Pessaries

 Pessaries: A Conservative Option for Pelvic Support

Pessaries are a non-surgical management option for Pelvic Organ Prolapse (POP) and can also be helpful for individuals experiencing Stress Urinary Incontinence (SUI), or urine leakage with activities such as coughing, jumping, or exercising.

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Pessaries come in many different shapes and sizes and can be customized to meet individual needs and lifestyles. Some people choose to wear a pessary only during specific activities, such as exercise or times of increased pressure on the pelvic floor (for example, during a respiratory illness). Others may wear a pessary during the day and remove it independently each night. In some cases, individuals prefer or need to return to the clinic for pessary removal, cleaning, and reinsertion every 3–4 months.

 

Who Can Benefit from a Pessary?

Pessaries can be effective for mild, moderate, and even severe pelvic organ descent, as well as for stress urinary incontinence. They may also be useful for individuals who experience vaginal laxity without a diagnosed prolapse—something that is particularly common in the postpartum period. Some individuals have symptoms secondary to a prolapse, such as incomplete bladder emptying and chronic UTIs. These symptoms can also be ameliorated with pessary use.

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Who should NOT use pessaries?

Pessaries are not recommended:

• For those with significant cognitive deficits who do not have consistent caretakers

• For those with active infections such as yeast or BV, pessary use can resume once infection is cleared

• When an active abrasion or wound to the vaginal tissues is present

• For those with significant Genitourinary Syndrome of Menopause who are not able or willing to use topical vaginal estrogen

• When individuals have untreated vaginal dermatologic conditions such as lichens sclerosis

 

It may be more difficult (though not always impossible) to find a "good fit" for those who:​

• Have had previous pelvic reconstructive surgery

• Have had a radical hysterectomy or have a short vaginal length

• Have a certain type of prolapse that is very close to the vaginal opening, especially on the low posterior vaginal wall (rectocele)

 

What does a pessary fitting session entail?

A pessary fitting session begins with a comprehensive medical and gynecologic history and a physical examination to determine whether pessary use is an appropriate option for you. We will also spend time discussing your symptoms, goals, lifestyle, and personal preferences, as these factors are critical in selecting the most effective and comfortable option.

 

Several considerations guide pessary selection, including:

• Whether you would like—and are able—to self-manage the pessary (removing, cleaning, and reinserting it independently)

• Whether you engage in penetrative sexual activity

• Your unique pelvic anatomy and support structures

• The health and integrity of your vaginal tissues

 

Based on this discussion and examination, a pessary type will be recommended that best aligns with your needs. We will review expectations for wear time, removal schedules, and clinic follow-up, so you have a clear understanding of ongoing care.

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If you choose to move forward, the appropriate size will be determined and the pessary will be inserted. The fit will then be carefully assessed to ensure it is secure, comfortable, and effective. This includes visual confirmation during bearing down, as well as a functional symptom check.

 

You will be encouraged to trial movements that typically provoke your symptoms, such as coughing, squatting, jumping, lifting overhead, or other daily or athletic activities. In some cases, you may want to test higher-level activities in our open gym (fully clothed!) to ensure the pessary performs well in real-world conditions. 

 

Occasionally, the clinic may not have the recommended pessary type or size in stock. If this occurs, the appropriate pessary will be ordered, and the fitting will be completed at a follow-up visit.​

 

What if a pessary fitting is not successful?

Pessary fitting is both a clinical skill and a personalized process, and finding the best option for you may require some trial and adjustment. When a pessary is well fitted, it is comfortable, remains in place, and either resolves or significantly reduces the symptoms it is intended to support.

 

If a pessary is too small or not the appropriate type, it may slip down, fall out, or fail to adequately improve symptoms. 

 

If a pessary is too large, it may cause discomfort or interfere with bladder emptying. During your fitting appointment, we ensure that you are able to urinate comfortably with the pessary in place. We will also confirm that the pessary is positioned correctly and that there is adequate space around it, ensuring proper support without excess pressure.

 

Occasionally, a pessary may feel "right" during the fitting but may cause discomfort or concern once outside of the clinic. Sometimes this is due to irritation from trialing multiple pessaries and practicing insertion/removal, and can subside. Sometimes, there is increased muscle guarding or nervous system changes that take time to resolve. At a follow-up visit, we may try a different pessary size or type, depending on the situation, or suggestions will be made to address individual pelvic floor concerns. This is why multiple follow-ups are recommended. You will be supported and guided through the process!

 

What happens after the initial pessary fitting?

After the initial pessary fitting, it is strongly recommended to follow up in 1-2 weeks, then again at 3 months. Beyond these initial follow-ups, the recommended return schedule depends on your pessary type, individual considerations like tissue quality, and your ability to self-manage.

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At a follow-up appointment, the pessary will be removed (by you or the clinician, per your preference and ability), and your skin will be examined to ensure all is well. We may practice insertion/removal if needed or desired. We will review hygiene practices, follow-up schedule, signs that indicate concern, and any other recommendations that have been made.

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For those who can self-manage a pessary, after the initial follow-ups (1-2 weeks, then 3 months), an annual visit is recommended to check vaginal tissues, to check fit (this can sometimes change over time), to inspect the pessary for changes, and to replace as needed. 

 

What are the costs of pessary fitting and follow-ups?

In-Clinic PT Evaluation (90 Min): $240

60-Minute Follow-up: $165

Pessary Fitting Fee $150

Pessary Replacement Fee $75 (lost pessaries, or choosing to try a different type)

       Insurance questions? Click here or scroll to the end.

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For those traveling from a distance or with multiple concerns, it is recommended to schedule a 2-hour Evaluation ($280)  and/or book a virtual consultation before an in-clinic visit to review your medical and personal history and to discuss individualized recommendations.

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After the initial pessary fitting, it is strongly recommended to follow up in 1-2 weeks, then again at 3 months. Beyond these initial follow-ups, the recommended return schedule depends on your pessary type, individual considerations like tissue quality, and your ability to self-manage.

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One important consideration to keep in mind is that pessary fitting is just one component of a comprehensive pelvic physical therapy evaluation and plan of care. Often, additional visits may be recommended to address pelvic floor strength, coordination, and the contribution of surrounding structures such as the hips and core.

Any recommendations for ongoing care are always guided by your goals, preferences, and available resources.  We will gladly coordinate care with other pelvic health and medical providers to work as part of your broader healthcare team to support you.

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What are the risks of pessary use?

Minor side effects:

• Increased vaginal discharge (varies by individual)

• Increased risk of infection, such as bacterial vaginosis, which can be reduced with best hygiene practices

• Mild vaginal abrasions (especially with a pessary that is too large, or for those with thinning and fragile tissue associated with Genitourinary Syndrome of Menopause).

​Major side effects, such as erosion or fistula, have been associated with pessary neglect (leaving a pessary in for longer than recommended), but generally do not occur in those who use pessaries as recommended.​

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Pessaries and Surgery: Understanding Your Options

Many people are told that surgery is their only option and are never offered a pessary trial. However, even advanced prolapse can often be well supported with an appropriately fitted pessary.

In fact, trialing a pessary before surgery—if surgery is being considered—can be beneficial for several reasons. A pessary can help identify urinary leakage that may be masked by prolapse and allows individuals to explore a conservative, reversible option before committing to a surgical intervention.

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Answers to other common questions:

Can a pessary be left in for sex?

• This depends on the pessary type. Space-occupying pessaries like a cube or gellhorn need to be removed for penetrative activities. "Support" pessaries, like a ring, can be left in place during sex, but many prefer to remove them.

Will using a pessary weaken my pelvic floor or cause vaginal laxity?

• Quite the contrary! Lifting the pelvic organs can reduce pressure on the pelvic floor structures, allowing for improved pelvic floor muscle performance, and allowing shortening of the connective tissues over time with consistent pessary use.

Will a pessary do more than just reduce symptoms- will it improve my condition?

• It depends on your exact concerns and changes. The body of evidence examining anatomical changes from pessary use is growing and very hopeful, but we do not have enough research yet to make definitive claims.

• POP: Boyd et al in 2021 found that the more consistent the pessary use, the greater the anatomic changes that occurred over time. Mendes et al in 2021 found that after 4 months of pessary use, a decrease in prolapse stage in at least one of the vaginal compartments and reductions in organ descent in all measures.

Can I use my insurance?

• Thrive Physio is NOT in-network with any private insurance but does bill straight Medicare (not Medicare Advantage- these are private replacement plans).

• Medicare will cover the cost of your visits, but not pessary fitting or replacement fees. Payment for these is due at the time of service. 

• If you have private insurance and would like to file your own out-of-network claims, a 'superbill' can be provided upon request with the necessary details.