Vaginal pessary for pelvic organ prolapse

What is a vaginal pessary?

A vaginal pessary is a removable device which is inserted into the vagina to hold a prolapsed vaginal wall or uterus in place. Pessaries are made of PVC, silicone or vinyl.

The insertion of a vaginal pessary may be suggested as an alternative treatment for women who are unfit for a surgical repair or when childbearing is not completed. It may also be suggested as a temporary measure while waiting for surgery for vaginal prolapse. A vaginal pessary is also an option for women who have decided not to have surgery.

Types of vaginal pessaries

There are a variety of types of vaginal pessaries but the 3 most commonly used in Gloucestershire Hospitals are ring, Gellhorn and shelf. The pessary size you will need will be assessed by your doctor, nurse specialist or practitioner.

Ring pessary - is round in shape and comes in different sizes. The ring pessary is used for patients who have either front or back wall prolapse, or sometimes both walls of the vagina are coming down.

Shelf pessary – is a hard plastic device used to provide extra support for the womb/vagina. It is also used as an alternative for women when the ring pessary does not stay in. However, it is not suitable if you are still sexually active due to the shape and position of the pessary.

Gellhorn - is a flexible silicone device to support moderate to severe prolapse of the womb or the top of the vagina (vault). However, it may not be suitable if you are still sexually active due to the shape and position of the pessary. If you are sexually active, we can teach you how to remove and replace the pessary.

Donut – is a silicone pessary used for severe prolapse of the womb (procidentia). However, it is not suitable if you are still sexually active due to the shape and position of the pessary.

Cube – is a silicone pessary used to support moderate to severe vaginal prolapse. This should be removed each night. The cube is more suitable for women who are still sexually active.

Before the pessary is fitted

Before having a pessary fitted, it is important that you understand that you must agree to attend regular appointments. If you are unable or unwilling to attend regularly, then a different way to manage your prolapse will need to be discussed and agreed with you.

If you leave the pessary in for too long it can become difficult to remove and, in some cases, would need to be removed by an operation while you are under a general anaesthetic or sedation. Leaving a pessary in for too long can cause serious problems, such as infection or tissue damage.

While the staff in the clinic are mainly female there is a possibility that your pessary will be fitted by a male doctor. Please let a member of the clinic staff know if you have any concerns about this.

Fitting the pessary

Following a discussion with your doctor, urogynaecology nurse specialist or practitioner about the best treatment for your vaginal prolapse, a pessary may be advised. The pessary will be fitted during the consultation.

Your doctor, urogynaecology nurse specialist or practitioner will explain the procedure and answer any questions that you may have. You will then be asked to undress from the waist down and lie on an examination couch with your knees bent and legs apart.

When you are comfortable, the doctor, urogynaecology nurse specialist or practitioner will perform a vaginal examination. They will insert an instrument (speculum) to look inside the vagina and at the cervix (neck of the womb) to check for any abnormalities. Following the examination, they will assess the type and size of pessary to be inserted. Lubricant or hormone cream will then be applied to the pessary before it is inserted into your vagina.

Once the pessary is in place you may be asked to ‘bear down’ (as if having your bowels open) or cough. This is to check the position of the pessary and try to make sure that it is unlikely to drop out.

Pessaries may not be suitable for everyone as every prolapse is different and vaginas are all different shapes and sizes. There is no easy way to measure the vagina. Pessaries are fitted by estimating the size required and either increasing or decreasing the size if it is uncomfortable or falls out.

If the pessary is uncomfortable or keeps falling out, an alternative pessary may be needed or another treatment option will be discussed.

It is important to understand that the fitting of a pessary is an estimation and is not an exact measurement. It can take trials of various sizes before the right fit is found.

Some women remove and replace their pessaries themselves. If you wish to consider this option you can discuss it with the nurse or doctor.

Are there any risks?

Vaginal discharge – You may notice an increase in vaginal discharge than normal. Your vaginal discharge may also develop an odour. If this happens you may need to make an appointment to see your GP to check for possible infection. Alternatively, you can contact the Urology Nurse Specialists for advice - the contact details are at the end of this page.

Infection – If there is a sign of vaginal infection, a swab will be taken. You may be given a course of oral antibiotics to start taking. Otherwise, when the results of the vaginal swab are received, they will be reviewed and if required, both you and your GP will be contacted so that treatment can be started. Your pessary will not be replaced, until the results of the swab are available and appropriate treatment has been given, if needed.

Ulceration and/or erosion of the vagina – This may give you abnormal bleeding or discharge. If so, you should see your GP or contact the Urology Nurse Specialists for advice. Simply removing the pessary for a few weeks and using some oestrogen cream in the vagina at night will often cure this problem. If the bleeding or discharge persists then you will be given a further hospital appointment so that it can be reviewed.

Bleeding – If you report any bleeding, we will need to review you in the clinic. If you have not had a hysterectomy and we think that the bleeding is not from vaginal erosion or ulceration we may need to arrange a pelvic ultrasound. After the ultrasound, you will be reviewed by your consultant, nurse specialist or practitioner in clinic a few weeks later to discuss the results. The size of the pessary will be reassessed and may be replaced depending on the pelvic ultrasound results.

Pessary may fall out – A pessary is fitted by estimating the size needed. If the pessary is too small it may fall out when passing urine or opening your bowels. This is nothing to worry about, it just means that you will need a different size fitted. If the pessary is too big it may be uncomfortable. If the pessary continues to fall out or be uncomfortable, an appointment will be made for you to see the consultant, nurse specialist or practitioner.

Risks during changing a pessary

You may feel some discomfort when a pessary is removed or a new one inserted. Any pain will be brief and temporary.

You may experience some bleeding immediately after the pessary is changed, this is normal so do not be worried about this.

Several attempts may be needed to make sure that you have the most appropriate pessary in the correct size. You should be able to pass urine without the pessary falling out and be comfortable when you leave the clinic.

What happens after fitting a pessary?

Once the pessary is inserted and placed in the vagina, it will need to be checked or changed initially in 3 months’ and then every 6 months. In some instances, the checks can be done more regularly than every 6 months, particularly for women who can self-manage or change their own pessary. The pessary may also need to be changed more frequently if there you experience recurrent ulceration or erosion of the vaginal wall. It is important to attend your next appointment to prevent complications occurring. During your clinic appointment, you will be asked to move around, sit down and pass urine before you leave the department. This is to make sure that the pessary is comfortable.

Some women using a ring pessary are able to remove, clean and replace the pessary themselves. Pessaries such as the cube will need daily removal therefore, these are less suitable for long term use.

It is possible to have sexual intercourse with the ring pessary in place, although your partner may feel the pessary and you may have to experiment with different positions to find the most comfortable.

If you have a shelf or Gellhorn pessary it is not possible to have sexual intercourse, this is because of the shape of the pessary. This type of pessary will not be offered if you are sexually active unless you are willing to learn to remove and reinsert the pessary.

Topical vaginal oestrogen

You may be advised to use vaginal oestrogen treatment 2 or 3 times each week, after 2 weeks of daily use. This will help to relieve vaginal dryness, make the pessary changes less uncomfortable and reduce the risk of pessary infection and vaginal ulcerations.

Oestrogen can be administered in to the vagina using an applicator or your finger. It is prescribed as either a tablet or cream.

If you cannot use a vaginal oestrogen or it is contraindicated (unsuitable due to another condition such as breast cancer), then a vaginal moisturiser can be used as a substitute. There is minimal absorption of topical vaginal oestrogen, so this treatment does not increase the risk of breast cancer or thrombosis.

What will happen during my follow up appointments?

You will be asked some questions about your satisfaction with the pessary since your previous appointment. You will also be asked if you have had any problems with bleeding or discharge, urinary or bowel problems or discomfort. You will also be asked if you have had any new symptoms from the prolapse.

With your consent, the pessary inserted at the previous appointment will be gently removed by inserting a well lubricated finger into your vagina. Sometimes a speculum will then be inserted into your vagina so that the vaginal walls can be examined for any abnormalities, such as infection or ulcerated areas. If there are no problems a new pessary will be inserted using a lubricant or oestrogen cream.

The pessary should help you carry out your day-to-day activities. For instance, you should be able to continue to take part in sports, cycle and walk long distances.

If you have any queries or complications with your pessary, such as the pessary falling out, any bleeding or discharge, bladder or bowel difficulty or pain, do not hesitate to contact the Urogynaecology Nurse Specialist or practitioner using the telephone numbers at the end of this page. Please leave a message and a contact number and the nurses will get back to you as soon as it is possible.

If you experience any severe pain or you are unable to pass urine or open your bowels, you should contact your GP for advice. Out of normal working hours you should contact NHS 111.

Contact information

Urogynaecology Nurse Specialist / Urogynaecology Practitioner

Tel: 0300 422 6246 (gynaecology reception) or

Tel: 0300 422 6278 (answerphone) – please leave your contact number and a brief message. A member of team will return your call within 24 to 48 hours.

Ward 9a (Gynaecology)

Gloucestershire Royal Hospital

Tel: 0300 422 6780

NHS 111

Tel: 111

Further information

For more information about vaginal pessaries, please visit the following website.

International Urogynecological Association (IUGA)

Website: www.yourpelvicfloor.org/conditions/vaginal-pessary-for-pelvic-organ-prolapse/

Reference

United Kingdom Continence Society - UK Pessary Guidelines 2021 (ukcs.uk.net)