By Cara McDougall, Reg. PT

The use of a pessary is considered a minimally invasive, relatively safe intervention for the treatment of pelvic organ prolapse. The relative safety of this treatment approach is particularly apparent when compared against the possible risks of surgical intervention. However, pessary use is not without potential side effects and risks and should still be regarded as the medical intervention that it is.

Side effects

First-time users of pessaries may be surprised to find that there is at least one common side effect of pessary use. Some women aren’t bothered by it at all and others find this side effect so bothersome that they discontinue pessary use altogether. It is good to be aware of the following potential side effect when considering if pessary use is the right intervention for you.

Increased vaginal secretions

This is the body’s natural reaction to a foreign object residing in the vagina. It is a protective response in order to provide extra lubrication to minimize friction between the pessary and the vaginal tissues. Plus, discharge is the body’s way of self-cleaning the vagina! What to look for to ensure your secretions are healthy is discussed below.

Risks

A pessary is typically a very safe option when users follow the instructions for care and management. However, there are certain risks associated with use of a pessary. In case of an emergency and you are unable to advise doctors that you wear a pessary, it is a good idea to tell a close friend or carry a note in your wallet declaring that you wear a pessary. The most common risks are denoted with an asterisk (*).

Irritation/fissure at the introitus*

The entrance of the vagina can become irritated to the point of tiny tears in the skin from repeated removal and insertion of the pessary. This is most likely to occur in the post-partum stage or in post-menopausal women, in both scenarios due to a lack of estrogen which helps to keep our tissues flexible and elastic. This can be combatted with the use of a topical estrogen or even vaginal moisturizer. If this occurs, stop pessary use, see your doctor and follow the treatment plan before resuming pessary use. Additionally, the frequency with which the pessary is removed may need to be reduced in order to allow a balance between hygiene and minimizing tissue irritation. This is something you and your pessary fitting professional can discuss on a case-by-case basis.

Vaginal infection as evidenced with yellow/green discharge with an offensive odour*

It is imperative that you clean your pessary thoroughly, as prescribed, that you rinse it completely after cleaning it, that you store it in a clean, dry place when you are not wearing it, and that you always wash your hands carefully before inserting or removing it. These safety measures will help to ensure you avoid vaginal infections. If you notice yellow or green discharge or foul-smelling discharge, remove the pessary and see your doctor. Ensure the infection has cleared before starting to use your pessary again.

Small amount of blood on pessary*

The pessary can rub on the tissues inside your vagina, irritating them and eventually causing small lesions. If you notice pinkish tinged discharge on your pessary when you remove it, keep it out and see your doctor. Your doctor will do a gynecological exam to assess your vaginal tissues. He or she might suggest a vaginal estrogen to improve the integrity of your tissues; this can help increase blood flow and increase the thickness, and therefore resilience, of the tissue. After the tissues have healed sufficiently, you will be able to resume use of your pessary.

Expulsion of the pessary with bearing down (heavy lifting or straining for a bowel movement)

If you bear down greatly (as if attempting to pass large, hard stool), a pessary can fall out. Afterall, we can bear children through the vaginal opening- surely, we can pass a pessary with enough straining! However, this should not happen on a regular basis with activities of daily living. If it does, contact your pessary fitting professional as you may require a different size or shape of pessary in order for it to fit more appropriately and stay in place.

Stress urinary incontinence

Sometimes the use a pessary will reveal unknown, pre-existing stress urinary incontinence (SUI). SUI is the leakage of urine with activity, for example with coughing, laughing, sneezing, jumping, or running. This unveiling can happen because when your bladder hangs lower than it is supposed to, it can kink the urethra (the tube that drains the bladder of urine). This kink helps to prevent unwanted urinary leakage. However, when the pessary holds the bladder in its proper position, it unkinks the urethra, thereby allowing urine to leak more easily. If this is your experience, ask to trial pessaries made specifically for SUI as well as POP. Your pessary fitting professional may also suggest pelvic floor muscle training to reduce/eliminate your stress urinary incontinence.

Irritation or ulcers with or without bleeding of the vaginal tissues

Pressure from the pessary on your vaginal tissues can lead to irritation and eventual breakdown of tissues leading to the formation of ulcers. If you feel pain with pessary use, see your doctor. He/she will conduct a gynecological exam to inspect the state of your vaginal walls, looking for signs of irritation or skin breakdown. If this is the case, you might be prescribed a topical estrogen to help your body increase the health of your tissues (increased blood flow and extensibility of tissues, decreased fragility). You will be directed to not use your pessary until your tissues have healed.

Difficulty/pain evacuating bowels or emptying bladder

A pessary should not negatively affect your ability to void your bladder or evacuate your bowels. If this is your experience, see your pessary fitting professional as a different size or shape may be warranted.

Urinary tract infection

See “vaginal infection” above for tips to minimize your chance of infection with pessary use. If you experience burning with urination and/or increased frequency and urgency of urination, see your doctor for a urinalysis where they will check for the presence of a bacterial infection.

Incarceration

Very rare: In cases where a pessary is forgotten or mismanaged and left in place for far longer than advised (years) without removal, the pessary can become stuck in the vaginal tissue. In this case, it would need to be surgically removed. This is why it is imperative to follow your recommended treatment plan and let someone close to you know that you wear a pessary.

Fistula

Very rare: A fistula occurs when the pessary wears the tissue down, creating a hole between two organs, for example between the vagina and bladder or the vagina and rectum. One hallmark symptom of a fistula is leaking bladder or bowel contents from the vagina. This is a serious medical condition requiring surgical repair.

Migration

Very rare: This occurs when the pessary moves from one organ to another (vagina to bladder or rectum). Requires surgical removal and management.

Increased risk of squamous cell vaginal cancer

There has been one documented case where the use of a pessary is believed to have led to squamous cell vaginal cancer. This was with prolonged use and inadequate supervision. Again, it is imperative to regularly follow-up with your physician every 6-12 months (or at an interval suggested by your physician) for a gynecological exam to ensure ongoing tissue health.

If you have questions or concerns about the potential risks of pessary use and are wondering whether the benefits outweigh the risks in your unique situation, give the clinic a call- we’d be happy to discuss your specific situation!

The information in this blog is provided as an information resource only and should not be used as a substitute for seeking personalized direction from your overseeing physician. Please consult your healthcare team before making any decisions about your pessary treatment plan, which is unique to you and your overall health. PPHC expressly disclaims responsibility, and shall have no liability, for any damages, loss, injury, or liability whatsoever suffered as a result of your reliance on the information contained in this blog.