Hodge Pessary Uses and Complications

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Questions and Answers

What is the normal position of the uterus?

Retroverted and retroflexed

Anteverted and retroflexed

Retroverted and anteflexed

Anteverted and anteflexed (correct)

What is the angle between the longitudinal axis of the cervix and that of the vagina?

Inversion

Flexion

Eversion

Version (correct)

What is the definition of genital prolapse?

Displacement of pelvic organs from their normal anatomical position (correct)

Malfunction of pelvic organs in their normal anatomical position

Displacement of pelvic organs to their normal anatomical position

Malfunction of pelvic organs from their normal anatomical position

What is the name of the prolapse that occurs when the upper part of the anterior vaginal wall with the base of the bladder descends?

Cystocele Signup and view all the answers

What is the name of the ligament complex that provides Level I support to the uterus?

Cardinal uterosacral ligament complex Signup and view all the answers

What is the term for the angle between the longitudinal axis of the uterus and that of the cervix?

Flexion Signup and view all the answers

What is the name of the prolapse that occurs when the lower part of the anterior vaginal wall with the urethra descends?

Urethrocele Signup and view all the answers

What is the term for the descent of one or more of the genital organs through the fasciomuscular pelvic floor below their normal level?

Genital Prolapse Signup and view all the answers

What is the purpose of keeping the pessary in hot water for a few minutes before insertion?

To make it softer and easier to insert Signup and view all the answers

What is a common complication of using a pessary?

Vaginal wall ulceration Signup and view all the answers

What is the most common surgical operation for uterine prolapse?

Vaginal Hysterectomy Signup and view all the answers

Which of the following is an indication for Vaginal Hysterectomy?

Post-menopausal prolapse Signup and view all the answers

What is the purpose of Manchester Repair (Fothergill's Operation)?

To repair the uterovaginal prolapse Signup and view all the answers

What is the benefit of using hygroscopic agents like acriflavin-glycerine in the treatment of decubitus ulcer?

To reduce congestion Signup and view all the answers

What is the purpose of repositing the prolapse in the vagina with the help of tampons and pessary?

To promote healing of the decubitus ulcer Signup and view all the answers

What is the type of surgical treatment for pelvic organ prolapse that involves the use of mesh?

Vaginal mesh surgery Signup and view all the answers

What is the primary sensation felt by a patient before the actual prolapse?

A sensation of weakness in the perineum Signup and view all the answers

Which of the following is a common urinary symptom in patients with prolapse?

Stress incontinence Signup and view all the answers

What is a common rectal symptom in patients with prolapse?

Constant desire to defecate Signup and view all the answers

What is a possible cause of leucorrhoea in patients with prolapse?

Chronic cervicitis Signup and view all the answers

What is the primary purpose of Bonny's stress test in the evaluation of prolapse?

To demonstrate stress incontinence Signup and view all the answers

Which of the following is a differential diagnosis for prolapse?

Cystic swelling in the vagina Signup and view all the answers

What is the first step in the diagnostic approach to prolapse?

Careful inspection of the vulva and vagina Signup and view all the answers

What is a possible complication of prolapse?

Decubitus ulcer Signup and view all the answers

What is the term for the complete anterior vaginal wall prolapse?

Cysto-urethrocele Signup and view all the answers

What is the term for the herniation of the pouch of Douglas?

Enterocele Signup and view all the answers

What is the degree of uterine descent where the cervix protrudes from the vulva on straining?

2nd degree Signup and view all the answers

What is the term for the descent of the vaginal vault after hysterectomy?

Vault prolapse Signup and view all the answers

What is the aetiological factor that contributes to prolapse due to increased stress on muscles, nerves, and connective tissue?

Erect posture Signup and view all the answers

What is the precipitating factor that can cause prolapse due to traction of the uterus?

Cervical polyp Signup and view all the answers

What is the mechanism by which pelvic floor disorders become symptomatic?

Two mechanisms Signup and view all the answers

What is the term for the complete prolapse of the uterus outside the vulva, with the vaginal wall becoming completely inverted over it?

Procidentia Signup and view all the answers

What is the recommended position of the patient for examination in cases of uterovaginal prolapse?

Dorsal lithotomy Signup and view all the answers

Which of the following is NOT a prevention method for uterovaginal prolapse during labour and puerperium?

Expressing the uterus when attempting to deliver placenta Signup and view all the answers

What is the primary goal of Vault suspension with uterosacral and cardinal ligaments during hysterectomy?

To avoid uterovaginal prolapse Signup and view all the answers

Which of the following is a hormone treatment option for uterovaginal prolapse?

Estrogen-releasing vaginal ring Signup and view all the answers

When is a pessary contraindicated in the management of uterovaginal prolapse?

When the patient is not a candidate for surgical intervention Signup and view all the answers

What is the primary function of a pessary in the management of uterovaginal prolapse?

To hold the genital tract in position Signup and view all the answers

What is the recommended frequency and duration of pelvic floor exercises for patients with uterovaginal prolapse?

3 times a day for 20 minutes each Signup and view all the answers

What is the benefit of encouraging pelvic floor exercise in patients with uterovaginal prolapse?

It helps to reduce bearing down Signup and view all the answers

Study Notes

Hodge Pessary and Ring Pessary

Size of the pessary depends on the size of the vagina
Sterilization and insertion of the pessary involves soaking it in hot water for a few minutes to make it soft and easy to insert
Follow-up is necessary, with the pessary being removed, cleaned, and reinserted at regular intervals of 6-12 months

Complications of Pessary

Constipation
Urinary incontinence
Bacterial vaginitis, ulceration of the vaginal wall
Cervicitis
Carcinoma of the vaginal wall
Impaction of the pessary
Strangulation of prolapsed tissue

Surgery

Vaginal Hysterectomy: most common operation, indicated for:
- Post-menopausal prolapse
- Uterine pathology like small fibroids or adenomyosis
- Menstrual disorders like dysfunctional uterine bleeding
- Prolapse during childbearing age, after completion of family
Burch Operation: for relief of symptoms of cystocele

Colporrhaphy

Anterior Colporrhaphy: for anterior vaginal wall prolapse
Posterior Colporrhaphy: for repair of the posterior vaginal wall and perineum
Manchester Repair (Fothergill's Operation): for repair of uterovaginal prolapse, carried out in women of childbearing age who have not completed their families and insist on preservation of the uterus

Utero-Vaginal Prolapse

Definition: displacement of pelvic organs from their normal anatomical position leading to their dysfunction
The uterus is normally anteverted, anteflexed
Version: the angle between the longitudinal axis of the cervix and that of the vagina
Flexion: the angle between the longitudinal axis of the uterus and that of the cervix

Types of Prolapse

Genital prolapse: descent of one or more of the genital organs (urethra, bladder, uterus, rectum, or Pouch of Douglas) through the fasciomuscular pelvic floor below their normal level
Vaginal prolapse: can occur without uterine prolapse, but the uterus cannot descend without carrying the vagina with it

Three Levels of Supports of the Uterus

Level I: The cardinal uterosacral ligament complex
Level II: The pubo-cervical and recto-vaginal fascia
Level III: The pubo-urethral ligaments anteriorly and the perineal body posteriorly

Anterior Vaginal Wall Prolapse

Prolapse of the upper part of the anterior vaginal wall with the base of the bladder is called cystocele
Prolapse of the lower part of the anterior vaginal wall with the urethra is called urethrocele
Complete anterior vaginal wall prolapse is called cysto-urethrocele

Middle Compartment Defect

Enterocele (Herniation of POD)
Eversion of the vagina

Posterior Compartment Defect

Enterocele
Rectocele
Perineal body descent

Uterine Descent

Utero-vaginal (the uterus descends first, followed by the vagina): usually occurs in cases of virgin and nulliparous prolapse due to congenital weakness of the cervical ligaments
Vagino-uterine (the vagina descends first, followed by the uterus): usually occurs in cases of prolapse resulting from obstetric trauma

Degree of Uterine Descent

1st degree: The cervix descends below its normal level on straining but does not protrude from the vulva
2nd degree: The cervix reaches up to the vulva on straining
3rd degree: The cervix protrudes from the vulva on straining
Procidentia: whole of the uterus is prolapsed outside the vulva, and the vaginal wall becomes most completely inverted over it

Vault Prolapse

Descent of the vaginal vault, where the top of the vagina descends (or inversion of the vagina) after hysterectomy

Aetiology

Erect posture causes increased stress on muscles, nerves, and connective tissue
Acute and chronic trauma of vaginal delivery
Aging
Estrogen deprivation
Intrinsic collagen abnormalities
Debilitation
Iatrogenic

Precipitating Factors

Increased intra-abdominal pressure
Increased weight of the uterus
Traction of the uterus by vaginal prolapse or by a large cervical polyp
Obesity
Smoking
Pulmonary disease (chronic coughing)
Constipation (chronic straining)
Recreational or occupational activities (frequent or heavy lifting)

Symptoms of Prolapse

Pelvic floor disorders become symptomatic through either of two mechanisms:
1. Mechanical difficulties produced by the actual prolapse
2. Bladder or bowel dysfunction, disrupting either storage or emptying
Clinical presentation:
- Before actual prolapse, the patient feels a sensation of weakness in the perineum, particularly towards the end of the day
- Later, the patient notices a mass that appears on straining and disappears when she lies down
- Urinary symptoms are common and troublesome, even with slight prolapse

Diagnostic Approach

Beginning with a careful inspection of the vulva and vagina to identify erosions, ulcerations, or other lesions
The extent of prolapse should be systematically assessed
Suspicious lesions should be biopsied

Examination

Local examination
Per speculum examination
Per vaginal/Bimanual examination
Bonny's stress test (reduction of prolapse)
Per rectal examination
Evaluation of tone of pelvic muscles by recto-vaginal examination
Position of the patient for examination:
- Standing and straining
- Dorsal lithotomy

Investigations

GUE
X-Ray
Ultrasound (abdominal)
MRI

Prevention

During labor and puerperium:
- Avoid premature bearing down
- Avoid long second stage
- Repairs all tears and incisions accurately in layers
- Use delayed absorbable suture
- Do not express the uterus when attempting to deliver the placenta
- Encourage pelvic floor exercises
- Avoid puerperal constipation-decreases bearing down
At hysterectomy:
- Vault suspension with uterosacral and cardinal ligaments
- Obliteration of deep cul-de-sac by Moschowitz sutures
- Sacropexy in high-risk situations like collagen disorders
- Increase acceptability of estrogen replacement therapy

Treatment

Lifestyle changes:
- Losing weight if you're overweight
- Eating a high-fiber diet to avoid constipation
- Avoiding lifting heavy objects
Pelvic floor exercises:
- Kegel exercises are used to tone up pelvic musculature
- These exercises are done 3 times a day for 20 min each
Hormone treatment:
- Estrogen is available as:
  - A cream you apply to your vagina
  - A tablet you insert into your vagina
  - An estrogen-releasing vaginal ring

Pessary

Indications:
- During pregnancy
- Immediately after pregnancy, during lactation
- When future childbearing is intended in the near future
- Refusal to operation by patient
- To promote healing in a decubital ulcer
A mechanical device for correcting and controlling UV prolapse
A pessary does not cure UV prolapse; it only holds the genital tract in position
Advised for patients who cannot undergo surgery

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Description

This quiz covers the uses and complications of Hodge pessary, a type of ring pessary used for vaginal support. Learn about its size, sterilization, insertion, and follow-up care, as well as potential complications such as constipation, urinary incontinence, and carcinoma.