Open removal of a migrated Gellhorn pessary and repair of a vesicovaginal fistula

Abstract

This is a case of a 91-year-old woman presenting with urinary incontinence following insertion of a Gellhorn pessary 10 months previously. She had unfortunately missed her 6 months appointment for a change of pessary as she was admitted to hospital. Our patient was found to have had erosion of her Gellhorn shelf pessary into her urinary bladder. She underwent an open removal of the migrated Gellhorn pessary in the bladder and repair of the vesicovaginal fistula with omental interposition. She recovered well and has elected to keep her suprapubic catheter long-term.

Background

Pelvic organ prolapse is a commonly encountered clinical scenario, first recognised in 1500BC.¹ There are various conservative and surgical treatment options available. Vaginal pessaries are the most frequently used non-surgical treatment for pelvic organ prolapse.² Oliver et al have provided a detailed historical description of the various types of pessaries used.³ There are no strict guidelines, but the generally accepted practice is to change vaginal pessaries every 6 months to avoid complications, such as erosion.²

With pessaries being used by many general practitioners, nurses, gynaecologists and urogynaecologists, it is important to recognise the potential complications and counsel patients appropriately. This case illustrates the need for regular follow-up and changes of pessaries to avoid significant complications.

Case presentation

A 91-year-old woman presented with urinary incontinence, having had a 2¾ inches Gellhorn pessary inserted 10 months prior. She had previously undergone a hysterectomy and was suffering from a symptomatic grade 3 cystocele and first-degree vault descent. She had previously used ring pessaries for about 18 months but this was replaced with a 2¾ inches Gellhorn pessary. She had been prescribed local oestrogen cream. This woman was due a follow up for a change of the pessary 6 months after initial insertion, as is routine clinical practice in our departments, but had missed her appointment due to acute hospital admission with a urinary tract infection and diarrhoea. She has a past history of mastectomy, hysterectomy and right hip replacement. She lives alone at home, mobilising with a frame and has support from her family nearby. On examination in the outpatient clinic, the pessary was not palpable in the vagina, but the stem of the Gellhorn pessary was felt via a fistulous opening within the urinary bladder.

Investigations

Cross-sectional CT imaging confirmed the erosion of the shelf pessary into the urinary bladder.

This woman underwent an initial examination under anaesthesia, cystoscopy and attempted removal of the Gellhorn pessary. At cystoscopy, the pessary shelf was seen within the urinary bladder, along with a 1.5 cm stone. Vaginal examination revealed a 3 cm vesicovaginal fistula, which was 2 cm from the bladder neck. The stem of the pessary was visualised vaginally but it was not possible to remove the pessary through the 3 cm fistula.

Treatment

Following further review and counselling, this woman underwent an open removal of the eroded Gellhorn pessary in the bladder and repair of the vesicovaginal fistula with omental interposition. The operation was undertaken by an experienced pelvic urological surgeon. The bladder was mobilised and opened longitudinally (bivalved) to reveal the shelf portion of the Gellhorn pessary within the bladder (figures 1 and 2). The pessary was removed and calcifications on the pessary were sent for microscopy, culture and sensitivities. Both ureteric orifices were visualised and cannulated with ureteric catheters over a guidewire (figure 3). The bladder was opened further posteriorly to the site of the 3.5 cm vesicovaginal fistula, which was mid-vagina, 3 cm above the trigone of the bladder. The posterior bladder wall was mobilised and dissected from the vagina. The vaginal fistula was closed transversely with interrupted 0 vicryl sutures (figures 4 and 5). Omentum was mobilised down the left paracolic gutter and sutured into the vesicovaginal space. The ureteric catheters were removed and the bladder was closed longitudinally with 2-0 vicryl sutures over an 18Ch urethral and 16Ch suprapubic catheter. A 20Ch Robinson drain was left in the pelvis.

Figure 1.

Gellhorn pessary shown within the bladder after dividing open the anterior bladder wall.

Figure 2.

Gellhorn pessary that had migrated into the bladder.

Figure 3.

Vesicovaginal fistula following mobilisation of the posterior bladder wall. Bilateral ureteric catheters in place.

Figure 4.

Transverse closure of vesicovaginal fistula with absorbable vicryl suture.

Figure 5.

Closure of bladder wall with continuous absorbable vicryl suture. Suprapubic catheter in place.

Postoperatively, she was monitored on the high dependency unit and was discharged 21 days postoperatively, with the delay due to social input requirement.

Outcome and follow-up

This woman was reviewed as an outpatient 2 months postoperatively. She had undergone a cystogram prior to this which showed no persistent leak. She was well and elected to have the suprapubic catheter remain as she had a small capacity bladder and some urethral incompetence. Currently, she remains with her suprapubic catheter due to reduce mobility and her and her family have chosen for her to keep it long-term.

Discussion

Vaginal pessaries are commonly used in the management of pelvic organ prolapse. They are relatively safe with a low complication profile. A review published in 2015 found that the risk of a vesicovaginal fistula among 1190 patients was 2.8% over a 62-year period.¹ In the 11 reported cases of vesicovaginal fistula associated with pessaries, the most likely type of pessary to cause this was the Gellhorn pessary.²

Migration of pessaries into the bladder, leading to a vesicovaginal fistula is rare. A recent case report published in 2017 also describes a similar presentation to this case, whereby the patient presented with urinary incontinence 1 week prior to her scheduled pessary change.⁴ Other reported significant complications in the literature include migration of pessaries into the uterine cavity and retained vaginal pessary for 3 years causing vaginal adenosquamous carcinoma.^4–6 Neglected pessaries, particularly ring pessaries can also become epithelialised and require division of the ring for ease of removal.⁷

While there is a known risk of pessary erosion, there is no clear guideline on the frequency of pessary change. A survey undertaken in 2014 of members of the International Urogynaecology Association found that 62% of gynaecologists would recommend patients having their pessary changed every 3–6 months by a healthcare professional.² In this case, the pessary had been in place for 10 months and even then, had already eroded into the bladder. With the use of pessaries occasionally being in elderly patients, scheduled changes within the appropriate time frame is key and therefore it is important to inform the healthcare professionals as well as the family or nursing home, where applicable.

Patient’s perspective.

Patient’s daughter’s perspective: ‘We have been very happy with how quickly she has received treatment since they found out what was wrong. But I can’t believe how long it took to find out what was wrong. She was in hospital 16 times from the start and no one knew. She still has her catheter now because she can’t move around very well anymore. I now live with her and look after her. Before the operation, she was on her own and independent. We’re very happy she’s had the operation to remove it but she hasn’t got back to her previous level of independence.’

Learning points.

• It must not be assumed that patients who present with urinary incontinence after the use of pessaries have urethral incontinence but must be examined to exclude a fistula.

• To avoid further similar incidences, perhaps a pessary registry could be set up to minimise ‘lost to follow-up’ occasions and subsequent complications.

• There needs to be an increased awareness among healthcare professionals and care providers to recognise that pessaries should be changed on a regular basis.