Pessaries are effective non-surgical devices for reduction of prolapse. However, use of
pessaries are limited in some women due to patient discomfort. While lidocaine can be
used to improve pessary checks, its use may be limited due to supply chain shortages,
lack of insurance coverage, and optimization of resource utilization. More techniques to
improve pessary examination comfort are needed. Perineal massage prior to delivery and at
the time of active labor has been noted to reduce perineal trauma and perineal
discomfort, theoretically by desensitizing the nerve endings in the skin, broadening the
vaginal opening, and increasing elasticity of the perineal tissue. Since most discomfort
with pessary checks is during removal and insertion through the vaginal introitus,
perineal massage may be a beneficial technique that women could potentially learn to
improve comfort with pessary checks.
The objective of this study is to examine the effectiveness of perineal massage prior to
pessary check in improving comfort of pessary checks for patients using a cross-over
randomized controlled trial.
Patients who follow up for pessary checks with the division of Urogynecology at UNC will
be approached about participating in this study. The study will involve two clinical
visits. At the first visit, the patient will be randomized to 2 minutes of perineal
massage with water based gel of the external perineum and sides of the vaginal vestibule,
as well as internal massage with the thumb, gliding from 4 to 8 o'clock, then tissue
stretching technique with one intracavitary finger and other external finger at the 4
o'clock and 8 o'clock positions three times; versus application of gel to the internal
vagina and external vagina without massage. Providers will be blinded to randomization
and proceed with pessary check as per normal clinical protocols.
Patients will rate self-reported pain before, during pessary check, and after the pessary
check on a VAS scale; and rate whether they would prefer to repeat this method at future
visits via Likert scale. Healthcare professionals will also rate perceived patient pain
on VAS scale; ease of pessary removal; and note any perineal or introital laceration or
abrasion that may occur during the pessary fitting.
At the following visit, patients will be assigned to the group to which they were not
initially randomized. Patients and healthcare professionals will again rate pain as
described above. Patients will also rank preference for perineal massage using PGI-I.