What Is Pessary

A pessary is a removal medical device that is inserted in the vagina or rectum to provide structural support or alter the position of pelvic organs. It is commonly used to address conditions affecting the pelvic floor. Below, we will expand on the different types of pessary devices, conditions they can manage, and more:

Types of pessary devices

A pessary supports and repositions organs like the uterus, bladder, or rectum when they shift or move out of their regular positions. This displacement can occur for various reasons, typically involving these organs' support structures.

The pessary helps by offering support and maintaining the proper alignment of these organs within the pelvic area. Pessary devices are an effective nonsurgical treatment option and can be successfully used long-term.¹

They come in various types tailored to address specific pelvic health conditions. Below is an overview of the different types of pessaries and their applications in promoting pelvic health and comfort.

Ring pessary

The ring pessary is a circular device with a central opening. It is one of the most commonly used types and effectively supports various degrees of pelvic organ prolapse.² The ring pessary is inserted into the vagina and positioned around the cervix to lift and support the uterus.

Gellhorn pessary

The type of pessary device has a more tapered shape, resembling a small, inverted bell. It is often recommended for women with advanced pelvic organ prolapse and can be successfully used long-term to provide support to the pelvic region.³ The tapered shape and design allow for easier insertion and removal.

Cube pessary

As the name suggests, a cube pessary is shaped like a cube. It is a solid, cube-shaped device used in cases of uterine prolapse. The design or shape is based on providing maximum stability as it prevents the device from shifting within the vagina. It maintains its position by creating a vacuum effect on its six concave surfaces within the vagina.⁴

Doughnut pessary

This pessary is shaped like a doughnut with a hole in the centre. This design is best suited for women experiencing vaginal wall prolapse, as it supports the surrounding tissues while allowing for easy passage of urine.

Shelf pessary

The shelf pessary is designed to support the rectum in cases of rectocele, where the rectum protrudes into the vagina. It resembles a shelf and is positioned to lift and support the rectum, alleviating symptoms of rectocele and improving quality of life.

Conditions treated with pessary devices

Pessaries serve as a primary intervention for various pelvic health conditions, offering adequate support and symptom relief. Here are some conditions for which pessaries are commonly recommended:

Pelvic organ prolapse⁵

POP arises from weakened or damaged pelvic support tissues, causing the descent or bulging of pelvic organs into the vaginal canal. Organs like the uterus, bladder, rectum, and occasionally the small intestine may be affected.

While more prevalent in women, particularly after childbirth, POP can also occur in women who haven't given birth and, less commonly, in men. Symptoms range from pelvic pressure and vaginal bulging to discomfort during intercourse, urinary issues, and bowel concerns.

Stress urinary incontinence⁶

Stress urinary incontinence (SUI) is often linked to the weakening of pelvic floor muscles and supporting tissues around the urethra. Factors like pregnancy, childbirth, ageing, and hormonal changes contribute to the loss of support. 

This lack of support results in the unintentional release of urine during activities that increase pressure on the abdomen. While more common in women, SUI can also affect men. A key symptom is involuntary urine leakage during actions such as coughing, sneezing, laughing, or exercising.

Cystocele and rectocele

Cystocele and rectocele are both types of pelvic organ prolapse. Cystocele (fallen bladder) occurs when the support tissues between the vaginal wall and bladder are weakened. This allows the bladder to protrude or fall into the vagina.

Rectocele, on the other hand, happens when the front wall of the rectum bulges into the back wall of the vagina. Again this is due to weakened support tissue, but here it's between the rectum and vagina. These conditions are frequently observed in women who have experienced challenging childbirth.

Some symptoms of the conditions include pelvic pressure, vaginal bulging, and diverse urinary and bowel issues.

Diagnosis: how do I know if I need a pessary

Diagnosing the need for a pessary involves a comprehensive evaluation by a healthcare professional, typically a gynaecologist or urogynecologist. The process typically involves the following steps:

1. Medical history - A detailed conversation about symptoms, prior pelvic surgeries, pregnancies, childbirth experiences, and overall health needs to be disclosed.
2. Physical Examination and POP-Q Exam⁹ - A physical examination involves assessing pelvic floor muscles, checking for signs of pelvic organ prolapse, and evaluating overall pelvic organ condition. This is followed by a POP-Q Exam, which measures the severity of pelvic organ prolapse by assessing the descent of pelvic organs.
3. Urodynamic testing¹⁰ - This test is done if urinary incontinence is a concern or presented. It assesses bladder function through pressure and flow rate measurements.
4. Cystoscopy or imaging¹¹ - Additional tools like cystoscopy or imaging studies (ultrasound, MRI) may be used for a detailed view of pelvic structures.
5. Trial pessary fitting - One of the critical considerations before using a pessary is ensuring the device is the right size and properly fitted. An ill-fitting pessary¹² can cause discomfort, erosion, or ulceration of vaginal tissues. This is one of the reasons a trial pessary is inserted during the examination to assess support and symptom relief.

Based on the findings from these diagnostic steps, the healthcare provider can determine whether a pessary is a suitable option for managing pelvic organ prolapse or urinary incontinence.

Insertion and removal of a pessary device

The initial insertion of a pessary device is a straightforward procedure conducted at the doctor's office. The patient is positioned comfortably, and the pessary is folded or compressed for insertion, similar to inserting a menstrual cup.

Once inside the vagina, the pessary unfolds or returns to its original shape, providing the necessary support. This process will be demonstrated to the patient so independent use can be done at home without issues.

When it comes to removal, it's good to know that these devices are specifically designed for easy extraction by either the patient or a healthcare provider. During removal, the pessary is gently compressed or folded again to support the removal process.

Considerations to remember during insertion and removal:

• Hygiene practices- Good hygiene practices are crucial before and after insertion and removal. This reduces the risk of possible infection.
• Comfort tips- When performing insertion and removal independently, consider enhancing comfort by using water-based lubricants.
• Frequency of removal and cleaning- The pessary device can be left in place for up to a week before removal. Cleaning the device is done with a mild soap or recommended cleansing solution and water. During the week, only external cleansing is advised. Douching or using unapproved vaginal products is not recommended.

If weekly frequency doesn't suit you, remove and clean the pessary before bed and replace it in the morning. Healthcare providers often give more direction on the frequency of removal and cleaning.

Potential complications when using pessary devices

While pessaries are an effective solution for managing pelvic floor conditions, individuals utilizing them may sometimes face specific challenges and complications. Recognizing and understanding these factors is crucial to ensuring optimal outcomes and addressing any complications that may arise throughout pessary treatment/use.

Let's delve into a more detailed exploration below.

Discomfort and irritation

Some individuals may experience initial discomfort or irritation when using a pessary. This is often temporary and can be addressed through adjustments in the size or type of the pessary. Proper lubrication and adherence to hygiene practices can also minimize discomfort.

Ulceration or erosion

In rare cases, prolonged use of a pessary may lead to ulceration or erosion of the vaginal tissues.¹³ Regular follow-up appointments are crucial to detect any signs of tissue damage early on. Adjustments to the pessary or, in severe cases, discontinuation may be necessary to prevent further complications.

Infections

Proper hygiene practices are essential to prevent infections associated with pessary use. To prevent infections, periodic removal for thorough cleaning using proper cleaning techniques and products is necessary. Follow-up appointments are essential to monitor the effectiveness of the pessary and address any issues that may arise. This ensures the longevity of the device.

 FAQs

1. Can I engage in sexual activity while using a pessary?

Yes, you can. Engaging in sexual activity is often possible while using a pessary. If you experience discomfort or pain, it may indicate incorrect device placement. Your healthcare provider can help in this case and make recommendations to ensure comfortable and safe intimacy.

2. Will using a pessary affect my vaginal discharge?

It may affect vaginal discharge. Some individuals may experience changes in vaginal discharge when using a pessary. This is normal and related to the device's presence in the vagina. However, if you notice any distinctive or persistent changes, you must consult your healthcare provider and go in for a check-up. 

3. Can I use lubricants with a pessary, especially during sexual activity?

Yes, you can use lubricants with a pessary, especially during sexual activity, to enhance comfort. However, it's crucial to choose a lubricant that is compatible with the material of your pessary. Always follow the recommendations set out by your healthcare provider for the best results.

4. How do I get the smell out of a pessary device?

To eliminate odour from a pessary, regularly clean it with mild soap and warm water. Ensure proper drying and storage. Practice good personal hygiene, and avoid scented products. If persistent odour occurs, consult your healthcare provider for guidance.

Summary

Pessary devices stand as a valuable non-surgical solution for managing various pelvic health conditions, ranging from pelvic organ prolapse to stress urinary incontinence. With diverse types designed to address specific needs, these medical devices offer crucial support and symptom relief, enhancing the quality of life for many individuals. 

The steps towards using a device to help manage your condition start with symptom diagnosis and tests. Once a suitable pessary device for your needs is identified, you can have it inserted and independently maintain your treatment long-term without any issues.