INTRODUCTION — Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are common problems that impact millions of individuals globally. A pessary is a vaginal support device that provides nonsurgical treatment for symptoms of POP, SUI, or both. Pessaries can provide nonsurgical treatment or a temporary solution until surgery is performed.
This topic will discuss pessary fitting and management for patients who elect a trial of a pessary. Pessary candidates, device types, approach to selection, as well as related topics on POP and SUI, are reviewed separately.
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
PESSARY FITTING — Once a patient has elected a pessary trial, the type of pessary must be chosen based upon the individual's symptoms and anatomy. Pessaries generally address pelvic organ prolapse, stress urinary incontinence (SUI), or a combination (table 1). The indications for pessary use, devices, and approach to device selection are presented separately. (See "Vaginal pessaries: Indications, devices, and approach to selection".)
Vaginal introitus size, vaginal length, and prolapse stage are used to guide selection of pessary type and size. However, pessary fitting is mostly a trial and error process, and several pessary types (picture 1) may be needed to obtain an adequate fit.
Physical examination and general approach — We perform the following steps for pessary fitting:
●Initial assessment – Assess postvoid urine residual and urinalysis to exclude urinary retention and infection, respectively.
●Pelvic examination – Patients to be fitted for a pessary are first examined with an empty bladder in the dorsal lithotomy position. We perform a pelvic examination to assess vulvovaginal atrophy, size of the vaginal introitus, stage of prolapse based on the Pelvic Organ Prolapse Quantification system (POP-Q), and vaginal length . The vaginal introitus is gauged by the number of fingerbreadths accommodated across the posterior fourchette (this is typically one to four fingers) . Pelvic floor muscle strength (Kegel squeeze) is also evaluated. (See "Pelvic organ prolapse in women: Diagnostic evaluation".)
●Pessary selection – Select a pessary type and size based on examination findings.
•Type – The type of pessary likely to be needed is determined by measuring prolapse stage and the size of the vaginal introitus; most patients can be successfully fitted with either a ring or Gellhorn pessary. If the vaginal introitus size is 1 to 2 fingerbreadths or the prolapse stage is II to III, a ring pessary is likely to be successful. For patients with a 3 to 4 fingerbreadth introitus or stage IV prolapse, a Gellhorn pessary is more likely to be successful .
•Size – The size of the pessary that will be needed is estimated by inserting two fingers to measure the width and length of the vagina (figure 1). It is important to get an overall estimate of the vaginal length and vaginal width together. If the vaginal length has been shortened by a prior hysterectomy or if the vaginal width has been narrowed by a prior prolapse surgery, then only smaller size pessaries will fit.
●Pessary insertion – The nondominant hand is used to separate the labia, gently open the introitus, and depress the perineal body. The dominant hand then inserts the pessary into the vagina. A nonlubricated glove is used, and a small amount of lubricant is applied to the leading edge of the pessary; if too much lubricant is used, the pessary will be too slippery to control. The clinician should be able to fit a finger between the pessary and vaginal side walls. If the vaginal side walls are under excessive pressure, erosions can result. (See 'Common complications and treatment' below.)
●Fit check and Valsalva maneuvers – After the pessary is inserted into the vagina, the patient is asked to perform maneuvers that raise the intraabdominal pressure in an attempt to determine if she will be able to retain the pessary during usual activities and assess for new urinary leakage as a result of pessary placement. While there is no single approach, clinicians can ask the patient to cough repeatedly on the examination table; ambulate, jump, or lunge in the office; or void and strain while sitting on a toilet. The patient ideally will have a negative cough stress test following pessary placement as she is unlikely to be satisfied if there are significant SUI symptoms. We reassure patients that it is not an emergency if the pessary is expelled; they should just bring the pessary back to the office, and a different type or size of pessary will likely be effective.
Ring pessary — The ring pessary is inserted by folding it in half like a taco and then inserting it with the curved side up (figure 2). The ring will then open to its circular shape. The lower rim of the pessary should rest behind the pubic symphysis (figure 3). The ring should then be turned one-quarter turn so that it will not easily fold onto itself and be expelled. The incontinence ring pessary has a knob that is placed beneath the urethra to increase urethral pressure when treating SUI (figure 4).
Gellhorn pessary — The Gellhorn pessary is inserted by first holding the stem and partially folding one side of the base up to the stem so that the base of the pessary is vertical and at a 90 degree angle to the introitus. Folding the base up to the stem gives the Gellhorn more of a two-dimensional shape. A finger from the opposite hand opens the introitus and depresses the perineal body. The leading edge of the base is placed into the vagina until it reaches the apex, and is then rotated so that the base supports the apex and the stem is in the long axis of the vagina. Flexible Gellhorn pessaries are easier to insert and remove than rigid devices and thus are preferred if they provide adequate support and are not expelled. Patients with a short vagina often benefit from use of a short-stem Gellhorn rather than a long-stem Gellhorn (picture 2).
Other — While the ring and Gellhorn pessaries are most commonly used, other devices exist (picture 1 and table 1). Instructions for insertion and removal of these devices can be found on manufacturer websites (figure 5 and figure 6 and figure 7) .
Use of topical analgesia — For patients who express concerns about pain, have atrophic vaginitis, or have a history of sexual abuse or trauma, the author applies 2% topical lidocaine gel to the introitus one to two minutes prior to pessary insertion or removal. Use of topical analgesia may facilitate pessary fitting and insertion both in the office and by the patient at home; patients can be given a prescription for self-use. One trial showed that 4 grams of lidocaine-prilocaine cream applied five minutes before pessary change reduced patient-reported pain .
Outcome of pessary fitting trials — Several cohort studies were reviewed to determine the outcome of pessary fitting trials in patients with prolapse and urinary incontinence. Nine studies were prospective [2,5-12], and 10 were retrospective [13-23]. They varied in the types of pessaries used (support only, space-filling only, or both), prolapse severity, indication for pessary (prolapse only, incontinence only, or both), time to first follow-up visit (one to four weeks), and study site (urogynecology practice or nurse pessary clinic) [2,5-23].
Outcomes were reported using one or more of three denominators: (1) all women offered a pessary (intention-to-treat), (2) only women who were fitted with a pessary at the first visit, or (3) women with a successful pessary fitting trial (ie, patient is fitted [or refitted] with a pessary and decides at the follow-up visit to continue use). Weighted averages and ranges were calculated for several outcomes, and the main findings are described below:
●At the first visit, 85 percent (range 71 to 94 percent) of patients were fitted with a pessary [2,5-8,12-14,16-19,23,24]. On average, two to three pessaries were tried before obtaining an adequate fit [2,13,14,23].
●For patients with prolapse, ring pessaries (sizes 3, 4, 5) were used in 70 to 74 percent, and space-filling pessaries (Gellhorn and donut) were used in 26 to 29 percent [2,6,19].
●Refitting with a new pessary at the first follow-up visit was necessary in 29 to 40 percent of patients and was successful in 76 to 85 percent [2,5,17,21].
●For patients with incontinence, incontinence ring or dish pessaries were used in 78 to 100 percent, and ring pessaries were used in 0 to 20 percent [12-14]; in two studies, the Introl and Uresta incontinence pessaries were used [7,8].
●A successful pessary fitting trial was achieved in 63 percent (range 41 to 86 percent) of all patients (intention-to-treat, includes patients initially unable to be fitted) [2,5-8,10,12-17,19,22] and 72 percent (range 24 to 95 percent) of patients initially fitted with a pessary [2,5-14,16-18,21,23].
Patients with prolapse were as likely as patients with incontinence to have a successful pessary fitting trial (71 and 76 percent, respectively). Common reasons for an unsuccessful pessary fitting trial were discomfort, expulsion, inadequate relief of prolapse symptoms, worsening or persistent urinary incontinence, de novo difficulty with voiding or defecation, and inconvenience.
Routine visit — A follow-up visit is scheduled one to four weeks after pessary fitting to assess for fit and potential side effects as well as to instruct the patient on pessary insertion/removal, as needed. Many clinicians do the insertion and removal teaching at a separate visit because the initial pessary choice may not adequately resolve the symptoms and the device or size may change. For established pessary users, the frequency of follow-up is based on the type of pessary and the patients' ability to periodically remove and clean the device themselves.
A typical pessary follow-up visit includes the following:
●Ask about comfort and side effects – At every pessary visit, we ask patients about pessary comfort or discomfort, expulsion, persistent bulge or pressure symptoms, persistent or de novo stress urinary incontinence (SUI) or urgency urinary incontinence, difficulty with urination or bowel movements, and vaginal bleeding or discharge. Patients with pressure, pain, or difficulty voiding/defecating may need to be refit with a smaller pessary size. Patients with de novo SUI may benefit from change to an incontinence pessary that provides additional urethral support. (See "Vaginal pessaries: Indications, devices, and approach to selection", section on 'Initial choice of pessary'.)
●Pessary cleaning and examination – The pessary is removed and cleaned with soap and water, and the vagina is examined for erosions. For patients with significant vaginal discharge, the discharge can be removed with dry rectal swabs, and/or the vagina can be swabbed with normal saline or betadine. In some patients, the width of the introitus may decrease in size after several weeks of pessary use. We refit these patients with a smaller size, or sometimes a smaller type, to allow for easier removal and insertion (picture 1 and table 1).
●Pessary insertion and teaching – If the pessary fits well and there are no side effects, motivated and able patients are taught how to remove, clean, and reinsert their pessary. Patients are instructed to wash their hands with soap and water prior to insertion, fold the pessary as indicated by type, and then insert the pessary through the introitus to the vaginal apex. To make insertion easier, the patient can lie down, squat, stand with one foot on a stool or chair, or sit on a toilet (although the device can fall into the toilet). The patient is typically seen for a second follow-up visit in 1 to 2 months and every 12 months thereafter. Studies have reported pessary self-management rates (ie, pessary care done by the patient rather than a clinician) of approximately 30 to 45 percent [25,26]. In a retrospective chart review of 563 patients fit with pessaries, factors associated with pessary self-care rather than clinician care included younger age (65 years versus 75 years), premenopausal status, mild (ie, stage I/II) prolapse, and use of a ring pessary (with or without support) .
Common complications and treatment — Common side effects of pessary use include vaginal discharge, odor, bleeding, and erosions.
Vaginal discharge and/or odor — Vaginal discharge, with or without odor, is very common in pessary users and has typically been incorrectly attributed to a change in bacterial flora that results from the postmenopausal rise in vaginal pH. In actuality, the pessary itself appears to incite an inflammatory response. Supporting data include:
●Impact on microbiota – Pessary use does not appear to alter vaginal microbiota unless vaginal erosions are present [27-29]. In one study of 100 postmenopausal patients, bothersome vaginal discharge occurred in 30 percent of pessary users versus 2 percent of non-users; pessary users had microscopic evidence of inflammation and vaginitis on Gram stain . However, the vaginal cultures of the two groups had nearly identical aerobic and anaerobic organisms. Thus, the inflammatory response appeared to be from presence of the pessary and not a change in vaginal microbiota. Similarly, an observational study of 30 patients reported similar vaginal pH and microbiota for pessary users without erosions (10 patients) and pessary non-users (10 patients). However, pessary users who had vaginal erosions (10 patients) had more alkaline vaginal pH and more diverse vaginal microbiota with an increase in Gram-negative species and a decrease in lactobacilli . It is not known if the change in vaginal pH precipitated the vaginal erosion or vice versa.
●Role of pro-inflammatory cytokines – A case-control study of 211 pessary users that compared patients who developed vaginal epithelial abnormalities (VEAs) with those who did not, VEA patients had higher levels of the pro-inflammatory cytokines, interleukin 6, tumor necrosis factor alpha, and interleukin 1-beta .
Treatments to address vaginal discharge and/or odor include:
●Low-dose vaginal estrogen – Patients with bothersome vaginal discharge or odor commonly have vaginal atrophy for which low-dose vaginal estrogen can be helpful. (See 'Role of low-dose vaginal estrogen' below.)
●pH-lowering product – A pH-lowering product (eg, Trimo-San gel, one applicator inserted vaginally twice a week) may be used alone or in combination with vaginal estrogen, although the clinical impact is unclear. One trial of women using pessaries for pelvic organ prolapse showed that use of hydroxyquinoline-based gel (commercial name Trimo-San) versus no treatment had no effect on the outcome of bacterial vaginosis and had no impact on continued use of the pessary . The prevalence of at least one vaginal symptom was similar for both groups at two weeks and three months of follow-up.
●Temporary pessary removal – If the symptoms persist, the patient can temporarily stop pessary use.
Patients with symptoms that do not respond to pessary change or medical treatment may consider surgical treatment for prolapse or stress incontinence.
Vaginal bleeding — Vaginal bleeding can result from tissue atrophy related to the hypoestrogenic state of menopause (ie, genitourinary syndrome of menopause), tissue trauma from pessary insertion or removal, vaginal erosion (see below), or other pathology of the genital tract. Patients who report vaginal bleeding undergo physical examination to identify a possible source of the bleeding and exclude erosion. Patients at risk for endometrial pathology should be evaluated with imaging and/or endometrial biopsy. Patients with tissue atrophy can be treated with low-dose vaginal estrogen once endometrial pathology has been excluded.
Vaginal erosions — Vaginal erosions, visible excoriations in the vaginal epithelium as a result of pressure from the pessary, are reported in 3 to 24 percent of women using pessaries (weighted mean 10 percent) [2,6,14,32]. Vaginal bleeding and irritative symptoms can be symptoms of an erosion. Patients with a vaginal erosion are typically treated with a course of pessary removal (typically four to six weeks) and low-dose vaginal estrogen, if clinically appropriate. These patients are followed with physical examination until the erosion is healed, at which time the pessary can be reinserted. Consideration is given to using a smaller pessary size or a different pessary shape, with the goal of reducing pressure and, thus, erosion risk. Rarely, erosions can lead to deeper pelvic infection or trauma. (See 'Serious complications' below.)
Other common side effects include de novo (occult) SUI, interference with sexual intercourse, and difficulty with bowel movements. Urinary tract infections have been reported in up to 13 percent of pessary users and bacterial vaginosis in up to 32 percent [14,15,32,33].
Role of low-dose vaginal estrogen — In our practice, we offer patients with evidence or symptoms of vulvovaginal atrophy treatment with low-dose estrogen vaginal cream (eg, estradiol vaginal cream 0.01%, 0.5 to 1 grams, two to three nights per week). While low-dose vaginal estrogen may reduce incident bacterial vaginosis for pessary users, it does not appear to decrease vaginal discharge, bleeding, or ulcerations when compared with no estrogen for pessary users .
While we typically prescribe low-dose vaginal cream, vaginal estrogen tablets and the vaginal estrogen ring can be used as well. The applicator for the cream or tablet can be inserted along the side of the pessary. The vaginal ring is more typically used for patients who are unable or unwilling to perform regular pessary removal and cleaning. If the vaginal estrogen ring is used with a pessary, the estrogen ring is inserted first and then the pessary is inserted. Diagnosis and treatment options for vaginal atrophy and other components of genitourinary syndrome of menopause are discussed in detail elsewhere.
UNSUCCESSFUL FITTING — Despite the range of pessary shapes and sizes, some patients are unable to find a pessary that comfortably fits, remains in place, and improves their symptoms.
Inability to fit a pessary — The most common predictors of an unsuccessful pessary fitting trial are prior prolapse surgery [13-17,35], prior hysterectomy [9,13,16,17], and concurrent pelvic organ prolapse (POP) and stress urinary incontinence (SUI) [6,10,15,32,35]. A meta-analysis of 24 studies identified 14 risk factors for an unsuccessful pessary fitting trial, including: younger age, premenopausal status, higher body mass index, stress urinary incontinence (SUI), prior gynecologic surgery (hysterectomy, pelvic organ prolapse repair, SUI treatment, and pelvic surgery), posterior vaginal prolapse, higher colorectal-anal distress inventory-8 scores, and anatomic outliers (short vaginal length, wide introitus, levator ani avulsion, and larger hiatal area on maximum Valsalva) .
Sexual activity does not appear to be a risk factor for failure [2,10,17,18]. Additionally, the following Pelvic Organ Prolapse Quantification system (POP-Q) examination parameters have been evaluated and found not to be risk factors for pessary failure: prolapse stage or grade (ie, severity) [2,6,15-17,32], the leading vaginal compartment of the prolapse (ie, anterior and apical) [2,16], and genital hiatus [2,12,13,16]. Unfortunately, the POP-Q examination fails to address introital width, vaginal caliber, atrophy of pelvic floor muscles, and shape of the pelvic bones, all of which may influence pessary success.
Pessary expulsion or displacement — Some patients will have a successful pessary insertion in the office but then have difficulty retaining the pessary during their regular activities (ie, the pessary is expelled from the vagina). In a prospective observational study of women with a successful pessary fitting in a specialty practice, 33.5 percent experienced pessary dislodgement within one year while 66.5 percent were able to retain the pessary . Risk factors for pessary dislodgement included stage III or IV prolapse, apical-predominant prolapse, and a large genital hiatus. Other patients will experience pessary displacement (ie, shifting of the pessary within the vagina that causes pressure or discomfort). For these patients, we typically try a different pessary shape or a smaller size.
PESSARY REMOVAL — While there are multiple approaches to pessary removal, we find the techniques below helpful.
●Ring – Smaller ring pessaries can be removed without folding prior to removal. A finger is inserted behind the ring, and the device is pulled from the vagina. For larger ring-type pessaries, folding the device in the vagina to reduce its size can make removal easier. The pessary is turned so the notched area (ring without support) or large holes (rings with support) are facing the introitus . The device is pinched to fold and then pulled through the introitus.
●Gellhorn – The clinician begins by using the nondominant hand to gently depress the perineum . The dominant hand then grasps the knob of the Gellhorn and pulls the pessary down so the knob is through the introitus. A corkscrew motion is used to ease disk surface of the pessary through the introitus. A Kelly clamp can be used to grasp the stem to assist with removal (one jaw of the clamp is inserted into the hole and the other jaw grasps the outside of the stem). Alternatively, a finger is placed along the stem and behind the disk, and the disk is then folded against the stem for removal; this approach only works for flexible Gellhorn pessaries. In addition, a string may be tied around the stem to aid in removal. If a string is used, it should be tucked into the vagina to avoid soiling with urine and feces.
●Shaatz – The clinician inserts one finger into the central hole of the pessary and pulls the pessary down toward the introitus . The clinician then uses the nondominant hand to depress the perineum while the dominant hand rotates the pessary parallel to the introitus and pulls it out.
●Cube – To remove a cube pessary, two or three fingers are inserted between the pessary and the vaginal wall to break the suction. The pessary is then pinched to reduce the size and removed (pulled) from the vagina. While there is a silicone string attached to the pessary, the string is to aid the user in finding the pessary and should not be pulled for removal. Pulling on the string to remove the pessary can traumatize the tissue because the suction has not been broken and the string can snap .
●Donut – To remove a donut pessary, the clinician uses the dominant hand, inserts a finger into the central hole of the pessary, and then pulls the device to the introitus . Fingers of the nondominant hand then depress the perineum, and the pessary is eased through the introitus.
PESSARY MAINTENANCE AND TEACHING
Periodic removal and cleaning — Pessaries should be removed on a regular basis to clean the device and remove the foreign body from the vagina. There are no data-driven standards for frequency of pessary removal and cleaning by either the patient or clinician. In absence of definitive data, we take the following approaches:
●Self-care – In general, we advise patients who elect pessary self-care to remove and clean the device, and leave the device out of the vagina overnight, every one to two weeks. Patients who prefer to remove and clean the pessary nightly, or use it only with certain activities, are encouraged to do so. Patients who develop minor skin tears at the introitus with nightly or weekly removal are advised to perform device removal at one- or two-week intervals, respectively, to reduce tissue trauma. Additionally, we counsel patients to remove the pessary before sexual intercourse, although some patients with smaller ring pessaries can have intercourse with the device in place.
●Clinician care – If the patient cannot or chooses not to remove and reinsert the pessary, then the patient should return for follow-up in one to two months for initial reassessment and then every three to six months thereafter for pessary cleaning and assessment by the clinician [38,39].
•A survey of 555 United Kingdom clinicians reported that 23 percent changed their patients' pessaries every 3 to 6 months, 67 percent every 6 months, and 10 percent every 6 to 12 months .
•In a study of patients using a pessary for POP, SUI, or both, and receiving office-based (provider) care of the pessary, vaginal epithelial abnormalities and patient satisfaction were similar for follow-up performed at three months or six months .
Compatibility with imaging studies — Patients undergoing imaging studies should report that they have a vaginal pessary in place. Pessaries that contain metal should be removed prior to magnetic resonance imaging (MRI; typically ring or spring-based pessaries). If the patient or clinician is unsure about the presence of metal in the pessary, removal is advised prior to MRI.
Duration of use and replacement — In the absence of new bothersome symptoms, pessary use may be continued indefinitely. Observational studies with two or more years of follow-up have reported pessary continuation rates of 75 to 86 percent [24,40,41]. A change in the pessary type or size may be needed over time. The pessary does not need to be replaced if it becomes discolored, but a new pessary should be given if it becomes cracked or loses its shape and strength.
Risk factors for discontinuing pessary — Risk factors for discontinuing pessary use in women with a successful pessary fitting trial for pelvic organ prolapse (POP) include severe posterior vaginal prolapse [17,35,42], development of occult stress urinary incontinence (SUI) , and desire for surgery at first visit . Although several studies have shown that prolapse stage or grade (ie, severity of POP) is not a risk factor for discontinued pessary use [6,15,20,42], a rectocele in a woman with severe posterior vaginal prolapse may be less well-supported by a pessary than a cystocele or vaginal vault prolapse, leading to dissatisfaction and discontinuation. Occult SUI (ie, de novo SUI that occurs with reduction of POP by the pessary) is a difficult problem to overcome. Treatment options include trial of an incontinence pessary, which provides additional support to the urethra, or surgical correction (of both POP and SUI). Prior hysterectomy and sexual activity are not risk factors for discontinued pessary use [6,15,17,18,42].
Conversely, the following have been identified as strong predictors of continued pessary use: age greater than 65 to 72 years [35,42,44], women whose baseline Pelvic Floor Dysfunction Index-20 score decreased by 50 percent after two months of use , and women who attain self-determined goals (ie, goals related to bladder function, physical activity, and general health) .
SERIOUS COMPLICATIONS — Common outcomes of pessary use include vaginal discharge, infection, and erosion; serious complications are rare. A few case reports have described pessary incarceration, fistula from the bladder or rectum, urinary or colonic obstruction, and vaginal cancer in patients with "neglected" pessaries [47-52]. At-risk patients are older women with cognitive difficulties who are unable to inform health care workers that they have a vaginal pessary in place. One study reported that women over age 75 were more likely to develop vaginal erosions from pessary use compared with women aged 65 to 74 years . Such complications are usually avoidable with routine care and follow-up, although there are reports of a vesicovaginal fistula and a rectovaginal fistula from a "well cared for" pessary patient [54,55] and one report of an undiagnosed vaginal cancer . Communication with the patient's family or caretakers is important to ensure that follow-up will be accomplished. Minor side effects are relatively common.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pelvic organ prolapse" and "Society guideline links: Urinary incontinence in adults".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Pelvic organ prolapse (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Pessary selection – Once a patient has elected a pessary trial, the type of pessary must be chosen based upon the individual's symptoms and anatomy. Pessaries generally address pelvic organ prolapse (POP), stress urinary incontinence (SUI), or both (table 1). Pessary fitting is mostly a trial and error process, and several pessary types (picture 1) may be needed to obtain an adequate fit. (See 'Pessary fitting' above.)
•Initial evaluation – As part of the initial pessary fitting visit, postvoid urine residual volume and urinalysis are performed to exclude urinary retention and infection, respectively. Pelvic examination is performed, and a pessary type and size are selected based on the width of the vaginal introitus, stage of prolapse, and vaginal length. (See 'Physical examination and general approach' above.)
•Device insertion – To insert a pessary, the nondominant hand is used to separate the labia, gently open the introitus, and depress the perineal body. The dominant hand then inserts the pessary into the vagina. Pessary location is confirmed, and the patient is asked to perform Valsalva maneuvers to assess for possible pessary expulsion. (See 'Physical examination and general approach' above.)
•Use of topical analgesia – For patients who express concerns about pain with pessary insertion, have atrophic vaginitis, or have a history of sexual abuse or trauma, the author applies 5% topical benzocaine ointment to the introitus approximately five minutes prior to pessary insertion or removal to reduce potential pain or discomfort. (See 'Use of topical analgesia' above.)
●Post-fitting follow-up – A follow-up visit is scheduled one to two weeks after pessary fitting to confirm fit, assess for potential side effects, and instruct the patient on pessary insertion/removal, as needed. Many clinicians do the insertion and removal teaching at a visit separate from the initial fitting because the first pessary choice may not adequately resolve the symptoms and the device or size may change. (See 'Routine visit' above.)
●Risk factors for inability to fit a pessary or device discontinuation
•Inability to fit a pessary – Risk factors for failure to fit a pessary include prior prolapse surgery, prior hysterectomy, and concurrent POP and SUI. Related risk factors are a short vaginal length (≤6 cm) and a wide vaginal introitus (over 4 fingerbreadths). (See 'Inability to fit a pessary' above.)
•Pessary discontinuation – Risk factors for discontinued pessary use are severe posterior vaginal prolapse, the development of occult SUI, and desire for surgery. Prolapse severity and desire for sexual activity are not risk factors for discontinued pessary use. (See 'Risk factors for discontinuing pessary' above.)
●Common side effects – Common side effects of pessary use include vaginal discharge, odor, bleeding, and erosions. Treatment options can include low-dose vaginal estrogen, vaginal hydroxyquinoline-based gel, and/or short-term pessary removal. Patients with vaginal atrophy generally benefit from treatment with low-dose vaginal estrogen. Patients with vaginal bleeding should be evaluated for other potential causes, including endometrial pathology. (See 'Common complications and treatment' above.)
●Duration of pessary use – In the absence of bothersome side effects, pessary use may be continued indefinitely. A change in the pessary type or size may be needed as a patient ages. (See 'Duration of use and replacement' above.)
●Complications – Major complications are rare, although vesicovaginal and rectovaginal fistulas may occur with a neglected pessary. Side effects include vaginal erosions, vaginal bleeding, and vaginal discharge. They usually occur in the setting of vaginal atrophy, and low-dose estrogen vaginal cream can treat or prevent these symptoms. (See 'Serious complications' above.)
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