Pessaries for Prolapse Management – A Non-Surgical Alternative for Some Women
Are you seeking to avoid prolapse surgery?
Want to reduce bothersome prolapse symptoms?
Pessaries have been used for centuries by women seeking to manage pelvic prolapse. The hand carved antique bone pessary (shown right) dates back to the 1860’s and is not too different to the modern day pessaries available today.
Unfortunately many women don’t know about how a pessary may help them better manage their prolapse symptoms and help to avoid prolapse surgery.
Read on now to learn all about pessaries for prolapse with:
- What is a pessary?
- Why use a pessary?
- How does a pessary work?
- Potential benefits of using a pessary
- How does a well fitting pessary feel?
- How is a pessary fitted?
- Vaginal oestrogen and pessary use
- When is a pessary not suitable?
- When is a pessary less effective?
- Side effects of pessaries
- Sex and pessary
What is a Pessary?
A pessary for prolapse is a support device that is inserted to sit high within the vagina.
Pessaries are designed to support the collapsed walls of the vagina, and the prolapsed organs (bladder, bowel and/or uterine prolapse). Modern day pessaries come in a wide range of shapes, sizes and different designs (shown right).
A support pessary is quite different from a pessary or tablet/capsule that is inserted into the vagina to delivery medication to the pelvic floor (e.g. vaginal oestrogen pessary).
Pessaries have been used by women for centuries manage pelvic organ prolapse. Reports of pessary use date back to ancient Egypt. Over the ages women have used a variety of materials for pessary support including fruit (pomegranates), stones, soaked cloth, cork, brass and rubber. Today most pessaries are made from medical grade silicone or plastic which are readily cleaned, and non absorbent.
Why use a Pessary?
Women may use a support pessary to support their prolapse for a number of reasons including:
- A desire to avoid or delay prolapse surgery
- To allow exercise with a prolapse
- Early stage prolapse
- Desire for future pregnancy
- During pregnancy or following childbirth
- When unsuitable for pelvic prolapse surgery
- Previous failed prolapse surgery
- To manage stress incontinence and prolapse
- During pelvic floor muscle rehabilitation for prolapse
- With advanced age.
It may well be that by pessary devices can help women with pelvic floor exercises by lifting and supporting prolapsed tissues – this has not yet been confirmed (but is currently being investigated) by studies but this is a plausible theory.
It is a surprising that more pessaries are not fitted to help women to exercise with a prolapse and avoid prolapse symptoms with exercise.
Overweight women struggling to improve their pelvic floor strength and prolapse support are another group who might benefit from the added support of a pessary. This might be worth discussing with your medical specialist as a possible management option if this applies to you.
How Does a Pessary Work?
A pessary provides a mechanical or physical support to hold up the prolapsed tissues within the vagina. It does this by occupying space high within the vagina. This can have the effect of lifting the walls of the vagina higher within the pelvis, and providing a support for the bladder, bowel or uterus.
The image (right) shows a fitted white ring pessary sitting at the top of the vagina.
Pessaries are designed in a variety of shape and sizes, and for different types and severity of prolapse. Some of the small flexible ring pessary designs can inserted on a daily basis or as required to support during exercise or activity. The less flexible space occupying pessaries are mostly designed to stay within the vagina for a designated period of time, before being changed over by the medical specialist.
Potential Benefits of Using a Pessary
There are a number of potential benefits that may be derived from pessary use. These potential benefits need to be weighed up against any possible side effects or risks, and in conjunction with the expert opinion of your medical specialist regarding your individual suitability.
Potential benefits of using a pessary for prolapse management may include:
- Decreased prolapse symptoms
- Delay or avoid pelvic prolapse surgery
- Possible prevention of prolapse worsening
- Allow for exercise with prolapse
- Possible aid or adjunct to pelvic floor muscle rehabilitation.
How Does a Pessary Feel?
A well fitting pessary is comfortable and the wearer is usually unaware it is even there.
Discomfort wearing a pessary can be a sign that the pessary is not the right size or that it may have slipped out of position. If you feel discomfort when wearing a pessary you should consult your treating doctor.
How is a Pessary Fitted?
A pessary device is usually fitted by a gynaecologist or obstetrician. Your medical specialist will take some internal measurements of your vagina based upon an internal vaginal examination and will consider the nature and severity of your prolapse, whether you seek to be sexually active with the pessary fitted along with these measurements to fit the correct pessary for you. He or she will usually fit the largest size pessary possible that feels comfortable when fitted.
Successful fitting is usually indicated when the pessary:
- Stays in place with walking, coughing and bending
- Feels comfortable and pain free
- Does not interfere with bladder or bowel emptying
- Does not cause unwanted bladder leakage.
Sometimes it takes a couple of attempts with different styles or sizes of pessary to get the correct fit. It should be possible to fit a finger around the outside of a well fitted pessary. It is useful to know that you can empty your bladder normally with the pessary in place comfortably before leaving your pessary fitting so that it can be changed if necessary.
Some of the flexible pessary designs allow women to use and remove themselves as desired. Other pessaries are designed to stay in place once fitted for a specified time before being changed by the specialist. This may be something you wish to discuss with your specialist before fitting.
A woman needs to be willing to have regular medical follow-up, have intact cognition and adequate manual dexterity to be considered appropriate for fitting with a pessary.
Vaginal Oestrogen and Pessary Use
Vaginal oestrogen is commonly prescribed before or at the time of pessary fitting. Vaginal oestrogen is often prescribed for pessary use to improve the thickness and condition of vaginal tissues for prevention of infection or tissue erosion. This is a consideration for women with previous breast cancer, where consultation with their treating breast specialist is warranted for assessment regarding their individual suitability for vaginal oestrogen.
When is a Pessary Not Suitable?
A pessary is not appropriate for women with:
- Active vaginal infection
- Pelvic Inflammatory Disease
- Ulceration of vaginal walls
- Vaginal bleeding where the cause is unknown
- Allergy to silicone and latex
- Poor compliance with ongoing medical supervision and follow-up.
When is a Pessary Less Effective?
It is quite common to require a number of pessary fittings to achieve the correct size and design.
There are a number of recognized predictors of poor success when fitting a pessary.
Predictors of poor success1 may include:
- Shortened vaginal length
- Wide vaginal opening
- Past pelvic surgery (including hysterectomy).
Side Effects of Pessaries
Pessary devices are generally considered to be a safe prolapse management option for women with few complications2. Possible complications or side effects can usually be avoided with ongoing medical monitoring have once been correctly fitted.
Some of the more commonly reported side effects of pessary devices include:
- Vaginal bleeding , constipation2
- Mild vaginal discharge, increased odour1
There have been some reported rare serious complications associated with pessary use, usually with devices that have not received regular ongoing medical supervision having once been fitted1.
Sex and Pessary
Your doctor will take into account your preference for sexual activity when fitting you with an appropriate pessary for your lifestyle.
Sexual intercourse can proceed with certain styles of support pessary not needing to be removed (e.g. ring, gehrung).
Some of the space occupying pessary designs do need to be removed before intercourse (e.g. cube).
Some pessaries, particularly those used for more severe prolapse cannot be removed by the user (e.g. gellhorn shown above right) and are therefore unsuitable for women seeking to remain sexually active with a pessary fitted.
A support pessary can provide a simple and effective prolapse management strategy and may be particularly for women seeking to avoid or delay prolapse surgery and minimize prolapse symptoms. Pessaries are not for everyone with a prolapse – some women choose to wear a pessary as an interim prolapse management measure while others find that a pessary helps them to manage symptoms as an alternative to prolapse surgery. The decision about whether or not to wear a pessary ultimately rests with you and your Obstetrician or Gynaecologist.
1 Shah et al (2006) The history and evolution of pessaries for pelvic organ prolapse. International Urogynecology Journal of Pelvic Floor Dysfunction. Feb;17(2):170-5.
2 Guidelines for the Use of Support Pessaries in the Management of Pelvic Organ Prolapse. Continence Foundation of Australia and International Centre for Allied Health Evidence, 18th July 2012.
ABOUT THE AUTHOR, Michelle Kenway
Michelle Kenway is a Pelvic Floor Physiotherapist and author of Prolapse Exercises Inside Out. Prolapse Exercises is a complete exercise guide for women with prolapse and after prolapse surgery seeking to exercise safely and protect their pelvic floor.