Pessary management

Pessary Management

Vaginal pessaries are removable devices inserted into the vagina to help patients with pelvic organ prolapse (POP) and urinary incontinence. They are designed to support the pelvic floor whilst attempting to restore the prolapsed organs to their normal position and relieve symptoms.

Pessaries are a suitable option for most women who want to give birth in the future, those who do not want surgery, or those awaiting surgery who want to manage their symptoms in the interim.

There are several types of pessaries, but the selected type depends on several variables, including the patient’s anatomy, whether they are sexually active and if they are able and wish to manage their own pessary. Some types of pessaries will need to be removed daily, whilst others will require regular reviews with doctors to remove, inspect and re-insert or replace them.¹

This article will explore all aspects of pessary management, including how they are fitted, patient follow-ups and self-management.

The different types of pessaries

Vaginal pessaries can be broadly split into two categories: support and space-filling pessaries.²

Support pessaries

Support pessaries include ring or an incontinence dish with or without additional support and Shaatz pessaries and are usually used for milder prolapse. They’re designed to elevate or lift the prolapsed tissue within the vagina.³

Space-filling pessaries

Space-filling pessaries are generally reserved for more advanced prolapses⁵ and work by filling the space within the upper vagina.³ They are available in a wide array of shapes including Gellhorn, shelf, cube, donut and Inflatoball pessaries.⁵

If you would like to learn more about this topic, we have published a full article on the different types of pessaries available.

Selecting the correct pessary

It’s important that patients are offered the correct pessary that is not only the most suitable for addressing their issue but is also comfortable, so fittings are carried out by healthcare professionals (HCPs). During the appointment, the clinician will determine the most suitable size and shape of pessary.⁶

Before deciding on the most appropriate type of pessary to offer, clinicians will assess the patient to determine:

The shape of the vagina.
The severity of the prolapse.
If the patient would like to self-manage their pessary.
If they wish to commence or maintain sexual activity.⁶

We have published a full article about types of prolapse and prolapse diagnosis, if you would like to learn more.

Pessary fittings

The fitting process is largely ‘trial and error’ and several different types may need to be tried before the patient is comfortable.⁷

Since pessaries come in a range of diameters, the HCP will estimate the width of the middle of the vagina and select an appropriately sized pessary, but there may need to be several attempts to find the correct size.^8,5 The patient should be fitted with the largest sized pessary that fits comfortably whilst the HCP can still fit a finger either side of the pessary.⁵

The pessary is inserted into the vagina and moved into place to sit behind the pubic bone, which may take around 30 seconds. It might be uncomfortable but it should not cause pain.⁹

Once inserted, the patient is examined whilst in a ‘supine’ position, where the patient is lying on their back in a neutral position.^{5, 10}

Post-fitting checks

After the fitting, the patient will be asked to stand, cough and, ideally, empty their bladder. This is to ensure the pessary is retained within the vagina and she can pass urine comfortably.⁸

If comfortable, the patient can go home, however, if there is pain or difficulty in passing urine, the pessary will need to be fitted again with a different size or pessary type selected.⁹

Pessary reviews

Clinical reviews are conducted at different times, depending on the type of pessary. During the reviews, the pessary is removed by the HCP, cleaned, examined for discolouration, cracking or deformation and replaced if needed. The pessary will then be reinserted after an internal examination to check for ulceration or bruising.⁵

Support pessary reviews

As mentioned, a ring pessary is usually considered the first choice due to ease of use.⁴ Women using this type of pessary will typically be reviewed every six months unless they are self-managing their pessary when they may be reviewed yearly.⁶

Space-filling pessary reviews

For most space-filling pessaries, reviews are typically conducted every 3-6 months, however with cube and Inflatoball pessaries, assessments are routinely performed after the first 4-8 weeks. Thereafter cube pessaries are checked every 3-6 months, and Inflatoball every 6-12 months to check the health of the vaginal walls.⁶

Self-management of pessaries

Self-management is where the patient manages the removal, cleaning and inspection and re-insertion of the pessary herself.¹¹

Pessaries fall under 3 categories in terms of how they can be managed. Firstly, there are those which can be challenging to remove by the patient so not often self-managed, such as a Gellhorn.⁵ Secondly, those which are suitable for self-management, if the patient wishes, such as a ring pessary.¹¹ Finally, some must be self-managed, such as a cube or Inflatoball pessary. ⁶

Which pessaries are suitable for self-management?

Ring pessaries are suitable for self-management, but it is up to the patient whether they choose to and they can visit their HCP every six months instead.¹¹ If a patient agrees to self-management, they will be taught how to remove and re-insert the pessary with clean hands and their competency in doing so will be assessed, they may then be asked to return for a review at 3-6 months, and then annually if there are no concerns.⁶

How frequently the patient needs to remove their pessary depends on the pessary type and patient choice.⁶

Which pessaries require self-management?

Cube pessaries are made of soft silicone and have 6 concave sides which are designed to suction onto the surface of the vagina. As a result, they are an effective option for more advanced stages of prolapse such as grade 3 and 4.⁵

Vaginal secretions can become trapped on the surface of a cube pessary, so they must be removed nightly for cleaning and are therefore only suitable for women who are willing and able to self-manage and have a good degree of manual dexterity to do so.⁵

Inflatoball pessaries have a head which is inflated in situ via a hand pump. As with the cube pessary, the Inflatoball must be removed nightly for cleaning so is only available for women who are able to self-manage their pessary.⁶

The benefits of self-management

Self-managing their pessary can give patients the freedom to remove and replace it at their choosing. There may be several reasons for choosing to do this, such as fewer doctor visits, sleeping more comfortably without the pessary or preferring to remove it before sexual activity.¹¹

One recent study into self-management found that women reported higher levels of convenience and ability to access help.¹²

In a review conducted by Cambridge University Hospital, patient satisfaction was highest amongst women who self-managed their pessaries with 95% finding the service convenient compared to 81% of those who visited the hospital to manage their pessaries.¹³

Additionally, self-management was found to reduce hospital appointments and free up capacity.¹³

The study also highlighted a cost saving to both the hospital and the wider health economy. Patients who received doctor-led care cost the hospital and commission group an annual total of £308, compared to the £30 per patient who self-managed their pessary.¹³

Why do some women choose not to self-manage?

Some women are not comfortable with self-management as they may find it difficult or fear that they will not remember to remove and replace their pessary.¹¹

This is not a problem, and the patient will be routinely seen by an HCP including a gynaecologist, GP or specialist nurse.