Primary Care Women’s Health Forum conservative management of prolapse: competency framework for primary care.

Factors contributing to an increased risk of prolapse:

• Pregnancy and childbirth
• Vaginal delivery
• Ageing
• Menopause
• Obesity, large fibroids, pelvic tumours
• Chronic cough, straining
• Heavy lifting
• Genetic conditions, e.g collagen deficiencies
• Previous pelvic surgery
• Spinal cord injuries/neurological conditions e.g MS, muscular dystrophy

Symptoms of prolapse:

• Often none
• Heaviness, awareness of bulge/protrusion, dragging sensation,
• Requirement to reduce prolapse to void/defecate
• Urinary: poor stream, recurrent urinary tract infections, frequency, urgency, stress incontinence
• Bowel: obstructed defecation
• Sexual dysfunction/discomfort
• Rarely—renal impairment

Grading of prolapse:

• 0: No descent of pelvic structures during straining
• I: The leading edge of prolapse does not descend below 1 cm above the hymen
• II: The leading edge of prolapse extends from 1 cm above the hymen to 1 cm below the hymen
• III: The prolapse extends more than 1 cm beyond the hymen but there is not complete vaginal aversion
• IV: The vagina is completely everted

Management of prolapse:

• Address concurrent medical problems may contribute
• Reduce weight where appropriate
• Avoid heavy lifting and adjust lifting techniques
• Manage constipation
• Ensure adequate vaginal oestrogen
• Pelvic floor exercises
• Supportive pessary
• Surgery

Supportive pessaries

• A pessary is a device inserted in the vagina to support the walls and related pelvic organs. It offers a low risk management option
• Pessary fitting is an important skill and requires knowledge and competency assessment to ensure identification and counselling of the appropriate patient, correct and safe technique and the understanding and management of complications

Indications for pessary management

• Symptomatic pelvic organ prolapse
• Patient choice
• As a therapeutic test—can aid pelvic floor assessment and treatment
• For women in whom childbearing is not complete
• For women who are medically unfit for surgery
• While awaiting surgery

Prolapse pathway

Is it appropriate to offer a pessary?

• Consider the following:
  • degree of prolapse
  • is the prolapse contributing to urinary or faecal incontinence
  • size of introitus
  • vaginal shape
  • health of vaginal tissues
  • is she sexually active?
  • dexterity if self-managing insertion and removals

Exclusion criteria

• Active vaginal infection
• Pelvic inflammatory disease
• Undiagnosed vaginal bleeding
• When follow up cannot be assured
• Consider referral for specialist management previous prolapse surgery using mesh
• If the vagina is not adequately oestrogenised offer vaginal oestrogen treatment as there is good evidence that this improves comfort and effectiveness of pessaries. It also reduces the risk of erosion

Types of pessaries available:

PVC ring pessaries:

• Sizes:
  • 52–80 mm in 3 mm increments
  • 80–110 mm in 5 mm increments

Silicone pessaries:

• There are a range of shapes and sizes. The following are available on an FPIO:
• Ring: sizes 44–127 mm
• Ring with support: may be helpful if cystocoele present. Sizes 44–127mm
• Gelhom short and long stem: second line option for higher degrees of prolapse—38–95mm
• A range of other shaped pessaries are available but not via the drug tariff
• Some pessaries such as the Gelhorn or shelf designs are not suitable in sexually active women

Initial fitting of ring pessary

• Examine patient and assess prolapse
• Estimate the size of pessary that will be required (tip: use PVC rings for sizing)
  • insert fingers into the posterior fornix
  • make note of where the fingers come into contact with the pubic bone
  • spread fingers wide to measure the vaginal width
  • remove fingers and compare to pessary sample
• Twist pessary to insert to posterior fornix
• Push anterior edge behind pubic symphysis to sit diagonally in the vagina

Checking for correctly sited ring pessary

• Should have slight movement, not too tight behind urethra
• Assess for comfort (should not be able to feel the pessary) and relief of symptoms
• Ask her if she has any discomfort when asked to cough, sit, stand, walk, empty bladder
• Re-examine to ensure ring remains in correct place and still feels the correct size
• If ring uncomfortable or too loose, try with a different size

Patient advice

• The need to contact the surgery for advice if she develops any new urinary symptoms including difficulty passing urine, following ring pessary insertion
• Review early if problems and no later than 6 monthly
• Some women opt to remove the pessary themselves—on weekly basis, wash in soap and water, leave out overnight and then reinsert. The review can then be at a year

Review procedure

Ask

• Do you like it?
• Is it working?
• Any complications/problems/issues?—including:
  • discharge
  • discomfort
  • smell
  • cleaning, removing and inserting,
  • bowel habit
  • voiding
  • sexual activity
• Do you want to keep on using it?

Examine

• Check position, comfort and effectiveness
• Remove pessary
• Perform a speculum examination to exclude vaginal or cervical ulceration/erosions

Reinsertion

• Replace with a larger PVC ring if previous pessary is now too loose, but if size is correct consider use of a silicone ring which can be re-used. If size appropriate but ring pessary is ineffective consider silicone ring with support or Gelhorn pessary

For silicone pessaries

• Wash pessary in soap and water to remove any powder prior to insertion
• Rotate rings and rings with support through 90 degrees after insertion such that hinges are lateral
• Patient unable or unwilling to manage independently requires a follow-up appointment at a maximum interval of 6 months

Managing complications

Vaginal discharge

• May be normal foreign body effect
• Swab for microbiology and treat with appropriate antibiotic/antifungal if indicated
• Consider treatment is oestrogen cream/ring; non-oestrogen lubricant
• May need more frequent removal and cleaning

Constipation

• Dietary advice
• Check ring size and change for smaller size if appropriate
• Consider treatment with laxatives

Erosions

• Swab for microbiology and treat with appropriate antibiotic/antifungal if indicated
• Pessary ‘rest’
• Consider adding or increasing vaginal oestrogen
• Non-oestrogen lubricant
• May need to change for smaller size ring if appropriate

De novo or worsening urinary incontinence

• Dipstix urine to exclude infection, haematuria or glycosuria
• Treat/refer if dipstix result abnormal
• Consider further investigations or referral to urogynaecology if necessary

Post-menopausal bleeding

• DO NOT assume PMB is due to the ring pessary
• Organise fast-track referral especially in absence of significant erosion

Forgotten pessary

• Potential complications of infection, chronic incontinence discharge and odour, the ‘stuck’ pessary, fistulae
• Caution with ‘office’ removal if seems stuck or glycosuria because of risk of trauma and haemorrhage
• Use vaginal oestrogen daily for 4–6 weeks before attempting removal

Stuck pessary

• Consider referral
• May need to be removed under anaesthesia
  • if patient is fit for anaesthetic they may opt for surgical repair of prolapse at same time

• Risk of fistula if pessary remains in situ, but usually low risk:

  • in very medically unfit women. It may be better to leave pessary and accept risk, and refer to gynaecology

Tips:

• If a pessary change is very uncomfortable for a woman consider use of vaginal oestrogens and/or applying Instillagel before the change
• Gelhorn pessaries can be difficult to remove as the vacuum between the disc and cervix/vagina needs to be broken. Using syringe to inject sterile water into the stem through the hole can facilitate this

Competency requirements

• Practitioners take responsibility for, and are accountable for, the care they offer. Their training and updating should meet the requirements and standards so they are competent to provide the service (initiating and changing or just changing ring pessary)
• Be competent to stage prolapse
• Be competent to communicate effectively about the management options including the use of a ring pessary
• Initial insertion—be able to perform abdominal and pelvic examination to exclude abdominal or pelvic cause for prolapse
• Be competent to perform speculum examination
• Be competent to undertake vaginal swabs
• Be able to manage/advise about the use of topical oestrogen (see PCWHF guidance on management of GSM)
• Be competent to assess when ring pessary treatment is no longer required
• A competent practitioner within the scope of their role will be able to demonstrate:
  • sufficient knowledge and skill within their role to ensure safe and effective practice
  • recognition of his/her limitations of expertise and knowledge
• All practitioners will be expected to perform an appropriate number of procedures each year to maintain their own professional standards

Peer support and clinical supervision

• It is important that practitioners do not work in isolation and take the opportunity to meet with other practitioners to share and critically reflect on their experiences, learning and preparation for appraisal

Clinical audit and service evaluation

• Systems for documenting results and management should be maintained for audit and service evaluation purposes to demonstrate effective and quality service delivery. For example, an annual audit including the number of procedures performed

Training standards

Initial assessment

• Observe two procedures
• Be observed performing a minimum of two satisfactory procedures

Follow-up and refitting ring pessaries

• Observe two procedures
• Be observed performing a minimum of two satisfactory procedures

Documentation requirements

• All women undergoing this procedure should give informed consent for the procedure to be carried out

Recording requirements:

• Size of pessary, lot number and expiry date
• Make of pessary
• Side-effects or complications of ring pessary treatment
• Fit of pessary and control of prolapse
• Vaginal appearance

Criteria for ongoing accreditation

• Continue to perform six satisfactory procedures/year to maintain competency
• Audit and reflect on complication rates