Pessaries for pelvic organ prolapse

What is Pelvic Organ Prolapse?

Pelvic organ prolapse (POP) occurs when there is weakness in the pelvic floor muscles or supporting structures of the pelvic organs (bladder, uterus or bowels/rectum) causing the organs to descend into the vagina. Common symptoms can include:

-Heavy dragging feeling 

-Lump or bulge in the vagina

-Bladder or bowel problems

-Discomfort during sexual intercourse   

It can affect your quality of life and limit physical activity and work due to vaginal discomfort.

Pregnancy, vaginal births, chronic constipation, and chronic cough are common causes of POP: however, symptoms may become worse following menopause due to the natural loss of oestrogen.

What is Pelvic Organ Prolapse?

A prolapse can be managed conservatively. A thorough vaginal examination by a physiotherapist or GP with specialist training in pelvic health, or a Gynaecologist. Recommendations for treatment depends on the degree of your symptoms and stage of prolapse. Treatment may include a combination of:

-Lifestyle modifications

-Pelvic floor muscle training

-Vaginal pessary

Surgery may also be a treatment option. This will require further discussion with your healthcare team.

What is pessary?

A vaginal pessary is a removable silicon device that can be inserted into the vagina to help provide support to the prolapse. The size and shape used will depend on the type and stage of your prolapse.

A pessary can assist in (Sung et al. 2016):

-Providing instant relief of POP symptoms

-Decreasing prolapse symptoms with exercise and daily activities

-Improving comfort during sexual intercourse

-Improving bladder and bowel function

-Pelvic floor muscles to work better (Demoulin 2017)

A pessary can be a short or long-term management option for POP. It cannot fix a prolapse, however it may significantly help to reduce its impact on your life.

Cube pessary

Gellhorn pessary

Ring pessary

How is a pessary fitted?

A pessary can be fitted by a gynaecologist or a specialist physiotherapist in collaboration with your GP. Once the correct pessary is successfully fitted (Cundiff et al. 2007), you can choose to self-manage which involves learning how to remove, clean and insert the pessary. Self-management reduces the risk of complications and frequency of follow-up appointments. Some women are unable to self-manage or choose to have their pessary managed by their healthcare team.

Follow up

It is important that patients follow the appropriate self-care advice and attend the required appointments for review.

Self-care includes removal, cleaning, and re-insertion as per requirements of the pessary you have been fitted with.

Follow up appointments for a self-managed pessary include:

-1-2 weeks post pessary fitting. This is to ensure that the pessary is well positioned and that there have not been any complications

-4 months with the physiotherapist

-Every 12 months with a GP or Gynaecologist. It may involve a speculum examination. (Robert et al. 2013)

The pessary will need to be replaced every 12 months as per manufacturers guidelines. (Profem 2019)

Is there risk of complications?

Most complications are mild, (Atnip & O’Dell 2012) can be managed by your GP or physiotherapist and can include:

-Vaginal discharge colour change or unusual smell: An increase in normal discharge is very common, and often will settle after a few weeks.

-Pain or discomfort in the pelvis or abdomen: It is possible a different pessary size or style is required.

-Difficulty emptying bladder or bowel.

If any of these symptoms occur, the health care practitioner should be contacted.

More rare and serious complications can occur when a pessary has been neglected or a patient has not attended reviews or appropriately followed self-care advice (Torbey 2014). These include infection, vaginal bleeding and ulceration or vaginal tissue erosion. If this occurs, a doctor will need to be contacted. (Nameth et al 2013)

It is important to attend follow up appointments to prevent more serious complications.

It is importat to continue pelvic floor muscel exercises?

Yes! Exercises may be helpful to reduce the need for the vaginal pessary when pelvic floor muscle strength has improved. With the use of a pessary, pelvic floor muscle training may be more effective. (National Guideline Alliance (UK) 2019)

Is vaginal oestrogen necessary?

If you are post-menopausal or currently breast feeding you may benefit from using vaginal oestrogen as natural levels will be low. Vaginal oestrogen can assist in reducing the risk of complications discussed above. Your GP can prescribe this. (O’Dell & Atnip 2013)