A Text-book of Diseases of Women

by Charles B. Penrose

The pessary may be introduced while the perineum is retracted with the speculum; or it may be passed into the vagina first, the speculum then being introduced and the pessary moved into the proper position. The pessary should be greased, the lower transverse bar should be grasped with the thumb and the index finger, and the instrument should be introduced in such a direction that one lateral bar lies in the vaginal sulcus. The upper transverse bar may readily be placed behind the cervix, by manipulation with the finger or the forceps, when the perineum is retracted with the speculum.

The speculum should be removed, and the woman should assume the Sims posture for a few minutes. She may then get up from the table, and the examination may be made in the erect posture, for in this position, better than in any other, the fit and the action of the pessary may be determined. It will be found that the lower bar of the pessary is in relation with the anterior vaginal wall at the position of the internal urinary meatus. It should not protrude from the ostium vaginæ. It should be possible to pass the finger readily between the vaginal walls and the lateral and lower bars of the pessary. The cervix should be felt directed backward through the upper portion of the ring of the pessary. It will be felt that the pessary is retained in the vagina not by any pressure against the vaginal walls, but by a suction—in other words, by the retentive power of the abdomen.

A vaginal douche of warm water should be administered once a day while the pessary is worn.

The woman should be directed to return for examination three days after the introduction of the pessary, or sooner if any discomfort is experienced. Sometimes the uterus becomes retroverted while the pessary is in position, and becomes flexed over the upper bar of the instrument, considerable pain resulting. In other cases, where the vagina is patulous and too small an instrument is used, the pessary becomes turned so that the long axis lies transversely. It is well to advise the woman to remove the instrument herself if it makes her very uncomfortable.

The pessary should be examined digitally in the dorsal or the erect position, or visually in the knee-chest position. If it is found that the retroversion has returned, the uterus should be replaced and a pessary better suited in size and shape should be introduced. It is always desirable to use as small an instrument as practicable. The intervals between examinations may be gradually lengthened to two weeks or a month. A woman using a pessary should always be under the supervision of a physician. The retroversion pessary does not interfere with sexual connection.

The bowels should be carefully regulated. The clothing should be supported from the shoulders, not from the waist, and heavy lifting should be avoided as much as possible.

After a woman has worn a pessary for three or four months, and it is found that the uterus remains in the normal position, the instrument should be removed and the result carefully watched.

If the uterus continues in its normal position of anteversion, a cure has been accomplished and the pessary may be discarded. If the retroversion returns, as it very often does, the pessary should be introduced again, and an unfavorable prognosis of cure by this means should be made. The patient must then choose between the use of the pessary for an indefinite period, under medical supervision, and cure by means of an operation.

The Smith pessary is better adapted to the shape of the vagina, which normally narrows from above downward, than is the Hodge instrument. The Thomas pessary, in which the upper bar is made very broad, is applicable to cases of sharp retroflexion with retroversion, in which the upper bar may become fixed in the angle of flexion in case the retroversion returns. The upper bar is made so broad that the angle of flexion would be spanned by it in case of such an accident.

The action of the pessary depends upon the integrity of the vagina and the pelvic floor. The retroversion pessary, therefore, cannot be used when there is a laceration of the perineum. In such a case the perineum must always be closed as a preliminary step.