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{{Short description|Device inserted into the vagina for medical purposes}} {{More citations needed|date=May 2008}} [[File:Gold-Plated Stem Pessary Intrauterine Device 2017.020.jpg|thumb|right|Gold-plated stem pessary ([[intrauterine device]]) from 1920]] A '''pessary''' is a prosthetic device inserted into the [[Human vagina|vagina]] for structural and pharmaceutical purposes. It is most commonly used to treat [[Stress incontinence|stress urinary incontinence]] to stop urinary leakage and to treat [[pelvic organ prolapse]] to maintain the location of organs in the pelvic region.<ref name=":1">{{Cite web|title=Pessaries - Treatments |publisher=Voices for PFD|url=https://www.voicesforpfd.org/about/pessaries/|access-date=2020-07-28 }}</ref> It can also be used to administer medications locally in the vagina or as a method of [[contraception]]. Pessaries come in different shapes and sizes, so it is important that individuals be fitted for them by health care professionals to avoid any complications.<ref name=":1" /> However, there are a few instances and circumstances that allow pessaries to be purchased without a prescription or without seeking help from a health care professional.<ref>{{Cite news|title=Cystoceles, Urethroceles, Enteroceles, and Rectoceles - Gynecology and Obstetrics - Merck Manuals Professional Edition|language=en-US|work=Merck Manuals Professional Edition|url=https://www.merckmanuals.com/professional/gynecology-and-obstetrics/pelvic-relaxation-syndromes/cystoceles,-urethroceles,-enteroceles,-and-rectoceles|access-date=2017-12-29}}</ref> Some side effects may occur if pessaries are not sized properly or regularly maintained, but with the appropriate care, pessaries are generally safe and well tolerated.<ref name=":6" /> == History == [[File:Pessaries.JPG|thumb|right|An assortment of pessaries]] Early use of pessaries dates back to the ancient Egyptians, as they described using pessaries to treat pelvic organ prolapse.<ref name=":6">{{Cite web|title=Contemporary Use of the Pessary {{!}} GLOWM|url=https://www.glowm.com/section_view/heading/contemporary-use-of-the-pessary/item/25|access-date=2020-07-31|website=www.glowm.com|language=en}}</ref> The term 'pessary' itself is derived from the Ancient Greek word {{lang|grc-Latn|pessós}}, meaning round stone used for games.<ref>{{cite dictionary|title=pessary |url=http://www.dictionary.com/browse/pessary|access-date=9 April 2018|dictionary=Dictionary.com}}</ref><ref name=":2">{{Cite journal|last1=Oliver|first1=Reeba|last2=Thakar|first2=Ranee|last3=Sultan|first3=Abdul H.|date=June 2011|title=The history and usage of the vaginal pessary: a review|journal=European Journal of Obstetrics & Gynecology and Reproductive Biology|volume=156|issue=2|pages=125–130|doi=10.1016/j.ejogrb.2010.12.039|pmid=21255901|issn=0301-2115}}</ref> Pessaries are even mentioned in the oldest surviving copy of the Greek medical text, the [[Hippocratic Oath#Earliest surviving copy|Hippocratic Oath]], as something that physicians should never administer for the purposes of an abortion: "Similarly I will not give to a woman a pessary to cause abortion."<ref>Hippocrates of Cos (1923). ''The Oath''. Loeb Classical Library. 147: 298–299. {{doi|10.4159/DLCL.hippocrates_cos-oath.1923}}. Retrieved 18 September 2018.</ref> The earliest documented pessaries were natural products. For example, Greek physicians [[Hippocrates]] and [[Soranus of Ephesus|Soranus]] described inserting half of a pomegranate into the vagina to treat prolapse.<ref name=":6"/> It was not until the 16th century that the first purpose-made pessaries were made.<ref name=":2" /> For instance, in the late 1500s, [[Ambroise Paré]] was described as making oval pessaries from hammered brass and waxed cork. Nowadays, pessaries are generally made from silicone and are well tolerated and effective among patients who need them.<ref name=":6"/> == Medical uses == === Pelvic organ prolapse === The most common use for pessaries is to treat pelvic organ prolapse. A pelvic organ prolapse can occur when the muscles and tissues surrounding the bladder, uterus, vagina, small bowel, and rectum stop working properly to hold the organs in place and the organs begin to drop outside the body. The most common cause of such prolapse is childbirth, usually multiple births. [[Obesity]], long-term respiratory problems, [[constipation]], pelvic organ cancers, and [[Hysterectomy|hysterectomies]] can all be causes for pelvic organ prolapses as well.<ref name=":12">{{Cite web|title=What Is Pelvic Organ Prolapse?|url=https://www.webmd.com/urinary-incontinence-oab/pelvic-organ-prolapse|access-date=2020-08-28|website=WebMD|language=en}}</ref> Some signs and symptoms include feeling pressure in the pelvic area, lower back pain, painful intercourse, urinary incontinence, a feeling that something is out of place, constipation, or bleeding from the vagina.<ref name=":12" /> Pessaries are manual devices that are inserted into the vagina to help support and reposition descended pelvic organs, which helps to prevent the worsening of prolapse, helps with symptom relief, and can delay or prevent the need for surgery.<ref name=":6" /><ref name=":2" /> Further, pessaries can be used for surgery preparation as a way to maintain prolapse without progression.<ref name=":6" /> This is especially useful when a surgery may need to be delayed.<ref name=":6" /> === Stress urinary incontinence === Stress urinary incontinence is leakage of urine that is caused by sudden pressure on the bladder. It occurs during activities that increase the amount of pressure on the bladder such as coughing, sneezing, laughing, and exercising.<ref name=":10">{{Cite web|title=Stress Urinary Incontinence (SUI): Symptoms, Diagnosis & Treatment - Urology Care Foundation|url=https://www.urologyhealth.org/urologic-conditions/stress-urinary-incontinence-(sui)|access-date=2020-08-05|website=www.urologyhealth.org}}</ref> The pressure causes opening of the [[Urethral sphincters|sphincter muscles]] which usually help prevent urine leakage. Stress urinary incontinence is a common medical problem, especially in women; about 1 in 3 women are affected by this condition at some point in their lives.<ref name=":10" /> Pessaries are considered a safe non-surgical treatment option for stress urinary incontinence, as they can control the urine leakage by pushing the [[urethra]] closed. Pessaries can be removed at any time.<ref name=":10" /><ref>{{Cite journal|last1=Rovner|first1=Eric S|last2=Wein|first2=Alan J|date=2004|title=Treatment Options for Stress Urinary Incontinence|journal=Reviews in Urology|volume=6|issue=Suppl 3|pages=S29–S47|issn=1523-6161|pmc=1472859|pmid=16985862}}</ref> === Other === Some additional uses for pessaries are for an [[Uterine incarceration|incarcerated uterus]], prevention of [[preterm birth]] and an incompetent [[cervix]].<ref name=":6" /><ref name=":11">{{Cite journal|last=Berghella|first=Vincenzo|date=December 1, 2016|title=Can pessaries prevent preterm birth?|url=https://www.contemporaryobgyn.net/view/gynecologic-care-considerations-for-transmasculine-people|access-date=August 5, 2020|journal=Contemporary Ob/Gyn Journal| series=Vol 65 No 08 | volume=64 | issue=8 }}</ref> In early pregnancy the [[uterus]] can be displaced, which can lead to pain and rectal and urinary complications.<ref name=":6" /> A pessary can be used to treat this condition and support the uterus.<ref name=":6" /> Preterm birth is when babies are born prematurely, which puts the baby at increased risk for complications and even death. Currently, the use of pessaries to help prevent preterm birth is an ongoing area of research.<ref name=":11" /> The use of pessaries for an incompetent cervix is not commonly practiced today, but they have been used in the past.<ref name=":6" /> Specifically, an incompetent cervix is when the cervix begins to open up prematurely.<ref>{{Cite web|date=2012-04-27|title=Incompetent Cervix|url=https://americanpregnancy.org/es/getting-pregnant/incompetent-cervix-886|access-date=2020-08-28|website=American Pregnancy Association|language=en}}</ref> This can lead to a preterm birth or even a miscarriage. Pessaries can be used to correctly position the cervix, increasing the success of pregnancy.<ref name=":6" /> ==Types of pessaries== [[File:Pessary.png|thumb|Different types of pessaries]] === Therapeutic pessaries === A '''therapeutic pessary''' is a medical device similar to the outer ring of a [[Diaphragm (contraceptive)|diaphragm]]. Therapeutic pessaries are used to support the [[uterus]], [[Human vagina|vagina]], [[Urinary bladder|bladder]], or [[rectum]].<ref name=":3"/> Pessaries are most commonly used for pelvic organ prolapse and considered a good treatment option for women who need or desire non-surgical management or future pregnancy.<ref name=":3">{{Cite journal|last1=Jones|first1=Keisha A|last2=Harmanli|first2=Oz|date=2010|title=Pessary Use in Pelvic Organ Prolapse and Urinary Incontinence|journal=Reviews in Obstetrics and Gynecology|volume=3|issue=1|pages=3–9|issn=1941-2797|pmc=2876320|pmid=20508777}}</ref> It is used to treat [[Uterine prolapse|prolapse of uterine]], vaginal wall ([[vaginal vault]]), bladder ([[cystocele]]), rectum ([[rectocele]]), or small bowel ([[enterocele]]). It is also used to treat [[Urinary incontinence|stress urinary incontinence]].<ref name=":8">{{Cite journal|last1=Viera|first1=Anthony J.|last2=Larkins-Pettigrew|first2=Margaret|date=2000|title=Practical Use of the Pessary|url=https://www.aafp.org/afp/2000/0501/p2719.html|journal=American Family Physician|language=en|volume=61|issue=9|pages=2719–2726|pmid=10821152|issn=0002-838X}}</ref> There are different types of pessaries but most of them are made out of silicone—a harmless and durable material.<ref name=":0">{{Cite journal|last=Culligan|first=Patrick J.|date=2012|title=Nonsurgical Management of Pelvic Organ Prolapse|journal=Obstetrics & Gynecology|language=en|volume=119|issue=4|pages=852–860|doi=10.1097/AOG.0b013e31824c0806|pmid=22433350|s2cid=21218937|issn=0029-7844}}</ref> Pessaries are mainly categorized into two types, supporting pessaries and space-occupying pessaries.<ref name=":2" /> Support pessaries function by supporting the prolapse and space-occupying pessaries by filling the vaginal space.<ref name=":6"/> There are also lever type pessaries.<ref name=":9">{{Cite journal|last1=Tam|first1=Theresa|last2=Davies|first2=Matthew|date=December 2013|volume=25|pages=42–44, 48–52, 59|publisher=OBG Management|title=Pessaries for vaginal prolapse: Critical factors to successful fit and continued use|url=https://www.mdedge.com/obgyn/article/79135/pelvic-floor-dysfunction/pessaries-vaginal-prolapse-critical-factors-successful|access-date=2020-08-03|website=www.mdedge.com|language=en}}</ref> ====Support pessary==== '''Ring with support pessaries''' are the supporting type.<ref name=":2" /> These are often used as a first-line treatment and used for earlier stage prolapse since individuals can easily insert and remove them on their own without a doctor's help. These can be easily folded in half for insertion.<ref name=":3"/><ref name=":0" /> '''Gellhorn pessaries''' are considered a type of supporting and space-occupying pessary.<ref name=":2" /> These resemble the shape of a mushroom and are used for more advanced pelvic organ prolapse.<ref name=":2" /><ref name=":0" /> These are less preferred than ring with support pessaries due to difficulty with self-removal and insertion.<ref name=":0" /> '''Marland pessaries''' are another type of supporting pessary.<ref name=":3"/> These are used to treat pelvic organ prolapse as well as stress urinary incontinence.<ref name=":3"/> These pessaries have a ring at their base and a wedge-shaped ridge on one side.<ref name=":0" /> Although these pessaries are less likely to fall out than standard ring with support pessaries, individuals find it difficult to insert or remove them on their own.<ref name=":0" /> ====Space-occupying pessary==== '''Donut pessaries''' are considered space-occupying pessaries.<ref name=":2" /> These are used for more advanced pelvic organ prolapse including cystocele or rectocele as well as a second or third-degree uterine prolapse.<ref name=":3"/> Due to its shape and size, it is one of the hardest ones to insert and remove.<ref name=":0" /> '''Cube pessaries''' are space-occupying pessaries in the shape of a cube that are available in 7 sizes. The pessary is inserted into the vagina and kept in place by the suction of its 6 surfaces to the vaginal wall. Cube pessaries must be removed before sexual intercourse and replaced daily.<ref name=":2" /> Cube pessaries are generally used as a last resort only if the individuals cannot retain any other pessaries.<ref name=":6"/> This is due to undesirable side effects such as vaginal discharge and erosion of the vaginal wall.<ref name=":6"/><ref name=":2" /> In order to remove the cube pessary, the suction must be broken by grasping the device.<ref name=":6"/> '''Gehrung pessaries''' are space-occupying pessaries that are similar to the Gellhorn pessaries.<ref name=":6"/> They are silicone devices that are placed into the vagina and used for second or third degree (more severe) uterine prolapse. These contain metal and should be removed prior to any MRI, ultrasound or X-rays. They can also be used to help with stress urinary incontinence such as urine leaks during exercising or coughing. These types of pessaries need to be fitted by a health care professional to ensure proper size. Once placed it should not move when standing, sitting, or squatting. It should be cleaned with mild soap and warm water every day or two.<ref>{{Cite web|title=Medline Gehrung Pessary {{!}} Pessary|url=https://www.healthproductsforyou.com/p-medline-gehrung-pessary.html|access-date=2020-07-31|website=www.healthproductsforyou.com|language=en}}</ref> ====Lever pessary==== '''Hodge pessaries''' are a type of lever pessary. Although these can be used for mild [[cystocele]] and stress urinary incontinence, they are not commonly used. Smith, and Risser pessaries are other types of lever pessaries and they differ in shape.<ref name=":0" /><ref name=":9" /> ===Pharmaceutical pessaries=== Treating vaginal yeast infections is one of the most common uses of pharmaceutical pessaries. They are also known as vaginal [[Suppository|suppositories]], which are [[Intravaginal administration|inserted into the vagina]] and are designed to dissolve at body temperature. They usually contain a single use antifungal agent such as [[clotrimazole]]. Oral antifungal agents are also available.<ref>{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK543219/|title=Vaginal yeast infections (thrush): What helps?|date=2019-06-19|publisher=Institute for Quality and Efficiency in Health Care (IQWiG)|language=en}}</ref> Pessaries can also be used in a similar way to help induce labor for women who have overdue expected delivery dates or who experience premature rupture of membranes. [[Prostaglandin]]s are usually the medication used in these kinds of pessaries in order to relax the cervix and promote contractions.<ref>{{Cite journal|last1=Thomas|first1=Jane|last2=Fairclough|first2=Anna|last3=Kavanagh|first3=Josephine|last4=Kelly|first4=Anthony J|date=2014-06-19|title=Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term|journal=Cochrane Database of Systematic Reviews|volume=2014 |issue=6|pages=CD003101|doi=10.1002/14651858.cd003101.pub3|issn=1465-1858|pmc=7138281|pmid=24941907}}</ref> According to [[Pliny the Elder]], pessaries were used as birth control in ancient times.<ref>{{Cite web | url=https://www.perseus.tufts.edu/hopper/text?doc=Plin.+Nat.+22.49&redirect=true |title = Pliny the Elder, the Natural History, Book XXII. The Properties of Plants and Fruits, Chap. 49.—Laser: Thirty-Nine Remedies}}</ref> === Occlusive pessaries === {{Main|Cervical cap}} {{See also|Womb veil}} Occlusive pessaries are most commonly used for contraception. Also known as a contraceptive cap, they work similar to a diaphragm as a barrier form of contraception. They are inserted into the vagina and block sperm from entering the uterus through the cervix. The cap must be used in conjunction with a spermicide in order to be effective in preventing pregnancy. When used correctly the cap is thought to be 92–96% effective. These caps are reusable but come in different sizes. It is recommended for anyone attempting this form of contraception to be fitted for the correct size by a trained health care professional.<ref>{{Cite web|title=The different types of contraception|url=https://www.nhsinform.scot/healthy-living/contraception/getting-started/the-different-types-of-contraception|access-date=2020-07-30|website=www.nhsinform.scot|language=en}}</ref> ====Stem pessary==== The stem pessary, a type of occlusive pessary, was an early form of the [[cervical cap]]. Shaped like a dome, it covered the cervix, and a central rod or "stem" entered the uterus through the external orifice of the uterus, also known as the cervical canal or the [[External orifice of the uterus|os]], to hold it in place.<ref>{{cite web|url=http://www.phisick.com/a4pessaluminium.htm|archive-url=https://web.archive.org/web/20090421095213/http://www.phisick.com/a4pessaluminium.htm|url-status=usurped|archive-date=April 21, 2009|title=Contraceptive Stem Pessary in Aluminium - Phisick - Medical Antiques|website=www.phisick.com|access-date=9 April 2018}}</ref> ==Side effects and complications== [[File:Gould Pyle 227.jpg|thumb|Pessary covered in [[phosphate]] after being left in the vagina for an extended time]] When pessaries are used correctly, they are tolerated well for pelvic organ prolapse or stress urinary incontinence.<ref>{{Cite web|title=Pessary|url=https://www.nm.org/conditions-and-care-areas/treatments/pessary|access-date=2020-07-30|website=Northwestern Medicine|language=en-US}}</ref> However, pessaries are still a foreign device that is inserted into the vagina, so side effects can occur.<ref name=":5">{{Cite journal|last1=Viera|first1=Anthony J.|last2=Larkins-Pettigrew|first2=Margaret|date=2000-05-01|title=Practical Use of the Pessary|url=https://www.aafp.org/afp/2000/0501/p2719.html|journal=American Family Physician|language=en|volume=61|issue=9|pages=2719–2726|pmid=10821152|issn=0002-838X}}</ref> Some more common side effects include vaginal discharge and odor.<ref name=":3"/> Vaginal discharge and odor may be associated with [[bacterial vaginosis]], characterized by an overgrowth of naturally occurring bacteria in the vagina.<ref>{{Cite web|title=Bacterial vaginosis - Symptoms and causes|url=https://www.mayoclinic.org/diseases-conditions/bacterial-vaginosis/symptoms-causes/syc-20352279|access-date=2020-07-31|website=Mayo Clinic|language=en}}</ref> These symptoms can be treated with the appropriate medications. More serious side effects include [[fistula]] formation between the vagina and rectum or the vagina and bladder, or erosion, or thinning, of the vaginal wall.<ref name=":3" /> Fistula formation is rare, but erosion of the vaginal wall occurs more frequently. Low estrogen production can also increase the risk of vaginal wall thinning.<ref>{{Cite web|title=Vaginal atrophy - Symptoms and causes|url=https://www.mayoclinic.org/diseases-conditions/vaginal-atrophy/symptoms-causes/syc-20352288|access-date=2020-07-31|website=Mayo Clinic|language=en}}</ref> For individuals with pessaries that are not fitted for them, [[hernia]]tions of the cervix and uterus can occur through the opening of the pessary. This can lead to tissue necrosis in the cervix and uterus.<ref name=":5" /> To prevent these side effects, individuals can be fitted properly for their pessaries and undergo routine follow-up visits with their health care professionals to ensure the individual has the correct pessary size and no other complications.<ref name=":3" /> In addition, those with an increased risk of vaginal wall thinning can be prescribed estrogen to prevent erosion and prevent these complications.<ref name=":6"/> If pessaries are not used properly or not maintained periodically, more serious complications can occur. For example, the pessary can become embedded into the vagina, which makes it harder to remove. Estrogen can decrease the inflammation of the vaginal walls and promote skin cells in the vagina to mature, so use of estrogen cream can allow removal of the pessary more easily.<ref name=":5" /> In rare cases, pessaries would need to be removed through surgical procedures.<ref name=":6" /> To prevent complications, individuals should not use pessaries if they have characteristics that exclude them from this method of therapy. [[Contraindication]]s to pessary use include current infections in the pelvis or vagina, or allergies to the material of the pessary (which can be silicone or latex).<ref name=":8" /> In addition, individuals should not be fitted for a pessary if they are less likely to properly maintain their pessary. ==See also== *''[[United States v. One Package of Japanese Pessaries]]'' *[[Diaphragm (birth control)]] *[[Suppository]] == References == {{reflist | 30em}} {{Dosage forms|state=expanded}} [[Category:Dosage forms]] [[Category:Drug delivery devices]] [[Category:Implants (medicine)]] [[Category:Medical equipment]] [[Category:Vagina]]
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