What Is a Pessary?

A pessary is a soft, flexible device that is inserted into the vagina to support pelvic structures such as the bladder, uterus, and rectum and to prevent their protrusion into the vagina. They are made in a variety of shapes and sizes and can be an effective, non-invasive way to treat pelvic organ prolapse.

Different forms of pessary have been used since ancient times, including a reference by Hippocrates in which half a pomegranate was used to support a prolapsed uterus. By the 16th century, pessaries were commonly made by dipping a ball of string into wax. It was only when vulcanized rubber was discovered in the 19th century that pliable pessaries were manufactured on a production scale.

Most pessaries today are made of medical-grade silicone and are durable, hypoallergenic, and relatively easy to insert and remove.

A pessary also describes vaginal suppositories used to deliver medications via porous vaginal tissues.

Types and Uses

When referring to pessaries, most people will take that to mean devices that are used to support the pelvic floor and treat conditions like urinary incontinence.

And, while it is true that pessaries are used mainly for these purposes, the term can also be applied to certain medications delivered intravaginally. Even a cervical cap, used to prevent pregnancy, can technically be considered a type of pessary.

Therapeutic Pessaries

Prolapse occurs when a body part slips out of its normal position and protrudes into an adjacent structure. A pelvic organ prolapse is used to describe the protrusion of the pelvic organs—most commonly the bladder—through the vaginal opening.

A pessary is a non-surgical way to treat pelvic organ prolapse. Given that the surgical treatment of pelvic organ prolapse is associated with high rates of recurrence, pessaries offer a welcome alternative for most women.

The design of the pessary can vary by the condition being treated, the most common which include:

• Uterine prolapse occurs when the uterus falls out of place and bulges into the vagina.
• Cystocele, also known as anterior prolapse, occurs when the bladder drops from its normal position, creating a bulge in the vagina.
• Rectocele occurs when the tissue between the rectum and vagina weakens, allowing the rectum to bulge against the back of the vagina.
• Enterocele occurs when the upper wall of the vagina weakens and allows the small bowel to bulge into the vaginal space.

To help relieve these and other conditions, pessaries are distinctly shaped to support the specific prolapsed structure. Among them:

• Ring pessaries are the most common support device, some of which are hollow like a doughnut and others of which have a perforated membrane in the center to facilitate urination.
• Cube pessaries are shaped like cubes with concave sides. They are used for milder, third-degree prolapse and are generally worn during the day only.
• Gehrung pessaries are shaped like a saddle and are sometimes used to treat rectocele or cystocele.
• Shaatz pessaries are used for more serious, first- or second-degree prolapse and are shaped like a solid well with a large central hole and smaller surrounding holes.
• Gelhorn pessaries are used to treat severe first-degree prolapse have a solid, round base and a finger-like stem that keeps the pessary from twisting.
• Inflatable pessaries are available to treat third-degree prolapse and allow for a custom fit as you inflate the ball-like device with a palm pump.
• Lever pessaries are distinctively shaped rings, some of which are bent and folded into different conformations. While less commonly used, they are sometimes indicated for the treatment of uterine retroversion ("tilted uterus")

Pharmaceutical Pessaries

Pharmaceutical pessaries are solid, single-dose medications that are inserted into the vagina to treat local infections or other conditions.

Pharmaceutical pessaries are usually cone-shaped and made with a wax-like substance that dissolves at body temperatures, allowing for the gradual absorption of a drug into porous vaginal tissues. They are not unlike rectal suppositories that deliver drugs via the rectum.

One of the most common uses of a pharmaceutical pessary is to treat a severe vaginal yeast infection. Such a pessary would contain a single dose of an antifungal drug (like clotrimazole) and be inserted before bedtime for easy overnight dosing.

There are also pessaries used to induce labor in women with prolonged pregnancy or the premature rupture of membranes. The pessary contains the hormone prostaglandin which helps soften the cervix and induce contractions.

Occlusive Pessaries

Occlusion is a term used to describe the blockage or sealing of a bodily structure. An occlusive pessary works by blocking entry through the cervix and, by doing so, prevent conception.

A cervical cap, also known as FemCap, is a silicone device shaped like a sailor's hat that is used in tandem with a spermicide to prevent pregnancy.

It is one of the least effective forms of contraception, and its use has dropped significantly given the superiority of hormonal contraceptives and intravaginal devices like the diaphragm.

Sizing and Preparation

Every vagina is different and requires a correctly fitted pessary to work well. The pessary should not only be comfortable but should not interfere with your ability to urinate. It should not fall out if you bear down or strain.

Therapeutic pessaries are fitted in a healthcare provider's office. To get the correct size, the healthcare provider will first perform a pelvic exam and try several different sizes until the right one is found. The largest size you can wear comfortably is usually the best choice.

If a pessary is used to treat stress urinary incontinence, you may be asked to cough when the pessary is inserted and removed. The correctly fitted pessary will not fall out.

There are factors that can interfere with the proper fit, including:

• Previous pelvic surgery
• Obesity
• Vaginal deformity
• Having given birth multiple times
• Vaginal length of less than 2.75 inches (7 centimeters)
• A wider-than-normal vaginal opening (referred to as introitus)

The cost of a pessary is usually covered by health insurance, at least in part, if medically indicated. Most silicone pessaries last for around five years if used and cared for appropriately.

How to Insert a Pessary

Most pessaries can be removed and reinserted at home. In some cases, a pessary may be inserted by a healthcare provider and removed, washed, and reinserted every three to six months.

A pessary usually requires an appropriate lubricant to help ease in the device. Postmenopausal women may be advised to use estrogen cream which helps relieve dryness and increase the thickness of the vaginal wall.

Your healthcare provider will show you how to insert the pessary correctly, but the procedure generally follows similar guidelines:

• Ring pessaries are folded in half before insertion. The folded edge is then lubricated and inserted into the vaginal opening. Once positioned, the ring is unfurled and urged into the large recess behind the cervix (called the posterior fornix). The ring is then given a slight twist to ensure that it fits snugly.
• Cube pessaries are squeezed tightly before insertion. They are placed at the deepest part of the vagina and released. The resulting suction holds the device in place. Unlike some of the other devices, cube pessaries must be removed nightly to avoid vaginal irritation.
• Gehrung pessaries are also folded so that the curved arch is flat. The heels of the pessary are then lubricated and inserted. When opened, the back arch will rest in the anterior fornix in front of the cervix, while the front arch will rest on the cartilage between the pubic bones (called the symphysis pubis).
• Shaaatz pessaries are stiff and need to be inserted vertically. They are then twisted into a horizontal position in the vagina.
• Gelhorn pessaries are folded so that one side of the base touches the stem. The pessary is then inserted into the vagina base-end first. Once unfurled, the stem should then rest comfortably inside the vaginal introitus, anchoring the device solidly.
• Inflatable pessaries are inserted deflated with the pump stem hanging out of the vagina. A palm-sized pump is then connected to the stem and compressed three to five times to inflate. Once filled, a ball bearing will keep the air from leaking out. The stem can then be left hanging out of the vagina or tucked into the vaginal introitus. Like cube pessaries, inflatable pessaries must be removed and cleaned every day.
• Lever pessaries are folded in half so that the curved end meets the flattened end. After lubrication, the pessary is inserted into the vagina and positioned so that the curved bar rests behind the pelvis and the horizontal end rests behind the symphysis pubis.

Removing a pessary typically involves a simple reversal of steps. With most pessaries, you can latch your index finger under the rim to gently pry the device up. Inflatable pessaries require a deflation key or release valve.

Care and Safety

Before insertion, always wash your hands and the pessary with soap and warm water. You should also wash your hands before removing the device and give it a good wash, rinsing well and allowing it to air-dry.

Some pessaries can be left in for weeks at a time but never longer than three months. Others must be removed and cleaned nightly.

Pessaries can sometimes fall out during a bowel movement, especially if you are straining. If it does, remove it from the toilet and soak it in rubbing alcohol for 20 minutes and clean water for another 20 minutes before washing it with soap and warm water.

If there are signs of injury, you will need to stop using the device until fully healed. In some cases, you may be fitted with a smaller pessary.

Possible Side Effects

Though effective, pessaries are not without their side effects and risks. If used appropriately, the risks are relatively low but may include:

• Vaginal irritation
• Pain
• Vaginal bleeding
• Constipation

Pessaries can also interfere with sexual intercourse and may even cause stress urinary incontinence, particularly if the device is ill-fitted.

Complications

More concerningly, compromised vaginal tissues are vulnerable to infection, including bacterial vaginosis (BV) and urinary tract infections (UTIs). Symptoms may involve:

• A foul, fishy-smelling discharge
• Vaginal itching and pain
• Difficulty urinating
• Burning during urination
• Cloudy or bloody urine
• A frequent or intense urge to urinate
• Pressure or pain in the back or lower abdomen
• Fever and chills

Most infections occur when a pessary is left in for too long, are kept for longer than five years, or are not cleaned properly between uses. The risk also increases if you ignore signs of vaginal irritation or fail to see your healthcare provider for routine monitoring.