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When diagnosed with uterine prolapse, in most cases, you will be able to elect to follow a conservative treatment plan to find relief. One of the most popular avenues for treatment is vaginal pessary, but their use is not as simple as you may think.

When it comes to uterine prolapse treatment, patients will quickly consult with Dr. Google and come across a number of tools and exercises to help manage their symptoms. About 40 percent of women have some degree of uterine prolapse world-wide [1]. Of these cases, about a quarter of the women will have some type of severe symptom pattern that can make life quite difficult as the patient ages. These women not only suffer from the physical limitations associated with a prolapsed uterus, such as bloating, urinary incontinence and abdominal discomfort but can also suffer from a number of psychological hardships as well. Women that have severe prolapse are consistently found to have decreased body image perceptions which can easily blossom into depression [2]. It is paramount that women find some type of therapy to manage their uterine prolapse conservatively before they need a more drastic operation. Vaginal pessaries may be exactly what the doctor ordered. 

The Perfect Fit 

When treating patients with uterine prolapse, an obvious fact that a patient much ensure is that they will not find any relief from their symptoms if the pessary is not fitted properly. Although the techniques of specialists vary in how to obtain their measures, a general constant is that patients with a properly sized pessary will have a finger's width of space between the pessary and the vaginal wall and the patient will also be able to stand, cough and strain without the pessary dislodging [3]. This may sound like a pretty straightforward process but even with these specific guidelines, only 54 percent of  266 patients tested were successfully fitted with a proper vaginal pessary during their first visit, 36 percent more during the second visit and up to 10 percent of the group needing to meet three times to find the proper size. As depicted in this data, fitting for a vaginal pessary is most certainly not an exact science.

Researchers concluded that the most likely barrier to determine the success of a properly fitted vaginal pessary was based on the vaginal length as well as the vaginal introitus width (the opening of the vaginal canal). Ring pessaries were much more frequently used in patients that only had a minor degree of prolapse compared to patients suffering from a higher degree of prolapse needing interventions such as a Gellhorn pessary. [4]

Past Medical History 

Another factor that can have a large impact on the ultimate success of placing a pessary is a patient's past medical history. Doctors need to consider this element when attempting to find an adequate uterine prolapse treatment. Patients with a history of having a hysterectomy can be difficult candidates to determine the proper pessary size [5]. Scar tissue and irregular post-operative physiological changes can make the vaginal canal warped or twisted in a manner that makes pessary placement and success much more difficult. In these groups of patients, ring pessaries are rarely used and instead, a physician will turn to Gellhorn pessaries without any delay. 

Another element that can potentially derail this conservative therapy for uterine prolapse is the status of the woman being considered. Women who have given birth multiple times present a challenge to consider because their vaginal canal will also be shaped differently and the degree of vaginal prolapse may also be more severe. 

Post-menopausal women are another difficult group to manage because of the decreased elasticity of their vaginal wall as estrogen is no longer being produced. Because of this natural change, placing a pessary may be extremely uncomfortable for a patient because of the friction on the skin. Women considering inserting a pessary after menopause are usually pre-medicated with estrogen cream up to 3 months prior to when they begin the fitting process for their pessaries to avoid such discomfort [6]. 

Patients with a predisposition to urinary tract infections should also weigh their options carefully before considering to manage their uterine prolapse with a pessary. These patients may have these infections due to a physiologically shortened vaginal canal making infections more likely, or it could be due to other chronic diseases like diabetes or poor hygiene [7]. Whatever the underlying cause may be, patients with pessaries are at an increased risk for opportunistic infections. Patients using pessaries are encouraged to remove them even daily in some circumstances to adequately sterilize them to prevent fungal infections. Patients will also be given some type of acidifier to help combat the mostly alkaline bacteria that make up a woman's vaginal canal [8]. This daily burden can be too burdensome for elderly women unable to care for themselves and alternative options for managing a prolapsed uterus must absolutely be considered instead.  

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