Pessary Research Articles

UNILATERAL HYDRONEPHROSIS, PYELONEPHRITIS, AND BACTEREMIA CAUSED BY A NEGLECTED VAGINAL RING PESSARY

To the Editor: Vaginal ring pessaries are frequently used as long-term treatment for pelvic relaxation in older women, especially those deemed to be poor surgical candidates. These pessaries require monthly monitoring and toilet to prevent local erosive complications.1 One previous case of bilateral ureteral obstruction and urosepsis secondary to a ring pessary has been reported.2 We report a case of pyelonephritis, Gram-negative bacteremia, and unilateral hydronephrosis in a woman with known renal calculi in whom the pessary was initially overlooked as the source of the ureteral obstruction. An 85-year-old female nursing home resident was admitted to the hospital from the Emergency Department with a 1-day history of lower abdominal pain, vomiting, headache, confusion, and visual hallucinations. The patient's past medical history was remarkable for bilateral staghorn calculi and recurrent urinary tract infections. She had previously been treated with prophylactic TMP-SMZ which was stopped because of urinary colonization with resistant organisms. She was gravida V, para 5, and had a flexible Gellhorn vaginal pessary placed at an unknown date because of pelvic relaxation associated with a large cystocoele and rectocoele. Initial vital signs included a core temperature of 39° C, pulse of 111 bpm, and a blood pressure of 167/112 mm Hg. Her examination was remarkable only for mild diffuse abdominal tenderness with an in-situ ring pessary upon pelvic examination. Initial laboratory data showed a white cell count of 17,600 with 83% neutrophils and 10% bands, creatinine was 1.6 mg/dL (baseline), and urinalysis was consistent with infection. The patient was treated medically for pyelonephritis with intravenous ampicillin and gentamicin; urine and blood cultures were subsequently positive for pan-susceptible Proteus mirahilis. She showed little improvement, and on hospital day 2, the white cell count increased to 22,000. Her fever persisted, and the creatinine rose to 2.5 mg/dL on hospital day 4. A renal ultrasound showed marked left hydronephrosis with at least one large calculus in the left renal pelvis (Figure 1). She underwent cystoscopy and retrograde pyelography, which revealed a moderately inflamed bladder, distorted trigone, and marked dilation of the left upper collecting system and ureter extending to the level of the ureterovesical junction without an obvious obstructing calculus (Figure 2). Ureterodilation and placement of a no. 6 French double-J ureteral stent was accomplished successfully. The vaginal pessary was identified as the cause of the ureterovesical junction obstruction. Once this was removed, the patient defervesced within 24 hours, and her white cell count and creatinine quickly became normal. . Renal ultrasound shows marked hydronephrosis of the left kidney (18 cm, with at least one calculus in the area of the renal pelvis. The right kidney was of normal dimensions (9.9 cm). . Retrograde pyelography at cystoscopy showed opacification of a significantly dilated left ureter and left upper collection system. No stone is identified. Uterine prolapse is a common condition in older women. Obstructive uropathy has been reported as a complication, preventable with the use of a vaginal ring pessary in patients who are not candidates for surgical correction. The vaginal ring pessary should not be overlooked, however, as a potential cause of unilateral ureteral obstruction, even in patients with known renal calculi. The appropriate management of pyelonephritis in older women with an in-situ vaginal pessary may require pessary removal in addition to antibiotics, especially if hydronephrosis is identified.

A phase I study of femcap ® used with and without spermicide : Postcoital testing

The objectives of the study were to assess the ability of the Femcap ®, a new vaginal contraceptive device made of silicone and designed to fit snugly around the cervix to prevent the penetration of sperm into midcycle cervical mucus when used with and without spermicide; and to compare it with the standard contraceptive diaphragm used with spermicide. Eight women underwent two baseline cycles of postcoital testing in which no device was used, followed by three test cycles in which Femcan with spermicide, Femcap with nonspermicidal lubricant (KY ® gel) or the Ortho All-Flex ® diaphragm with spermicide was used. The sequence of testing cycles was randomized. In each cycle, condoms were used prior to midcycle, then a midcycle cervical mucus specimen was examined to ensure midcycle characteristics and the absence of sperm. Each woman then had intercourse using either no device (baseline cycles) or the prescribed device (test cycles) and returned 2–3 h afterwards. Cervical mucus was again assessed for adequacy and the presence of spermatozoa. The average number of progressively motile sperm seen per high power field was as follows: first baseline cycle, 18.0; second baseline cycle, 17.8; test cycle with Femcap used with nonspermicidal lubricant, 0.1; test cycle with Femcap used with spermicide, 0.2; and test cycle with the diaphragm used with spermicide, 0.0. There was no significant difference between baseline cycles or among test cycles in the average number of progressively motile sperm seen (p > 0.05). the average number of progressively motile sperm seen in each test cycle did, however, differ significantly from the average number seen in either baseline cycle (p < 0.05). Femcap, used with either a spermicidal lubricant or a nonspermicidal lubricant, appears to be comparable with the diaphragm used with spermicide in preventing sperm from entering midcycle cervical mucus.

Lea's Shield ®: A phase I postcoital study of a new contraceptive barrier device

Lea's Shield ® is a new vaginal barrier contraceptive that may offer advantages over existing methods. It is made of silicone which is resistant to petroleum-based lubricants, does not absorb odors, and does not cause allergic reactions in users with latex sensitivity. It has an anterior loop for ease of insertion and removal and a one-way flutter valve. Its novel design has sufficient volume to fill the posterior fornix, which helps keep it in place and prevent sperm from entering the cervical os. This study evaluated with a standard postcoital test (PCT) the ability of the Lea's Shield ® used with spermicide or non-spermicidal lubricant to prevent sperm from entering midcycle cervical mucus. Ten sterilized women underwent four PCT cycles: one cycle in which no contraceptive barrier was used (a baseline cycle) and 3 cycles in which one of the following was used: Lea's Shield ® with spermicide, or with non-spermicidal lubricant, or the contraceptive diaphragm used with spermicide. All volunteers demonstrated more than 5 progressively motile sperm per high power field in the cervical mucus after intercourse in the baseline cycle. No motile sperm were found in the cervical mucus in any cycle in which Lea's Shield ® or the diaphragm was used with spermicide. No motile sperm were found in cervical mucus in 9 of 10 cycles in which Lea's Shield ® was used without spermicide. Only two progressively motile sperm were present in the cervical mucus of one volunteer who used the shield with non-spermicidal lubricant. This volunteer used a smaller Lea's Shield ® which is no longer manufactured. There were no serious adverse experiences in any volunteer. This study suggests that the Lea's Shield ® can prevent the passage of motile sperm into midcycle cervical mucus with or without the use of spermicide and is as effective as the standard diaphragm used with spermicide.

A comparative multicenter study of the effects of continuous lowdose estradiol released from a new vaginal ring versus estriol vaginal pessaries in postmenopausal women with symptoms and signs of urogenitalatrophy

A comparative multicenter study of the effects of continuous lowdose estradiol released from a new vaginal ring versus estriol vaginal pessaries in postmenopausal women with symptoms and signs of urogenitalatrophy

Severe edema of the uterine cervix — an unusual cause of acute urinary retention in pregnancy

A very unusual case of a healthy pregnant patient who developed recurrent acute urinary retention is described. A 34-year-old multiparous woman was admitted to the hospital in the 17th week of gestation with acute urinary retention and complete obstruction of the urethra. The reason for this was an enormous enlargement of the uterine cervix — possibly an acute allergic reaction to a new kind of a body lotion. She was treated with catheterization during the acute episode, and prolonged use of a vaginal ring pessary. She was admitted again several times at later stages in the pregnancy, with the same complaint. The possible reasons for such repeated episodes of retention and the need for prompt diagnosis and treatment are discussed.

Severe genital prolapse and its relationship to detrusor instability

Twelve women with severe genital prolapse through the vaginal introitus were evaluated urodynamically with and without a properly fitted vaginal ring pessary in order to evaluate the relationship between severe genital prolapse and detrusor instability in women. Provocative retrograde medium-fill urethrocystometry confirmed detrusor instability in all patients. Seven women showed resolution of uninhibited detrusor contractions during provocative maneuvers after pessary placement. Nine women underwent vaginal hysterectomy and vaginal repair operation; a bladder neck suspension was performed if indicated. Five women returned postoperatively for urodynamic evaluation. Three of 4 women who responded to pessary placement with resolution of uninhibited detrusor contractions had a stable bladder and no uregency symptoms postoperatively. One patient who did not respond to pessary placement continued to have symptomatic motor urge incontinence after a vaginal repair procedure. The data suggest that genital prolapse may provoke uninhibited bladder contraction by increasing urethral resistance, and that vaginal pessary placement may be useful in predicting which patient with genital prolapse and uninhibited detrusor contractions during cystometry will have a stable bladder after vaginal repair operation.

Growth Inhibition of Trichomonas vaginalis by Gossypol

Vaginitis, produced by Trichomonas vaginalis, is a public health problem. The disease presents a high refractory frequency to current medications, such as metronidazole. We report here an in-vitro inhibitory effect of gossypol upon this parasitic species. Gossypol, formulated as a pessary, is an effective spermicide. Its potency (IC50 = 50 μM) is similar to that currently reported for against Trichomonas (IC50 = 43·27 ± 0·06 μM). Thus, gossypol pessary formulation could act with a dual pharmacological effect—as a spermaticide and as a medication for vaginitis.

A comparative multicenter study of the effects of continuous low-dose estradiol released from a new vaginal ring versus estriol vaginal pessaries in postmenopausal women with symptoms and signs of urogenital atrophy

Our purpose was to study the efficacy, safety, and acceptability of a new estradiol-releasing (6.5 to 9.5 micrograms per 24 hours) silicone rubber vaginal ring compared with Ovesterin 0.5 mg estriol vaginal pessaries. Gynecologic clinical status, vaginal pH, cytologic characteristics, and occurrence of bacteriuria were determined before starting and after 3 and 12 weeks of treatment in 146 postmenopausal women. Both treatments alleviated the subjective and objective symptoms of estrogen deficiency excellently, and both were equally effective at restoring the vaginal pH to levels normally seen in fertile women (< 5.5). Vaginal cytologic studies showed a significant difference in maturation value in favor of the estradiol-releasing silicone rubber vaginal ring, as measured by the pathologist's assessment of the proliferation of the vaginal mucosa. A total of 77% of users were classified as responders, compared with 39% in the pessary group. Both treatments were well accepted. The administration of the pessary was associated with a significantly higher (p < 0.001) incidence of discomfort than that of the ring, which was given better (p < 0.001) rating by the patients at the 12-week visit. A strong preference (p < 0.001) for the ring was shown by patients with previous experience with pessaries. Treatment of urogenital symptoms in postmenopausal women with an estradiol-releasing vaginal ring is shown to be an effective and safe method, exhibiting advantages over treatment with estriol vaginal pessaries.

Possible Role of the Pessary in the Etiology of Toxic Shock Syndrome

Medical technology often has unforeseen effects on human health. For example, indwelling urethral catheters promote gram-negative endotoxin shock, and improved absorbency in tampons triggered an epidemic of toxic shock syndrome. The pessary is an ancient gynecologic device used to support or position a displaced or prolapsed uterus. As an invasive device, similar to a vaginal tampon or contraceptive diaphragm, the pessary may have increased a woman's risk of vaginal infections, possibly including toxic shock syndrome, especially during the 19th century when prolapsus uteri was a common diagnosis among young women. Evidence for the involvement of the pessary in the syndrome is drawn from early medical texts that attribute toxic-shock-type symptoms, specifically high or fatal fevers, to absorbent pessaries. Further evidence comes from the culture of Staphylococcus aureus from nonabsorbent pessaries.

Perforation and Fistulization from a Vaginal Ring Pessary

An extremely rare complication of a ring pessary, erosion through the vaginal mucosa, causing two rectovaginal fistulae is presented. Management of removal of the pessary and subsequent repair of the fistulae and the procedentia are described. (J GYNECOL SURG 10:93,1994)

The pathological effects of glove and condom dusting powders.

Dusting powders are used on latex gloves and condoms. They help to release these products from their moulds during manufacture and facilitate processing and donning. Dusting powders are also used on contraceptive diaphragms, sanitary napkins and in toiletries. There are numerous dusting powders in current use around the world. At present a consensus exists about the best dusting powder to use on surgical gloves, based on data about the safety of these agents in humans, as well as their manufacturing qualities. No such consensus exists for the use of dusting powders in other situations. However, there is uncertainty about whether dusting powders used in situations other than on surgical gloves are responsible for harmful effects. This study uses intraperitoneal injections in rats to examine the pathological effects of dusting powders that are in current use on surgical gloves and condoms. We suggest that dusting powders may be a source of morbidity when used in situations other than on surgical gloves and confirm the findings of previous investigators that the dusting powders we tested differ in their ability to produce pathological effects.

Use of standard contraceptivediaphragm in management of stress urinary incontinence

<h2>Abstract</h2> The management of stress urinary incontinence (SUI) consists of either surgical interventionand/or pharmacologic manipulation. Twelve patients with SUI were evaluated for management by the use of a fitted standard contraceptive diaphragm. Complete resolution of SUI was achieved in 11 of 12 patients (91 &). Two of the 12 patients achieved continence but withdrew from the study because of associated discomfort from the diaphragm, therefore, complete resolution of SUI was achieved in 9 of 12 patients (75 &).

241 Preinduction cervical ripening with controlled-release PGE 2 pessary

241 Preinduction cervical ripening with controlled-release PGE 2 pessary

The Gynaeseal diaphragm tampon

Medical Journal of AustraliaVolume 152, Issue 1 p. 52-53 Letter to the Editor The Gynaeseal diaphragm tampon John F. Cattanach DObstRCOG, John F. Cattanach DObstRCOG 68 Manningtree Road, Hawthorn, VIC, 3122Search for more papers by this author John F. Cattanach DObstRCOG, John F. Cattanach DObstRCOG 68 Manningtree Road, Hawthorn, VIC, 3122Search for more papers by this author First published: 01 January 1990 https://doi.org/10.5694/j.1326-5377.1990.tb124442.xCitations: 2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume152, Issue1January 1990Pages 52-53 RelatedInformation

EFFECTS OF TREATMENT WITH OESTRADIOL/LEVONORGESTREL ON BONE, LIPOPROTEINS AND HORMONE STATUS IN POSTMENOPAUSAL WOMEN

The aim of the study was to investigate the effects of an oestradiol/levonorgestrel regimen, administered parenterally, on bone metabolism, bone density, lipoprotein metabolism and hormone status. Twenty-five women who had undergone a surgical menopause had an oestradiol/levonorgestrel-containing vaginal ring pessary in situ for 6 months. Within the first month there were sustained changes in the biochemical indices of bone metabolism in keeping with a marked reduction in bone turnover and decrease in bone resorption. Bone mineral content in the distal forearm was measured in 14 patients and a small increase was noted in every patient. Levonorgestrel was well absorbed and the serum levels remained almost constant throughout treatment. There was a gradual increase in serum total oestradiol which became significant at 6 months. Dialysable oestradiol levels rose from 2.6% of total oestradiol at 0 time to 3.3% at 1 month with no further change thereafter. SHBG levels were 23% of pretreatment levels at 6 months. There were sustained decreases in triglyceride, VLDL and HDL cholesterol levels and a transient fall in LDL cholesterol. Total HDL, HDL2 and HDL3 cholesterol levels were reduced by 25, 40 and 21% respectively. The results suggest that levonorgestrel exerts a protective influence on bone either directly or by its effect on the proportion of oestradiol circulating in the free, physiologically active form. The effects on lipoproteins were predominately those of the progestogen component, the lipoprotein risk factors for coronary heart disease being adversely affected.

The vaginal contraceptive diaphragm and the condom — a reevaluation and comparison of two barrier methods with the rhythm method

The use-effectiveness and continuation rates of two barrier methods of contraception, the diaphragm and condom, were studied during a two-year follow-up in a group of 85 and 98 women, respectively. All were highly motivated. Results were compared to a group of 64 women using the periodic abstinence or rhythm method, i.e. not using any contraceptive. The patients selected the method of contraception they preferred and were instructed in their proper use. Results showed good continuation rates in the groups using a diaphragm and the condom for 2 years, for a total follow-up of 5570 cycles. Pregnancy rate after 24 months of use, as calculated by Pearl's formula, was 2.48 for the diaphragm, 3.21 for the condom, and 5.19 in the rhythm group. No serious side effects or complications occurred in either group. The study demonstrated a fair acceptability and use-effectiveness for barrier contraceptive. We suggest that these harmless and complication-free methods may still be reasonable alternatives for the “modern” methods, the pill and the IUD.

Personal and environmental characteristics related to epithelial ovarian cancer. II. Exposures to talcum powder, tobacco, alcohol, and coffee.

Vaginal exposures to talc and other particulates may play an etiologic role in epithelial ovarian cancer. Surgical sterilization may protect against ovarian cancer by blocking entry of such particulates into the peritoneal cavity. The authors assessed histories of talcum powder use, tubal sterilization, and hysterectomy with ovarian conservation in 188 women in the San Francisco Bay Area with epithelial ovarian cancers diagnosed in 1983-1985 and in 539 control women. To investigate the roles of blood-borne environmental exposures on ovarian cancer risk, they assessed lifetime consumption of coffee, tobacco, and alcohol in these women. Of the 539 controls, 280 were hospitalized women without overt cancer, and 259 were chosen from the general population by random digit telephone dialing. Ninety-seven (52%) of the cancer patients habitually used talcum powder on the perineum, compared with 247 (46%) of the controls. Adjusted for parity, the relative risk (RR) = 1.40, p = 0.06. There were no statistically significant trends with increasing frequency or duration of talc use, and patients did not differ from controls in use of talc on sanitary pads and/or contraceptive diaphragms. Fewer ovarian cancer patients (7%) than controls (13%) reported prior fallopian tube ligation (RR, adjusted for parity, = 0.56, p = 0.06), and fewer patients (20%) than controls (28%) reported prior hysterectomy (RR = 0.66, p = 0.05). The protective effect of hysterectomy was confined to those who underwent this surgery 10 or more years prior to interview and to those who had not undergone prior tubal sterilization. Consumption of cigarettes and alcohol did not differ between cases and controls. By contrast, 11 (6%) cases never regularly consumed coffee, compared with 31 (11%) hospital controls and 26 (10%) population controls (RR, adjusted for smoking, = 2.2, p = 0.03, for the comparison using all controls). Overall, ovarian cancer risk among women who had drunk coffee for more than 40 years was 3.4 times that of women who had never regularly consumed coffee (p less than 0.01). However, the data exhibited no clear trends in risk with increasing consumption. Although risk ratios relating duration of coffee drinking to ovarian cancer were unaffected by adjustment for several characteristics, further study is needed to exclude potential confounding by other unmeasured characteristics.

High-field-strength MR imaging and metallic biomedical implants: an ex vivo evaluation of deflection forces

Ferromagnetic biomedical implants are considered a contraindication for MR imaging primarily because of the potential hazards associated with their movement or dislodgment. Many metallic biomedical implants are composed of nonferromagnetic materials and do not present a danger to patients during MR imaging. Therefore, to evaluate the ferromagnetic qualities of 36 different metallic biomedical implants (four aneurysm clips, six hemostatic clips, four dental implants, seven prosthetic heart valves, eight orthopedic prostheses, one artificial urinary sphincter, three contraceptive diaphragms, and three cerebral ventricular shunt tube connectors) not previously evaluated with a high-field-strength MR system, we measured deflection forces at the portal of the magnet of a 1.5-T MR system. Fourteen of the 36 metallic biomedical implants were determined to be ferromagnetic as indicated by their deflection in the static magnetic field. However, only the four aneurysm clips (Drake, Mayfield, McFadden, and Sundt-Kees) had sufficient ferromagnetism to warrant exclusion of patients with these implants from imaging with a 1.5-T MR system because of the possibility of movement or displacement. The calculated deflection forces for these aneurysm clips were comparable with previously reported values of certain aneurysm clips that have been designated to present a risk for patients undergoing MR imaging. Patients with 32 of 36 metallic biomedical implants tested can be safely imaged with high-field-strength MR systems.

Diaphragm insertion increases human vaginal oxygen tension

The normal insertion of a contraceptive diaphragm into the vagina of five young women induced a dramatic increase in the vaginal oxygen tension (131 ± 13 mm Hg, mean ± SD, n = 5), which slowly fell at an initial rate of 0.9 ± 0.2 mm Hg/min. Withdrawal of the diaphragm immediately restored vaginal oxygen tension to the normal hypoxic state (11 ± 12 mm Hg). The change in gaseous equilibrium created by the trapped air of the diaphragm could have significant actions on the microbial activity and balance of the vagina.

Prophylaxis against infection in Singaporean prostitutes.

One hundred prostitutes were interviewed about the prophylactic measures they took against infection. The use of contraceptive diaphragms and clandestine antibiotics correlated significantly with fewer gonococcal infections.