Pelvic Organ Prolapse and Pessaries

How I Practice Video Series 
Joseph M. Novi, DO, FACOG, FACOOG

Transcript: Pelvic Organ Prolapse and Pessaries

When I examine a woman in the office with Pelvic Organ Prolapse, my approach is to evaluate the vaginal apex, the anterior compartment, and the posterior compartment in that order.  I document my findings using the POP-Q examination but it’s also reasonable to use the Baden-Walker system as long as you’re consistent.  An important component of my examination is the standing exam.  I have virtually every patient with prolapse stand with one foot on the floor and one foot on a low stool.  I place a finger in the vagina and have the patient Valsalva. I think this is the best way to evaluate apical prolapse and will often demonstrate greater prolapse than the supine exam.  We then talk about treatment options.  I offer every patient with prolapse a trial of vaginal pessary.  I think that patients appreciate being offered a non-surgical option and even if that’s unsuccessful they feel better about moving on to surgery.  After I have done my exam and I decide upon a size that I think will work for pessary, I will often start with one size smaller to place in the vagina.  And I do this because if you place the pessary and the patient has any discomfort she is not likely to allow you to try a different size; however, if the pessary is comfortable even if it falls out or it doesn’t adequately support the prolapse, she will likely allow you to try another size.  When placing a ring pessary, you don’t put the leading edge behind the pubic bone. The pessary won’t stay there and it’s actually designed to lay against the distal levator muscles. By pushing the pessary behind the pubic bone you will cause some discomfort and probably limit your use of pessaries.  It’s a common misconception that a pessary needs to be taken out nightly and cleaned.  In fact, most pessaries can stay in for a month or more without causing a problem.  However, a very important point to remember when using pessaries is never put a pessary in a patient who is unreliable.  So a neglected pessary that is in for months to years has the potential to erode into the bladder, the rectum, or the abdominal cavity. When I am placing a pessary, I want to make sure that the patient can manage it herself or she has the ability to return to my office frequently for examinations.  And then lastly, we talk about surgical options.  I was privileged to have been mentored by two brilliant surgeons, Dr. Mark Morgan and Dr. Keykay Goshe. And what I learned from them is to be a student of anatomy for the rest of your life. So I have a saying that I borrowed from them and it’s: fat stays with the bladder. If you’re in a difficult surgery, having difficulty finding where the bladder edge is, look for the fat layer. If you stay below that, you’ll be in a safe plane of dissection.  This is how I practice.

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