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Pessaries inserted for uterine prolapse are easily forgotten in the old, and can be hazardous.
A woman of 88 was admitted after a fall at home. Her medical history included chronic atrial fibrillation, cerebrovascular disease, osteoarthritis, and utero-vaginal prolapse. She reported a three-month history of constipation interrupted by bouts of diarrhoea, weight loss, lethargy and a decline in mobility. On examination she was frail, malnourished and dehydrated. There were hard faeces in the rectum. Respiratory and abdominal examinations were normal. Plasma urea was 13.37 mmol/L, albumin 27 g/L. Abdominal X-ray revealed faecal loading throughout the colon.
The patient was rehydrated and her constipation was treated with faecal softeners and enemas. It was then noticed that she was passing faeces per vaginam. On enquiry she said this had happened on several previous occasions. A hard rubbery object was now felt in the rectum, and a soluble-contrast enema established the presence of a rectovaginal fistula. On colonoscopy a vaginal pessary was identified eroding through the upper rectum; impacted faeces were evacuated and multiple biopsies were taken (no evidence of malignancy). A pelvic examination was performed simultaneously and a shelf pessary was removed. The cervix was normal, the uterus was small and mobile, and no adnexal masses were palpated. Closure of the fistula was attempted per rectum but this subsequently failed. Pneumonia and upper gastrointestinal bleeding complicated her postoperative recovery and she died two months later.
Vaginal pessaries are devices of varying composition (rubber, clear plastic, silicone, or soft plastic with internal mouldable steel reinforcement) that serve to reposition and support prolapsed genitourinary organs1. Various shapes and sizes are available to provide comfortable anatomical support. In the UK, ring and shelf pessaries are commonly used.
Although surgery is the definitive treatment for severe uterine prolapse, pessaries can give satisfactory results in women who wish or need to avoid surgery2. Complications are usually due to inadequate hygiene—e.g. leucorrhoea, cellulitis, abscess formation. Others are incarceration, ulceration and metaplasia3, intestinal obstruction4,5, urosepsis and hydronephrosis6,7,8. Russell9 reported seeing 14 patients with complications over a 4-year period: one woman had a rectovaginal fistula, the pessary having been in place for 18 years; the others had vaginal cancer (7) or chronic vaginitis (6).
In retrospect, questioning our patient about pessary use at the time of admission could have resulted in more prompt diagnosis. However, most internal physicians have little experience with these devices; furthermore, pelvic examination tends to be omitted in elderly patients unless specifically indicated. When an elderly woman is fitted with a pessary, long-term follow-up is desirable—especially if she has dementia2,3.