Management of Incarcerated Vaginal Pessary in Geriatric Woman

Doctor Zeinab Lami1, Doctor Rajaa Samaka2, Doctor Zahraa Lami3, Doctor Omaema Al Baghdadi1

1Tawam Hospital, Abu Dhabi, UAE. 2Ishtar Medical Center, Abu Dhabi, UAE. 3Latifa Hospital, Dubai, UAE

Case report

Objective:

Vaginal pessaries are effective and safe mode of treatment for symptomatic pelvic organ prolapse, urinary incontinence, and uterine retroversion. It is particularly invaluable in elderly patients with comorbidities that preclude pelvic floor reconstruction surgery. The complications associated with embedded vaginal pessaries include profuse foul smelling vaginal discharge, vaginal erosions, and pessary incarceration.

Here we present a case of forgotten vaginal pessary leading to incarceration.

Case Report:

A 71-year-old postmenopausal woman presented with offensive foul smelling vaginal discharge that is occasionally blood-tinged. She is diagnosed with dementia, diabetes and chronic kidney disease. The patient‘s family and caregiver are unaware of any gynaecological interventions done for the patient during her lifetime. 

On vaginal examination, a calcified vaginal ring was seen entrapped in the vaginal wall with presence of granulation tissue around it, making it challenging for the pessary to be retrieved easily. As the patient’s condition was unfit for general anesthesia, the patient’s family were counselled for surgical removal of pessary under sedation. Assessment of vaginal ring pessary reveals a calcified, hard, impacted pessary in the anterior and lateral vaginal walls and is surrounded by vaginal mucosa. The bands of tissue were excised and others were released by digital dissection. Still, it was difficult to remove the pessary as one piece. Bone cutter was used to cut hardly with protection of surrounding tissue. The ring was then removed in one piece. The vaginal tissue was then noted to be fibrosed and inflamed. Thorough vaginal irrigation was made and the procedure was well tolerated. There were no post procedure complications recorded.

Discussion:

Vaginal ring incarceration is commonly seen in cases of neglected pessaries. It is preventable by effective pessary fitting, local oestrogen use and timed follow-ups. When unfit for surgery, the pessary can only be removed under sedation.

In the present case, the presence of offensive vaginal discharge of prolonged duration in postmenopausal women should arise the suspicion of a forgotten pessary or foreign body. When the patient has dementia or accompanied by a caregiver, it is necessary that the caregiver is made aware of the fitted pessary and required follow up visits. 

Conclusion:

Pessaries offer a safe and effective option got treating pelvic organ prolapse in selected patients. Major complications though uncommon, are usually associated with neglect of the device following prolonged use. Patient education and strictly timed follow-ups are of paramount importance in reducing the risk of such complications.