What Is a Pessary?: A Pelvic Floor Therapist's Perspective
Who are pessaries for?
Pessaries are a strong conservative option for people of any age with symptoms of pelvic organ prolapse (POP) or stress urinary incontinence (SUI). Before we get into the weeds of what exactly pessaries are and who they can help, let's make sure we are all on the same page with some definitions:
Pelvic organ prolapse (POP) commonly referred to as simply “prolapse,” is when one of the neighboring organs pushes into or onto the vagina due to dysfunctional connective tissue.
Stress urinary incontinence (SUI) is the type of leakage that happens when there is an increase in intra-abdominal pressure, such as with a cough, sneeze, laugh, impact exercise, and even some daily movements.
Prolapse can involve laxity or mobility in either the front vaginal wall (close to the bladder), back vaginal wall (close to the rectum), or the top part of the vagina or vaginal vault. The research consistently reports increasing age to menopause, increasing number of vaginal births, and connective tissue disorders as culprits to prolapse, in addition to other contributors with more mixed evidence (i.e., forceps birth or degree of tearing, constipation, increasing BMI, hypertension, recurrent cough/smoking/asthma, family history of POP, heavy lifting, previous gynecological surgery etc.).
Check out our blog on prolapse for more information on what exactly prolapse is if you are concerned if you have prolapse or are eager to learn more.
Some people with prolapse also experience SUI, although some people have prolapse and have absolutely no current concerns with urinary leakage. The inverse is also true. Someone can be experiencing SUI but not have any evidence of POP.
The good news is that pessaries are an internal support option for both prolapse and SUI, whether they occur separately or combined.
Examples of people that could benefit from a pessary include those with prolapse or SUI that are:
Still menstruating, no longer menstruating, or are in menopause
Preferring a non-surgical intervention or are awaiting a surgery and desire relief of symptoms in the meantime
Sexually active or not sexually active
Many people out there could benefit from a pessary yet have no idea they even exist. We hope to start changing that while breaking any barriers or stigma. Pessaries can be for anyone with a vagina experiencing symptoms of prolapse or SUI -- period!
What are pessaries?
Pessaries are medical-grade devices typically made of silicone that are inserted into the vagina to support the position of pelvic organs as well as the urethra, which is the small tube that allows urine to exit your bladder and leave your body. Pessaries also impact proprioception, which is the awareness of oneself and their body in space.
Fitting, placement, and wearing of pessaries are minimally invasive and can provide significant support and relief of prolapse symptoms and reduction of urinary leakage from SUI. Common symptoms from prolapse may include pelvic heaviness, pressure, or feelings of something falling out. Our clients with pessaries often report that their "pessary is like a sports bra for the pelvic floor."
How do pessaries help prolapse and incontinence?
Pessaries do not “fix” prolapse, but they can help to prevent worsening of prolapse over time and help to provide a sense of relief right away and while wearing the pessary. Pessaries work by providing the just-right support for your specific anatomy and your type and stage of prolapse to decrease symptom bother and get you back to doing the things you love that you have been worried to do for fear of worsening symptoms.
Wearing a pessary could help decrease the need for surgery if you are a surgical candidate or help to prevent you from becoming one because you are supporting your connective tissue more effectively against gravity. The support is provided and symptom resolution or reduction is present when wearing the pessary, though may return when the pessary is removed.
Pessaries can also help to prevent SUI by supporting the bladder neck at the bottom of the bladder. Many people ask if they can still urinate while wearing a pessary. The answer is yes! We have our clients urinate before leaving our clinic after being fitted for a pessary to ensure they will be able to comfortably urinate while wearing the pessary. By supporting the bladder neck, the pessary will help to prevent involuntary leakage while ensuring you can voluntarily empty yourbladder without any issue.
What does a pessary feel like?
Pessaries are often made of a flexible, yet sturdy enough, silicone material. When pessaries are fit correctly, you should not be able to feel much at all and it should not be painful to wear. While inserting the pessary and removing can sometimes be uncomfortable, it should not be very painful if fitted correctly.
Many pessaries are made to be inserted and removed by the person wearing the pessary (self-managed) while some others require removal by the fitting provider. Some people technically wear a self-managed pessary but have a preference for insertion and removal by their provider, which is always an option with us.
How do I know which pessary is right for me?
There are many different types of pessaries. Just like us, pessaries come in all shapes and sizes. Some people are baffled when they see the pessary fit for them appears much larger or smaller than they would have predicted.
Overall body size does not equate with pessary size. The size and shape of the pessary fit for you takes into account many factors.
Pessary styles can be separated into two major categories, which include support pessaries and space-occupying pessaries. A few examples of support pessaries include a a pessary shaped like a ring, a dish/cup, or an oval. Examples of space-occupying pessaries include shapes like a cube or donut.
The lists go on and your provider will get more into specifics with you on more of the variety they may trial at your pessary fitting as applicable. Since measuring and fitting is not exact, it may take a few trials of options to ensure the right style and fit for the person. This may change in the future with 3D printing and the evolution of science... stay tuned!
Your medical professional (commonly a urogynecologist or a pelvic floor therapist with advanced training in pessary fitting) will determine which pessary is right for you based on your anatomical presentation, type and stage of prolapse, measurements, and additional factors, such as if you experience a menstrual cycle or if you are sexually active.
For example, a cube pessary may be helpful if you are experiencing a back or posterior vaginal wall prolapse, sometimes referred to as a rectocele, while a ring or ring with support pessary may be used more commonly for those with only a prolapse of the front or anterior vaginal wall. Note that this is an example and has many caveats depending on the other factors mentioned, stage of prolapse, etc.
Do I need pelvic floor therapy if I wear a pessary?
Yes! Pelvic floor therapy can be beneficial before and after being fit for a pessary for long-term symptom resolution. Rather than an alternative to pelvic floor therapy, pessaries can help people get more out of the work they put into pelvic floor therapy because they will have the support in place to be able to more effectively strengthen their pelvic floor muscles.
Pelvic floor therapy combined with the support from a pessary is ideal for long-term, global pelvic health and decreased prolapse symptoms.
At Bloom Pelvic Therapy, we work with many people across the lifespan that may benefit from a pessary at some point in their pelvic health journey. Pessary fitting is something we are proud to offer in-office as a part of the comprehensive treatment plan when applicable.
This enables us to follow clients through the pessary process to ensure their needs are met and symptoms are reduced with more demanding activities, such as exercise, daily life activities, or caregiving. We are often the first providers to mention the option of a pessary or that pessaries even exist to many of our clients!
People are often happy to hear that there is a conservative option that can prevent more issues down the line and help them get more out of their pelvic rehabilitation.