We read with interest the case report of incarcerated genital tissue within a ring pessary and the accompanying impressive imagery.

Thubert and Deffieux present an 84-year-old patient who had genital incarceration and urinary retention 5 days after insertion of a ring pessary for genital prolapse. The authors treated her with cold-knife resection of the device and subsequent replacement of a different type of pessary: the doughnut.

It is vital to consider that women of the geriatric cohort with impacted pessaries may be treated by means other than surgical resection. Many patients in this cohort may be poor candidates for anesthesia and, thus, an indication for use of pessary as opposed to surgical intervention to begin with. The following alternative measures in these patients might be used: After placement of an indwelling bladder catheter and the local application of magnesium sulphate compresses on the edematous “genital prolapse or incarceration,” significant reduction in swelling will occur and facilitate pessary removal by gentle manipulation. In a case of incarceration with concern for acute tissue perfusion, the use of topical magnesium sulphate lends a rapid, noninvasive response to allow digital rotation of the device. In addition, topical use of estrogen cream increases turgor of vaginal mucosa, promotes adhesiolysis, and allows manipulation and removal of an impacted pessary efficiently. Case reports support that estrogen treatment is highly effective in as early as 48 hours. Such management may avoid the need for resection of the device and any potential injury to thin and atrophic vaginal wall mucosa and surrounding bladder and urethra and avoids the need for more anesthesia, which is advantageous particularly in patients with complex comorbidities.