Pessary

What is a pessary?

A pessary is a removable device that you or your healthcare provider can insert into your vagina to support your pelvic organs. Your pelvic floor muscles provide the structural support necessary to hold your pelvic organs in place. These organs include your uterus, bladder, urethra (the tube that your pee comes out through) and rectum.

If your pelvic floor muscles become injured or weak, the organs can slip out of place and cause uncomfortable symptoms. This is what happens if you have pelvic organ prolapse (POP).

Even common experiences — ranging from pregnancy and childbirth to repetitive heavy lifting — can lead to muscle weakness and slippage over time.

A pessary is one potential treatment option that can help.

What are pessaries used for?

A pessary can help manage the symptoms of pelvic organ prolapse and stress incontinence.

• With pelvic organ prolapse, you may feel an unpleasant fullness in your vagina from the organ that’s slipped down into it. With severe prolapse, you may be able to feel the organ poking out of your vagina.
• With stress incontinence, you may dribble pee or have accidents when you laugh, cough, sneeze or exercise.

In most cases, people choose a pessary when they want symptom relief but want to avoid surgery to fix their pelvic floor muscles. Or, you may choose a pessary if you have medical problems that make surgery too risky.

Sometimes, a pessary is an option after other conservative treatments, like pelvic floor exercises and physical therapy, haven’t helped.

What types of pessaries are available?

Pessaries come in different shapes and sizes. Most are made of safe, nonabsorbent soft silicone.

The two most common types of pessaries are the:

• Ring pessary: This O-shaped pessary is the one most healthcare providers recommend for treating stress incontinence and mild to moderate pelvic organ prolapse. They come in different varieties, so your provider can pick the version that’s best for you.
• Gellhorn pessary: A Gellhorn pessary is usually the go-to option for advanced pelvic organ prolapse. This pessary is disk-shaped with a knob in the center. A Gellhorn pessary is called a space-filling pessary. In addition to providing support, like the ring pessary, the Gellhorn fills the space in the upper part of your vagina. It creates a barrier that prevents pelvic organs from slipping into your vaginal canal.

Your healthcare provider may fit you for other types of pessaries, including the:

• Shaatz pessary: Disk-shaped (like the Gellhorn) but without the knob.
• Gehrung pessary: U-shaped with a rubber membrane (especially useful in treating prolapse involving your uterus or bladder).
• Donut pessary: Like the ring but thicker (often used as an alternative to the Gellhorn).
• Cube pessary: Cube-shaped but with concave sides that suction to the sides of your vaginal walls (often used as an alternative to the Gellhorn).

Most pessaries require an in-office fitting with your healthcare provider, but some pessaries that treat stress incontinence are available over the counter (OTC). Once inside your vagina, they support your urethra so that pee doesn’t dribble out.

Over-the-counter pessaries include:

• Impressa®.
• Uresta®.
• Contiform®.

How is a pessary fitted?

During your visit, your healthcare provider will fit you with a pessary. On the day of your appointment, they’ll:

• Perform a pelvic exam. They’ll examine your vagina and your pelvic organs closely. The size of your vaginal opening, the length of your vaginal canal and the severity of your prolapse all play a role in helping your provider pick the right pessary.
• Determine the type and size of pessary you need. A pessary that’s too small may fall out when you use the bathroom. A pessary that’s too big can feel uncomfortable. The goal is to find a pessary that’s large enough to stay in place but comfortable enough that you don’t feel it.
• Place the pessary. They’ll gently insert the pessary. To ensure your comfort, they may lubricate the pessary so it slides in easily. If you’re concerned about discomfort, they may apply lidocaine to numb your vaginal opening before insertion. Communicate with your healthcare provider about what’s comfortable for you.
• Test that the pessary works. You may need to stand, sit, squat or perform other maneuvers to ensure your pessary stays put. Your provider may ask you to cough to check that you’re not dribbling. They’ll ask you to empty your bladder before you leave. You should be able to pee with your pessary in.

They’ll also tell you what to do if your pessary slips out of place or isn’t working. Don’t feel frustrated if your first pessary fitting isn’t your last. It may take two or three fitting attempts to get things right. Your provider will work with you to find the right device and fit.

How do you care for a pessary?

The ring pessary is the easiest to take care of on your own. If you have a ring pessary (or another type that you can remove and reinsert), you can remove and clean it weekly or even nightly. Caring for it is simple:

1. Wash your hands with soap and water and gently pull out the pessary.
2. Wash it with mild soap and water.
3. Rinse and dry it completely before reinserting.

You’ll need follow-up visits every six to 12 months in your provider’s office. During the visit, your provider will examine your vagina to ensure the pessary isn’t scraping or bruising your vaginal walls. They’ll ensure the pessary’s still in perfect working condition.

If you can’t remove the pessary on your own, you’ll need to see your healthcare provider every three to six months for cleaning and checkups.

How long can a pessary be left in?

It depends on the type. Hard-to-remove pessaries can be left in for a few months. You won’t need to remove it until your next provider visit to have it cleaned.

If you can remove your pessary yourself, you may choose to clean it nightly or weekly. Some people prefer to clean it before bed, sleep without it and reinsert it the next morning.

Although you can wear smaller ring pessaries during intercourse, some people choose to remove them before sex.

Follow your provider’s guidance on inserting and removing your pessary based on the type you use.

What are the benefits of a pessary?

A pessary can reduce (and often resolve) symptoms of pelvic organ prolapse and stress incontinence without surgery. Also, pessaries are inexpensive and safe to use.

Are there any risks or complications from using a pessary?

A pessary is a safe treatment, with minimal risks. But pay attention to changes in your body. If something seems off, contact your provider. There are often straightforward solutions to fix the issue.

Signs to look out for include:

• Pain or discomfort. This usually means the pessary doesn’t fit correctly. You likely need a different size.
• Pink or bloody discharge. Pink or bloody discharge is a sign that your pessary is rubbing against your vaginal wall. You’ll likely need a different size pessary. You may need to remove the pessary for a while to give your skin time to heal. Your provider may also prescribe low-dose vaginal estrogen. This can help improve the health of your vaginal skin, which gets thinner with age.
• Unusual vaginal discharge and odor. White-colored vaginal discharge is normal with a pessary. But an unpleasant vaginal odor signals an infection. You may need antibiotics to clear it.

What is the downside of using a pessary?

Pessaries aren’t for everyone. The downsides of getting one include:

• The trial and error of finding the right type and fit: It’s common to need multiple fittings to find a pessary that stays in place without feeling uncomfortable. The trial and error can feel frustrating.
• Upkeep: A pessary requires frequent provider visits to ensure it’s safe and working correctly. Some people prefer long-term solutions, like surgery.
• Removal for sex: The types of pessary that fill your vagina (the Gellhorn, donut and cube) need to be removed before you can have intercourse. Many people need a provider to remove and reinsert them. Depending on your lifestyle, a pessary can put a damper on your sex life.
• Long-term effectiveness: Pessaries don’t work for everyone. A pessary may be the ideal long-term treatment for you. Or, you may eventually need surgery. Some people with stress incontinence report better results with treatments like Kegel exercises to strengthen weakened pelvic floor muscles over pessaries.

When should I call my healthcare provider?

Contact your healthcare provider if you’re experiencing pain or discomfort, or if you’re noticing an abnormal, foul-smelling discharge. You may need to be refitted for a pessary, or you may need treatment for an infection.

Is it better to have a pessary or surgery?

The short answer is: it depends.

Often, a pessary provides symptom relief so you can avoid more invasive treatments. But if your prolapse is severe, a pessary may not work for you. Some studies show that while pessaries and surgery both improve symptoms for advanced-stage pelvic organ prolapse, surgery may provide more long-term satisfaction.

Surgery may be a better option if you’re unable to attend the follow-up appointments needed to check on your pessary’s placement and the health of your vagina. These visits are essential.

Your healthcare provider can help you weigh the pros and cons of choosing a pessary over surgery.