Pesser ring is a non-surgical conservative treatment commonly used in pelvic organ prolapse. When the follow-up and maintenance are not regular, we encounter various complications that lead to death. The most common complications are; pelvic pain, bleeding and bad odor. In our case, the complication of an infected pessary ring forgotten for more than 15 years, which caused isolation from social life, was reported.
CASE:88-year-old, multiparous patient came to our clinic with vaginal bleeding and foul-smelling vaginal discharge. Pesser ring was placed at least 15 years ago due to uterine prolapse and
since then it was learned that no doctor had been examined. On initial examination, severe anaerobic malodorous purulent vaginal discharge and bleeding were observed. A pessary ring embedded in the vagina was detected. Body temperature was normal and physical examination revealed abdominal and adnexal sensitivity.Serum leukocyte 15,400 and C - reactive protein (CRP) 33 )L, procalcitonin 0,202 (> 0,05)was measured. The Pesser ring was deeply infiltrated into the peripheral tissues, especially in the posterior wall. Because of the patient's active vaginal bleeding, the pesser ring was removed by blunt and sharp dissections from the vagina after the first dose of antibiotic treatment. The figure was removed from the vagina by means of an iron-cutting tool (Figure 1). povidone was washed with iodine and physiological saline. In metiodynamic therapy 3 * 500 mg IV was administered Metronidazole. After the procedure, vagina was washed twice with plenty of povidone iodine and saline once a day. Approximately 6 cm of hard tissue was palpated on the patient's rectum. Because the patient's renal function tests were high, the pelvic mass was removed without contrast. The mass could not be defined exactly as a result of MR. (Figure2) Biopsy was planned to be taken but the patient did not accept it.
DISCUSSION:Pessary rings in the treatment of uterine prolapse have been described in the literature since Hippocrates. It is made of different materials like rubber, plastic, silicone etc. The foreign bodies in the vagina can be present for a long time without any symptoms, but they cause life-threatening complications when buried deeply. In the cases reported for long-forgotten pessary rings, clinical manifestations were malodorous vaginal discharge and irregular bleeding in the vagina. Because the foreign body is covered with granulation tissue and pus, it is often difficult to separate it from other tissues. Treatment with antibiotics has been shown to be beneficial prior to removal of the wash with antiseptic solution. In almost all cases, the difficulties in removing the embedded pesser ring have been reported and there is no specific technique described. Dissection and rotation as well as traction with various instruments have been described. In the present case, the tissue covering the metallic ring was distributed gently and the ring was removed by traction. Complicated pesser ring complications include chronic vaginitis, ulceration, and metaplasia and vaginal cancer. Other complications include vesicovaginal rectovaginal fistula formation, bowel obstruction, urinary tract infection, and hydronephrosis.
In our case, it was not possible to exclude the possible cervical malignancy.
CONCLUSION: It should be kept in mind that the patients who cannot be treated surgically can be confined to various complications which may lead to death even when the pessary ring is used as a conservative treatment.
Keywords: Pessary, Treatment of uterine prolapse ,