Incarcerated Vaginal Pessary

Vaginal pessary is a safe device for the conservative management of pelvic organ prolapse. Incarceration, a rare longterm complication of this device due to lack of follow-up is here presented. A 63 year-old postmenopausal woman had insertion of a silicone ring-shaped vaginal pessary for the management of pelvic organ prolapse. She stopped follow-up only to discover she could not remove the pessary which had become very adherent to the vaginal wall. She had excision of vaginal tissue and removal of the pessary under sedation. Women on vaginal pessary need regular follow-up to avoid complications such as infection, ulceration and incarceration.


Introduction
Pelvic organ prolapse is a common gynaecological condition that has profound effect on the quality of life of affected women. It occurs in up to 50% of parous women [1]. Although surgery is the definitive treatment of this condition, the use of vaginal pessary is an acceptable and satisfactory treatment option for conservative management in women who need to avoid surgery [2]. It is particularly invaluable in frail, elderly women who may be unfit for surgical operation due to co-existing medical morbidities such as cardiac or respiratory problems, those who are unwilling to undergo surgery, pregnant women or those who wish to have more children.
Over the years, the use of vaginal pessary has been shown to be an effective, safe, and acceptable mode of management of pelvic organ prolapsed [3]. It has been associated with a high success rate, minimal complication and high patient satisfaction [3]. Its cost-effectiveness in the treatment of prolapse has also been proven [4]. It has therefore been recommended as the first-line treatment for all women presenting with pelvic organ prolapse and stress incontinence [3]. Insertion of vaginal pessary for the conservative management of pelvic organ prolapse is an old practice. They can be used for all types and all stages of pelvic organ prolapse. They can also be used for stress incontinence, urge incontinence and overflow urinary incontinence [5]. Vaginal pessaries are made primarily of medical grade silicone which makes them inert and less likely to have an odour or cause an allergic reaction [5]. The ring pessary is the most commonly used type because it fits most women [6]. Complications associated with its use include vaginal discharge, vaginal bleeding, expulsion, incarceration, vaginal erosions, vesico-vaginal fistula and recto-vaginal fistula. Major complications are uncommon with pessary use. Most are due to neglect of the device, which emphasizes the importance of continued and diligent follow-up [3]. A rare complication which is incarceration of this device due to lack of follow-up is presented.

Case Report
A 63 year-old Para10+1, 7 alive, postmenopausal women presented with complaints of offensive vaginal discharge with occasional vaginal bleeding. She had insertion of a ring-shaped vaginal pessary in another centre 10 years earlier for the management of her pelvic organ prolapsed. Her symptoms were relieved and she discontinued follow-up and did not adhere to the instruction for care of the vaginal pessary.
Physical examination revealed an elderly woman with no abnormality found in the cardiovascular and respiratory systems. Her abdomen was also normal. Speculum examination of the vagina showed an atrophic vagina with offensive vaginal discharge. There was a ring pessary buried in the vaginal wall with bands of vaginal tissue overgrowing it. A digital vaginal examination revealed a rim of smooth, hard, ring-like material stuck to the upper third of the vaginal and embedded in the anterior and lateral vaginal walls.An assessment of incarcerated vaginal pessary was made.
She was counseled for surgical removal. Baseline investigations such as haematocrit and urinalysis were carried out and the results were within normal limits. She had removal of the ring pessary following excision of the bands of vaginal tissue under sedation. The operative findings included a 50mm-ring pessary with about 75% of it embedded in the anterior and lateral walls of the vagina. The procedure was well tolerated and she was given antibiotics and analgesics. She was observed for 2 hours post-operatively and discharged thereafter. She presented for follow-up 2 weeks later and she had no complaints.

Discussion
The vaginal pessary is one of the oldest medical devices available and its use is one of the oldest remedies in medicine. Mechanical devices as a conservative management tool for pelvic organ prolapse have been used for many centuries [5,7]. Pessaries can be used for diagnostic and therapeutic purposes. They may be considered in all women presenting with symptomatic pelvic organ prolapse and/or urinary stress incontinence [3]. Their use is especially indicated in women who are unfit for surgery, those unwilling to undergo surgery, pregnant women or those who wish to have more children [3]. Most women can be successfully fitted with a pessary when they present with a prolapsed [3]. Pelvic organ prolapse remains the most common indication for pessary use [8].
Contraindications to the use of vaginal pessary are not many thereby allowing the clinician an opportunity to consider its use in a wide variety of patients [8]. They include pelvic infection, vaginal ulceration, allergy to silicon or latex, patients who are likely to be non-compliant or those who may not show up for follow-up [8]. Long-term use of vaginal pessary is generally safe and serious side effects are infrequent [8]. Complications are usually minor and vaginal discharge is the most common complaint [3]. Other minor complications include itching, odour and erosions all of which can be successfully treated. Major complications include incarceration, vesico-vaginal and recto-vaginal fistulae and are usually seen with neglected pessaries [3,9,10,11,12]. These are usually preventable by ensuring appropriate fitting, local oestrogen use and regular follow-up [8].
Women with vaginal pessary require regular follow-up. New users are seen within 2 weeks to assess fitness and for instructions on removal and care [3]. The pessary should be removed weekly and washed with soap and water, rinsed with water and re-inserted. Clinic follow-up can then be done 3-monthly. In women who cannot carry out the self-care, 3-monthly follow-up at the clinic is advocated [3]. At the clinic, vaginal epithelium should be in-spected for erosion and ulceration. If there are no complications and self-care is optimal, the interval between clinic visits can be lengthened to 6 months to 1 year [3]. Although follow-up intervals are variable, in a prospective study, a simplified protocol in which women were seen at 2 weeks following insertion and 3-6 monthly subsequently showed there were no serious complications associated with the use of the device [13]. Specific practices for followup and management are however variable and largely based on expert opinion and individual experience [14].
The patient reported had used the device for 10 years without regular follow-up. She presented with offensive vaginal discharge with occasional bleeding. These symptoms when found in elderly women should arouse the suspicion of a foreign body such as a neglected pessary. Other authors have also reported similar symptomatology [6,9,12,15,16,17]. A detailed examination is therefore necessary not only to confirm the presence of foreign bodies but also to exclude other pathologies with similar presentation such as genital tract malignancies. Vaginal examination in this patient confirmed the presence of a ring pessary embedded in the vaginal wall. The incarcerated pessary was safely removed by excision of the adherent vaginal tissue. There were no complications following removal.
In conclusion, vaginal pessary is a very important device for the conservative management of pelvic organ prolapse and/or urinary stress incontinence in women who need to avoid surgery [2]. It should be inert and compact with a design that allows easy removal and insertion by the patient [8]. Although the device is easy to use, it requires care by both the patient and the healthcare provider. Hence major complications though uncommon, are usually associated with neglect of the device following prolonged use [3]. To prevent such complications, proper training on its insertion, regular removal, cleaning and follow-up are advocated [3,8,9,18].