifts out of place, especially, you know, in the pelvic floor, it masks a whole host of other issues.

It really does.

So restoring that anatomy is literally unkinking the hose.

You put the organs back where they That is honestly the perfect mental image to kick off this Last Minute Lecture.

So if you are a college nursing or advanced practice student listening right now, welcome to your deep dive.

We are so glad you're here.

We really are.

Think of us as your study buddies who have already sat down and synthesized all the must -know clinical realities of Chapter 53, which is Pessary Insertion from Advanced Health Assessment of Women, the fifth edition.

Yes, the classic.

And our mission today is to walk you step by step through the process exactly as it appears in the text.

We're connecting your history taking directly to the focused examination and tying that right into clinical interpretation and management.

Because the goal is for you to walk into clinical practice feeling, you know, totally confident about the procedures, the safety precautions, and really the mechanical engineering behind these specific device types.

Exactly.

So let's just start with a big picture here.

Why is this specific skill becoming

so incredibly critical in women's health right now?

Well, honestly, demographics are driving this entirely.

I mean, the geriatric population is just booming right now.

Yeah, the numbers are huge.

They are.

The number of women aged 65 and older is projected to double in the next 20 years.

Double.

Double.

So because of that shift, the clinical demand for Pessaries is expected to grow by like 45 % in just the next three decades.

That's a massive jump.

It really is.

So this isn't some niche skill anymore.

It is the absolute first line treatment for all women presenting with symptomatic pelvic organ prolapse, which you'll often see abbreviated as POP in your charts and for stress incontinence.

Right.

So rather than just rushing these patients straight to the operating room, we use these pelvic organs, just holding them in closer alignment to their proper anatomic position.

Exactly.

And this is heavily utilized for treating second through fourth degree prolapses.

And for continence, the mechanics are actually kind of brilliant.

The device basically stabilizes the base of the bladder, right?

Like by anchoring right behind the pubis emphasis and the posterior vaginal fornix.

Yep.

It sits right in that space.

So the structure of the device literally compresses the urethra.

It increases the closing pressure so urine doesn't just leak out when the patient, you know, sneezes or coughs.

Which is huge because for patients who are at a really high surgical risk, maybe due to their age or other comorbidities, this provides a completely life -changing alternative to going under the knife.

Absolutely.

And kind of circling back to your garden hose analogy from earlier, pessaries also serve as a crucial diagnostic aid.

Oh, right.

The unmasking effect.

So imagine you have a patient with a severe prolapse that physically kinks the urethra.

It's literally obstructing their urinary outflow.

They might not even realize they have underlying stress incontinence because the prolapse tissue is basically plugging the leak.

Oh, wow.

So you place the pessary, you prop that prolapse tissue back up where it belongs and suddenly, boom, you uncover that hidden urinary incontinence.

Exactly.

Or, you know, on the flip side of that, you might uncover incomplete bladder empty.

Like urinary retention.

Yeah, exactly.

A patient might have a really high post -void residual urine volume, meaning they just can't empty their bladder fully.

But once the prolapse is structurally reduced with the device, they can finally empty completely.

That makes so much sense.

It does.

And as you start fitting these, just a really great clinical pearl to anchor on here, most patients do incredibly well with the middle size.

Okay.

So like what sizes are we talking about?

Usually that means starting with a size three or a size four.

Good to know.

Yeah, there's no need to overcomplicate the initial approach.

Yeah.

Advanced practice providers become, you know, highly adept at finding that sweet spot really quickly.

Love that.

Okay, so let's move into the pre -assessment phase because this is where a patient's lifestyle really dictates the clinical approach, right?

100%.

During history taking, the very first subject that has to be addressed is coitus.

Like, are they sexually active?

Yes.

And you can never, ever assume a geriatric patient is not sexually active.

Right.

Because if you make that assumption, you could really mess up their quality of life.

Exactly.

Certain pastries physically occupy the vaginal canal in a way that blocks intercourse entirely.

Like which one?

So devices like a Gellhorn or a doughnut or a cube or the shots, if you fit a sexually active patient with one of those and they cannot easily remove and reinsert it themselves, well, you've just severely impacted their life.

Yeah, you've created a huge barrier.

So the chosen device really must align with their lifestyle.

Absolutely.

Okay, so then tissue preparation is kind of the next barrier, right?

Because to ensure the device doesn't cause damage to that delicate mucosal tissue, clinical guidelines recommend estrogen therapy.

Yes.

Usually two to six weeks before the fitting.

And this is usually applied directly via the vaginal route, right?

Like an estrogen cream or an estradiol vaginal ring, which is often called an S -string.

Yeah, that's the standard.

But I actually have to ask though, kind of pushing back on that a little bit.

Wait, if you have a patient who is already on systemic hormone replacement therapy, like say an oral pill or an estrogen patch,

do they really still need this localized vaginal estrogen just for the fitting?

Well, so based on the text, they might not strictly need it.

But local vaginal estrogen is generally preferred, like heavily recommended as an adjunct.

Really?

Even with the systemic HRT?

Yeah, because systemic estrogen doesn't always provide enough direct support to the vaginal mucosa.

Oh, I see.

Localized application directly nourishes those specific vaginal tissues.

It matures the squamous epithelial cells so the tissue actually becomes thicker and, you know, less prone to micro tears.

Oh, that makes a lot of sense.

You're basically toughening up the specific area.

Exactly.

It increases the pliability of the connective tissue and it improves perineal

You want that target tissue to be as healthy and resilient as possible to handle a structural support device.

Okay, so preparing the tissue is one thing, but measuring for the actual fit is like a physical skill you really have to master.

It is a totally tactile skill.

Right.

So the standard technique is to insert your first two fingers deep into the vaginal canal, reaching all the way back to the posterior fornix, which is that deep space right behind the cervix or at the apex of the vaginal vault.

Right.

And once your fingers hit that posterior depth, you fold your thumb against your forefinger exactly where it touches the entroitus, the vaginal opening.

Okay, so you're basically using your hand as a set of calipers.

Exactly.

You hold that measurement firmly, you withdraw your hand, and you literally measure your fingers against the fitting kit or the device itself.

Wow.

You are looking for a size that will fit comfortably from that posterior space all the way to resting snugly behind the pubic bone.

I'm just picturing the anatomy here.

If the goal is for this device to sit securely in the vaginal vault, there just have to be physical limitations.

What if the vaginal canal is simply too short to even accommodate the device?

Yeah, that is a major barrier.

So a vaginal length of less than six centimeters makes fitting incredibly difficult.

The device just lacks the real estate to anchor.

Makes sense.

Are there other factors that make a fitting unsuccessful?

Definitely.

A wide vaginal entroitus, specifically if it's wider than forefinger breaths, means a support pessary will likely just slip right out.

Right, there's no ledge to hold it in.

Exactly.

And obesity is another major complication because the increased intra -abdominal pressure acts almost like a piston.

It literally forces the device down and out.

Oh wow.

I didn't even think about the intra -abdominal pressure.

Yeah, it's a huge factor.

And of course, previous pelvic surgeries can also alter the anatomical angles, which really complicates the fit.

Okay, so let's assume the anatomy is suitable.

The tissue is beautifully prepped with estrogen.

We are moving right into the hands -on insertion and immediate assessment.

The fun part.

Right.

So first step,

you have the patient completely empty their bladder and rectum, except, wait, there is one very strategic exception to this rule, isn't there?

There is.

If you are fitting a continence pessary, which is a device specifically engineered to stop

Some providers prefer the patient does not void beforehand.

Because you need to test it.

Right.

You need urine in the bladder to test if the device is actually working.

So you place the device, ask the patient to cough aggressively right there on the exam table, and you immediately assess if the urethra is sufficiently compressed to prevent leakage.

That is so practical.

Okay, so for the physical insertion, you take the device you've approximated using the finger measurement technique.

I would imagine the instinct is to just use a really generous amount of lubricant, especially if the introitus is narrow.

You would think so, but no.

The clinical warning on this is strict.

You only lubricate the entering edge.

Really?

Why just the edge?

Because if you slather the entire device in lubricant, it becomes so slippery that it is nearly impossible for you to compress, hold, or maneuver it into place.

Oh yeah, it would just shoot right out of your hands like a watermelon seed.

Exactly.

So you just lube the edge, you spread the labia, ask the client to bear down, and you grade the prolapse.

And this is vital.

Before the device goes anywhere near the introitus, you must manually reduce the prolapse back inside the vagina using your fingers.

Right, you can't push a structural support device into a totally collapsed space.

No, you have to put the anatomy back where it belongs first.

If the prolapse is massive, you might literally be holding it back with one hand while inserting the device with the other.

Okay, so once it's in, the immediate reassessment begins.

You separate the labia and you ask the patient to bear down again.

Yep.

And you might see the device descend slightly toward the introitus under pressure, but it should descend right back up into the vault when they relax.

And then you get them moving, right?

Yes.

Ask the patient to walk around the room, to sit in a chair, and to use the toilet.

If it shifts out of place or falls out during any of those activities, you likely need to go up a size.

But there's a really vital tactile check before they even get off the exam table.

Because I mean, I'd imagine sticking a firm device into a mucosal space runs the risk of compressing the tissue way too much.

Is that where the finger sweep test comes in?

Precisely.

Once the device is seated, you must be able to sweep the tip of your index finger entirely around the device.

You're feeling the space between the rigid material and the vaginal wall.

If you cannot fit your finger around it, the fit is simply too tight.

And a tight fit restricts capillary blood flow, which rapidly leads to severe tissue breakdown and necrosis.

Yikes.

Okay, so you've successfully placed the device, you've swept your finger around it, and the patient is walking around comfortably.

We obviously can't just send them out the door forever, though.

Oh, definitely not.

A successful fitting in the office is literally just the starting line.

Patient education and ongoing management are where the real work happens.

So what is the follow -up timeline?

Well,

clients who cannot independently remove, clean, and reinsert their device need a scheduled return appointment at four to six weeks initially.

As they prove stable and their tissue adapts, you can expand that interval up to about 12 weeks, but clinics must maintain a really strict tracking list of all users to ensure they are seen every two to three months.

Because a forgotten pessary is an absolute clinical disaster.

It really is.

And the physiological reason why is just fascinating.

The textbook notes that the vagina and the cervix actually have very limited nerve endings.

Right.

So it's not like getting a rock in your shoe where you feel this sharp immediate pain.

It is more like having a rock in your shoe when your foot is completely numb.

Oh, that's exactly what it's like.

A severe ulceration could literally be forming, tissue could be breaking down from undue pressure, and the patient might not sense any pain whatsoever until the damage is extensive.

And that reality really informs the strict contraindications for this therapy.

Like, according to box 53 .2, you absolutely cannot place one if there is active vaginitis or acute pelvic inflammatory disease, which is an infection of the upper reproductive organs, or an abnormal pap test.

Oh, sure.

And crucially, you never ever use one in a non -compliant patient or a patient with dementia who lacks a reliable caregiver to manage that strict follow -up schedule.

Right.

And even with ideal follow -up, patients do discontinue use, like box 53 .1 outlines.

The main reasons they quit include inconvenience, physical discomfort, electing for surgical repair instead, or just frustration because the device simply won't stay in place.

Yeah, that happens a lot.

But for those who do stay the course, we have to monitor for complications.

Now, an increase in vaginal discharge is expected, right?

Like a mild to moderate yellow or white discharge is just a normal physiological reaction to a foreign body.

Yes, exactly.

But if there's a foul odor, that is an immediate red flag.

Right, because foul odor means infection.

Exactly.

So if that happens, you perform a wet mount.

That's where you swab the discharge and look at it under a microscope on a glass slide to identify the specific pathogen.

And you treat the infection comprehensively.

Yep.

And you only replace the device after the infection is fully resolved.

Also, if you discover ulcerations during your exam, you remove the device entirely for three to four weeks to allow the mucosa to completely heal.

So to prevent those ulcerations and infections in the first place, maintenance is everything.

If patients are self -managing, they should clean the device with warm, soapy water.

But clinicians frequently recommend something called Trimosan gel.

Yes, Trimosan.

What exactly does that do?

So it's a specialized cleansing and deodorant gel, and it contains oxyquinoline sulfate.

Because a foreign object can really disrupt the naturally acidic environment of the vagina, which allows bacteria to overgrow.

Right, you lose that natural flora.

Exactly.

So this gel actually has a pH of four, which purposefully maintains that antibacterial acidic environment.

That is so smart.

And you also need to track their urination habits, right?

Instruct the patient to keep a one -week voiding diary, noting their fluid intake, their leak triggers, and their pad usage.

Yeah, documentation is key.

And pairing this structural support with muscle rehabilitation is incredibly powerful.

The text says to prescribe Kegel exercises.

With dedicated compliance, Kegels have a success rate of over 80 % for resolving incontinence within just four to eight weeks.

80 % is huge.

It really shows how much the muscular support matters alongside the device.

Okay, this brings us to what I think is the most visually complex and structurally fascinating part of our discussion.

The pessary wardrobe.

Oh yes, the wardrobe.

The specific care, instructions, and lifestyle limitations you discuss with your patient rely entirely on which piece of hardware you select.

Yeah.

So we really need to systematically break down these exact types and shapes to understand their functional mechanics.

Let's do it.

Let's start with the most popular.

The ring pessary, which comes either with or without a central support membrane.

Right.

So the ring is the number one choice for most providers, mostly due to its versatility.

Inserting it is very similar to inserting a contraceptive diaphragm.

You basically fold it in half at these structural notches, collapsing it like a taco.

Okay, taco fold.

Yep.

You guide it in with the folded arc facing upward, push it deep past the cervix, and then release it so it springs open.

Then you give it a quarter turn.

Ah, the quarter turn.

Why is that important?

That rotation is vital.

It locks the notches out of alignment with the vaginal opening so it cannot just fold back in on itself and slip right out.

And importantly, coitus is entirely possible with the ring in place.

Which is great for quality of life,

but compare that to the Q pessary.

This one is deployed for third degree prolapses, and the mechanism is completely different.

Oh, completely.

It literally has six concave sides that act as independent suction cups, adhering firmly to the vaginal walls.

The engineering on the Q is just remarkable.

Six suction cups holding those collapsing walls open, but that intense suction means it absolutely must be removed daily.

Every single day.

Yes.

Because the longer it remains in place, the stronger that negative pressure becomes.

Now the Qube does feature a string, but you must never simply pull the string to remove it.

Right, because of the suction.

Exactly.

If you yank the string while those six cups are vacuum sealed to the tissue, you will cause really painful tears in the fragile mucosa, or you'll just snap the string entirely.

Ouch.

Yeah.

You have to slide your fingertips along the side of the device to physically break the suction seal first, before compressing and extracting it.

Okay, moving on to severe prolapse, particularly procedentia, where the uterus entirely falls outside the vaginal opening.

For this, we use the Gellhorn pessary.

Gellhorn, yes.

It looks almost like a mushroom, right?

Like a flat, concave disc that the cervix rests against, and a rigid stem that points downward toward the introitus.

And it's manufactured in either flexible silicone,

or rigid acrylic.

Right, and material care is paramount here.

If you are handling an acrylic Gellhorn, never boil it, never autoclave it, and never clean it with alcohol.

Oh really, no alcohol?

No alcohol.

Heat warps the precise shape, and alcohol chemically degrades acrylic.

It'll give it this, like, shattered, fractured appearance.

You must disinfect it in a high -level liquid disinfectant, like Siddex.

Good to know.

And removing the Gellhorn takes practice, right?

Because that concave disc also creates a really powerful suction effect against the upper vault.

It does.

It generally requires a two -handed technique where you have to reach behind the disc to tip it forward and break the seal.

But there's a brilliant clinical hack for this.

Oh, the water syringe hack.

Yes.

You use a 20 -milliliter syringe filled with warm water.

You stick the tip of the syringe straight through the little drainage hole in the stem, and you flush the fluid upward.

That is genius.

Right.

The water pressure neatly breaks the suction right behind the disc, allowing it to slide right out.

I love that.

Okay, then we have the doughnut pessary.

It is exactly what it sounds like.

A large, thick ring that simply occupies the upper vaginal space, making it excellent for vaginal vault prolapse after a hysterectomy.

Yep.

And the physical mass of the doughnut must be greater than the levator muscle defect.

Meaning it has to be bulkier than the stretched -out opening of the pelvic floor muscles that are failing to hold the organs up.

Precisely.

And just note, coitus is not possible with this space -occupying device.

Right.

Now, for stress incontinence specifically, we turn to the incontinence ring, or the incontinence dish.

These have a really specialized design feature, a distinct, hardened little knob.

Yes.

The knob is key.

When you insert the device, you rotate it so that this knob sits squarely behind the pubic bone.

It directly compresses the urethra against it to stop leaks during physical exertion.

Brilliant.

And then we also utilize lever piscaries, specifically the Hodge, Smith and Risser models.

These are unique because their primary job isn't lifting a prolapse, is it?

No.

They are actually used for uterine retroversion, where the uterus tips backward toward the spine.

So they act as physical levers.

They displace the cervix posteriorly, which mechanically forces the body of the uterus to tip forward into normal and averted position.

And the long arm of these devices actually straddles the rectum to achieve that leverage.

Right.

And coitus is usually possible if they are fitted correctly.

Okay.

We absolutely cannot skip the gheron pessary.

Yeah.

It is indicated for correcting a cystosal, where the bladder herniates down into the vagina, and a rectosal, where the rectum bulges forward into the vagina simultaneously.

Yeah.

The gheron looks intimidating.

It really does.

It's shaped like a horseshoe or a U.

Right.

Its unusual shape definitely makes clinicians nervous, but it functions as this brilliant architectural support.

You fold the arches together, insert it sideways, and then rotate it 90 degrees.

And it forms a literal bladder bridge.

The heels of the device rest securely on the posterior vaginal wall, while the structural arches cross over the top to raise and support the herniated bladder.

This intricate design completely avoids placing any undue pressure on the rectum.

The engineering is just amazing.

We also see the inflato ball, which is exactly what it sounds like.

A silicone globe attached to a stem with a two -way valve.

Oh, so you pump it up.

Exactly.

You insert it completely deflated, which allows it to pass easily through a narrow entroitus.

And then you just pump it up with air until it provides the necessary support.

And again, always ensuring one finger can pass around its circumference to verify blood flow.

Always do the finger sweep.

Finally, we have to mention the non -traditional inserts making their way into patient care.

There is the Poise Impressa, which is an over -the -counter device.

It looks exactly like a tampon, but it deploys a structural tent to support the urethra for up to eight hours to manage stress incontinence.

Right.

Very accessible.

Then there's the Uresta, which is a self -managed Canadian device shaped like a small bell that patients don't even have to remove to void.

Oh, that's super convenient.

And the Colpexin Sphere, which is a space -occupying plastic orb that reflexively causes the pelvic floor muscles to contract just to hold it inside.

It essentially forces the patient to perform continuous Kegel exercises while they wear it.

Wow.

Talk about a workout.

As we wrap up this comprehensive breakdown, I really want to leave you with this final takeaway.

The sheer variety of these devices, from the taco folding mechanism of the ring to the independent section cups of the cube to the structural architectural bridge of the gyrung, it really highlights a beautiful reality in women's health.

It really does.

Anatomy, tissue resilience, and daily lifestyle are deeply, deeply individual to every single patient.

By mastering these physical structural tools, you gain the ability to offer highly personalized, truly life -changing care.

And you can do it frequently without ever needing to refer a patient for a scalpel.

That is just incredible.

It all comes down to finding the exact right mechanical fit to unkink that hose and restore normal pain -free function.

Well, we want to extend a really warm, encouraging thank you to you for joining us on this Deep Dive.

From the entire Last Minute Lecture Team, we wish you the absolute best of luck in your clinical practice, your patient interactions, and your studies.

You've got this.