An Entrapped Shelf Pessary

Abstract

Although corrective surgery is the definitive treatment for uterine-vaginal prolapse, vaginal pessaries are often used as a non-invasive alternative in the elderly, in women who are at high risk for medical complications with surgery and in women who wish to avoid surgery. Complications can occur with use of these pessaries but are usually rare. We present a case of an impacted shelf pessary, which required a midline episiotomy and incision of the band of vaginal tissue under general anaesthesia for its removal.A 92-year-old woman attended the Gynaecology outpatient clinic with complaints of blood stained discharge per vaginum for last two-three weeks. She had a size 10 shelf pessary inserted about nine months ago for utero-vaginal prolapse and had not attended for her follow-up appointment at six months. She was partially deaf and suffered from dementia and peripheral vascular disease. Her carer, who had first noticed the discharge, was accompanying her. On examination, the introitus barely admitted two fingers and the prolapse appeared to be well supported with the pessary. The vaginal tissues were extremely atrophic and bled to touch. A transabdominal ultrasound was performed which showed a thin endometrium measuring 3mm. This ruled out any endometrial cause of postmenopausal bleeding and was reassuring for the patient. Estrogen cream was applied locally and removal of the shelf pessary was attempted in the clinic. However the procedure was extremely painful for her and the pessary could not be removed. In order to prevent complications from the retained pessary, she was booked for its removal under anaesthesia.