What are pessaries?
Pessaries are prosthetic devices (like orthotics) that are placed inside the vagina to support the internal organs. They come in MANY shapes and sizes depending upon which organ(s) need(s) support, and what symptoms need improving. They are generally made of silicone, but can be made of other medical-grade materials too.
My favorite analogy about pessaries is that they are like a sports bra for your internal organs! So there is no shame in needing to use one, especially for higher-impact activities. And just like a sports bra, they don't make the surrounding muscles weaker, they just provide you a little lift right where you need it.
Fun fact, pessaries have been around since at least 400BC. People used to put ALL kinds of things inside vaginas to support the internal organs...my favorite is half a pomegranate soaked in wine as described by Hippocrates!
What can pessaries help with?
Pessaries help lift organs back towards their original position when they have started to shift due to pelvic organ prolapse. But, pessaries also help control symptoms typically associated with prolapse, like urinary incontinence and pelvic pressure.
One of the number one indications for a pessary also is stress urinary incontinence, which most people don't know! So even if you only have stress incontinence with exercise, but don't necessarily have a prolapse, a pessary can still help you.
Most of the time we think that pessaries are just helping to decrease symptoms while the pessary is in place. But, there is some emerging evidence to show that regular pessary use can actually improve the grade of the prolapse. This is because the pessary can reduce the strain on the prolapsed organ's ligaments, and then over time those ligaments may shorten and provide better support to the organ.
Do they really work?
Yes!! Pessaries have a really high acceptance rate of over 70% (Vasconcelos 2020). And it's been established in multiple studies that pessaries in combination with pelvic floor muscle training is very effective, more so than either alone (Bugge 2020). Plus, once they are fit well, pessaries generally are a good long-term option. 60% of people are still using their pessaries after 2 years from the initial fitting (Mao 2019).
The combo of pessaries and pelvic floor exercise can really make sense when you think about the pressure that a prolapsed organ can place on the pelvic floor. If you always have something pushing down against a muscle you are trying to work, it will be much harder for you to engage/activate that muscle. So, with a pessary in place, your pelvic floor can engage much better and get stronger more easily than without it!
Are pessaries helpful for all types of prolapse?
Not necessarily—this is the big bummer about pessaries. Pessaries can be incredibly effective for bladder and uterine prolapse. However, for rectoceles (rectum falling into the vagina), pessaries are very hard to fit and much less effective. This is because most pessaries for the bladder and uterus will pop in place by sitting behind the pubic bone. The pubic bone and pelvic floor will act like a little "shelf" to help hold it in place. But, for the backside of the vagina (the rectum), there isn't anything for the pessary to rest against.
It doesn't mean that if you have a rectocele you can't find a pessary that works for you, but just remember that it might be a longer and more-frustrating process than average. And in the end, you may decide you are better off without a pessary than with one.
Who might need a pessary?
A pessary can be helpful for you if you:
Have pelvic organ prolapse
Have stress incontinence
Do not need or do not want to have surgery
Need surgery but are unable to undergo surgery for medical reasons, or because you aren't done having children yet (and yes you can use pessaries while pregnant!)
Who may not do well with a pessary?
If you fit any of these criteria, a pessary may not be for you:
Are a smoker
Have a shortened vaginal length from radiation or any other medical procedures
Have had prior vaginal surgery
Have had a pelvic floor avulsion during childbirth (not a typical tear, but where the pelvic floor muscle is pulled off the pubic bone)
Have fragile vulvar tissues or are otherwise prone to skin breakdown
Aren't pessaries just for old ladies?
Absolutely not! Anyone can use a pessary at any age, and at any stage of prolapse. As we've discussed before, the stage/severity of prolapse and the symptoms of prolapse don't necessarily match. So some people have very minimal prolapse with very severe symptoms, while others can have advanced prolapse with little to no symptoms. So, especially if you've already worked on your pelvic floor, gone to PT, etc etc and are still struggling with prolapse and/or stress incontinence symptoms, a pessary may be really helpful for you.
The bonus to being younger and using a pessary is that it typically means you’ll have an easier time inserting and removing the pessary on your own. Some older people, or generally people with arthritis or limited mobility, can’t reach their vagina well. Or, they may have trouble with the finger dexterity needed to put the pessary in or take it out. So if you don’t live with arthritis or limited mobility and only have symptoms with exercise, you can put the pessary in for exercise and take it out when you are done. Or you can remove it for intercourse and put it back in afterwards without a big hassle. And some pessaries you can even leave in for intercourse depending upon their shape and size.
How do I insert them, and what do they feel like?
Pessaries are really similar to menstrual cups and discs in this manner as most of them are very flexible. You typically squeeze them between your fingers, slide them in vertically, and then they pop into place behind the pubic bone. Once they are inserted, you shouldn't feel them.
Other types of pessaries that are called "space-filling" pessaries (like cube pessaries) rely on suction to stay in place. These do not compress in your hand. So those you push up into the vaginal canal like a tampon, and then they will stay in place on their own.
What about cleaning?
This is a great question and you may get different advice depending upon your sources! The difference here really relies upon whether or not you can insert and remove your pessary on your own. If you are able to do so, then it's recommended you take it out and clean it with soap and water about 1-2x/week. However, I've also heard the argument that if you are only doing it 1-2x/week you are likely to forget! So every day may be best. And if you do have sex with it in, you need to take it out and clean it afterwards.
If you cannot remove it on your own (especially if you have arthritis in your hands, or otherwise have some limitation with upper extremity mobility), then you do need to visit your doctor once every 3 months to have it removed, cleaned, and re-inserted.
Where and how do I get a pessary?
Most gynecologists (GYNs) have the ability to fit pessaries. However, depending upon their individual experience they may not feel comfortable fitting all types of pessaries, or may not have a lot of options for you to choose from. So, as I've said in previous posts you may want to see a your gynecologist if you have trouble fitting your pessary, or don't do well with the one your GYN gave you.
The good news is that PTs can now fit pessaries too! However, this is very new to the PT scope of practice (at least in the US), so not many PTs are offering this service yet. But if you think about it, it makes sense for PTs to fit pessaries. We have the luxury of spending more time with patients, so we can make sure to get the exact right fit. Plus since we have more space we can usually have you stand up, walk around, even jump or run, etc to make sure it stays in and is comfortable. And we already have experience with things like foot orthotics, so this is just like a foot orthotic for your vagina! I'm excited to see more and more PTs be able to offer this service to their patients.
Most of the time pessaries are covered by insurance, but like most things in women's health care, this can be variable. So if you have questions about coverage, make sure to discuss it with your provider, or even better call your insurance company ahead of time.
Pessaries often get a bad rap or are not thought of for most of us who are younger with prolapse and/or incontinence. But they can be SO helpful, and really should be the first line intervention after pelvic floor exercise/PT for prolapse and stress incontinence! They are pretty cost-effective (certainly less than surgery and PT), don't limit your future options (unlike surgery), and can always be removed and/or changed in size if they become uncomfortable. In fact, it's pretty normal to have to change sizes over time if you use a pessary long-term.
Bugge, C., Adams, E. J., Gopinath, D., Stewart, F., Dembinsky, M., Sobiesuo, P., & Kearney, R. (2020). Pessaries (mechanical devices) for managing pelvic organ prolapse in women. The Cochrane database of systematic reviews, 11(11), CD004010. https://doi.org/10.1002/14651858.CD004010.pub4
Mao, M., Ai, F., Kang, J., Zhang, Y., Liang, S., Zhou, Y., & Zhu, L. (2019). Successful long-term use of Gellhorn pessary and the effect on symptoms and quality of life in women with symptomatic pelvic organ prolapse. Menopause (New York, N.Y.), 26(2), 145–151. https://doi.org/10.1097/GME.0000000000001197
Vasconcelos C, Gomez M, Geoffrian R ,et al. Pessary evaluation for genital prolapse treatment: From acceptance to successful fitting. Neurourology andUrodynamics. 2020;39:2344–2352.
Photo by Alexy Almond: https://www.pexels.com/photo/woman-in-pink-top-and-leggings-stretching-3757739/