Entrapped Pessary After Liver Transplant

Objectives: To describe a novel case of an entrapped pessary after liver transplant and discuss the timing of routine pessary maintenance.

Methods: A 64-year-old with a history of stress urinary incontinence and pelvic organ prolapse presented to the clinic for consultation. Patient had successfully been treated with a Gelhorn pessary for approximately one year prior. Patient was interested in surgical management of her condition but was not a surgical candidate due to renal insufficiency and liver failure. Recommendation was to continue pessary use, with regular follow up, until after liver transplantation.

Patient received a successful transplant. Patient’s regular 3 month pessary cleaning visit was approximately 3 weeks post-transplant. Pessary was cleaned and replaced with no concerning findings. The patient was advised to return in another 3 months for follow up.

At next routine maintenance exam, patient noted increased rectal pressure but was still able to have a bowel movement and fully empty her bladder. On physical exam, the pessary was noted to be displaced with the stem pushing into a posterior vaginal wall defect. Rectal exam showed no erosion into the rectum. Attempts to remove the pessary in the clinic were unsuccessful due to patient discomfort.

Results: Patient was scheduled for pessary removal in the operating room under general anesthesia. Despite elevating the pessary, the stem of Gelhorn was lodged in the posterior vaginal wall (see figure 1). Digital rectal exam suggested the pessary pushing lateral around the rectum without rectal injury. Anoscopy confirmed no injury to the anal or rectal mucosa. The pessary was then elevated and a 1.5cm incision in the posterior vaginal epithelium was created distal to the knob. The pessary was thereby easily removed. A small cavity without injury to rectum or anal cavity was noted, but was left open due to concern for bacterial colonization (see figure 2). Hemostasis was noted.

Conclusions: This case suggests a need for more frequent pessary maintenance in patients with changes in health, body habitus, or lifestyle. In our patient, for example, the reduction of ascites after transplant may have changed the pessary fit and resulted in the complication described. Further, patients should be counseled to seek care if they have new bowel or bladder dysfunction symptoms with pessary use. Adjustments to the pessary maintenance schedule should be considered according to changes in patient history and health.