Written By Dr. Sharon Ransom
OB/GYN of Taos Health Systems
There once was a woman named Mary
Who desired a repair intercessory,
For when she jumped high
On her way to the sky
She exclaimed “Oh Dear I need a pessary!”
No Laughing Matter
Pelvic organ prolapse is a condition which has affected women since recorded time. Egyptians were the first to describe pelvic organ prolapse and the pessary was known treatment. Historical references to the pessary cite Hippocrates as mentioning the use of a half of a pomegranate placed in the vagina to treat prolapse. The use of readily available groceries to manage the descent of the uterus, bladder and vagina seemed to be common occurrences. A pomegranate cut in half and soaked in vinegar is attributed to Soranus. In De Medicina, Aurelius Cornelius Celsus (27BC –AD50) mentions the pessary. In excavations of Pompeii, archeologists discovered a bronze cone-shaped vaginal pessary with a perforated circular plate at its widest end.
Trotula (AD1050), the first recorded female practitioner of gynecology originated the use of a ball pessary that was made of strips of linen and filled the vagina in cases of prolapse. The treatment of pelvic organ prolapse follows the history of humanity in regard to materials used, for example, women have used sponges bound with string, dipped in wax; wax balls; oval shaped pessaries of hammered brass; pessaries made of gold, silver, or brass; cork; cork dipped in wax; vulcanized rubber; polystyrene plastics, and now, silicone-based materials, to support the structures of the pelvis.
Defining the Problem
Pelvic organ prolapse is a health concern affecting millions of women worldwide and is the third most common indication for hysterectomy in the United States.
Among women in the Netherlands, a recent survey determined that 75% of Dutch women, aged 45-85 years had at least some degree of prolapse. At a teaching hospital in Ghana, the prevalence of pelvic organ prolapse was found to be 12.07%, with 62.5% of women at a premenopausal age range.
Worldwide, a large majority of women suffering (and enduring) pelvic organ prolapse share a common background- childbearing and physical labor. For women living in rural areas whose lives involve daily lifting, carrying water, loading and carrying farm produce, firewood, and traded goods, activities which ensure economic survival, the options to modify lifestyle is not an option. In contrast, the research performed in European settings indicate that most women present with pelvic organ prolapse in their menopausal, post-childbearing years.
Pelvic organ support is maintained by complex interactions among the pelvic floor muscles, pelvic floor connective tissue, and vaginal wall. These work in concert to provide support and also maintain normal function of the bladder, vagina, urethra, and rectum. The symptoms many women describe include a sensation of a “bulge”, pelvic pressure, pelvic pain, inability to completely empty the bladder, inability to completely evacuate bowel movements, incontinence, and/or obstruction.
The treatment of pelvic organ prolapse with a pessary involves fitting to the anatomical specificities of each woman. The pessary is a device (as noted above) that is worn within the vagina to either support the prolapsing structure, improve function of the bladder, improve function of the rectum, or temporarily improve quality of life while planning a strategic surgical repair.
Pessaries are designed in a number of different shapes and a wide variety of sizes. The pessaries we use at the Women’s health Institute are made of a non-allergenic, durable silicone. The risk of incurring a toxic-shock-like reaction is unlikely because the pessary will not absorb secretions.
Prior to providing a pessary, the nurse-midwives and physicians at the Women’s Health Institute engage in a thorough discussion with each woman which includes a review of her medical history, current medications, herbs, homeopathic remedies, surgical history, onset of symptoms of prolapse, and whether the focus is a consideration of a pessary or a surgical intervention.
For some women, the thought of managing the pessary becomes quite daunting; however, we provide written information and an opportunity to have time to answer all questions. Our goal is to honor the individual approach to this problem, to cultivate each woman’s self-confidence in her choice, and, above all, to assure that health literacy has been achieved.
Although pelvic organ prolapse is not a life-threatening condition, it can affect the quality of a woman’s life. Achieving an appropriate degree of comfort and function for each woman can be challenging, but not insurmountable!
i Lewicky-Gaupp, C Glob.libr.women’s med.,(ISSN:1756-2228) 2010;DOI 10.3843/GLOWM 10025
ii Lewicky-Gaupp, C Glob.libr.women’s med.,(ISSN:1756-2228) 2010;DOI 10.3843/GLOWM 10025
iii Williams gynecology, 2nd ed,2012; (633-658)
iv Chantal M et al, Int Urogynecol J (2017) 28:307-313
v DOI: http://dx.doi.org/10.4314/gmj.v48i4.7
vi Williams gynecology,2nd ed.2012;(633-658)