Pessaries for Pelvic Organ Prolapse

Pessaries for pelvic organ prolapse

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What is prolapse?

Prolapse is the descent of one or more of the following structures: the anterior vaginal wall, the posterior vaginal wall, the uterus (cervix), or the apex of the vagina. About 40% of women will experience prolapse in their lifetime and typically report feeling one or several of the following symptoms: 

· A feeling of ‘something coming down’ into the vagina

· Pelvic pressure or heaviness 

· Urinary symptoms - incomplete emptying of bladder, urinary frequency 

· Bowel symptoms - incomplete emptying of bowels, straining, fecal smearing

· Pain (rare)

The causes of prolapse can be multifactorial, with some of the most common being: 

· Pregnancy and vaginal delivery 

· Hysterectomy 

· Pelvic surgery 

· Sustained increased intra-abdominal pressure which could be the cause of things like: (Obesity, chronic cough, constipation, or repeated heavy lifting)

Gold standard treatment for prolapse 

· Pessaries in addition to pelvic physical therapy are the gold standard for conservative management of prolapse based on current research. A pessary fitting would be appropriate in situations where the patient is unable to exercise at her desired level of activity (i.e running, weight lifting, or HITT) or if they are experiencing symptoms of heaviness and pressure throughout everyday activities. 

The role of pessaries for prolapse management 

· After having a pessary fitted, the patient can utilise the pessary based on her specific needs. For example, if a patient finds that they are only symptomatic while performing some form of exercise like running, the pessary may be inserted prior to beginning and then removed afterwards. Alternatively, some patients may prefer to leave their pessary inserted for a longer period of time either due to preference or due to physical limitations in their ability to remove the pessary independently. In these cases, it is possible for the device to safely stay inserted for up to 3 months. 

· It is also important to remember that a pessary may only be needed while working on strengthening the pelvic muscles in pelvic physical therapy but not be needed after the muscles have become strong enough to support the pelvic organs independently.

· Options for treatment include: 

o Pelvic floor muscle training (PFMT)

o Vaginal pessaries 

o Surgery

Types of pessaries

· The most common types of pessaries that we use at Women In Motion Physical Therapy are variations of a dish or a ring pessary. These are designed to aid most specifically with mild grades of bladder prolapse and symptoms of stress urinary incontinence and heaviness or pressure. Your therapist will decide with you what type would be most ideal for you at your fitting.

o   Dish

•   The dish pessary is best for minor degrees of prolapse. The dish with the knob is used in the case of urinary incontinence due to providing additional pressure against the urethra. This type of pessary is fairly flexible making it easier than the ring to bend and insert but may not stand up to strenuous activity, depending on the grade of prolapse. 

o   Ring 

• The ring pessary is used for first and second degree prolapse. The ring with the knob is used to provide additional pressure to the urethra in the case of urinary incontinence. These pessaries are slightly more inflexible making them a good option for those participating in sports that increase intra abdominal pressure significantly such as weight lifting or high levels of plyometrics.  

o   Examples of types of pessaries used (note the most commonly used in our clinic are the dish and the ring.)

What does a pessary fitting entail?

· A vaginal exam to assess vaginal length and grade of prolapse 

· Decision on type and size of pessary that is most appropriate 

· Placement of pessary and movement assessment

o Patient walking around, squatting, moving to ensure good placement

· Patient practice placing and removing for home (if applicable) 

o When a pessary is properly fit, you should not feel it and it should never be painful.

· If a patient doesn’t feel comfortable removing and cleaning the pessary on their own, it can safely be left in place for up to 3 months.

Call our Clinic Today to schedule your pelvic floor evaluation and pessary fitting!

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Q&A

• Will I always have to use this pessary?

  Not necessarily. Your pelvic floor muscles may strengthen enough that the pessary is no longer needed. Or you may only need to wear your pessary with strenuous activity

• Can a pessary be painful?

  No. A properly fit pessary should not be painful. If your tissue changes over time, it is possible that a pessary could become uncomfortable in which case your provider should be consulted.

• How often should I remove the pessary?

  If you are able, it is recommended that you remove the pessary every 3-4 days for cleaning. If you are unable to remove it on your own, you will need to make an appointment with your provider for removal and cleaning. It is safe for a pessary to remain in place for up to 12 weeks.

• Can I have sex with my pessary in place?

  Yes, you can with most pessary types. However, if you want to remove it then do so.

• How would I know when to notify my provider about a problem?

  o New onset of vaginal bleeding

  o Fever or chills

  o Foul-smelling vaginal discharge

  o Pain with urination

  o Difficulty with urination or bowel movements

  o Vaginal itching or irritation

Evidence supports pelvic floor therapy as the number 1 conservative treatment for pelvic organ prolapse. At your evaluation our therapist can determine if a pessary may be appropriate for you.