Vaginal pessary may be opted for management of uterine prolapse as a safe option, but to avoid complications regular follow-up is a must. We are reporting a case of neglected vaginal pessary in a 72 year old female which got embedded in vaginal mucosa and required excision of vaginal band for its removal

Jain, Meenu

Rani, Jyotsna

Sehgal, Alka

English

International Journal of Reproduction, Contraception, Obstetrics and Gynecology

   http://dx.doi.org/10.5455/2320-1770.ijrcog20140367                                                                                     Volume 3 · Issue 1    Page 291 International Journal of Reproduction, Contraception, Obstetrics and Gynecology Jain M et al. Int J Reprod Contracept Obstet Gynecol. 2014 Mar;3(1):291-292 www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789 Case Report Neglected vaginal pessary Meenu Jain, Jyotsna Rani*, Alka Sehgal            INTRODUCTION Vaginal pessary may be opted for conservative management of uterine prolapse as a safe option, but to avoid complications regular follow-up is a must. Sometimes neglected vaginal pessary may cause serious complications and rarely require surgical intervention. Here we are reporting a case of embedded vaginal pessary which needed excision for its removal.  CASE REPORT A 72 year female with history of coronary angioplasty using vaginal ring pessary for second degree utero-vaginal prolapse for 12 years, presented with complain of foul smelling vaginal discharge for one year. She had ignored all instructions and care of pessary after initial follow ups. Speculum examination revealed a ring pessary buried in vagina with band of tissue overgrowing the ring in both lateral fornix. Uterus was atrophied with first degree prolapse. Vagina was atrophied & infected. Vaginal swab culture however reported sterile & pap smear was normal. The band of vaginal tissue required excision under short general anesthesia for removal of pessary (Figure 1). Patient refused any further management hence advocated use of estrogen cream & vaginal antiseptics locally.  Figure 1: Ring pessary embedded in lateral fornices bilaterally with first degree uterovaginal descent. DISCUSSION In developing countries vaginal pessaries have been a management modality for pelvic organ prolapse, incontinence, very elderly women medically unfit for surgery or for temporary relief during pregnancy. They Department of Obstetrics & Gynecology, Government Medical College and Hospital, Sector-32, Chandigarh, India  Received: 03 November 2013 Accepted: 13 November 2013  *Correspondence: Dr. Jyotsna Rani, E-mail: dr.jyotsna.pmch@gmail.com © 2014 Jain M et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Vaginal pessary may be opted for management of uterine prolapse as a safe option, but to avoid complications regular follow-up is a must. We are reporting a case of neglected vaginal pessary in a 72 year old female which got embedded in vaginal mucosa and required excision of vaginal band for its removal.  Keywords: Vaginal pessary, Uterine prolapse, Complication of vaginal pessary DOI: 10.5455/2320-1770.ijrcog20140367 Jain M et al. Int J Reprod Contracept Obstet Gynecol. 2014 Mar;3(1):291-292 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                       Volume 3 · Issue 1    Page 292 are easy to insert but require care by patient and health care provider. Since geriatric population may also suffer from forgetfulness and dementia, neglected pessary care may compound complication like, vaginal discharge, malodor, allergic reaction, vaginal irritation and erosion.1 Forgotten pessary may cause pressure necrosis and the ulcerative mucosa which may later heal over the rim of pessary leading to impaction.2 Use of estrogen cream may decrease inflammation, ease removal of impacted pessary and then promote epithelial maturation. Rarely extreme impaction may require surgical intervention, as in our patient.  Severe complications like vesicovaginal fistula,  rectovaginal fistula, bowel obstruction,  hydronephrosis or urosepsis have also been described in literature.3-5 Rare instances of bowel incarceration through a ring pessary and even cancer of vagina have been reported.6,7 Vaginal pessary may improve the quality of life but command proper care in elderly patients. Literature lacks adequate consensus on cleanliness or replacement protocols. Initially three monthly, followed by biannual visits has been advocated to reduce complication rate with immediate clinical evaluation if pain or vaginal bleeding pursues.8 Local application of estrogen 4-6 weeks prior to pessary insertion increases the comfort and compliance rate. For minor side effects, use of vaginal douches with H2O2, diluted vinegar, estrogen creams etc. have been advocated. Though vaginal pessaries for uterine prolapse is getting obsolete and younger generation is unfamiliar with its usage, however if advocated in some inevitable situation, proper training on its insertion, care by patient and a regular follow up is must to prevent complications. Funding: No funding sources Conflict of interest: None declared Ethical approval: Not required REFERENCES 1. Bash KL. Review of vaginal pessary. Obstet Gynecol Surgery. 2000;55:445-60. 2. Nallendran V, Hannah L, Watson AJ. Neglected vaginal ring pessary. J Obstet Gynaecol. 2006;26:274-5. 3. Ray A, Esen U, Nwabineli J. Iatrogenic vesico-vaginal fistula caused by shelf pessary. J Obstet Gynaecol. 2006;26(3):275-6. 4. Kankam OK, Geraghty R. An erosive pessary. J R Soc Med. 2002;95(10):507. 5. Duncan LE, Foltzer M, O’Hearn M, et al. Unilateral hydronephrosis, pyelonephritis, and bacteremia caused by a neglected vaginal ring pessary. J Am Geriatr Soc. 1997;45:1413-4. 6. Ott R, Richter H, Behr J et al. Small bowel prolapse and incarceration caused by a vaginal ring pessary. Br J Surg. 1993;80:1157-9. 7. Jain A, Majoko F, Freites O. How innocent is the vaginal pessary? Two cases of vaginal cancer associated with pessary use. J Obstet Gynaecol. 2006;26(8):829-30. 8. Wu V, Farrell SA, Basket TF, et al. A simplified protocol for pessary management. Obstet Gynecol. 1997;90:990-4.           DOI: 10.5455/2320-1770.ijrcog20140367 Cite this article as: Jain M, Rani J, Sehgal A. Neglected vaginal pessary. Int J Reprod Contracept Obstet Gynecol 2014;3:291-2. 

Neglected vaginal pessary

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Neglected vaginal pessary

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International Journal of Reproduction, Contraception, Obstetrics and Gynecology