2025 Urogynecology for the Advanced Practice Provider-Do Pessaries Better

Video Transcription

certified in urology and has more than 18 years of clinical practice in urogyne. Since 2012, she's been the co-owner and clinician at a public health clinic called Pelican Health.  She's an active member of AUG, serving on two APP committees. And she's been an adjunct instructor at the University of Mary since 2003. Thank you. Do pessaries better?  Pretty fascinating recommendation they have for you there. My thanks to Maya Angelou who said, we do the best that we can until we know better.  And when we know better, we do better. And that's why we're all here. We're learning so that we can take back new information and do better for our patients when we get home.  Now, I first want to thank the planning committee for inviting me to speak again today. It's really quite an honor to be a part of this group and presenting to you.  Because when I look across the room, I see a lot of experts on pessary care in here. I see Amy Hall. I see you back there, Amy. Can you give me your hand a little bit there?  Thank you. Amy is right here in Nashville, Vanderbilt. And Amy has been part of a coalition of pessary coalition where she published information that helps us as APPs  better understand pessary care. It was published a couple years ago. And that was with SUNA and AUGs, a great group of APP individuals that represent us.  Jen, Sarah, you met her earlier today. She's doing awesome work in University of Nebraska.  She has been working on a lot of projects, one of them with digital imaging of the pelvis to help us as APPs better understand anatomy and ultimately fit pessaries.  I know we've got APPs in the industry out in the hallway. And they are advocating for us for better products. We have several pessary queens on social media.  Are any of you here the pessary queens? There's several of you. Hello, pessary queen. Yes, thank you. Thank you for having an online presence.  There's Facebook, social media, LinkedIn, and Instagram. So thank you. We appreciate how you bridge the education for us from one conference to the next.  So, again, lots of wealth of knowledge that we have within this group.  And so for some of you that are a little bit more novice at pessary care, I encourage you just to visit with the  people that are surrounding you today at lunch and at breakfast because there is a lot of information we can gain from one another here.  I do have to mention that I'm a KOL for Pathgnostics. And I also want to take this opportunity to thank everybody that has attended the pessary workshop in the past.  We are in our third or fourth year. I have kind of lost count with it.  But I am so appreciative of those of you that shared your time and money to attend those workshops in the past. And, most importantly, you gave us feedback.  And your feedback was heard. And I am so excited. Amy, you are going to love this. I'm so excited. We have two brand-new, finally, beautiful, beautiful pessary models.  They are so fabulous. I got the goosebumps when I saw them, which is kind of weird. But they are being used for the very first time at this conference.  And so I'm so excited to work with those and encourage you, for those of you that are attending next year, to be  able to participate with that because I think they'll really help facilitate our learning curve with pessary fittings. All right. Planning committee, are any of you in here?  Can you raise your hand? Again, I want to thank you for giving me this opportunity. I know there, there. Okay. Thank you. All right.  Whenever I present on pessaries, of course I'm going to look at the publications for the past year and make sure we're all up to date on anything that's new and up and coming.  But I also want to pick a theme for that pessary conversation, too, because we just get a quick 25-minute burst of information to share.  And for those of us that are new with pessaries, we could talk about this all day long.  But when we have a short little burst, I'm going to pick a theme. Sometimes I talk about fittings. Sometimes I talk about making your clinic more efficient with pessary care.  But today I wanted to talk about how we can minimize our side effects associated with pessaries. And there's nothing fancy about this. It's not a novel concept.  When we talk about minimizing the side effects, I'm talking about self-management.  And I think it's really important that we take a stance on self-management and kind of shift our perspective.  Twenty years ago when I started with pessaries, I had very few people that self-managed. They came in every three months like clockwork and came in for their cleaning.  But on occasion I have patients that really advocated for themselves and wanted to self-manage.  But over time what I saw and found is that these patients did really well, and I didn't hear from them.  They came in every year or two to get a new pessary, but they did really well when they took care of their pessary on their own terms.  And so over time I have shifted and changed my pitch when patients come in for a new pessary. I don't really rarely have them come in for cleanings now, for clinical management.  I really encourage them to give self-management a chance.  All right, we all know that pessaries are going to be utilized for several reasons, prolapse being one of them.  And we are going to also allow some of our patients to use them for incontinence. Sometimes patients leak more with a pessary. Sometimes their leaking improves.  And for our patients that are not surgical candidates, a nice option, although we have many patients using pessaries that are good surgical candidates,  but maybe they are waiting until their children are a little bit older. My average age of pessary users has gotten younger over the years,  and patients that have used their menstrual cups, these pessaries are just a piece of cake for them.  And so I'm really happy when I hear that they've used menstrual cups because they really do quite well with pessary management on their own.  We can sometimes use pessaries as a diagnostic tool. Some practices don't necessarily do urodynamics when they're assessing for maybe a de novo stress incontinence with a prolapse.  So maybe they'll put a pessary in and see if their leaking shows up when their prolapse is lifted up. That helps surgeons sometimes understand more what they need to offer a patient  when they're scheduling and planning their surgery. We use the pessaries as adjunct therapy with our physical therapists.  As our physical therapists are stepping more into the pessary ring, they really are starting to understand the value of using both pessaries  and pelvic floor physical therapy at the same time. We still wonder if there's some strategies for pessaries to prevent prolapse from occurring or incontinence from worsening.  And we also wonder if there's some value in biofeedback. Again, as our physical therapists are using pessaries more, there's some realization that women that have a pessary in place  almost have a greater awareness of their pelvic floor and can be helpful for them when they're conditioning.  But remember that pessaries are not perfect and they're not necessarily easy and we are not going to be successful at fitting our pessaries 100% of the time.  We are going to fail with our pessary fittings. And there's no strict guidelines in how we are going to manage or fit our patients.  The vaginas are all different. The prolapses are all different. The algorithms are not there to guide us into perfect fittings.  And we really don't even have required training that says this is how much you have to do or how much you have to know before you can start fitting and managing pessaries.  And then here I am saying, oh, hey, have your patients self-manage. Well, we don't even have any strict recommendations as to how much education our patients need.  Now, that said, I don't want you to think that your patients have to go through a course in order to self-manage their pessary.  I don't want you to look at this as something that's going to be very time-consuming and consume a whole hour of your clinic day. We know that that's not even reasonable.  It really comes down to your pitch, how you tell or ask patients to consider self-management rather than not even giving them that option. It starts with you.  So we know from multiple studies that there are going to be some patients that have better success rates with pessaries.  But I in particular liked the Zoll publication this past year because they used patients as stage 4 prolapses. And sometimes when I go in and see a patient and they have a stage 4,  I kind of get nervous. I'm like, ah, man, this is a really bad one. I'm going to skip over the ring pessary because that's my favorite, and I'm going to go to the big cube guy.  But this study here helped me understand that stage 4 prolapses can be treated successfully with a ring pessary, and they do really quite well.  So we don't have to get scared of those big prolapses, and we can start with our favorite pessaries if we'd like, and they can do quite well.  But we also know that there are going to be certain types of patients that are going to do better with pessaries, like they have fewer vaginal deliveries. They still have a uterus.  The uterus kind of serves as an anchor for the pessary. They have a smaller introitus. Our patients with higher BMI are going to do better with pessary fittings.  We have adipose tissue in our pelvis, and so our higher BMI patients are going to do better with fittings. Now, try not to get that confused with self-management.  Patients with lower BMI are going to do better for self-managing. Our patients with longer vaginal length and cervical length,  I think they're going to do better with pessary fittings as well. Super overwhelming when you have a cart full of pessaries,  and you have to take your cart of pessaries and pick three of them, three or four, that you're going to try and fit this patient.  And so how do you get it narrowed down to three or four pessaries before you walk into that room again for the patient? I like to break them down into categories,  and I'll look at my big cart of pessaries, and I'll break it down into my support pessaries, filling, and my levers. My favorites are the support pessaries.  And again, my goal is to have a patient self-manage. They're going to do better with support pessaries. So that's going to be my starting point.  Again, our support pessaries are going to be our rings, dishes, our shots as well. I want you to take note of the picture here.  This is a pessary that the artist depicted in a more vertical position. This is a real common image that we see on Google and the Internet  and in a lot of our patient education forms as well. But I am going to come back to this, but I just wanted you to take note here.  We have our space-filling pessaries, which are exactly what they say they are. They take up space. These are going to be the pessaries that I'm going to transition to  if a patient doesn't do well with a ring because these are more difficult to self-manage. They have a little bit of suction to them. They're more challenging.  Not as many patients are going to be able to self-manage a space-filling pessary. And then we have our levers. I use levers the least amount.  They're malleable, and so if a patient is going to self-manage, which is my goal, they might misshape and they might not be as effective,  although they are really nice to try if somebody's got a very small introitus. They work the best if they have a cervix  and they're kind of intended to kind of anchor onto the cervix. I want to make a note that pessaries move, and I didn't always appreciate that as a young pessary fitter.  I had in my mind what the image was supposed to look like. The image is supposed to be this vertical pessary  because that's what the published artist, the artist that depicted the pessary in that more vertical position. But these move.  Some patients are going to fit more horizontally to the pelvic floor. Some are going to fit a little bit more vertically. Neither is wrong. They both can work.  And so don't be discouraged if your pessary that you're fitting doesn't look exactly like the picture show. I just had a patient come in on Monday, and she was doing fabulous.  She was two weeks from her pessary fitting, doing really well. Symptoms are controlled. But as she was starting to practice self-management at home  and removing the pessary, she got interested and was Googling things and found some images. And the images she found on Google were the pessary that was more vertical.  And hers was fitting more horizontally. So even though she was doing really well, the pictures made her question it. And so she wanted to come in and be reassured  that she was still doing okay with this pessary. And the same goes for us as young, as new pessary fitters. Sometimes we can get a little bit discouraged  because that pessary doesn't fit exactly with how the picture shows.  Movement, though, is part of that pessary dynamics, though, and how, if we're having good success with our pessaries or not. Now, when I measure for a pessary,  there are three things I'm looking at. The first thing I'm gonna look at is the opening of the introitus. If I have somebody with a really small vaginal opening  and maybe has vaginal atrophy, so it's a little stiff, I better not come into the room if I want her to self-manage with a number six ring. It's not gonna go well.  She's not gonna wanna take that pessary out on her own. She's gonna cause injury every single time. I also need to know what the vaginal depth is. If I have a short vaginal depth,  then I'm gonna have to use a smaller pessary. Because of that movement, that motion of the pessary, if I have a short vagina and I can put in  a pretty large ring, a four or five ring, because it's sitting horizontally to the pelvic floor, but the motion, the movement, we move into a more vertical position,  that pessary, all of a sudden, is gonna move to the opening of the introitus, and they are, patient's gonna feel that. They're gonna feel like a tampon is falling out,  and eventually it might even come out altogether. I also wanna know what the apex of the vaginal vault, the size of that is as well.  I wanna try and get the largest pessary in there as I can. I want a nice fit, but I don't want it to be too tight and hurt, kind of like if we were bra fitting.  We want a nice, supportive bra, but we don't want it too tight that it's constricting and causes bra lines.  So the complications or the side effects that I'm referring to are the side effects that bother women, not to the point that they're  getting sick from it, but they're bothered by, primarily, odor and discharge. They are gonna complain to you about this over and over again.  Sometimes we get infection, but it doesn't, it's not necessarily the pessary puts you at higher risk. There's the perception that it's an infection,  but it's just your body's response to a pessary. You might have more discharge and more odor. Now, how do we manage that? With more cleanings,  and that comes down to self-management then. We also know that we can have fewer ulcerations and erosions and bleeding and fistulas as well,  if we are self-managing and cleaning more often.  We can look at the literature, and we don't have a lot of guidance on the preventative measures, but we know that when we started using our medical-grade silicone pessaries,  that things got better in terms of odor and discharge, but certainly didn't solve the problem, though. We have no consensus on how often we're supposed to self-manage,  how often we are supposed to take the pessary out, how long of a break we're supposed to take, and how we're supposed to clean it. Do we use water? Do we use soap?  Do we use peroxide? We don't have great guidelines on that yet either. Some of us might question, though, should we use some estrogen? We've got a lot of data on estrogen use,  but it isn't as helpful with pessaries as we initially thought. Maybe it helps decrease some bacterial vaginosis for post-menopausal women, but it's not that it's helping  of infections caused by a pessary.  We know that might help decrease some discomfort and dryness, but really doesn't help all that much with vaginal ulcerations.  It's use, we don't really have a strong agreement on it, though.  We do have a pretty good understanding of where Trimacin Gel sits. For those of you that have been using pessaries for a while, you remember the days that Trimacin Gel  was handed out with every new pessary, and this anti-bacterial properties were supposed to decrease any odor or infection or discharge,  but it certainly did not turn out to be the case. I have some patients that have been using pessaries for a long time that really insist on continued use of the Trimacin Gel.  It's actually at a point now where it's very hard to find, and when you do find it, it's really costly.  We are finding more patients using hyaluronic acid over the counter, very accessible. We don't have a lot of literature, though, that says that it helps or that it does much for us,  but we know it does help women with vaginal dryness and irritation, and there's no reason that they can't use it with their pessary, but we don't know if it helps  with pessary-related complications yet.  Dr. Probst published just this past year with some of her colleagues that some of these patients are eventually gonna go to surgery, and we know that, no matter what kind of pessary  that they have, that some of them are gonna go on to surgery, but many of these patients are going on to surgery because of those side effects, the odor and the discharge primarily,  and so they're being forced to make a decision in surgery that they don't want, but it just came down to odor and discharge, but if we can help them embrace self-management,  they can minimize those side effects and maybe be able to work around having to move on to surgery.  Again, we know from multiple studies that if it's self-managed, there's a decreased conversion rate to surgical options. We know that they're gonna use their pessary  a lot longer, and they're gonna have fewer complications, but do they wanna self-manage? We don't, of course, have studies on that, again, but I can say from a clinical perspective,  patients are very open to it if presented and if my pitch has been polished.  At first, I was kind of awkward about it. I was like, well, you can, maybe you don't have to, but you can think about it, get back to me.  I was rambling, and I had no nice little pitch, but now I tell them in a way that I almost expect them, that they're going to want to do this on their own.  They are not gonna wanna come in and see my face again every three months and pay his dumb co-pay that they're gonna complain about every single time,  and so when they can do this all on their own at home and minimize those side effects, they're much happier in the end. Now, my patients have been using pessaries forever.  They're not gonna buy into this. I've tried, I've tried, I've tried bribing them. They won't do it, but they are, but they found out something that works for them,  and they don't mind. The ones that have been using it for a while, they don't mind, and I'm not gonna be able to talk them out of it, and you probably won't either,  but for your new patients, I would highly recommend that you prioritize self-management for them.  Can they do it? Sure they can, especially, again, our ladies that are using their menstrual cups. They have no problem with this, especially if we're using our rings.  If we can get a ring to fit nicely with them, they're gonna manage it beautifully, but we're only teaching them this 35% of the time. That's on us.  We can do a lot better on that, and this isn't something that's gonna consume an hour of your time. It's how you present it to them,  and you encourage them, and a simple education sheet. They do really well with just that little information.  We've got high, they can perform this often. They are not discontinuing their pessary as often, as the clinical-managed pessaries,  and of course, you're gonna have patients that can't. You're gonna have your rheumatoid arthritis patients that have poor dexterity. They can't grab on to it.  You're gonna have body habitus that limits some patients from doing their pessary cleanings, but many majority of your women will be able to do so.  We don't know how often. We're gonna tell them to self-manage. We're all over the board on this as well, anywhere from nightly to every six months.  We have a study that came out in 2020 that they used gale horns every single day, and their patients took their gale horn out every day and did really well.  Great, I don't have any patients that do that, but that is awesome, and it gives me confidence in knowing that if I do have a gale horn patient  and they do need to take it out, okay, that's not unheard of, and I have the confidence to give that recommendation. Oggs and Suna, our consensus group,  they say you can clean your pessary as needed. You got extra discharge today? All right, take it out. Put it back in the next day. It's bugging you a little bit today?  Fine, take it out. So it's an as-needed approach. The UK clinical guideline group says it depends on the pessary type. If you have acute, take it out every night.  If you have a ring, you can leave it in for several months. And then for my clinical practice personally, I take the approach of just recognizing  that we're all creatures of habit, and if I can help the patients adopt a new habit, they're gonna be much more successful in regular maintenance of that. So I help them pick a day.  I have them maybe pick a Sunday. So every Sunday, you're gonna take out your pessary before you go to bed, you're gonna clean it up, give your vagina a rest for a night,  and you're gonna put it back in on the next morning. And so when I give them that day, and we kind of schedule it, and then they are,  they develop a confidence about that cleaning too, because the more they do it, the better they get. It's kind of like the first time you start wearing contacts  for contacts wearers out there. Remember the first time you start putting your contact in? Hours, right? It took you hours to get that contact in,  and to take it out took you even more hours. And it's the same thing with pessaries. When they first start using it, they just take time, and they try different positions,  and they try different rooms in the house,  but they finally figure out their pattern, and what is the most comfortable.  There is a collapsible pessary that's been generating some publications this past year as well, and there's a couple of them. And the one that I'm thinking of in particular  is a string on it, so it's dispensed like a tampon, and then you pull it out with a string, and it collapses before you remove it.  Is anybody using that in their clinics, or prescribing that?  Great, I wanna hear from you guys at the end. I wanna hear what your thoughts are on that. But the patients are finding them to be more comfortable  because of course they collapse before they come out. I divide my pessary appointments into two. Two appointments, the first one is I just want them  to figure out if the pessary works for them. I don't want them to worry about anything else. Does it help their symptoms? Are they comfortable with it?  Do we think we can make this work? When they come back, if it's working,  that's when I try to get them to buy into the self-management. I'm not gonna try to convince them of self-managing something that doesn't work or they don't like.  But if they're liking it, it's a much better sell, much easier sell to get them to self-manage.  So, how will you do pessaries better?  First, I hope you're gonna use the Urogyne Journal. Majority of my references are from Urogyne Journal. As AUGS members, we go onto the website  and that journal is really easy to work with. You can put in a search for pessaries and you get a whole list of beautiful articles.  I also ask you to take a look at your education sheets. Do they need to be updated? Do you have some that are 15 years old? Do you have some that don't have  the current recommendations on them? Could they be cleaned up a little bit? We have wonderful resources again on our AUGS website that talks about pessary use. You can use those.  They're up-to-date and they're really nicely done. Or do you wanna create your own and customize your education for your patients? I love using the online platform Upwork.  It's a bunch of freelancers that you can, at a very inexpensive cost, create images without trademark infringements, and you can create some beautiful education sheets.  Now, for those of you in larger organizations, you might not be able to do so, but for those of you in smaller ones, that's a really nice resource.  And then commit to developing a better pitch and getting your patients to self-manage. I'd love to hear any of your questions, and I would love to hear about collapsible pessaries.  This is usually a huge question-based talk, but we'll get to that in a minute.

Video Summary

The speech is centered around advancements and best practices in pessary care, focusing on empowering patients through self-management. The speaker, an experienced urogynecologist, stresses the importance of educating patients to manage their pessaries, citing that self-management can minimize common side effects like odor and discharge, and reduce dependence on surgical solutions. She highlights the value of medical-grade silicone pessaries and the ongoing exploration of other supportive measures like estrogen and hyaluronic acid. The discussion includes the challenge of fitting pessaries, the significance of patient anatomy, and the lack of strict guidelines or formal training. The speaker advocates for patient education, noting that a well-crafted pitch can significantly increase self-management success. She concludes by encouraging the use of resources like the Urogyne Journal and updating clinic education sheets to reflect contemporary practices and knowledge in pessary care.

Asset Subtitle

"Pessaries in Practice" at AUGS APP covers clinical indications for pessary use, step-by-step fitting techniques, self-management strategies, and tips for managing complications. This session will also address and dispel common concerns about pessary use, equipping attendees with practical knowledge to improve patient outcomes.

Learning Objectives:

Review clinical indications for a pessary.
Examine the steps for a pessary fitting.
Review self-management tips.
Describe techniques to manage pessary complications.
Dispel common concerns regarding pessaries.

Speaker - Melanie Schlittenhardt DNP, APRN, FNP, CUNP

Keywords

pessary care

self-management

urogynecologist

patient education

medical-grade silicone

Urogyne Journal