Application: The urethra bowl pessary consists of flexible tissue tolerant silicone. Patients with stress incontinence and/or various degree of prolapse are treated with the urethra bowl pessary, whereby an eventual combined cystocele is supported by the bowl. An intact pelvic floor is a prerequisite for this pessary. The pessary's thickening is supposed to lift the urethra, shift the transition between bladder and urethra up and forward and thus to avoid an opening of the upper urethra under stress (picture). The shifting may also avoid seeping of urine into the urethra, which may have a positive effect on urge incontinence or a mixture of stress and urge incontinence.
Sizes: The pessaries are adapted according to their diameters (minimum 50 and maximum 90mm diameter). The pessary which achieves the best continence when coughing in a standing position and in addition, allowing for micturition should be chosen. Often one will have to change to a larger size after 1 or 2 months, due to tissue relaxation. If the thickening is too small, it can be individually adapted by gluing additional caps. When inserting the pessary, the bowl will be led through the vaginal vault so that the thickening will lift the transition between bladder and urethra behind the symphysis (picture).
Use: In general, for the first trial the physician should insert the pessary with a filled bladder on the examination chair. A coating with estrogen cream (containing estriol which has a shorter receptor adhesion) facilitates the insertion. Since one needs only a small amount of cream (small surface) for reaching gliding effects, we recommend to use a higher dispensed estriol (e.g. 1 mg estriol / 1 g cream). The estriol also ensures a better blood circulation. When the patient stands up to cough, one can register the loss of urine. Ideally, a stress incontinence should be immediately redressed, i.e. no further loss of urine should occur. This may motivate patient and treatment team to
continue with the pessary therapy. If the incontinence is treated, there is no doubt about the diagnosis of stress incontinence. After the test, the position of the pessary and the thickening should be checked again by the physician. Urethra bowl pessaries are usually used during daytime. It is recommended that the patient should remove the pesssary in the evening and insert it in the morning. For inserting the pessary the patient may pose one foot on a chair; if this is not possible, she may slightly spread the legs while leaning against a wall or while lying. Thereby the thickening should be placed behind the symphysis under the upper urethra; when removing the pessary, the thickening should be dislocated by inserting the forefinger into the hole of the bowl. The fixation of an additional thread on both sides of the thickening may facilitate the handling and additionally fix the pessary.
Side Effects/Complications: The therapy with pessaries has the aim, in combination with additional measures, to cure the patient's problems and possibly after a certain time even to enable her to manage without the pessary. Also if a surgery is planned in the long term, the pessary can be looked at as a ,,trial pessary" and as a diagnostic test in favour or against an operative therapy. The daily removal at night avoids complications, which may arise if the pessary stays for too long, like infections, bleedings or even ulcers. Stress incontinence does not need any therapy during the night anyway. If any problems with incontinence remain despite having changed the sizes and despite careful training, the diagnosis and choice of the pessary have to be reconsidered. It is possible that the thickening cannot rise because of insufficient levator muscles or a scarred vagina wall, e.g. after a previous operation. In this case, in order to loosen the scars, one has to change to a cube pessary and local estriol therapy at least temporarily. Contraindications for estriol creams should be considered (e.g. pregnancy, lactation period, estrogen- dependent tumors). If the patient is not able to change the pessary herself, it may be advisable to integrate a nurse or a member of the family into the procedures.
Advice: The product should only be used by one patient and can be stored by room temperature. The pessary may be cleaned under warm running water without using any disinfectant.