Forgotten Vaginal Ring Pessary

Author Information
Khadkikar R*, Panchbudhe S**, Channawar S***, Chauhan AR****
(* Assistant Professor, ** Assistant Professor, *** Assistant Professor, **** Additional Professor
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)

Abstract

Vaginal foreign body is quite common in young children but is a rare finding in adults. This is a case report of a long forgotten vaginal foreign body (ring pessary) accidentally found more than 30 years after its insertion. An eighty years old postmenopausal widow presented with foul smelling, and occasionally bloody discharge from vagina. She had an impacted, encrusted ring pessary which required anaesthesia for its removal.

Introduction

Vaginal pessaries have been used to treat pelvic organ prolapse for over two thousand years. Approximately 20 different pessary types are available; ring, Gelhorn type and donut pessaries are used most frequently.^[1] They are indicated for the treatment of genital prolapse in elderly women with significant co-morbidities that preclude major surgical pelvic floor reconstruction, in women who desire future childbearing or temporary relief of prolapse while waiting for surgery, during pregnancy and in women who do not desire surgical repair. When used properly, pessaries are effective in correcting prolapse and improving the quality of life in older patients.^[2] If forgotten and neglected, they can lead to complications like vesicovaginal and rectovaginal fistulae (VVF and RVF), fecal impaction, hydronephrosis, urinary infection, cervical and vaginal carcinoma ^{[3, 4]} Vaginal foreign bodies are common in children; however there are several reported cases of forgotten vaginal foreign bodies in adults.^[5] A high index of suspicion is required to arrive at the diagnosis.

Case report

An eighty years old widow, postmenopausal since 30 years, presented to our outpatient department with history of foul smelling discharge, vaginal bleeding on and off, and burning and frequency of micturition for one year. There was no other significant past medical or surgical history. The patient had 9 full term normal home deliveries without medical assistance; last childbirth was 40 years ago.

On examination, her general and abdominal examination was unremarkable. Speculum examination was difficult and revealed a urethral caruncle of 1cm diameter, a firm to hard foreign body in the vagina and a mucopurulent and blood stained discharge. The cervix was unhealthy, with circumoral erosion which bled on touch. Papanicolaou smear was collected. On vaginal examination, the uterus was anteverted, atrophic and bilateral fornices were free. The foreign body was embedded in the mid vagina with encrustations and calcifications on its surface. On digital probing it was a thick, hard and circular ring pessary. The vaginal walls were inflamed with multiple ulcerative lesions; on attempting to remove the pessary these lesions bled and the pessary could not be dislodged. On enquiry, the patient recollected that a vaginal ring pessary had been inserted 30 years ago in her village for the reduction of prolapse after her last childbirth. Thereafter she had not followed up.

Routine blood and urine investigations were normal. Papanicolaou smear showed cervical intraepithelial neoplasia (CIN 2). Transperineal ultrasonography and pelvic radiography revealed a ring shaped foreign body of approximately 4 to 5 cm diameter with evidence of calcifications over it. We performed removal of pessary and cervical biopsy with cryocauterization under general anaesthesia. Removal of the pessary was difficult. Multiple Allis’ forceps had to be used for its extraction. There was no active bleeding from the site where pessary was embedded and no obvious vaginal lesions were seen. The vagina was irrigated with povidone iodine and the patient was given a course of tablet co-Amoxiclav 625 mg twice a day for seven days. 

Fig 1: Forgotten pessary during removal

Fig 2: Forgotten pessary after removal

The ring pessary was sent for culture and sensitivity which showed no growth of organisms including actinomycetes. Histopathology report of cervical biopsy specimen revealed no malignancy.

Discussion

Vaginal pessaries are devices of made of rubber, silicon, clear plastic, or soft plastic with internal mouldable steel reinforcement that serve to reposition and support prolapsed genitourinary organs. Removal of the foreign body can be difficult and traumatic if impacted in the vagina, as it is associated with erosion and formation of granulation tissue. Impacted pessaries can be removed only under anaesthesia; vaginal trauma and bleeding are immediate problems if the removal is forceful. Irrigation with an antiseptic solution and packing with a pad after removal are recommended. Forgotten or neglected vaginal pessary can present with postmenopausal bleeding and VVF^[6]. Other differentials like carcinoma of the cervix and vagina should also be kept in mind.

Our unusual case draws attention to the fact that foul smelling vaginal discharge of prolonged duration in elderly women should arouse suspicion of a forgotten ring pessary, especially with a past history of prolapse. These women remain unaware of the presence of the foreign body in the vagina or have forgotten about its insertion, hence do not usually seek medical attention. When the pessary is fitted, the cognitive ability of the patient should be assessed, and if she has dementia or has a caregiver, it is essential that the caregiver is made aware of the pessary placement and follow up requirements. Patient education and careful follow-up are of paramount importance in prevention of such problems.

Similar case of a Gelhorn pessary neglected for 3 years leading to a large VVF was reported in an 89 years old woman by Arias; it had to be extracted under anaesthesia using Schuchardt incision to increase exposure.^[4] Hanavati presented a case of rectovaginal fistula developing secondary to a forgotten vaginal pessary. ^[7]

To conclude, pessaries are safe and play an important role in managing pelvic organ prolapse in selected patients. With regular follow up, the majority of pessary complications can be avoided.

References

1.      Baber MD, Walters MD, Cundiff GW, PESSRI Trial group. Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery and pessary treatment for pelvic organ prolapsed. Am J Obstet Gynecol 2006; 194:1492-1498.

2.      Sulak PJ, Kuehl TJ, Shull BL. Vaginal pessaries and their use in pelvic relaxation.  J Reprod Med 1993; 38:919-923.

3.      Schraub S, Sun XS, Maingon P, Horiot JC et al. Cervical and vaginal cancer associated with pessary use. Cancer 1992;69:2505-9.

4.      Arias BA, Ridgeway B & Barber MD. Complications of neglected vaginal pessaries. International Urogynaecology Journal 2008; 19:1173-78.

5.      Sticker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatric Child Health 2004; 40:205-7.

6.      Biswas A, Das HS. An unusual foreign body in the vagina producing vesicovaginal fistula. J Indian Med Assoc 2002;100:257-59. 

7.  Hanavati, Derham Hall, Oke, Aston. Forgotten vaginal pessary eroding into the rectum. Annals Royal College Surgeons of England 2004; 86:18 -19.

Citation

Khadkikar R, Panchbudhe S, Channawar S, Chauhan AR. Forgotten Vaginal Ring Pessary JPGO 2014 Volume 1 Number 1 Available from: http://jpgyob.blogspot.in/2014/01/forgotten-vaginal-ring-pessary.html