Understanding prolapse, the use of pessaries and the impact on the microbiome

Pelvic organ prolapse (POP) is a common condition where the pelvic organs, such as the bladder, uterus, or rectum, shift from their normal position due to weakened pelvic floor muscles.

 

Menopause

Menopausal women may experience pelvic organ prolapse due to a combination of hormonal, physical, and age-related factors. It is estimated that around 40% of women will experience prolapse in their lifetime. These can be:

1. Decrease in Oestrogen

• Oestrogen helps maintain the strength and elasticity of tissues, including those in the pelvic floor muscles and the connective tissues (ligaments and fascia) that support pelvic organs like the bladder, uterus, and rectum. As women reach menopause, oestrogen levels decrease significantly, leading to a weakening of these tissues. This can reduce their ability to support the pelvic organs, increasing the risk of prolapse.

2. Weakening of the Pelvic Floor Muscles

• Pelvic floor function: The pelvic floor muscles play a key role in holding the pelvic organs in place. With age and hormonal changes after menopause, these muscles may weaken or lose tone.
• Impact of childbirth: Childbirth, particularly multiple pregnancies and vaginal deliveries, can stretch and weaken the pelvic floor muscles and connective tissues, making prolapse more likely, especially later in life.

3. Increased Abdominal Pressure

• Chronic pressure: Conditions that cause increased abdominal pressure, such as chronic coughing (from smoking or respiratory conditions), obesity, or heavy lifting, can exacerbate the risk of prolapse. This added pressure can push the pelvic organs downward, particularly in women whose pelvic floor muscles and connective tissues are already weakened.

4. Aging and Loss of Tissue Elasticity

• Natural aging process: As women age, all tissues in the body naturally lose elasticity and strength. This affects the ligaments and muscles that support the pelvic organs, making them more prone to prolapse.
• Impact on connective tissue: Aging also contributes to changes in collagen and elastin, which are the proteins that give tissues their strength and flexibility. The loss of these proteins makes the tissues less able to support the organs.

5. Other Risk Factors

• Genetics: Some women may be more predisposed to prolapse due to genetic factors that affect the strength and elasticity of their connective tissue.
• Previous surgery or trauma: Hysterectomy or pelvic surgery can also increase the risk of prolapse by disrupting the normal anatomy and support structures of the pelvic area.

 

Types of Pelvic Organ Prolapse:

Pelvic organ prolapse occurs when one or more of the pelvic organs (bladder, uterus, rectum) drop down into the vaginal canal due to weakened support structures. The main types of prolapse include:

• Cystocele: Prolapse of the bladder into the vaginal wall.
• Rectocele: Prolapse of the rectum into the vaginal wall.
• Uterine prolapse: When the uterus drops into the vaginal canal.
• Enterocele: Prolapse of the small intestine into the vaginal canal.

 

Non-surgical treatments for prolapse

One of the most effective non-surgical treatments for POP is the use of vaginal pessaries. A pessary is a medical device inserted into the vagina to support the pelvic organs and alleviate symptoms of prolapse.

 

Pessaries are an option for women who either want to avoid or delay surgery, and they are also suitable for those whose health conditions make surgery risky.  Currently, there is no standard definition for a successful pessary fit. Other lifestyle interventions include weight loss, reduced caffeine intake, and physiotherapy.

Here’s a closer look at the types of pessaries available, how they are managed, and the potential side effects.

 

Types of Pessaries

There are several types of pessaries, and the right one depends on the degree of prolapse, the patient’s anatomy, and individual preferences. Some of the most commonly used pessaries include:

 Image:NHS CUH

 

1.Ring Pessary: The ring pessary is a simple, flexible device shaped like a ring. It is typically used for mild to moderate prolapse and is one of the easiest pessaries to insert and remove. It is one of the most commonly used rings and can remain in place during sexual intercourse, offering convenience for many users.

 

2.Gellhorn Pessary: This pessary is shaped like a disc with a stem and is ideal for more severe prolapse. The Gellhorn pessary provides stronger support than the ring pessary, making it suitable for women with advanced pelvic organ prolapse.

 

3.Cube Pessary: The cube pessary is a small, cube-shaped device that provides support through suction. It is often used when other types of pessaries have not been effective or for women with more severe cases of prolapse.

 

4.Donut Pessary: Shaped like a donut, this device is larger than a ring pessary and is used for more advanced cases of prolapse. Its thicker design provides additional support.

 

Each type of pessary is designed to provide different levels of support, and a healthcare provider typically determines the best fit based on a patient's specific needs. Comfort and suitability depend on individual circumstances, so consulting a healthcare provider is essential.

 

How Often Do Pessaries Need to Be Changed?

The frequency with which a pessary needs to be changed or removed varies depending on the type of pessary, the severity of the prolapse, and the individual’s comfort. Some women can insert and remove their pessary on their own, while others prefer to have a healthcare professional do it. This is typically carried out by secondary care.

 

Self-managed pessaries: Women who are able to remove and insert their own pessaries may need to take them out every day or every few days for cleaning. Ring pessaries, for instance, can be removed, cleaned with mild soap and water, and reinserted.

 

Clinician-managed pessaries: For women who cannot manage the device on their own, pessary changes may be scheduled every 3 to 6 months at a doctor’s office. Healthcare providers will clean, check, and reinsert the pessary during these appointments.

 

The exact frequency will depend on individual recommendations from a healthcare provider, but regular follow-up visits are essential to ensure the pessary is functioning properly and to prevent complications.

 

Side Effects and Risks of Using Pessaries

While pessaries are a highly effective treatment for pelvic organ prolapse, there are some potential side effects and risks to be aware of, many stemming from the impact on the microbiome

 

1.Vaginal Irritation or Discomfort: Some women may experience irritation, discomfort, or pressure, especially when the pessary is first fitted. In many cases, the discomfort lessens over time, but if it persists, a different type or size of pessary may be needed.

2.Increased Vaginal Discharge: Pessary use can sometimes cause an increase in vaginal discharge. This is generally harmless but can be bothersome. If the discharge becomes foul-smelling or is accompanied by other symptoms, it could indicate an infection and disruption of the microbiome.

3.Vaginal Infections or Ulcers: Prolonged use of a pessary without proper hygiene or follow-up care can lead to infections or the formation of vaginal ulcers. To reduce this risk, regular removal and cleaning of the pessary are essential, as is adhering to recommended follow-up care.

4.Urinary Tract Issues: Some women may experience difficulty urinating or have an increased risk of urinary tract infections (UTIs) due to the presence of the pessary. Adjusting the fit or type of the pessary can often resolve this issue.

5.Displacement: In some cases, the pessary may shift from its intended position, causing discomfort or reduced effectiveness. Regular check-ups can help ensure the pessary remains in place and is providing adequate support.

 

Conclusion

Pessaries offer a reliable, non-surgical solution for managing pelvic organ prolapse. With several types available, women can work with their healthcare providers to find the one that best suits their needs. While the use of pessaries does require regular maintenance and carries some risk of side effects, they remain an effective option for many women. Regular follow-ups and proper care can minimize risks and improve overall comfort and quality of life for those experiencing pelvic organ prolapse.

Links

1. NICE Guideline (2019) Urinary incontinence and pelvic organ prolapse in women: management. National institute for Health and Care Excellence.
2. Pelvic Organ Prolapse (2022) Royal College of Obstetricians and Gynaecologist
3. Gorti and Hydelist (2009) Evaluation of vaginal pessary management: a UK-based survey. Journal of Obstetrics and Gynaecology. 29 (2).
4. Miceli, A., Sanchez, M.F. and Diez, J.L (2021) How often should ring pessaries be removed or changed in women with advanced POP? A prospective observational study.
5. Gold, Bauch, Amir, Gordon and Groutz (2021) A tailored flexible vaginal pessary treatment for pelvic organ prolapse in older women. Journal of the American Geriatrics Society.