Pessaries are an effective treatment option for many women with symptomatic vaginal prolapse, but they do need to be removed on a regular basis to prevent complications and ensure tissue integrity. This patient is an 88-year-old woman with a history of atrial fibrillation and metastatic breast cancer who had been treated for her stage 3 vaginal vault prolapse with a Gellhorn pessary. She presented to our office five years later complaining of urinary incontinence. At initial evaluation in the office, she was noted to have continuous flow of urine from the vaginal vault and the pessary was embedded high in the vaginal vault surrounded by a significant amount of granulation tissue. On examination under anesthesia, the pessary was noted to have significant calcifications. An attempt was made at removal using ring forceps, but the pessary was firmly embedded in the surrounding tissue. This patient had a number 3 Gellhorn pessary, which is generally used in advanced stages of prolapse in patients who are no longer sexually active. Removal and insertion is difficult and typically not done by the patient herself. We then proceeded with cystoscopy to evaluate the extent of the fistula. On entry to the bladder, the stem of the Gellhorn was noted in the midline just above the level of the trigone. Similar to what was noted in the vagina, calcifications covered the stem of the Gellhorn. The actual fistula track appeared to be epithelialized and there was no evidence of granulation tissue. We turned our attention to vaginal removal of the Gellhorn. An open-sided speculum was placed in the vagina and ring forceps was used to grasp the pessary. A number 10 blade scalpel on a long handle was then used to separate the pessary stem from the base. A long alice clamp was used to grasp the stem of the Gellhorn and with steady traction, the stem was removed from the bladder. We then turned our attention to removal of the remainder of the pessary. The number 10 blade scalpel was used to cut a wedge out of the pessary. We utilized a right angle retractor in the vagina to help prevent unintentional injury to the vaginal epithelium. This served as a backstop for the scalpel. We continued to remove segments of the pessary in a stepwise fashion. Pessaries are typically made of silicone, a synthetic polymer that is commonly used in medicine given its inherent low chemical reactivity, low toxicity, hydrophobic nature, and natural resistance to microbiological growth. Given the length of time this patient had the pessary, you can see there is significant discoloration of the pessary itself. Pessaries do come in a variety of shapes and sizes. In general, there are two classes of pessaries, support pessaries and space-filling pessaries. The Gellhorn pessary shown in this video is classified as a space-filling pessary. Pessaries are held in place laterally by the levator muscles and distally by the pubic bone and the vaginal introitus. The Gellhorn pessary has a broad, firm, circular base with a stem protruding from the center. The base provides support to the vaginal apex and the stem sits normally on the long axis of the vagina. The stem keeps the circular base from rotating into the long axis of the vagina and being expelled. The base is slightly concave, allowing suction to form against the vagina. While uncommon, the use of pessaries does carry risks of fistulization into the bladder or bowel. It is therefore important to emphasize to patients and their caregivers the importance of routine pessary care. Eventually, we are able to grasp the remaining fragment of the pessary and remove it completely. While not shown in this video, we performed copious irrigation once the pessary was removed, since there were small calculi fragments remaining in the vagina. Here you can see all the segments of the pessary reassembled. Once the pessary had been removed, we turned again to cystoscopy. Given the size of the vesicovaginal fistula, a latex glove was placed in the vagina to help occlude the opening and allow for adequate distention. You can see here bilateral ureteral jets in close proximity to the site of the erosion. We then fitted the patient with a diaphragm and attached malicot catheter, which provides drainage into a collection bag. Unfortunately, due to multiple comorbidities, she was not a candidate for fistula repair.

vaginal prolapse

Gellhorn pessary

urinary incontinence

pessary removal

routine pessary care