A vaginal pessary is a removable device, usually made from body-friendly silicone, latex, vinyl or rubber. It is designed to be worn comfortably inside the vagina to add support where the pelvic floor muscles have become so weak that one or more pelvic organs have prolapsed, or are in danger of prolapsing. It acts as a brace, offering structural support for the pelvic organs. They are often favoured as a long term solution for pelvic organ prolapses, where surgery is not suitable and/or future children are wanted. They can also be used as a temporary measure before a prolapse repair surgery to relieve symptoms, and are often so successful that surgery is no longer desired.
If you think you might be experiencing a pelvic organ prolapse, as with all medical conditions it is important that you talk to your doctor as early as possible.
How Do Vaginal Pessaries Work?
A pessary works to support the drooping, falling or prolapsing of pelvic organs into a women's vagina. It can offer a valuable non-surgical approach to pelvic organ prolapse. Correctly fitted vaginal pessaries are clinically proven to improve the support of the pelvic organs and reduce sagging, thus reducing the genital hiatus - the distance between the urethra and the back wall of the vagina. Clinical studies show that genital hiatus size can be reduced by several centimeters when wearing a pessary for only three months, and for some users in as little as two weeks of continued use.
A pessary is fitted during an appointment with your doctor. Once your doctor has estimated the most suitable size and design of pessary, it can take about 30 seconds to place the pessary in the most comfortable and beneficial position behind the pubic bone. To test the pessary you will be asked to walk around for 15-20 minutes to ensure the pessary remains in place and does not interfere with using the toilet. It may take two or three attempts to find the pessary that works for you.
Removing most pessaries for daily or weekly cleaning, with gentle running water, is easy. Insert a finger into the vagina and pull on the pessary. It may have a hole in which to insert a finger, or a stem to pull on. Remove the pessary weekly at least, to give your vaginal walls a rest. If you are not comfortable removing the pessary yourself, or if you have a pessary which you cannot remove, please arrange an appointment with your GP.
The type of pessary you have fitted will determine how often it should be changed. Usually pessaries are replaced every six months by your doctor. However, some pessaries can remain in place for a year, although they may become embedded and difficult to move after this time.
Types of Vaginal Pessary
There are many different types, styles and sizes of vaginal pessary. The one that is best for you will depend on your personal circumstances and the level of prolapse support that you require.
The most common pessaries are:
- Ring pessary - The most common type of pessary, a hollow soft ring pessary is ideal in helping with the stress urinary incontinence associated with pelvic organ prolapses. Ring pessaries are one of the few types that can be used by women who are sexually active, however, they cannot be used with a diaphragm and are not a form of contraception themselves. A ring pessary is likely to be the first you try first with your doctor. Although you may need to improve your pelvic floor muscles to successfully use it due to its shape and the soft material that it is made of making it easy to otherwise slip out of place.
- Shelf pessary - A shelf pessary is a hard plastic pessary often prescribed for women suffering from a prolapse of the top of the vagina or uterine prolapse and have struggled holding the ring pessary in place. It is a great option where a hysterectomy is not wanted as it provides support for the uterus. Sex is not possible when this type of pessary is used due to its shape and structure.
- Gellhorn pessary - The Gellhorn pessary is a similar shape to the shelf pessary, but is made of a softer material. They are used for severe pelvic organ prolapses and are a great option for those where surgery is not suitable but the prolapse is advanced. A shorter stem Gellhorn pessary is available for women with a short vagina or when the uterus is very low. The position and shape of this pessary, makes it not suitable for women who are sexually active. The Gellhorn pessary is known as a space occupying pessary as it can be three inches in size. It rests alongside the prolapse, creating suction to keep it in place.
Less common pessaries include:
- Gehrung pessary - Made to help women suffering from moderate to severe cystocele, rectocele and uterine prolapses. This is one of the most difficult pessaries to insert as it sits alongside the anterior vaginal wall like a bridge. However, it can provide great results.
- Mar-land and Incontinence Dish pessaries - These flexible support pessaries are designed to provide support for women suffering from stress incontinence, mild uterine prolapse and mild cystocele.
- Doughnut pessary - Slighter larger than a ring pessary and offering more support, it is a type of space occupying pessary often used by women suffering from moderate uterine prolapse and cystocele. The smooth, rounded shape makes it one of the hardest to insert and remove.
- Cube pessary - Recommended for women suffering from moderate to severe uterine prolapse, cystocele or rectocele. The curved edges mean that even if the prolapse is severe, the pessary can stay in place comfortably due to the suction created by the walls of the vagina. The cube pessary is a daily pessary, to be removed and cleaned nightly to avoid the build up of vaginal secretions.
- Shaatz pessary - This support pessary is designed for use by women who are suffering from a uterine prolapse and may also have a cystocele. The rounded, slightly domed shape is flexible for easy insertion and provides support to the prolapsed organ which can help to relieve the symptoms of prolapse.
- Lever pessary - This group of pessaries include the Smith, Risser and Hodge pessaries. These are designed for those with more extreme pelvic shapes, such as those with very narrow vaginas, insufficient cervix's and well-defined or shallow pubic notches. They will support mild cystocele and uterine prolapses.
- Inflatable pessary - This variant is a special type of inflatable latex pessary designed for women with the most severe prolapses, cystocele or rectocele. It is an air-filled ball that can be inflated through the attached stem, which can also be used to aid removal.
- Falk pessary - A solid vaginal pessary designed to support prolapsed organs in women suffering from uterine prolapse. While a pessary cannot cure a womb prolapse, it can help with the everyday symptoms and prevent the prolapse from getting worse.
What Are the Benefits of Using a Vaginal Pessary?
Vaginal pessaries are hugely beneficial and widely used for a number of reasons:
- Medical research shows that a pessary can actually slow the downward progression of a pelvic organ prolapse, improve the severity or stage of a prolapse and prevent other prolapses.
- As soon as the pessary is fitted you can continue with exercise as normal, without any recovery time.
- You can be sexually active with some pessaries, and you may also notice improvements in your sex life as neither you nor your partner will be aware of the pessary or prolapse.
- Pessaries do not effect your menstrual cycle and some can even be worn when trying to conceive.
- If you fall pregnant whilst wearing a pessary, it can remain in place. As your uterus grows, the prolapse will likely move and your pessary will no longer be needed.
- Pessaries are a long term solution as they do not have to be changed often and follow up appointments can be as infrequent as once every six months.
- Pessaries take the pressure off your weak pelvic floor, leaving you free to get your pelvic floor muscles strong through perfecting your Kegel / pelvic floor exercises.
- A pessary is ideal for women who have had prolapse surgery, but it has failed. Sadly, this is in the region of one in three women who have had surgery. Following initial prolapse surgery, many women are understandably reluctant to go through it again.
- A small study has shown that women with vaginal wind (affectionately known as ‘fanny farts’) had less embarrassing episodes when fitted with a pessary.
What Are the Risks and Side Effects of using a Vaginal Pessary?
Pessaries can become uncomfortable and occasionally fall out. If you experience any of the following side effects, they can be easily reversed by removing the pessary:
- an occasional increase in urinary incontinence due to the position of the pessary
- a degree of vaginal discharge is normal, however you should not experience any unpleasant discharge
- potential bleeding as a result of an ulcer where the pessary has rubbed
- the pessary has slipped and is no longer beneficial
To avoid and reduce these risks, you will have regular check ups to slightly alter the position of the pessary and check the health of the surrounding organs. If you are suffering from ulceration, you will be prescribed an oestrogen cream to apply to the affected area. Once the area has healed, a new pessary can be fitted.
Is a Vaginal Pessary or Surgery Better at Treating a Pelvic Organ Prolapse?
Using a vaginal pessary to support a pelvic organ prolapse is ideal for women wanting to keep active and avoid surgery, reducing and eliminating many of the symptoms. It’s also the best solution for women who plan to have children in the future. Falling pregnant after opting for pelvic organ prolapse surgery will more than likely reverse the effects of the surgery.
There is a wealth of evidence that alongside daily Kegel / pelvic floor exercises, wearing a pessary can be used as a long term treatment of many pelvic organ prolapses. As such, they are often favoured over surgery. 62% of women report success in using a vaginal pessary with even the most severe stages of prolapses - with success being considered as when symptoms are relieved and the prolapse begins to reduce. Success rates increase with age and in patients of a healthy weight. With a degree of prolapse resolution occurring in 92% of patients.
If you decide to undergo surgery, you may look into wearing a vaginal pessary in the time before hand to support the prolapse and, alongside pelvic floor exercises, strengthen your pelvic floor muscles. This will not only improve your recovery time following an operation, but may also reduce the prolapse to the degree that surgery is no longer necessary. In fact, over 70% of women that elect for a vaginal pessary, do not need to go on to have pelvic organ prolapse surgery.
Since one of the most popular prolapse surgeries fell out of favour due to the controversy surrounding vaginal mesh, the humble pessary has been thrust into the spotlight - and quite rightly so! The high rates of recurrence following surgeries, and the many risks of complications lead most women to opt for different treatments such as the pessary.
Most patients that opt for surgery, do so as they are unable to commit to the six monthly check-up appointments. Or are unhappy or embarrassed by the fitting of a pessary, which can cause some minor grazing.
To read about other non-surgical treatments for pelvic organ prolapses, visit our prolapse treatment page.
Sources
Alba, F. M. Dunivan, G. C. Jeppson, P. C. Komesu, Y. M. Lyons, K. E. Ninivaggio, C. S. Rogers, R. G. (2016). Female Pelvic Medicine & Reconstructive Surgery. Pelvic Organ Prolapse Stage and the Relationship to Genital Hiatus and Perineal Body Measurements. [online] 22(6), p 497-500. [viewed 22/03/2018]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5111866/
Barking, Havering and Redbridge University Hospitals NHS Trust. (2016). Insertion and care of vaginal pessary. [online] Barking, Havering and Redbridge University Hospitals NHS Trust. 2016 [viewed 22/03/2018]. Available from: https://www.bhrhospitals.nhs.uk/download.cfm?doc=docm93jijm4n2177.pdf&ver=4266
Brighton and Sussex University Hospitals NHS Trust. (2016). Department of Gynaecology. Vaginal Pessaries for Pelvic Organ Prolapse. Patient Information. [online] Brighton and Sussex University Hospitals NHS Trust, 2016 [viewed 22/03/2018]. Available from: https://www.bsuh.nhs.uk/wp-content/uploads/sites/5/2016/09/Vaginal-pessaries-for-pelvic-organ-prolapse.pdf
Central Manchester University Hospitals NHS Foundation Trust. (2014). Saint Mary's Hospital, Gynaecology Service - Warrell Unit. An operation for prolapse - Vaginal Hysterectomy. Information for Patients. [online] Central Manchester University Hospitals NHS Foundation Trust, 2014
Chan, S. S. Cheung, R. Y. Chung, T. K. Lee, J. H. Lee, J. H. (2016). Obstetrics & Gynecology. Vaginal Pessary in Women With Symptomatic Pelvic Organ Prolapse: A Randomized Controlled Trial. [online] 128(1), p 73-80. [viewed 22/03/2018] Available from: https://www.ncbi.nlm.nih.gov/pubmed/27275798
Bongers, M. Y. Coolen, A. L. W. M. Mol, B. W. J. Roovers J. P. W. R. Troost, S. (2018). International Urogynecology Journal. Primary treatment of pelvic organ prolapse: pessary use versus prolapse surgery. [online] 29(1), p 99-107. [viewed 22/03/2018] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5754400/
Davies, M. Tam, T. (2013). OBG Management. Pessaries for vaginal prolapse: Critical factors to successful fit and continued use. [online] 15(12), p 42-59. [viewed 22/03/2018] Available from: https://www.mdedge.com/sites/default/files/issues/articles/OBGM_1213_Tam.pdf
Ellison, R. Jones, K. Lee, T. Lowder, J. L. Meyn, L. Moalli, P. Yang, L. Zyczynski, H. M. (2008). Obstetrics & Gynecology. Effect of pessary use on genital hiatus measurements in women with pelvic organ prolapse. [online] 112(3), p 630-636. [viewed 22/03/2018]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18757662
Giarenis, I. Robinson, D. (2014). F1000Prime Reports. Prevention and management of pelvic organ prolapse. [online] 6(77). [viewed 27/03/2018]. Available from: http://f1000researchdata.s3.amazonaws.com/f1000reports/files/9008/6/77/article.pdf
Harmanli, O. Jones, K. A. (2010). Reviews in Obstetrics & Gynecology. Pessary Use in Pelvic Organ Prolapse and Urinary Incontinence. [online] 3(1), p 3-9. [viewed 22/03/2018] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320/
Royal College of Obstetricians and Gynaecologists. (2013). Information for you: Pelvic Organ Prolapse [online] Royal College of Obstetricians and Gynaecologists, 2013 [viewed 26/03/2018]. Available from: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/gynaecology/pi-pelvic-organ-prolapse.pdf
Stanton, S. Thakar, R. (2002). The BMJ. Management of genital prolapse. [online] 324(7348), p 1258-1262. [viewed 23/03/2018]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1123216/
White, B. (2016). Department of Urogynaecology. Vaginal Pessary for prolapse. Information for women. [online] Oxford University Hospitals, NHS Foundation Trust, 2016 [viewed 22/03/2018]. Available from: http://www.ouh.nhs.uk/patient-guide/leaflets/files/14030Ppessary.pdf