Dr Pankaj Desai - Debate - Is Pessary Obsolete Debate

Some time back Dr. R. V. Bhatt asked us to invite opinions on “Is Vaginal Pessary obsolete in modern management of prolapsed?” To this we received many opinions. We have displayed most of them below

OPINION BOARD

I passed in the year 1960; using PVC ring pessary even today in some situations. It inspired me to learn from his experience that with the use of oestrogen vaginal cream twice a week there is no need to replace the staff early every one or two months. The most comfortable massage for me is when he says “These women are very happy and satisfied leading a normal life“

Modern scientific advancement no doubt offers newer and safer technique often with newer gadgets but at the same time one possibly should agree when I say that

Some of the older yet simpler procedures should not be ignored completely.
In this complex society of today with different socio-economic status more in an elderly with limited means, we need to be honest to assess her bare need and next try to explore how to make her happy enjoying the rest of her life with simple cost effective procedures
I am healer, entrusted not only to correct her physical ailment but ensure ease and comfort restoring mental peace and happiness in life.
We are to be aware that she does not become a burden to others in her family. I have to adopt a technique to fit to her liking either for a short term or long term procedure.

Dr. K. K. Das

The vaginal ring pessary is not obsolete. I am still using the pessary in following situations:

1) Pregnancy with uterine prolapse. I keep it upto 28 wks gestation.

2) In patients with third degree uterovaginal prolapse, not fit for major surgery

3) Preoperative, till the infected tropic ulcer heals.

Dr. Sunil Rautmare

Vaginal ring pessary is not obsolete. We still use it in situations like postponing the surgery, for decubitus ulcer healing etc.

Dr. Sundari

I thoroughly agree with Dr Rohit that such cases can be managed by PVC pessary but problem lies that these techniques not only students do not know but so also their tutors who will teach the teachers?

I would like to tell you that now a days there is nothing like trial labour and normal vaginal delivery in pre C S , now one C S is always CS .

DR Sheroo Zamindar

Ring pessaries definitely have a role in selected group of population. We have at least 8-10 patients with ring pessary for different indications. 3 pts are 80+ age & with ring pessary since last 8-10 yrs & we keep changing it every 3-4 month & intermittently removing it for a month or so if little excoriation develops. They are with H/O IHD & family members are not willing to take any risk. Other 2 pts are 70 + & are alone as children stay away & unable to come down for their care. 2 are with vault prolapse & fear operation. 1 pt is 30 yr age with B/L hydronephrosis so we've replaced uterus back with help of ring pessary & is called back after fortnight & we'll be doing regular follow-up & if hydronephrosis resolves we can do definitive surgery. we do apply ring pessary if badly infected trophic ulcer is there give time to control infection & proceed

Dr Sangeeta Kamra

Read the article on vaginal pessary which is quite a good reminder to all of us that vaginal pessary is still around. Definitely in the cases mentioned it of good use& also in cases where there are big decubitus ulcers in which pessary can help in relieving congestion. This will help in decreasing waiting time for surgery.

Dr. Mamta Sahu

I feel vaginal pessary is far from obsolete. We have a patient Mrs D, who has a IIIrd degree prolapse and is very uncomfortable, so much so that she finds walking difficult. She also has global ischemia and cardiologists have declared her unfit for surgery. At 78 years it was a troublesome time for her. She was brought to us by her son who requested.....SOME relief. And now with a ring pessary in place she looks like a new person. We remove lavage and reinsert the pessary every 3 weeks. Proves that the world is round!

Dr Kedar Padte

PVC is a good alternative option.....

Dr. Uma Devi

1. true it is obsolete

2. can be used by postgraduates for research

3. history students should know

4. do not use it

5. with advances one should go for new things

6. but back to nature can be theme for reinvestigating the use of vaginal pessary

Dr. Kavita Bapat

Vaginal ring pessary has got a definite role in prolapse in the elderly. But these are rarely available. i will be highly obliged if i find information of its manufacturer and the procedure to choose the appropriate size needed to a particular patient

Dr. Pramod Kumar Sahu

My opinion regarding vaginal pessary is that it should be used according to need of the patient in elderly patient not fit for surgery -vaginal pessary is a boon in younger patient till surgery is done pessary can be used to treat the prolapse symptoms so old is gold

Dr Sarita Gupta

in my opinion ring pessary use is not obsolete. In England still it is used. In cases where patient is not suitable or fit for surgery, pessary is the answer to give patient relief from sufferings.

Dr Yashlaha

I was to insert vaginal pessary in 2 pts- an old female with prolapse not willing for surgery, a 20 wk pregnant lady with prolapse. However the pts refused at the last moment. What i feel is that advanced age pts unwilling/unfit for surgery, Midtrimester pts, to buy time in trophic ulcers, to help pt wind up her commitments it is an extremely helpful mode.. However our textbooks do not train us to decide the size and mode of insertion. i would be highly obliged if light could be thrown on these issues.

Dr. Preeti Verma

In my opinion use of Vaginal Ring Pessary is not obsolete now-a-days especially for temporary/short term use. But their uses for permanent indications need to be reassessed—in terms of patient compliance! In our country most of the prolapse cases are in rural areas where people are poor and illiterate—neither they will understand the need for hygiene & regular change of pessary nor they will follow up regularly.

Dr. Mrudu Sinha

I still use the ring pessary in old high risk women and in pregnancy with prolapse. I am sure many of us old timers still do so, to good effect

Dr. Ajit Joshi

I concur with Dr Bhatt, that ring pessary is almost forgotten.Pl add one more indication, when lady is not willing for surgery recently yet wants sexual function maintained. PVC pessary available is of very poor quality. Industry has to do something about it, i generally advice two pessaries to be in use from hygienic point of view. In view of surgeries as sling surgeries, mesh surgeries, usage of ring pessary has come down; definitely it has role and usage as delineated.

Dr. Randhir Puri

I feel vaginal ring pessary is not obsolete. As rightly pointed out by Dr R V Bhatt it has several advantages even in modern era of safe anesthesia and surgical advancement. But this question does lead to an important question; why do we gynecologist feel that vaginal pessary is obsolete? I feel this is because we as students were very minimally exposed to pessaries. Pessaries are not easily available, having the need to order and then wait for replacement - where to order? which size? In absence of reliable pap smear screening program and patients follow up, the risk of vaginal wall erosions and carcinoma remain scary and real. In the US, several patients are routinely using pessaries for vaginal support. Contraception is also available as a ring/pessaries and are quite popular in young women.

Dr. Monali Desai

Ring pessary is a cheap and comforting to a lady who is 75plus or can’t afford but I change it every month for fear of infection.

Dr Ela Mehrotra

Vaginal ring pessary is not obsolete, it is very useful and give some relief to very old age patients who are bad surgical risks, afraid of surgery or not fit for surgery

Dr. Sarju Asalia