What is a Vaginal Pessary?

A vaginal pessary is a medical device inserted into the vagina to provide structural support to pelvic organs. Primarily used to manage conditions such as pelvic organ prolapse (POP) and urinary incontinence, pessaries come in various shapes and sizes, each designed to address specific anatomical challenges and patient needs. They are a non-surgical treatment option, offering relief and improved quality of life for many individuals.

Understanding Pelvic Organ Prolapse and Urinary Incontinence

Before delving into the specifics of pessaries, it’s crucial to understand the conditions they treat.

Pelvic Organ Prolapse (POP)

Pelvic organ prolapse occurs when the muscles and tissues that support the pelvic organs weaken and sag, causing one or more of the pelvic organs (uterus, bladder, rectum, or vagina) to descend from their normal position. This weakening can be caused by several factors, including:

• Childbirth: Vaginal delivery, especially multiple or difficult births, can stretch and damage pelvic floor muscles.
• Aging: As women age, natural hormonal changes, particularly after menopause, can lead to decreased muscle tone and elasticity.
• Chronic Strain: Persistent pressure on the pelvic floor from chronic coughing (due to conditions like COPD or asthma), constipation, or heavy lifting can contribute to prolapse.
• Obesity: Excess body weight increases intra-abdominal pressure, placing additional strain on pelvic structures.
• Surgery: Pelvic surgeries, such as hysterectomy, can sometimes alter pelvic support.

Symptoms of POP can vary depending on the severity and which organs are affected but often include:

• A feeling of heaviness or fullness in the vagina.
• A sensation of something “falling out” of the vagina.
• Lower back pain.
• Discomfort during intercourse.
• Urinary or bowel problems, such as difficulty emptying the bladder or bowels, or leakage.

Urinary Incontinence

Urinary incontinence is the involuntary loss of urine. The most common types related to pelvic floor weakness are:

• Stress Urinary Incontinence (SUI): Leakage of urine during activities that put pressure on the bladder, such as coughing, sneezing, laughing, jumping, or lifting. This is often due to a weakened urethral sphincter or poor support of the bladder neck.
• Urge Urinary Incontinence (UUI): A sudden, intense urge to urinate followed by an involuntary loss of urine. This is often associated with an overactive bladder muscle.
• Mixed Urinary Incontinence: A combination of stress and urge incontinence.

Pessaries are particularly effective for stress urinary incontinence by providing mechanical support to the urethra and bladder neck, helping to prevent leakage during increased abdominal pressure.

Types of Vaginal Pessaries

The wide array of pessary designs reflects the diversity of pelvic floor conditions and the need for tailored solutions. Pessaries are generally made from medical-grade silicone, latex, or plastic, materials chosen for their durability, flexibility, and biocompatibility. They are designed to be inert, meaning they do not react with body tissues.

Ring Pessaries

The ring pessary is one of the simplest and most commonly used types. It is a flexible ring, often with a supporting skirt or flange.

• Purpose: Primarily used for mild to moderate uterine prolapse and mild vaginal vault prolapse (when the top part of the vagina prolapses after a hysterectomy). They can also provide some support for mild stress urinary incontinence.
• Mechanism: The ring sits in the vagina, holding the prolapsed organs in place. The skirt can help to support the anterior (front) vaginal wall, assisting with bladder support.
• Variations: Available in various diameters and with or without a supporting skirt. Some have a knob for added support.

Gellhorn Pessaries

The Gellhorn pessary is characterized by its mushroom or funnel shape and a stem.

• Purpose: Designed for more severe cases of pelvic organ prolapse, particularly when there is significant descent of the uterus or vaginal vault. It is also used for significant vaginal dryness and atrophy.
• Mechanism: The wide, flat base of the pessary sits against the cervix or vaginal vault, while the stem fits into the vaginal canal, providing robust support. The suction effect created by the pessary when it is removed can also help to reduce swelling in some cases.
• Variations: Available in different sizes and stem lengths.

Cube and Donut Pessaries

These pessaries are distinct in their shape and are typically used for specific types of prolapse.

• Cube Pessary: This pessary is shaped like a cube and is often made of a firm but flexible material.
  • Purpose: Effective for managing moderate to severe uterine prolapse and enterocele (prolapse of the small intestine into the vagina). It works by creating a vacuum effect that helps to hold the organs up.
  • Mechanism: The cube is inserted into the vagina, and its firm structure provides a solid point of support. The vacuum created as it settles into place is a key component of its effectiveness.
• Donut Pessary: As the name suggests, this pessary is shaped like a ring with a hole in the center.
  • Purpose: Primarily used for uterine prolapse and vaginal vault prolapse.
  • Mechanism: Similar to a ring pessary, it provides support by sitting within the vaginal canal and holding the prolapsed organs. The central opening can sometimes be more comfortable for individuals with certain anatomical considerations.

Marland Pessaries

The Marland pessary is a more complex design aimed at managing specific prolapse configurations.

• Purpose: Used for complex prolapse, including simultaneous anterior, posterior, and apical prolapse. It can also be helpful for managing significant stress urinary incontinence.
• Mechanism: This pessary often has multiple components or a specific shape designed to provide multidirectional support to the vaginal walls and pelvic organs.

Incontinence Pessaries

While some general pessaries can help with incontinence, specific designs are optimized for this purpose.

• Urethral Support Pessaries: These are designed to apply pressure to the urethra, elevating it and providing support to the bladder neck.
  • Purpose: Primarily for managing stress urinary incontinence.
  • Mechanism: They are typically inserted into the vagina to sit beneath the urethra, helping to keep it closed during activities that cause leakage. Some have a ridge or projection that specifically targets urethral support.

Pessary Fitting and Management

The successful use of a vaginal pessary relies on proper fitting and consistent management. This is a process that should always be overseen by a healthcare professional.

The Fitting Process

• Pelvic Examination: A healthcare provider, usually a gynecologist, urogynecologist, or nurse practitioner specializing in women’s health, will conduct a thorough pelvic examination to assess the type and severity of prolapse and/or incontinence.
• Sizing: The provider will use a set of trial pessaries of various sizes and types to determine the best fit. A properly fitted pessary should:
  • Remain in place without falling out.
  • Be comfortable, with no significant pressure points or pain.
  • Provide adequate support to the prolapsed organs or improve continence.
  • Not interfere with urination or defecation.
• Patient Education: Once a pessary is selected, the patient will receive detailed instructions on how to care for it, including how to remove, clean, and reinsert it if self-management is appropriate.

Self-Care and Hygiene

• Regular Removal and Cleaning: For most patients, the pessary is removed, cleaned, and reinserted by the healthcare provider during regular follow-up appointments (typically every 3-6 months). However, some individuals may be taught to remove, clean, and reinsert their pessary at home.
• Cleaning: Pessaries are typically cleaned with mild soap and water. Some may require specific cleaning solutions.
• Signs of Problems: Patients are advised to contact their healthcare provider if they experience any of the following:
  • Pain or discomfort.
  • Vaginal discharge or odor.
  • Vaginal bleeding.
  • Difficulty with urination or bowel movements.
  • The pessary falling out.

Potential Complications

While generally safe, pessaries can have potential complications if not managed properly:

• Vaginal Irritation and Ulceration: Prolonged use without regular removal and cleaning can lead to irritation, inflammation, and the formation of ulcers on the vaginal wall.
• Increased Vaginal Discharge: The presence of a foreign body can stimulate increased secretions.
• Infection: While rare, there is a small risk of infection.
• Constipation: In some cases, a pessary can exacerbate constipation.
• Difficulty with Intercourse: Some pessary types or sizes may make intercourse uncomfortable or impossible.

Advantages of Pessary Use

Pessaries offer several significant advantages as a treatment option for pelvic floor disorders.

• Non-Surgical: They provide an effective alternative to surgery for many individuals, avoiding the risks, recovery time, and costs associated with operative procedures.
• Immediate Symptom Relief: For many, the relief of symptoms like pelvic pressure and urinary leakage is immediate upon fitting.
• Improved Quality of Life: By alleviating distressing symptoms, pessaries can significantly improve a patient’s ability to engage in daily activities, exercise, and social interactions.
• Cost-Effective: Compared to surgical interventions, pessaries are a relatively inexpensive solution.
• Suitable for Various Health Conditions: Pessaries can be a good option for individuals who are not candidates for surgery due to age, other medical conditions, or personal preference.

Who is a Good Candidate for a Pessary?

A vaginal pessary is an excellent treatment option for a wide range of individuals experiencing pelvic floor dysfunction. The primary candidates include:

• Individuals with Pelvic Organ Prolapse: Especially those with mild to moderate prolapse of the uterus, bladder, or vaginal vault. They can also be beneficial for severe prolapse in individuals who are not surgical candidates.
• Individuals with Stress Urinary Incontinence: Particularly those whose incontinence is primarily due to urethral hypermobility or poor bladder neck support.
• Individuals Seeking Non-Surgical Options: Those who wish to avoid surgery due to personal beliefs, fear of surgical risks, or other medical reasons.
• Elderly Patients: Pessaries can be a safe and effective way to manage pelvic floor issues in older adults who may have multiple comorbidities that increase surgical risk.
• Pregnant Individuals: Certain pessary types can sometimes be used during pregnancy to support a prolapsed uterus or manage pregnancy-related incontinence, although this requires careful management by a healthcare provider.
• Individuals Awaiting Surgery: Pessaries can provide temporary relief while an individual waits for surgical intervention.

Conclusion

Vaginal pessaries are a vital, versatile, and often underutilized tool in the management of common pelvic floor disorders like prolapse and urinary incontinence. By offering a non-surgical, effective, and customizable solution, they empower individuals to regain control over their bodies and significantly enhance their quality of life. Understanding the different types of pessaries, the importance of proper fitting, and diligent self-care are key to achieving optimal outcomes and continuing to enjoy an active and fulfilling life. Consulting with a healthcare provider is the essential first step in exploring whether a vaginal pessary is the right choice for you.