By Leeanna Maher PT, MSc PT, H.BSc

What is a pessary?

A pessary is made of medical grade silicone or plastic.  It is a device that is inserted into the vagina and its positioning helps to provide support to the vaginal walls in order to elevate and support the pelvic organs such as the bladder, rectum, and/or uterus. It acts like a sports bra for the pelvic organs.  A pessary is intended to achieve the following:

1.  Alleviate uncomfortable sensations of pelvic heaviness/pressure due to pelvic organ prolapse

2. Improve any difficulties associated with bladder or bowel emptying as a result of pelvic organ prolapse

3. Prevent urinary incontinence associated with coughing, sneezing, laughing, jumping or any other form of higher impact activities

Who can use a pessary?

Historically, it was believed that pessaries were only for those who were “older” or post menopausal.  It is now accepted that pessary use is not age specific.  Candidates who may benefit from trialing a pessary are those who have comorbidities that preclude them from having surgical correction of their pelvic organ prolapse.  Similarly, those awaiting surgical correction can trial a pessary to help alleviate symptoms in the short term.  Those experiencing symptoms of pelvic organ prolapse during pregnancy may also have success with wearing a pessary under the close supervision of an obstetrician.  In basic terms, anyone who is experiencing stress urinary incontinence and/or pelvic organ prolapse symptoms, is undergoing conservative pelvic physiotherapy exercise guidance at the same time, may benefit from trialing a pessary. 

How does a pessary help for pelvic organ prolapse?

Pelvic organ prolapse is a condition in which there is a defect in the supportive structures that hold up the pelvic organs inside the pelvis.  As a result, the bladder, rectum and/or uterus shift and descend in the vaginal canal.  There are different degrees of descent.  For some the shift is mild and for others the movement of the pelvic organs can extend beyond the vaginal opening creating a bulge of vaginal tissue that can be easily seen externally.

Symptoms associated with pelvic organ prolapse may include a heaviness/dragging/pressure sensation within the pelvis and/or lower abdomen, seeing a bulge or lump of tissue coming out of the vagina, difficulty emptying the bladder, a weak urinary stream, urinary urgency, urinary incontinence, and/or difficulty emptying bowels. 

A pessary inserted into the vagina, supports the vaginal walls, elevates the pelvic organs, and decreases or resolves the symptoms associated with pelvic organ prolapse.  Pessaries are especially helpful for prolapses that extend just beyond the vaginal opening as a means of lifting up the tissues back into the vaginal canal thereby, preventing friction and irritation of the vaginal tissue as it rubs against clothing and the labia.

How does a pessary help for incontinence?

Pessaries are particularly helpful for stress urinary incontinence.  This is a condition in which there is an involuntary loss of urine with physical exertion and impact activities like jumping, or with an increase in intra-abdominal pressure during sneezing, coughing, or laughing. 

The shape of incontinence pessaries include a small knob at the front of the pessary like the devices below:

The knob supports the urethra and bladder wall by providing gentle compression of the urethra against the pubic bone.  This pressure reduces or resolves incontinence when intra-abdominal pressure increases.  

How is a pessary fitted?

A pessary is fitted by obstetricians, gynecologists, and specially trained pelvic health physiotherapists.  A pessary fitting involves some level of trial and error and it is not uncommon for multiple pessaries to be trialed during the session.  During a fitting session, the client will be examined with the pessary inserted while lying down and in standing.  The client will be asked to walk around, empty their bladder, bear down, and recreate any provocative movements that normally would cause symptoms.  A successful fitting is achieved when the pessary is considered “comfortable”, it does not shift downwards or fall out during any movements or when voiding, prevents urinary incontinence, and alleviates uncomfortable sensations associated with pelvic organ prolapse.

How does one care for a pessary?

Pessaries can be worn all the time or for shorter durations of time such as during exercise or if a client expects to be standing or walking for an extended period of time.  It is not absolutely necessary for a pessary to be removed overnight unless the client chooses to do this or if the pessary is a cube shaped pessary.  If a client is managing the cleaning on their own, it is recommended that the pessary be removed and cleaned at least once a month.  If it is difficult for the client to remove the pessary for cleaning due to dexterity issues, it is common for client’s to have regular check ups with the specialist that fit them to remove, inspect, clean the pessary, and reinsert.

A pessary can be cleaned with water and a mild hand soap.  The pessary can be left to air dry on a clean towel.  It is important to inspect the pessary every removal to look for any cracks, splitting, or bending of the material.  If this is identified, the pessary should be replaced.  High grade silicone pessaries tend to last 5-7 years.  Discolouration of the pessary over time is normal and is not considered harmful.  

How is a pessary inserted?

A pessary can be inserted in a lying down or standing position.  If the pessary is inserted in standing, it is often recommended to prop one foot up on the toilet or edge of the bathtub.  Prior to insertion, the pessary ring is folded similar to the shape of a taco.  Lubricant is placed along the leading edge of the pessary and it is recommended that lubricant be placed at the vaginal opening to enhance ease of insertion.  Once the pessary is inserted inside the vagina, it unfolds and opens up on its own to its original shape.  If there is a knob on the pessary, the knob is pushed up anteriorly behind the pubic bone to allow for the gentle compression of the urethra.  If the pessary is in the right position, it should feel very comfortable.  Some people are not even aware that the pessary is inside the vaginal canal when it is inserted properly. 

What can be used to help support the vaginal tissues with a pessary?

If a client is peri or post menopausal, the primary health care provider may suggest the use of local vaginal estrogen or a vaginal moisturizer along with the concurrent use of a pessary.  The reason for this is that estrogen has been shown to optimize vaginal tissue health by maintaining optimal vaginal pH levels.   It is believed that vaginal estrogen may reduce the risk of developing abrasions or skin breakdown with the use of a pessary but there is limited evidence to support this.  It has been suggested that local estrogen may decrease the risk of developing bacterial vaginosis and reduce vaginal discharge.  A recent systematic review has suggested the efficacy and tolerability profile of hyaluronic acid are similar to those of vaginal estrogen.   Therefore, a vaginal moisturizer with hyaluronic acid may offer an ideal, non-hormonal alternative to supporting vaginal tissue health with the use of a pessary. 

What signs indicate that medical attention is needed with a pessary?

• Vaginal bleeding not related to menstruation

• Pain

• Abnormal vaginal discharge

• If the pessary falls out during wear

• Inability to remove or reinsert the pessary

• Difficulty emptying bladder and bowels

• Urinary tract infection 

• Vaginal itching/concerns of infection

According to the Journal of Obstetrics and Gynecologists of Canada, it is recommended that pessaries should be considered in all those presenting with bothersome symptoms of pelvic organ prolapse and/or stress urinary incontinence (I,A).  The statement goes on further to state that most who can be successfully fitted with a pessary experience excellent symptom relief,  high satisfaction rates, and minimal complications.  

References

https://www.tandfonline.com/doi/abs/10.1080/13697137.2022.2079973?journalCode=icmt20

https://www.scielo.br/j/rbgo/a/KtBT7XwQZCdwWQjdSwpY4rC/?format=html&lang=en&stop=next

https://www.scielo.br/j/rbgo/a/KtBT7XwQZCdwWQjdSwpY4rC/?format=html&lang=en&stop=next

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5909791/

https://www.jogc.com/article/S1701-2163(20)30913-0/pdf