If you’ve been told you have a prolapse, the word “pessary” may have come up. A pessary is a small, removable device worn inside the vagina to support the pelvic organs. For many women it’s a simple, non-surgical way to ease the heaviness, bulge and dragging feeling of prolapse, and it’s used more often than most people realise.
This is the first of two posts. Here we cover what a pessary is, the different types of pessary, how one is fitted and who it suits. In the second post we look at living with a pessary day to day.
What is a pessary?
A pessary is usually made of soft, medical-grade silicone. It sits in the vagina and supports the bladder, uterus or bowel where they have dropped. Think of it as an internal brace: it holds things in a better position so you feel less of the bulge, heaviness or dragging.
A pessary doesn’t repair the underlying weakness, but it gives support for as long as it’s in place. When it’s the right size and type, you shouldn’t feel it.
When is a pessary used for prolapse?
Prolapse is extremely common (affecting 50% of people who have had a baby). It’s not really a problem unless you’re having symptoms that bother you. This could include a sense of bulge, heaviness or dragging, or you have trouble emptying your bladder or bowel. Mild prolapse often causes no symptoms and doesn’t always need treatment.
A pessary may be worth considering if you:
- want to try a non-surgical option
- would like to avoid or delay surgery, or surgery isn’t suitable for you
- are doing pelvic floor rehab and want extra support while you build strength
- are waiting for surgery and want symptom relief in the meantime
Pessaries are also sometimes used for stress urinary incontinence. This post focuses on prolapse.
Pessary, pelvic floor exercises or surgery?
It’s not an either/or choice. For mild to moderate prolapse, current guidelines (including NICE guideline NG123) support supervised pelvic floor muscle training as a first step, ideally over at least four months with an experienced pelvic health physiotherapist. A pessary is another non-surgical option, and it can be used on its own or alongside pelvic floor training.
A review of the evidence found that a pessary combined with pelvic floor muscle training probably improves prolapse symptoms and prolapse-related quality of life more than pelvic floor training alone. Surgery is generally kept for women whose symptoms haven’t improved with non-surgical treatment, or who prefer to go straight to an operation.
Types of pessary for prolapse
There are two broad groups: support pessaries, which sit under the pelvic organs, and space-filling pessaries, which hold themselves in place. The most common types are:
- Ring pessary (with or without support): usually the first type tried. It folds for insertion and sits behind the pubic bone. Many women can have sex with a ring pessary in place, and your physiotherapist will talk this through with you.
- Gellhorn and Shaatz pessaries: often used for more advanced prolapse, or when a ring won’t stay in.
- Donut pessary: a bulkier option for more severe prolapse, particularly when the support at the vaginal opening is lax.
- Cube pessary: a space-filling type that is taken out every night and put back in the next morning.
Apart from the cube, pessaries can usually stay in for around two weeks at a time before being taken out, cleaned and put back. We cover this in more detail in the next post.
The right choice depends on your type and degree of prolapse, the length and shape of your vagina, whether you’ve had a hysterectomy, and what suits you.
How is a pessary for prolapse fitted?
Four of our pelvic physiotherapists are highly skilled and experienced in fitting pessaries. It’s common to try more than one size or type at the first fitting session. We have a wide range of fitting kits with lots of different sizes, meaning we can trial different ones to see which works best for you (the trial ones are sent away for sterilising afterwards). That way you can be more sure that the one you buy is the right fit for you.
A typical first appointment looks like this:
- We talk through your symptoms, bladder, bowel and sexual function, and do an internal examination to see which organs are involved and how far they’ve dropped.
- Choosing a pessary. We explain how the different types work, and we choose the type that will help your symptoms, and we measure the size you need – everyone is different.
- Fitting. The pessary is inserted with a little water-based lubricant. A good fit sits comfortably inside, you’re not aware of it and it gets rids of your symptoms.
- Testing it. We’ll ask you to walk around, cough, squat and go to the toilet to check it stays in, feels comfortable and doesn’t get in the way of emptying your bladder.
- Learning to look after it. We teach you how to insert and remove your pessary so you can manage it yourself. A cube pessary comes out every night, and other types can usually stay in for around two weeks at a time. We also plan a check soon after fitting, then regular reviews.
After menopause, vaginal oestrogen is often suggested to keep the vaginal tissue healthy and comfortable. We cover this in the next post.
Does a pessary work?
For most women, yes. Studies vary, but in many clinic studies roughly 7 to 9 out of 10 women can be fitted successfully. An international review showed that once a pessary is fitted well, bulge and pressure symptoms settled in more than 90% of cases.
Long-term use varies. Depending on the study, 50-80% women are still using their pessary a year later, and many use one for years. Common reasons for stopping include the pessary falling out, irritation, not enough improvement, or difficulty managing it. Others stop using it because their prolapse has improved and they no longer need it! Women who can look after their pessary themselves, or have support to do so, are more likely to keep using it, which is why we teach self-management.
Some situations make fitting harder, such as previous prolapse surgery or hysterectomy, a short vagina, a wide vaginal opening, or prolapse of the bowel wall (the back wall of the vagina). These don’t rule a pessary out. They may just mean more trial and error.
Is a pessary right for me?
It’s worth asking about if you have symptoms of prolapse and want to avoid surgery, or want more support while you work on your pelvic floor. It’s not suitable for everyone, which is why an assessment comes first. Pain, bleeding you can’t explain, or a possible infection need to be checked before a pessary is fitted.
If you’re not sure what’s going on, start with an assessment. We can tell you what type of prolapse you have, what your options are, and whether a pessary is likely to help.
Frequently asked questions
Is a pessary for prolapse able to be felt?
A well-fitted pessary shouldn’t be noticeable. If you can feel it, or it’s uncomfortable, the size or type may need adjusting, so let us know rather than putting up with it.
Is fitting painful?
It shouldn’t be. Some women feel a little pressure or mild discomfort while it’s being placed. Pain once it’s in is a sign that something needs changing.
Can I have penetrative sex with a pessary in?
It depends on the type of pessary you have. Some people can have sex with a ring pessary in place, while others need to remove it first. Cube pessaries need to be removed before sex. We’ll tell you what applies to your pessary.
Will it fall out?
It can. Falling out is one of the reasons people stop using a ring pessary, which is why getting the one matters. If it does come out, it can usually be refitted, sometimes with a different size or type.
Can I look after the pessary myself?
Yes, and we encourage it. We teach you how to insert and remove your pessary, so you don’t need a clinic visit every time it’s changed. A cube pessary comes out every night and goes back in the next morning. Other types can usually stay in for around two weeks at a time. We’ll take you through it step by step.
Do I have to use a pessary forever?
No. Some women use one for a short time, for example while they build pelvic floor strength or wait for surgery, and others use one for many years. Some even find their symptoms improve enough to stop.
Do I need a referral to get a pessary for prolapse?
No. You can book directly with our clinic without a referral.
Thinking about a pessary? Four of our specialist pelvic floor physiotherapists are experienced in fitting pessaries. We can assess your prolapse, talk through your options (including pelvic floor rehab, a pessary and when to see a gynaecologist) and teach you to manage a pessary yourself. No referral needed.
Also in this series
Living With a Pessary: Care, Check-Ups and What’s Normal [insert link when published]
