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Introduction[edit | edit source]

A pessary is a conservative, minimally invasive device used to manage pelvic organ prolapse (POP) and stress urinary incontinence (SUI).[1] The purpose of the pessary is to keep the POP from bulging beyond the opening of the vagina and help reduce symptoms associated with POP.

Pelvic organ prolapse is a condition where the pelvic organs descend below their anatomical position, causing alterations in the vaginal, genital canal, or rectal walls. [1]

Use of a pessary can provide immediate relief to symptoms associated with POP.

Indications for a Pessary[edit | edit source]

Symptoms of POP include:[1]

  • A visible bulge
  • Reports/feelings of pressure
  • Voiding dysfunction
  • Defecatory dysfunction
  • Sexual dysfunction

Research has shown that pessaries are effective in eliminating symptoms of POP, preventing the progression of POP, maintaining control of SUI, improving QoL, improving patient's body image, and improving bowel symptoms. [2][3][4][5][6]

Pessaries can be used short-term or long-term. A physical therapist should collaborate and communicate often with the patient's other medical providers involved in their urogynecological care. [1]

Side Effects of Using a Pessary[edit | edit source]

Common side effects of using a pessary include:[7]

  • Vaginal discharge
  • Odor

Severe complications with pessaries are rare, but may occur:[7]

  • Vesicovaginal fistula
  • Rectovaginal fistula
  • Erosion and subsequent impaction

These complications can be avoiding with appropriate pessary fitting, local estrogen, and regular follow-up medical care.

Precautions for a Pessary[edit | edit source]

If a patient is being considered for a pessary and has any of the below conditions, they should be referred to their advanced medical providers for the appropriateness of pessary fitting.[1]

  • Genitourinary syndrome of menopause
  • Pregnancy
  • Cognitive impairment
  • Urinary retention
  • Vaginal dermatoses (i.e. lichen sclerosis and lichen plans)
  • Obesity[7]

Contraindications for a Pessary[edit | edit source]

  • Active infections of pelvis or vagina
  • Short vaginal length
  • Prior hysterectomy
  • Prior POP surgery
  • Patients who are non-compliant or unlikely to follow-up for medical care [5]

Types of Pessaries[edit | edit source]

Pessaries are classified into Support, Space filling, and Incontinence groups.

Support Pessary[edit | edit source]

Support pessaries are used for all stages of POP. These commonly include ring (with and without support), Gehrung, and Shaatz pessaries.

Support pessaries are inserted into the vagina and are positioned between the pubic bone and the posterior vaginal fornix.[8]

Space filling Pessary[edit | edit source]

Space filling pessaries are typically used for more severe POP (stages 3 and 4).[6] These commonly include Gellhorn, cube, and donut pessaries.

Space filling pessaries provide support by filling the vaginal space to prevent further POP progression. These pessaries create a suction effect around the pessary to increase the likelihood of retention.[8]Sexual intercourse is not possible with a space filling pessary.[7]

Incontinence Pessary[edit | edit source]

Incontinence pessaries are used to manage stress urinary incontinence. These commonly include incontinence ring and incontinence dish pessaries. [5]

Incontinence pessaries compress the urethra against the upper posterior portion of the pubic symphysis and elevates the neck of the bladder to increase the outflow resistance during voiding. [5]

For patient's that only experience SUI during strenuous activities, such as running or jumping, a cube pessary inserted before exercises may be used. [5]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4
  2. Brazell HD, Patel M, O'Sullivan DM, Mellen C, LaSala CA. The impact of pessary use on bowel symptoms: one-year outcomes. Female Pelvic Med Reconstr Surg. 2014;20(2):95-98. doi:10.1097/SPV.0000000000000060
  3. Lamers BH, Broekman BM, Milani AL. Pessary treatment for pelvic organ prolapse and health-related quality of life: a review. Int Urogynecol J. 2011;22(6):637-644. doi:10.1007/s00192-011-1390-7
  4. Patel MS, Mellen C, O'Sullivan DM, Lasala CA. Pessary use and impact on quality of life and body image. Female Pelvic Med Reconstr Surg. 2011;17(6):298-301. doi:10.1097/SPV.0b013e31823a8186
  5. 5.0 5.1 5.2 5.3 5.4 Viera AJ, Larkins-Pettigrew M. Practical use of the pessary [published correction appears in Am Fam Physician 2002 Jul 1;66(1):30]. Am Fam Physician. 2000;61(9):2719-2729.
  6. 6.0 6.1 Deng M, Ding J, Ai F, Zhu L.  Clinical use of ring with support pessary for advanced pelvic organ prolapse and predictors of its short-term successful use.  Menopause.  2017; 24 (8): 954-958.  doi: 10.1097/GME.0000000000000859.
  7. 7.0 7.1 7.2 7.3 Jones KA, Harmanli O. Pessary use in pelvic organ prolapse and urinary incontinence. Rev Obstet Gynecol. 2010;3(1):3-9.
  8. 8.0 8.1 Bugge C, Adams EJ, Gopinath D, et al. Pessaries (mechanical devices) for managing pelvic organ prolapse in women. Cochrane Database Syst Rev. 2020;11(11):CD004010. Published 2020 Nov 18. doi:10.1002/14651858.CD004010.pub4