What is a pessary?
A pessary is a device that can be used as a support to your pelvic organs. It may take on a few different forms but one of the most common shapes looks like a ring. There are also many other shapes of pessaries including but not limited to a donut, cube, and tampon. This device is typically made of plastic or silicone and can be inserted into the vaginal canal. Pessaries often act like a support for the organs that lie above or may be space-occupying in nature for more advanced forms of prolapse.
Do I need one?
Identify whether the symptoms listed below sound familiar to you.
- Heaviness in lower abdomen
- Heaviness in pelvis
- Discomfort in the pelvis that gets more severe towards the end of the day
- Feeling tissue rubbing on your clothes
- Difficulty fully emptying your bladder
- Pelvic discomfort during intercourse
- Leakage of urine with coughing/ sneezing/ exercise
- Seeing a bulge of tissue inside or protruding from vaginal opening
…if some of these symptoms are relevant, keep reading to learn more about conditions that may be impacting you and how you may be able to use a pessary to help you manage your symptoms.
Feeling symptoms of heaviness in your lower abdomen and pelvic region, seeing or feeling a bulge of tissue in the vaginal canal, experience discomfort during intercourse, and or leakage of urine with sneezing, coughing, or exercise, may be an indication that you are experiencing symptoms of prolapse and or stress urinary incontinence.
A prolapse is a bulging of tissue from the abdomen into or outside of the pelvis. There may be a bulge of the bladder, uterus, rectum, or intestines into or outside the pelvis through the vaginal or rectal openings. The severity of the bulge may be graded on a scale of 0-4. 0 referring to no signs of a bulge to 4, which refers to a prolapse that is bulging completely outside the pelvis. Symptoms of prolapse typically feel more pronounced in the evening or after workouts (especially those that include high impact or jumping). For patients who may be in the postpartum stage it is also common to see exacerbation of symptoms after prolonged exercise that can fatigue the muscles of the body including the pelvic muscles.
Stress urinary incontinence is leakage of urine due to an increase of intra-abdominal pressure. Example scenarios where there may be an increase of intra-abdominal pressure is with coughing, laughing, jumping, or running. Any amount of involuntary loss of urine with an increase in pressure is considered stress urinary incontinence (a small dribble to an episode of full bladder emptying).
What is pessary used for?
The most common use of a pessary is to provide support to the structure that is protruding into the vaginal canal. Think about it like a strong net that is holding contents up. When your pelvic floor muscles are too tight or weak or both of these classifications, this can cause dysfunction in the pelvic floor where the structures from the abdominal and pelvic cavity start to protrude downwards. The pessary is the net that is being used as a bolster to help perform the job of the ligaments in the pelvis and pelvic muscles to keep the structures above in place.
Another advantage of using a pessary is the protruding tissue can be supported upwards to prevent abrasion of grade 4 prolapsed tissue against undergarments. The pessary can help decrease some of the symptoms associated with having a prolapse in a nonsurgical manner. With repositioning of the prolapsed tissue, less discomfort in the abdomen, pelvis and low back may be experienced.
Furthermore, a pessary may be prescribed to help treat symptoms of stress urinary incontinence. If you notice leakage of urine with exercise, coughing or sneezing, please seek care from a physician for individualized assessment and care. Conservative options for treatment of stress urinary incontinence include pelvic floor therapy, behavioral modification including weight loss and smoking cessation, constipation management, and supports including pessaries.
A pessary can support the urethra and bladder wall. The physical support helps prevent leakage by acting as a supportive sling when there is an increase of intra-abdominal pressure. When you jump, run, cough or sneeze, the pessary would be able to support the bladder and urethra helping decrease chances of urinary leakage.
How long does a pessary stay in?
A pessary can remain inside the pelvis as long as you decide to keep it inserted but it should be removed daily, weekly, or monthly to be cleaned. For easy to remove and insert pessaries, daily or weekly cleaning may be advised. For difficult to insert and remove pessaries, your healthcare provider may be able to schedule visits with you monthly to help you with this task. Outside of cleaning the pessary, it can generally stay inserted; however, space occupying pessaries, such as a cube or donut, must be removed prior to having penetrative intercourse as the pessary would act as a block. In contrast, a supportive pessary, such as a ring, can remain inserted during intercourse. In addition, you should be able to wear your pessary comfortably and be able to pass urine.
What are possible complications of pessary use?
Overall, pessaries make for safe usage for most individuals who use it. However, ‘56% of women wearing a pessary reported one of the following symptoms: a foul smell, vaginal discharge, bleeding, pain and constipation as a side effect but a regular follow up can help avoid and help keep complications to a minimum’ (Lamers).
Odor and vaginal discharge
Odor and vaginal discharge are the most commonly reported side effects of pessary use (Dabic). Although it’s important to remove and clean your pessary at the moment, there is no fixed rate of removal and cleaning of the pessary that has been found to improve vaginal discharge symptoms. One study has shown that ‘women who remove their pessaries less often than once weekly have an increased prevalence of anaerobic predominance and bacterial vaginosis in their vaginal microenvironment at 3 months after fitting, but no difference in pessary satisfaction or vaginal symptoms’ (Fregosi).
Bleeding/ spotting
Sometimes bleeding may be experienced with pessary use. You may notice spotting on your underwearing or when going to wipe post voiding. Bleeding may be caused by your pessary rubbing against the tissues in the vaginal canal. If this occurs you should visit your provider so that they can adjust the type or size of the pessary you are using to decrease friction that may be occuring.
Constipation
Some people may experience constipation with use of a pessary if the pessary is too large. The pessary may be putting pressure towards the posterior pelvic muscles which can lead to symptoms of incomplete bowel emptying.
Infection
Although uncommon from pessary use, if you feel chills and or have a fever this may be from an infection and it is important to seek emergency care from your provider.
Ensuring the fit of the pessary is comfortable, taking proper care of the pessary with regular cleaning and having check-ins with your provider who can check the overall health of your vaginal canal are all good strategies to help avoid complications (Po).
When can I consider asking my doctor about using a pessary?
A pessary can serve as a valuable tool for those with any degree of prolapse. It may also help those with symptoms of stress urinary incontinence, and also in cases where surgery isn’t suitable as a form of treatment for one’s prolapse. Pessaries are considered a first line of intervention for prolapse and success rates range from 41% to 74% (Jones & Harmanli, 2010).
Should I consider using a pessary or should I get surgery?
According to research, ‘about 10% of women get surgery to manage their prolapse at some point in their lives’ (Bodner). The decision on getting surgery vs using conservative efforts to manage symptoms is highly dependent on the patient’s preference. Things to consider are age, comorbidities, severity of symptoms. For management of prolapse, typically younger women with more advanced stages of prolapse opted for surgery vs using conservative treatment strategies (Bodner). Physical therapy for treatment of prolapse can be quite effective at reducing subjective symptoms a patient may be experiencing and objective severity of symptoms. A 2015 ‘meta-analysis demonstrated women who received pelvic floor muscle training showed a greater subjective improvement in prolapse symptoms and an objective improvement in pelvic organ prolapse severity.’ (Li Gong). When weighing pessary use and surgery for prolapse treatment is it important to note the side effects of each. Pessary use has some complications, some of which are mentioned earlier. Also, ‘after 24 months 24.5-36% of women stopped using a pessary’ (van der Vaart). Surgery side effects may include “newly reported stress urinary incontinence (9.9%), recurrence of POP (36% over 10 years of follow‐up), newly reported dyspareunia (10%) and a reoperation rate of 17%” (van der Vaart). Provided there are pros and cons for each treatment option, it is important to weigh each with the guidance of your provider.
For symptoms of stress urinary incontinence, pelvic floor physical therapy and pessary use can be a good conservative first line of treatment option. Treatment recommendations for stress urinary incontinence include behavioral modifications followed by devices and pharmacological interventions; once this is exhausted, surgery is often recommended for those who are unresponsive to prior treatment (Al-Shaikh). For those who don’t respond to behavioral modification, are pregnant or elderly and surgery poses risk, or for people who have failed stress urinary incontinence surgery prior, using a pessary to help manage symptoms can be an appropriate next step (Al-Shaikh). Furthermore, some people may have very isolated episodes of stress urinary incontinence. For example, in PT some patients will note that they are having leakage while doing jumping jacks but no other times. In this case, using a pessary during part of the workout where they are doing jumping jacks could be appropriate. The pessary can serve as a temporary assist and support to regulate symptoms while undergoing pelvic floor physical therapy treatment to address the underlying deficits that may be contributing to symptoms. If there’s a resolution of symptoms, the use of a pessary can be discontinued.
Provided pessaries are relatively low cost, easy to use, and pose low risk, they can be a good first line of treatment for those with prolapse or stress urinary incontinence (Al-Shaikh).
Does a pessary prevent further prolapse?
A pessary depending on the type can either support or block the organs above from descending into or outside the pelvis. This said, it may not necessarily keep the prolapse from getting worse. To prevent further prolapse it is important to identify and resolve underlying factors which may be impacting and resulting in you developing it in the first place if possible. For example, if you are experiencing or causing increased pressure in the abdominal cavity or pelvis it’s important to learn how to decrease this. This may be through learning how to properly evacuate your bowels without straining, addressing symptoms of constipation, learning how to cough & sneeze without bearing down on the pelvic floor muscles or even through retraining muscle use as needed with lifting/carrying/ exercising.
If you suspect having any of the issues above, a physical therapist can help evaluate and treat these symptoms. Physical therapists play a role in helping assess and address musculoskeletal imbalances in your system. We can assess your pelvic floor, posture, overall muscle strength and flexibility, identify your pressure management strategies and watch you move to help us address underlying issues that may be playing a role in symptoms of prolapse.
After reading this blog if you suspect you are having symptoms of prolapse, know our team at Beyond Basics is here to help support and guide you in your road to recovery!
REFERNCES:
Al-Shaikh, G., Syed, S., Osman, S., Bogis, A., & Al-Badr, A. (2018). Pessary use in stress urinary incontinence: a review of advantages, complications, patient satisfaction, and quality of life. International journal of women’s health, 10, 195–201. https://doi.org/10.2147/IJWH.S152616
Bodner-Adler, B., Bodner, K., Stinglmeier, A., Kimberger, O., Halpern, K., Koelbl, H., & Umek, W. (2019). Prolapse surgery versus vaginal pessary in women with symptomatic pelvic organ prolapse: which factors influence the choice of treatment?. Archives of gynecology and obstetrics, 299(3), 773–777. https://doi.org/10.1007/s00404-019-05046-7
Dabic, S., Sze, C., Sansone, S., & Chughtai, B. (2022). Rare complications of pessary use: A systematic review of case reports. BJUI compass, 3(6), 415–423. https://doi.org/10.1002/bco2.174
Fregosi, N. J., Hobson, D. T. G., Kinman, C. L., Gaskins, J. T., Stewart, J. R., & Meriwether, K. V. (2018). Changes in the Vaginal Microenvironment as Related to Frequency of Pessary Removal. Female pelvic medicine & reconstructive surgery, 24(2), 166–171. https://doi.org/10.1097/SPV.0000000000000520 (Fregosi)
Jones, K. A., & Harmanli, O. (2010). Pessary use in pelvic organ prolapse and urinary incontinence. Reviews in obstetrics & gynecology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320/
Lamers BH, Broekman BM, Milani AL. Pessary treatment for pelvic organ prolapse and health-related quality of life: a review. Int Urogynecol J. 2011 Jun;22(6):637-44. doi: 10.1007/s00192-011-1390-7. Epub 2011 Apr 7. PMID: 21472447; PMCID: PMC3097351.
Li, C., Gong, Y., & Wang, B. (2016). The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. International urogynecology journal, 27(7), 981–992. https://doi.org/10.1007/s00192-015-2846-y
Lugo T, Riggs J. Stress Incontinence. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539769/
Mayo Foundation for Medical Education and Research. (2022, December 6). When surgery could help with urinary leakage. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/in-depth/urinary-incontinence-surgery/art-20046858
NHS. (n.d.). NHS choices. https://www.nhs.uk/conditions/pelvic-organ-prolapse/
Pessary for treating prolapse. University of Iowa Hospitals & Clinics. (n.d.). https://uihc.org/educational-resources/pessary-treating-prolapse
Pessary for prolapse. University of Utah Health | University of Utah Health. (2023, October 20). https://healthcare.utah.edu/womens-health/pelvic-care-incontinence-center/pelvic-prolapse/pessary
Po, W. (n.d.). Complications of pessary use. SASGOG Pearls of Exxcellence | The Society for Academic Specialists in General Obstetrics & Gynecology. https://exxcellence.org/list-of-pearls/complications-of-pessary-use/ ?categoryName=&searchTerms=&featured=False
Van der Vaart, L. R., Vollebregt, A., Milani, A. L., Lagro-Janssen, A. L., Duijnhoven, R. G., Roovers, J. P., & Van der Vaart, C. H. (2022). Pessary or surgery for a symptomatic pelvic organ prolapse: the PEOPLE study, a multicentre prospective cohort study. BJOG : an international journal of obstetrics and gynecology, 129(5), 820–829. https://doi.org/10.1111/1471-0528.16950\
