Draft 1 Pessary case scenarios

Bruyere FHT

Click on an exam room to begin

Exam Room 3

Pessary Removal

Pessary Insertion

Exam Room 2

Exam Room 1

You order a CXR of the child.

Does the child have a diaphragmatic hernia?

A 70 year old woman comes to your clinic for a follow-up appointment for her routine pessary care. What complications must you ask about when managing this patient? (Click on the bubbles to check what each question is asking about. Use the back arrow to return to the main slide.)

Unfortunately, 5 minutes later he is still cyanotic and in distress. He then becomes bradycardic. What treatment should you now administer?

Mrs. Smith is a 65 year old post menopausal woman, presenting with new onset pelvic pressure. What pertinent questions on history are indicative of pelvic organ prolapse? (Click the bubbles to check your answers. Use the back arrow to return to the main slide.)

A normal gestation neonate is born via uncomplicated vaginal delivery. At one minute old he is cyanotic and in respiratory distress.

What is your immediate treatment?

This would have no effect as the baby was born at term and is producing it’s own endogenous surfactant.

Bleeding may be indicative of the presence of abrasions or erosions. If this is confirmed on the physical exam, DO NOT re-insert the pessary.

Treat the patient with vaginal hormone or moisturizer and reassess in 4-6 weeks. Re-insert pessary when healed.

Note:

o Non-healing vaginal erosions should be biopsied.

o Recurring erosions is an indication for re-fitting.

Strong risk factors for pelvic organ prolapse include: vaginal delivery, older age, high BMI, previous surgery for prolapse, genetic factors (e.g., various connective tissue disorders, white ancestry, etc). A weaker risk factor is increased intra-abdominal pressure. Asking about these may help guide you in your diagnosis and management.

A CXR is not the appropriate immediate treatment for a neonate in respiratory distress.

Extracorporeal membrane oxygenation is still not indicated in this situation. It is only used as a last possible option for infants that are nonresponsive to other therapies.

A properly fitted pessary should not be felt by the patient. If the patient indicates any new discomfort, the fitting and degree of prolapse should be reassessed. New urinary leaking is another sign of poor fit.

Pressure can be felt in the vaginal area. In severe cases, patients can even see and feel the vagina or the cervix bulging from the vaginal opening.

Yes. Surgery is the definitive treatment for a diaphragmatic hernia therefore the child undergoes surgery and does well.

A) Exogenous surfactant

B) ECMO

C) Intubation

D) Bag-mask positive pressure ventilation

Yes, 100% O2 would be an appropriate quick and easy first line treatment for a neonate in respiratory distress.

A) Have you noticed any bleeding?

B) Do you experience a sensation of vaginal pressure?

C) Do you have any symptoms of a UTI?

D) Have you noticed any foul smell or vaginal discharge?

Yes, at this point in time intubation and transfer to the NICU is essential.

Some symptoms of a UTI include: increased frequency, urgency or dysuria. Perform a urine dip if any of these are reported and treat accordingly.

It is important to ask about the loss of urine during physical exercise. As the anterior vagina loses support, the bladder and urethral support is lost, potentially affecting the continence mechanism.

Less commonly seen, urinary retention occurs with severe pelvic organ prolapse (POP), when there is descent of the anterior vagina, which compresses the bladder infrastructure.

A) Ask about risk factors such as vaginal delivery.

B) Do you experience a sensation of vaginal pressure?

C) Do you experience any urinary incontinence or retention?

D) Do you suffer from constipation?

E) All of the above.

A) CXR

B) 100% O2 mask

C) Intubation

D) ECMO

While this may help it is more efficient and expedient to go straight to intubation as 100% O2 administration has not helped the child already.

A) Yes

B) No

C) Can't tell

Intubation can take a bit of time in babies this small therefore this may be needed but would not be the first option.

Incorrect. Note the cyst like structures in the left hemithorax; they are loops of bowel that have herniated through the defect in the diaphragm.

In the presence of any foul smelling discharge, collect a sample using a vaginal swab, and re-insert the pessary. If a vaginal infection is confirmed, treat according to the standard treatment of vaginal infections. The pessary may be left in place during the treatment (expert opinion).

Extracorporeal membrane oxygenation is not a first line treatment for respiratory distress. It is only used as a last possible option for infants that are nonresponsive to other therapies.

Protrusion of the rectum (posterior vaginal wall) into the vagina may result in faecal impaction and constipation.

Incorrect. Note the cyst like structures in the left hemithorax; they are loops of bowel that have herniated through the defect in the diaphragm.

Correct! All of the above options are commonly associated with POP. The following are other questions to keep in mind as you consider other diagnoses.

- Pelvic pain: An uncomfortable sensation during sexual intercourse is mainly associated with advanced-stage pelvic organ prolapse (POP).

-Disordered defecation: A non-specific sign of posterior wall support loss, sometimes requiring digitally assisted defecation.

-Sexual dysfunction: Dyspareunia, lack of satisfaction or orgasm.

-Lower back pain: A rare presenting symptom.

Source: http://bestpractice.bmj.com/best-practice/monograph/659/diagnosis/history-and-examination.html

By the time you confirm the diagnosis it is now 1 am in the morning. What is your next step?

You now take the time to physically examine the baby and note he has a scaphoid abdomen and only has breath sounds in the right lung and heart sounds also seem louder in the right chest.

Given these findings and a normal history what would your most likely differential diagnosis be?

Choose the most accurate description of the finding on the patient's physical examination. (Click the magnifying glass for the image).

The patient reports occasional bleeding and irritation. After removing the pessary, the speculum examination can be seen on the magnifying glass. Choose the correct finding.

This is unadvisable as the appendix may perforate and cause sepsis and death at worst. Additionally, the use of antibacterials with appendicitis is a new treatment and protocols may differ hospital to hospital.

Incorrect!

In grade I POP, the most distal portion of prolapse is more than 1 cm above the level of hymen.

This would be among the differentials however the findings of auscultation would point towards a different diagnosis.

Incorrect.

The red, inflamed appearance of the mucosa is not normal. Try again!

Yes, the correct step is to watch and wait. The next morning you inform the general surgeon of the case. He examines the child and determines an appendectomy is needed soon and schedules it for later that day. The surgery goes well and the child recovers and is home within the week.

Incorrect!

In grade II POP, the most distal portion of the prolapse is situated between 1 cm below or above hymen.

A) Send the child home with antibiotics, to come back if the pain gets worse

B) Watch and wait, admitting patient overnight

C) Page the general surgeon on call for an immediate appendectomy

D) Give the child high dose opiates for the pain

This could be likely as it would interrupt the proper functioning of the diaphragm however it is highly unlikely as other organs innervated by the phrenic nerve seem to be functioning properly.

CORRECT!

This is in fact an erosion.

This is unnecessary as the child is not in urgent danger of perforation and will receive better care in the morning when a surgeon can properly evaluate the case.

A) Respiratory distress syndrome

B) Phrenic nerve dysfunction

C) Pulmonary Hypertension

D) Diaphragmatic Hernia

A. Grade I pelvic organ prolapse

B. Grade II pelvic organ prolapse

C. Grade III pelvic organ prolapse

D. Grade IV pelvic organ prolapse

A) Normal exam

B) Mucosal erosion/abrasion

C) Infection

D) Can't tell

Incorrect!

In grade III POP, the most distal portion of prolapse is more than 1cm beyond the introitus.

This is unlikely as it would have also presented with edema and none of the auscultation findings.

Vaginal infections may be accompanied by increased, or foul smelling discharge as seen below. The history may include things like vaginal pruritus, a new sexual partner and other risk factors. In our patient, the exam demonstrates a mucosal erosion

Yes, a congenital diaphragmatic hernia is the most likely given the symptoms.

This is unnecessary and dangerous as high dose opiates can be addictive. Additionally in children only lower doses titred to the child’s weight should be given for pain.

Correct!

In grade IV POP, -also known as procidentia, - the entire uterus extends outside of the plane of the hymen.

It is useful to go through some images for normal vaginal mucosa in order to understand what abnormal looks like. A normal mucosa looks the following:

What is the appropriate management for your patient?

Incorrect!

The patient did not complain of any lower urinary tract symptoms suggestive of a UTI. Additionally, the pessary does not need to be removed while being treated for any underlying infection.

While this is necessary and should be done, this is not the most pressing investigation that should be conducted.

While this is necessary and should be done to evaluate inflammation status, this is not the most pressing investigation that should be conducted.

CORRECT!

This patient has an erosion. In the presence of abrasions or erosions, DO NOT re-insert the pessary. Treat the patient with vaginal hormone or moisturizer and reassess in 4-6 weeks. Re-insert pessary when healed.

Note:

• Non-healing vaginal erosions should be biopsied.
• Recurring erosions is an indication for re-fitting.

A) urinalysis

B) CRP assay

C) Ultrasound

D) AXR

Yes, ultrasound is combined the most sensitive and specific test for clarifying the diagnosis.

Yes, the non-compressible inflamed appendix shown with the arrow heads lies next to the well-compressible ileum. The appendix is dilated to more than 7 mm.

A) Do no re-insert the pessary until any infection (urinary tract or vaginal) clears.

B) Do no re-insert the pessary until a follow-up exam demonstrates a healed vaginal mucosa.

C) Perform a pap smear, then re-insert the pessary.

D) Just re-insert the pessary.

E) None of the above.

Unless you're lucky enough to see a calcified fecalith in the appendix you cannot tell much about the appendix on a plain AXR

Incorrect!

A pap smear may be performed if the patient is due for one, but the examination does not suggest a cervical malignancy as the lesion is on the vaginal wall. A biopsy would be indicated if the lesion persists on repeat examination despite a break from the use of the pessary.

Incorrect!

In the presence of abrasions or erosions, DO NOT re-insert the pessary.

• Children with atypical findings of appendicitis warrant diagnostic imaging
• In children with typical findings and at high risk for appendicitis, you should consult a pediatric surgeon prior to obtaining urgent imaging studies

Keep in mind the three rules of testing:

1. Do not order a test unless the results of that test will truly change your management.

2. Do not order a test if you do not know the tests inherent accuracies in the context of your patient otherwise you will not know what the test result actually means for your patient.

3. Consider the risk of the test and whether the risk of testing is appropriate in the context of your patients present and future health.

Incorrect! Try again.

Your patient returns a month later and the mucosal now looks as follows (click on the magnifying glass). What do you do now?

Incorrect!

You do not have to wait after observing a healed mucosa.

Incorrect!

There are no signs of infection based on the image alone.

A) Do no re-insert the pessary for another 4-6 weeks.

B) Treat the patient with antibiotics and re-insert the pessary.

C) Take a biopsy, then re-insert the pessary.

D) Re-insert pessary and tell the patient to resume

its use.

Incorrect!

This patient's an erosion has healed. If the erosion did not show any signs of healing despite stopping pessary use, such lesions should be biopsied.

CORRECT!

After treatment with vaginal hormone or moisturizer, the patient clearly demonstrates a healed mucosa.

Pessary Types

Insertion Instructions

Removal Instructions

Insertion Instructions

For a ring pessary, fold the pessary in half so that the concavity of the arc formed points downwards. Apply lubricant only to the tip of pessary. While opening the vulva with your non-dominant hand, slide the pessary gently while keeping the pessary folded with your non-dominant hand as your dominant hand guides the pessary through the introitus. Insert the pessary, directing the tip towards the posterior fornix, past the cervix and allow the pessary to unfold into its ring shape once it passes the introitus. With thumb and index finger, give the pessary a quarter turn so that the folded hinge lies transversely so that the pessary cannot be expelled. A properly inserted pessary lies posterior to the cervix and behind the symphysis pubis.

Removal Instructions

For removal, turn the pessary until the notch can be found, and remove the pessary by hooking your index finger behind the ring, moving the pessary with a twist and asking patient to perform Valsalva manoeuvre.