Neglected doughnut pessary in the uterine cavity

Abstract

Vaginal pessary is a practical and effective tool for pelvic organ prolapse management. Nevertheless, serious complications can occur in neglected patients such as vesicovaginal and rectovaginal fistula, erosion and impaction in adjacent structures. We report a case of neglected pessary found in the uterine cavity. The patient was treated with abdominal hysterectomy with in situ doughnut pessary. Proper pessary care and regular follow-up should be emphasised among patients, caregivers and related healthcare personnel to early detect as well as to avoid complications.

Background

Vaginal pessary is a practical and effective tool for management of pelvic organ prolapse.^{1 2} It is considered a good treatment option for elderly women who were unsuitable for surgery due to complex medical diseases.² In Thailand generally, physicians could train on the use of pessary for pelvic organ prolapse and how to manage common complications. Serious complications are rare with proper care, regular removal and continuous monitoring.² Neglected pessaries can lead to severe complications such as vesicovaginal and rectovaginal fistula, erosion and impaction in adjacent structures.^{2 3} We report a rare case of a 77-year-old patient who presented with a neglected doughnut pessary in the uterine cavity.

Case presentation

This is a case report of a 77-year-old, para 5, non-sexually active woman who initially presented at the Urogynecology Clinic, Department of Obstetrics and Gynecology, Siriraj Hospital with a stage IV uterovaginal prolapse. Due to underlying medical problems of type 2 diabetes and triple vessel disease post-balloon angioplasty, conservative treatment option with a doughnut pessary was offered. Following pessary fitting, the patient’s daughter was successfully trained to manage the pessary at home. Weekly pessary care including removing, cleaning and re-inserting was recommended. The patient managed to return for follow-up at 3- and 6-month interval during the first year of treatment, and then lost to follow-up thereafter.

After 7 years of pessary negligence, the patient re-presented at the Urogynecology Clinic with a 3-month history of brownish vaginal discharge without pelvic pain, fever or any proof of pessary falling out. Vaginal examination revealed a shortened vagina of 5 cm and partially obliterated upper vaginal portion with brownish discharge. The cervix and the pessary could not be clearly identified (figure 1). A smooth and firm extraluminal mass was palpated at the level above vaginal fornix during rectal examination.

Figure 1.

Vaginal examination reveals obliterated vagina but cannot identify cervix and pessary.

Investigations

Although the transvaginal ultrasound was able to depict a hyperechoic ring-shaped mass in the pelvic cavity, it had failed to detect the exact location of the pessary (figure 2). A CT of the whole abdominal cavity was conducted and was able to demonstrate a doughnut pessary located in the uterine cavity (figure 2).

Figure 2.

Transvaginal ultrasonography shows hyperechoic mass in the pelvic cavity. CT of the whole abdomen demonstrates a doughnut pessary located in the uterine cavity.

Treatment

In order to confirm the diagnosis and to provide the definitive treatment, the patient was thoroughly examined under anaesthesia. With obliteration of upper vagina and stenosed external cervical os, the pessary could not be removed via transvaginal approach. Laparotomy was then performed. With the pessary in situ and concomitant subserosal leiomyoma, abdominal hysterectomy was eventually carried out. Having carefully inspected the opened specimen, the doughnut pessary was located in the lower portion of the uterine cavity causing minimal local infection (figure 3). Regarding the previous history of advanced stage prolapse, an additional reconstructive procedure to address pelvic support defect after hysterectomy was mandatory. Having considered the risks and benefits, abdominal sacrocolpopexy was believed to provide more durable and global support for apical, anterior and posterior vaginal compartments without the need for concurrent vaginal repair. With the high possibility of vaginal cuff dehiscence and wound separation due to chronic inflammation and localised infection, the operative field was meticulously irrigated with warm saline and postoperative antibiotics were readily administered.

Figure 3 Opened specimen after hysterectomy shows intrauterine location of the pessary.

Outcome and follow-up

Postoperatively, the patient developed dyspnea which resulted from anaemia-induced congestive heart failure. She was uneventfully treated with antidiuretics, fluid restriction and two units of red cell transfusion, and was discharged from the hospital on postoperative day 5. Unfortunately, her postoperative course was rather complicated with abdominal wound dehiscence diagnosed 10 days after surgery for which daily wound care and wound re-approximation were required. At 9-month postoperative follow-up, the patient was found to have fully recovered with no prolapse beyond stage I. No mesh complication was encountered.

Discussion

Although vaginal pessary is a relatively safe and effective treatment choice for pelvic organ prolapse, especially among elderly patients with underlying medical conditions who are poor candidates for surgery, serious complications frequently occur in those with pessary negligence. Several cases of neglected pessaries are often reported in frail elderly patients having multiple medical problems along with cognitive impairment. With prolapse reduction after successful pessary fitting, all bothersome prolapse-related symptoms generally disappear leaving no warning signal to trigger the patients and their caregivers to return for pessary follow-up and eventually resulting in pessary negligence.

Pessary impaction in adjacent organs, as presented in this case report, is considered one of the rare complications ever demonstrated. The plausible mechanism which caused the pessary to be impacted could be the excessive force during pessary insertion leading to subsequent trauma and pressure necrosis onto the cervix. The traumatised cervix spontaneously healed and re-epithelialised to cover the whole pessary. According to the previous case reports of embedded, impacted, epithelialised and incarcerated pessaries,³ all were successfully managed by cutting off the pessary^{4 5} or excising the band of vaginal tissue.^{6 7} However, with the impacted pessary in the uterine cavity, there was difficulty for pessary removal for which a more complicated procedure such as enbloc hysterectomy was required to take out both uterus and pessary at the same time. This has given us a lesson that preventing is always better than treating the complications. Therefore, when a vaginal pessary is being considered as a treatment of choice, a thorough discussion with the patient, the family members and the caregivers regarding indications for pessary use, proper care and the need for regular follow-up is mandatory. Clinicians and related healthcare personnel, both in the obstetrics and gynaecology and other fields of medicine, should also have awareness and concerns of any possible adverse events, especially in patients who have lost to follow-up, in order to avoid and early detect serious complications as well as to provide appropriate and adequate treatment.

Although vaginal pessary is a relatively safe and effective treatment option for pelvic organ prolapse, serious complications frequently occur in patients with pessary negligence. Proper care and regular follow-up are mandatory and should be emphasised among patients, family members, caregivers and healthcare personnel to avoid complications.

Learning points.

• This report shows a rare case of neglected pessary in the uterine cavity.

• Patients treated with pessary insertion should receive regular cleaning, replacement and monitoring to prevent serious complications.

• The clinicians should emphasise the importance of follow-up and proper care of pessary.