Vaginal pessaries: Indications, devices, and approach to selection

INTRODUCTION — Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are common problems that impact millions of women globally. A pessary is a vaginal support device that can be used to treat symptoms of POP, SUI, or both. Pessaries are inert; typical materials include silicone or plastic. Advantages of pessaries include potential for long-term use and avoidance of surgery. Pessary treatment is also generally inexpensive, well-tolerated, and safe, although the overall efficacy is unclear because of limited data.

This topic will review the applications, approach to selection, and types of vaginal pessaries for use in gynecologic patients. A detailed discussion of pessary fitting and insertion is presented separately. (See "Vaginal pessaries: Insertion and fitting, management, and complications".)

Detailed discussions of POP, SUI, and pessary use for obstetric indications are presented elsewhere.

●(See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management".)

●(See "Female urinary incontinence: Treatment".)

●(See "Cervical insufficiency", section on 'Pessary'.)

●(See "Incarcerated gravid uterus", section on 'Postreduction care'.)

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. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

TERMINOLOGY — Terminology used in this topic includes:

●Pelvic organ prolapse (POP) – The herniation of the pelvic organs to or beyond the vaginal walls.

●Anterior compartment prolapse – Hernia of anterior vaginal wall often associated with descent of the bladder (cystocele) (figure 1).

●Posterior compartment prolapse – Hernia of the posterior vaginal segment often associated with descent of the rectum (rectocele) (picture 1).

●Enterocele – Hernia of the intestines to or through the vaginal wall.

●Apical compartment prolapse (uterine prolapse, vaginal vault prolapse) – Descent of the apex of the vagina into the lower vagina, to the hymen, or beyond the vaginal introitus (picture 2). The apex can be either the uterus and cervix, cervix alone, or vaginal vault, depending upon whether the woman has undergone hysterectomy. Apical prolapse is often associated with enterocele.

●Uterine procidentia – Hernia of all three compartments through the vaginal introitus.

The classification of prolapse is presented in detail separately. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Classification of pelvic organ prolapse'.)

GENERAL PRINCIPLES

Mechanism of action — Pessaries are used for the treatment of pelvic floor defects and their functional sequelae, such as pelvic organ prolapse (POP) and stress urinary incontinence (SUI). When used for POP, pessaries provide support to the vaginal hernia defect, including anterior, posterior, apical, and combined sites.

The mechanism of action of vaginal pessaries for SUI is related to improved urethral function. Urodynamic studies of women treated with a pessary for SUI have shown increases in functional urethral length [1] and urethral closure pressure [1-3], absence of urethral obstruction to flow [1], and resolution of detrusor instability in women with severe prolapse and detrusor instability [4]. Anatomically, pessaries improve urethral support as there is a reduction in the straining Q-tip angle [2], and dynamic magnetic resonance imaging studies show a decreased posterior urethrovesical angle, elevation of the bladder neck, and increased urethral lengths [3].

Efficacy

For POP or SUI — Pessaries are commonly used as first-line therapies for symptomatic POP and SUI based on supporting data from validated questionnaires. A meta-analysis of eight studies with 627 patients demonstrated benefit with pessary treatment of POP, with significant reductions in the Pelvic Floor Distress Inventory-20 (mean change -46), the Pelvic Floor Impact Questionnaire-7 (mean change -36), and the Pelvic Organ Prolapse Impact Questionnaire-7 (mean change -16) [5]. A meta-analysis of 10 studies with 376 patients demonstrated subjective and objective benefit with pessary treatment for SUI [6]. Urinary Distress Inventory and Incontinence Impact Questionnaire scores decreased significantly, by 47 and 68 percent, respectively.

Compared with other treatments — Studies have compared pessary use with pelvic floor muscle training (PFMT) and surgical correction.

●Pelvic floor muscle training – PFMT requires more time for a patient than pessary use. By contrast, exercises have no associated adverse effects, while pessary use may be accompanied by vaginal erosions and malodorous vaginal discharge. Given these clinical considerations and the data presented below, in women with SUI, we prefer PFMT rather than continence pessary use for women who do not otherwise have a preference for one of these nonsurgical modalities and in women whose incontinence interferes with sexual function. (See "Female stress urinary incontinence: Choosing a primary surgical procedure".)

Treatment of SUI with a pessary appears to be less successful than PFMT during the first few months of therapy; however, long-term use of either strategy is associated with similar outcomes. The highest quality data regarding this issue are from the Ambulatory Treatment for Leakage Associated with Stress Incontinence (ATLAS) trial that randomly assigned 446 women with SUI to one of three treatment groups: continence pessary, behavioral therapy (PFMT and other strategies), or combined use of a pessary and behavioral therapy [7]. At three months, significantly fewer women in the pessary versus behavioral or combined groups reported a complete absence of bothersome incontinence symptoms (33, 49, and 44 percent, respectively) and treatment satisfaction (63, 75, and 79 percent, respectively). These outcomes did not differ significantly between the behavioral and combined groups. At 12 months, there were no significant differences among the three groups for absence of incontinence symptoms (35, 40, and 33 percent, respectively) or patient satisfaction (50, 54, and 54 percent, respectively).

A subsequent study from the ATLAS trial reported that, among women successfully treated for SUI, improvement in continence during sexual activity was greater in the behavioral and combined groups than in the pessary group [8]. In a different planned secondary analysis of the same trial, predictors of success and satisfaction with nonsurgical management (all types) included postmenopausal status, higher education, no previous urinary incontinence surgery, and lower incontinence frequency [9]. This information may help providers in counseling patients regarding nonsurgical treatment outcomes.

In women with POP, pessary use combined with PFMT improves POP symptoms more than PFMT alone [10]. In a trial of 276 women with POP (all were receiving PFMT) that compared pessary use with non-use, both groups reported improvements in prolapse symptoms and quality of life, but the mean improvement was greater for women in the pessary plus PFMT group (-29.7 compared with -4.7) [10]. The outcomes were measured using the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaires (PFIQ).

●Surgery

•POP symptoms – While both surgery and pessaries improve POP symptoms, some observational studies have suggested surgery may be associated with greater improvement [11-13]. In attempt to resolve the issue, a noninferiority trial compared surgery or pessary in 440 randomized patients with symptomatic stage 2 POP [11]. Although similar numbers of patients reported subjective improvement at 24 months (76.3 versus 81.5 percent, risk difference -6.1, 95% CI -12.7 to ∞), definitive conclusions regarding treatment equivalence were limited because 118 of 218 patients (54 percent) crossed over from the pessary group to the surgery group. We counsel patients that both methods are effective, surgery may have some additional benefit, and the decision for pessary or surgery comes down to patient preferences regarding the risks and benefits of the two treatments.

•Sexual function – As with POP symptoms, both surgery and pessary use may improve sexual function, but surgery appears to have greater benefit. A cohort study evaluating sexual function, as measured with a validated questionnaire, reported improved condition-specific and condition-impact domains for patients undergoing surgery compared with those using a pessary at 24 months of follow-up [14]. In addition, patients in the surgery group were more than twice as likely as those in the pessary group to change from no sexual activity to being sexually active.

•Conversion from pessary to surgery – In a study of 444 patients with POP who were successfully fit with a pessary, 31 percent ultimately elected surgery over a five-year period [15]. Approximately 60 percent underwent surgery within one year and 90 percent within two years.

Clinical applications — A pessary trial can be offered to all women with POP, SUI, or both, regardless of patient characteristics. Clinical settings where pessary use should be considered include the following:

●Patient preference for nonsurgical treatment.

●Presence of severe medical comorbidities that make the patient a poor surgical candidate.

●Need to delay surgery for several weeks or months.

●Recurrent POP or SUI and patient preference for avoidance of repeat surgery. However, prior prolapse surgery and prior hysterectomy are risk factors for failure to fit a pessary. (See "Vaginal pessaries: Insertion and fitting, management, and complications", section on 'Inability to fit a pessary'.)

●Vaginal ulcerations caused by severe POP. Reduction of POP through use of a pessary and application of vaginal estrogen cream both promote healing of the ulcers within three to six weeks, which is useful prior to surgical repair.

●POP in a current pregnancy.

●Desire for future childbearing. The benefit of surgical repair of POP may be nullified by subsequent pregnancy and childbirth.

Pessary use to treat cervical insufficiency in pregnant women is presented separately. (See "Cervical insufficiency", section on 'Pessary'.)

Contraindications — Contraindications to pessary use are rarely encountered. Potential contraindications include:

●Local infection – Active infections of the vagina or pelvis, such as vaginitis or pelvic inflammatory disease, preclude the use of a pessary until the infection has been resolved.

●Exposed foreign body – An exposed foreign body, such as vaginal mesh, should preclude pessary use until the exposure of the foreign body has been resolved.

●Latex sensitivity – The Inflatoball pessary is made of latex; therefore, it is contraindicated in women with latex allergies. The other pessaries discussed below are nonallergenic.

●Noncompliance – Noncompliance with follow-up could be harmful since an undetected and untreated erosion could put the patient at risk of developing a fistula.

●Sexually active women who are unable to remove and reinsert the pessary – Inability to manage the pessary around coital activity could be discouraging.

Patient acceptance — Patient acceptance of pessaries varies from 42 to 100 percent [16-19] and is related to appropriate counseling and encouragement from the provider [20]. Patients who decline a pessary trial are more likely to be nulliparous [17], younger [18,19], or have severe prolapse and incontinence [18]. This was illustrated in two studies of treatment choices among women with POP that reported older women were more likely than younger women to choose a pessary whereas women with prior prolapse surgery, more severe prolapse, and more severe symptoms related to bowel emptying, sexual function, and quality of life were more likely to choose surgical treatment [19,21,22]. Similarly, in two studies of women with stage II POP or greater, women ages >65 years were more likely to use a pessary for more than one year compared with women ≤65 years [23,24].

OUR APPROACH

Patient evaluation — The initial assessment includes taking a history to understand the patient's most bothersome symptoms, concerns, goals, and activity limitations, as well as a physical examination to understand the pelvic anatomy and exclude pathology. In addition to the routine gynecologic history, we focus on urinary symptoms (urinary incontinence, voiding difficulty, urinary tract infection, and overactive bladder), bowel symptoms (defecation difficulty, fecal incontinence, constipation), and on pelvic organ prolapse (POP) symptoms (vaginal bulge, pelvic pressure, heaviness, discomfort). The symptom cluster helps guide us toward pessary choice; we consider a support pessary for urinary incontinence symptoms and either a support or space-filling pessary for prolapse symptoms, with or without urinary or bowel symptoms. In general, support pessaries can be used for women with stage II to III POP, and space-filling pessaries can be used for women with advanced stage III to IV prolapse [16]. (See 'Support versus space-filling pessaries' below.)

Components of the gynecologic history and examination, particularly as they relate to women with POP or stress urinary incontinence (SUI), are presented elsewhere.

●(See "The gynecologic history and pelvic examination".)

●(See "Female urinary incontinence: Evaluation".)

●(See "Pelvic organ prolapse in women: Diagnostic evaluation".)

●(See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Using the POP-Q system'.)

Initial choice of pessary — Pessaries are designed to reduce symptoms of POP, SUI, or both. Pessaries come in several different shapes and sizes (picture 3 and table 1). Most are made of silicone, which is nonallergenic, durable, autoclavable, and does not retain odors. A few are made of other materials, such as latex or polycarbonate. Patients should be asked about latex allergies prior to being fit with a latex pessary. (See "Latex allergy: Epidemiology, clinical manifestations, and diagnosis".)

Support versus space-filling pessaries — Pessaries can be classified into essentially two categories: support and space-filling (table 1). The support pessary is used to treat all stages of POP and SUI whereas the space-filling pessary is mostly used for severe POP (stage III to IV). Both types are held in place proximally by the uterus (or the vaginal apex following hysterectomy), laterally by the levator muscles, and distally by the pubic bone and the vaginal introitus. Space-filling pessaries and larger size pessaries are often needed for severe prolapse (stage III or IV), as vaginal capacity can increase significantly as a result of levator atrophy and an enlarged vaginal introitus can allow a support pessary to rotate and be expelled.

Surveys of gynecologists [25] and female pelvic medicine and reconstructive surgery specialists [26] reported that the ring pessary (support type pessary) was the most commonly used pessary. A prospective observational study reported that most women with stages II and III prolapse (100 and 71 percent, respectively) were successfully fitted with ring pessaries whereas women with stage IV prolapse usually required a Gellhorn pessary (space-filling pessary; 64 percent) [16]. A randomized crossover trial compared the "ring with support" with Gellhorn pessary in women with stage II to IV prolapse and showed significant improvement in prolapse, urinary, and rectal symptoms with both and no difference in symptom response between pessaries [27].

Empiric trial of ring or Gellhorn pessary — Ring and Gellhorn pessaries are typically the first-line devices for patients who elect a pessary trial. For patients with SUI but no POP, ring pessaries, with or without an incontinence knob, are typically tried first. (See 'Incontinence pessaries' below.)

For women with POP, the author always tries to use a ring pessary (with support) if possible (picture 3) and then tries a Gellhorn pessary if the ring is unsuccessful. In one trial of 134 patients with POP, ring and Gellhorn pessaries were similarly effective in symptom reduction [27]. (See 'Support pessaries' below and 'Space-filling pessaries' below.)

Advantages of the ring pessary include the following:

●Will fit approximately 70 percent of patients [16]

●Easy to insert and remove

●More easily removed and inserted by the patient compared with space-filling pessaries

●May allow intercourse while in place

In the author's experience, if the vaginal introitus size is 1 to 2 fingerbreadths or the patient has stage II to III POP, a ring pessary is likely to be successful. For women with small to moderate prolapse or SUI, the author routinely uses the "ring with support" [16]. Most women with prolapse can be treated with ring sizes 3, 4, or 5. Ring pessaries are the only support pessaries that the author uses as use of only one type of support pessary is practical and the lever, Gehrung, and Shaatz pessaries have minimal added benefit.

Advantages of the Gellhorn pessary include the following:

●Provides support for larger degrees of prolapse

●Reduces rectoceles and related symptoms

●Retained by patients with a wide genital hiatus

For patients with a 3 to 4 fingerbreadth introitus or advanced stage III to IV POP, a Gellhorn pessary is more likely to be successful [16]. For women with advanced POP, especially with a prior hysterectomy, the author starts with Gellhorn pessary sizes 2.5, 2.75, and 3 inches. The smallest size that resolves the symptoms and remains in place is selected. In unusual cases of prolapse, a combination of both pessaries may be used (ie, ring and Gellhorn pessaries together) [28,29].

A detailed discussion of how to insert and fit a pessary is presented separately. (See "Vaginal pessaries: Insertion and fitting, management, and complications".)

Ring pessaries — The ring pessary, as in letters F, G, and L in the picture (picture 3), will fit 70 percent of women [16]. It is the most commonly used pessary as it can treat all stages of POP as well as SUI [16,25,26]. Additionally, it is comfortable and easily removed and inserted by the patient, and sexual intercourse may be possible when it is left in place. A string may be attached to the ring to aid in removal; this string should be tucked into the vagina to avoid soiling with urine and feces. However, the ring can usually be removed easily without a string.

●The "ring with support" pessary has a thin diaphragm across the ring and is especially useful for women with uterine prolapse and/or cystocele, but it may also be used to treat rectocele and vaginal vault prolapse. Although the ring pessary is available in sizes 0 to 9, most women can be managed with sizes 3, 4, and 5 [16].

●The "ring without support" pessary is useful in younger women as they have less atrophy of the levator muscles and a more oval contour to the vagina. The absence of the support diaphragm allows this pessary to take an oval shape and conform to the shape of the vagina.

Gellhorn pessary — The Gellhorn pessary has a broad, firm, circular base with a stem protruding from the center, as in letter K in the picture (picture 3). The broad base provides support to the vaginal apex, and the stem sits in the long axis of the vagina. The stem keeps the circular base from rotating into the long axis of the vagina and being expelled (figure 2). The base is slightly concave, allowing suction to form against the vagina, which helps hold the pessary in place, but can make it difficult to remove manually. There are small holes in the base to allow drainage as well as a hole in the stem (picture 4). The Gellhorn sizes reflect the diameter of the base and are available in 1.5 to 3.5 inch sizes in one-quarter inch increments. Most women can be managed with the 2.5, 2.75, and 3 inch sizes [16].

If initial pessary is not successful — For women in whom the first pessary choice does not work, the selection of the next pessary is guided by the reasons for initial failure. If the initial ring pessary came out, we try the next larger size and continue to increase the size until the pessary remains in place or the patient is uncomfortable. If the ring pessary was initially uncomfortable, we try the same pessary in the next smaller size. Patients with persistent or de novo SUI may benefit from an incontinence-specific device (table 1). For patients in whom the ring pessary continues to come out, we change to a Gellhorn pessary as these devices are often successful in patients with an enlarged genital hiatus (eg, gaping introitus) or advanced prolapse (eg, POP stage III or IV). (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Using the POP-Q system'.)

A detailed discussion of pessary insertion and fitting is presented separately. (See "Vaginal pessaries: Insertion and fitting, management, and complications".)

Trial of problem-specific pessary — For clinicians who have a range of pessary types available to them or for patients in whom the ring and/or Gellhorn pessaries are unsuccessful, trial of less commonly used pessaries may be helpful. While there are no limitations as to which device can be fit to which patient/problem, some pessaries are designed to address specific issues (SUI, POP, or both) (table 1).

●POP only – If Gellhorn pessaries are not successful, a donut pessary can be tried. If the patient is willing to remove the pessary daily, a cube pessary may be used successfully (but must be removed daily due to risk of vaginal erosion). In a study of 214 women with POP fitted with a cube pessary, 174 (81 percent) were using it four weeks later, and 143 (67 percent) used it for five or more years. Adverse effects of malodorous vaginal discharge and/or mild vaginal bleeding occurred in 15 percent of the five-year pessary users [30]. Not uncommonly, if pessaries fail, then surgery is elected.

●SUI only – If the ring pessaries are not successful, an incontinence dish pessary can be tried. The patient can purchase the Impressa pessary over-the-counter (but the once daily use is expensive). A study including 50 participants reported similar benefit between the Impressa and an incontinence pessary [31]. Alternatively, the patient may order the Uresta or Contiform pessary (available for purchase online without a prescription). Some women with mild SUI can use a tampon during exercise to control SUI. As mentioned above, pelvic floor physical therapy is preferred over pessary use for SUI. If childbearing is completed and conservative measures have failed, then surgery is commonly elected. (See 'Compared with other treatments' above.)

OUTCOMES

Unsuccessful fitting — While most patients can be successfully fit with a pessary, risk factors for unsuccessful fitting include prior hysterectomy and short vagina (<6 cm). A detailed discussed of unsuccessful pessary fitting is presented in related content. (See "Vaginal pessaries: Insertion and fitting, management, and complications", section on 'Unsuccessful fitting'.)

Symptom resolution — Most short- and medium-term studies note improved symptoms in women treated with a pessary. After two to four months of pessary use, observational studies have reported the following:

●Prolapse symptoms – Seventy to 90 percent of patients reported resolution of prolapse symptoms (bulge, pressure, splinting) [27,32,33].

●Urinary symptoms – Forty to 50 percent of patients reported resolution of associated urinary symptoms (stress and urgency incontinence and voiding difficulty) [7,27,33-35].

Observational studies have reported short-term efficacy (one month or less) of pessaries for both stress and mixed urinary incontinence, with improvements in pad testing, bladder diaries, and quality of life [24,36-38]. A literature review reported a subjective cured/improved rate of 63 percent after one month [39]. Medium-term (6 to 13 months) satisfaction and continued use was 59 percent (range 39 to 76 percent) for women with a successful pessary fitting trial and 43 percent (range 16 to 59 percent) by intention-to-treat [2,17,40-42].

●Bowel symptoms – Thirty to 50 percent of patients reported resolution of bowel symptoms (anal incontinence, anal urgency, and obstructive symptoms) [27,35,43].

●Sexual function – Forty to 60 percent of patients reported increased sexual frequency and satisfaction [35,44]. Seventy percent removed the pessary for intercourse [35,44].

Additionally, when validated questionnaires are used to assess patient-centered outcomes, women with pelvic organ prolapse (POP) report better urinary function and prolapse reduction [13,45,46], body image [45], and goal attainment [47] after pessary insertion. However, while pessary use is reported to improve sexual satisfaction, women who undergo surgical correction may have greater improvements in sexual function compared with women who use a pessary [48].

Other studies have reported on non-symptom-related outcomes of pessary use. Examples include:

●Anatomic changes – There are limited data on the anatomic changes following pessary use. One study reported a decrease in size of the genital hiatus after three months of pessary use from 4.8 to 3.9 cm [49]. Another study reported an improvement in POP stage in 21 percent of women after one year of use [50].

●Hydronephrosis – Among women with stage III to IV POP, coexisting hydronephrosis was found in 30 percent, and improvement or cure of the hydronephrosis occurred in 77 percent of women who successfully used a pessary compared with 30 percent in women who chose expectant management [51].

Satisfaction and continued use — For patients who are successfully fitted with a pessary, initial satisfaction rates are high but decline over time. Most women who choose not to continue using a pessary stop use within one to two months [40,42]. The most common reasons given are persistent incontinence, resolution of incontinence with pelvic floor muscle exercises, and pessary discomfort or expulsion. Prior incontinence surgery has been reported as a risk factor for discontinued pessary use [42].

●Short-term – Short-term (two to six months) observational studies have reported patient satisfaction and continued use rates of approximately 80 percent (range 63 to 92 percent) for women with a successful pessary fitting trial [27,33,34,50,52,53]. In intention-to-treat analysis, the range dropped to 40 to 77 percent.

●Medium-term – Over one to two years of follow-up, for women with a successful pessary fitting trial, patient satisfaction and continued use drops to 62 percent (range 53 to 83 percent) and 40 percent (range 30 to 63 percent) by intention-to-treat [18,24,27,34,45,50,52,54-56].

●Long-term – Observational studies with two or more years of follow-up have reported pessary continuation rates of 75 to 86 percent [57-59]. In the study with a mean of 26 months of follow-up, pessary discontinuation typically occurred within 12 months and was associated with shorter vaginal length (<7.5 cm) and lower baseline scores on the Pelvic Organ Prolapse Distress Inventory 6 [58]. However, a retrospective study of 167 women from Australia with 14 years of follow-up reported the pessary continuation rate dropped to 14 percent [60]. It is unknown if longer duration of pessary use leads to a greater likelihood to pursue surgical treatment. This hypothesis is plausible since the author has operated on several older women who were successfully using pessaries for many years but who expressed a desire for surgery "before [they] got too old." The small sample size, different populations, and different study designs limit the interpretation of these results.

For prediction of surgical outcome

●Urinary incontinence – Occult stress urinary incontinence (SUI) has been reported in 27 to 68 percent of women with severe prolapse [61-65]. A pessary placed during urodynamic evaluation of women with POP can diagnose occult (potential) SUI and predict whether anti-incontinence surgery will be therapeutic [64-66]. The evaluation and management options for occult SUI are discussed elsewhere. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Occult SUI'.)

●Relief of urinary obstruction – In another study, pessary reduction in women with severe anterior vaginal prolapse and urinary retention (postvoid residual >100 mL) predicted cure of urinary retention by prolapse surgery: 79 percent were cured by surgery, and the pessary was 89 percent sensitive [67]. A similar study found urethral obstruction on urodynamic evaluation in 72 percent of women with grade 3 or 4 cystocele, with resolution of the obstruction in 94 percent following pessary insertion [68].

DETAILED DESCRIPTION OF PESSARY DEVICE TYPES

Support pessaries — Support pessaries are essentially two-dimensional and sit in the long axis of the vagina. Types of support pessaries include the ring (with [F, as shown in the picture] or without a support diaphragm [G]), the lever (A, B, C, and E), the Gehrung (D), the Shaatz (I), and the incontinence ring (L) or dish pessaries (picture 3 and table 1). Most women can remove and reinsert support pessaries. Sexual intercourse is still possible when they are left in place.

●Commonly used

•Ring pessaries – Ring pessaries are commonly available and will fit up to 70 percent of women [16]. The ring pessary is the preferred support pessary used by the author as the other types provide minimal additional benefit. These pessaries are discussed in detail above. (See 'Ring pessaries' above.)

The author prefers to fit women first with a ring with support pessary due to ease of insertion and removal. A ring pessary will be attempted on all women with stage II and early stage III pelvic organ prolapse (POP). If the patient still has her uterus, it is very likely to be successful. Some women with stage III to IV POP can be successfully fitted with a ring pessary, as long as there is only mild pressure pushing down against the prolapse; otherwise, these women can be fit with a Gellhorn. (See 'Space-filling pessaries' below.)

The author also prefers to fit all women with stress urinary incontinence (SUI) with a ring pessary, with or without a support diaphragm, with or without an incontinence knob. Incontinence ring pessaries (ie, with a knob) are discussed below. (See 'Incontinence pessaries' below.)

The insertion and fitting of ring pessaries are reviewed separately. (See "Vaginal pessaries: Insertion and fitting, management, and complications", section on 'Ring pessary'.)

●Less commonly used

•Shaatz pessary – The Shaatz pessary is a rigid ring pessary and essentially the same as the Gellhorn pessary without the stem (ie, just the base of the Gellhorn), as in letter I in the picture (picture 3). It folds minimally and thus is inserted on the diagonal and then rotated to a horizontal position. The concave surface promotes adherence to the anterior vaginal wall and theoretically reduces risk of slippage or expulsion. Some providers use this pessary, but the author rarely uses it for POP or SUI.

•Lever pessaries – The Smith, Hodge, and Risser pessaries, as in letters A, B, C, and E in the picture (picture 3), are collectively referred to as lever pessaries. These devices were originally intended to treat uterine retroversion. They may be used for uterine prolapse and cystocele, and case reports have described use in pregnancies complicated by cervical insufficiency. They are no longer commonly used. The author never uses this pessary for POP or SUI; it is cumbersome for patients to insert correctly and remove.

When inserting a lever pessary, the uterus is manually anteverted if it has been retrodisplaced. The pessary is then folded and inserted into the vagina. The index finger is placed against the posterior bar until it rests posterior to the cervix. The anterior bar should rest posteriorly to the pubic symphysis (figure 3).

•Gehrung pessary – The Gehrung pessary is designed to treat cystocele and/or rectocele. It has a U-shaped, flexible rim with a rubber diaphragm, as in letter D in the picture (picture 3). When inserted properly, the two bases rest on the posterior vagina against the lateral levator muscles, and the concave surface and diaphragm support the anterior vagina. There are no studies of this pessary. The author never uses this pessary for POP or SUI as it is also challenging for patients to use.

Space-filling pessaries — Space-filling pessaries are essentially three-dimensional and differ from the support pessaries in that they have a large base that supports the vaginal apex (or cervix). They include the Gellhorn, donut, cube, Inflatoball, and Colpexin sphere pessaries (picture 3 and table 1). They are often needed in women with severe (stage III or IV) POP, especially posthysterectomy vaginal vault prolapse, but offer no advantage in the treatment of SUI. Space-filling pessaries are often difficult for patients to remove, and sexual intercourse is not possible when they are in place.

●Commonly used

•Gellhorn pessary – Variations of Gellhorn pessaries include flexible or rigid devices with short or long stems, as in letters J and K in the picture (picture 3). To simplify office management, the author mainly uses flexible Gellhorn pessaries in patients with advanced stage III to IV POP, especially if the individual has previously undergone a hysterectomy. While some experts find rigid and long-stem Gellhorn pessaries helpful for patients with very large prolapse, the author does not use rigid Gellhorn pessaries. (See 'Gellhorn pessary' above.)

Insertion and fitting of Gellhorn pessaries are discussed in detail separately. (See "Vaginal pessaries: Insertion and fitting, management, and complications", section on 'Gellhorn pessary'.)

•Donut pessary – The donut pessary is similar to a ring pessary, but the ring is thick and hollow, as in letter N in the picture (picture 3). The thick, hollow ring fills the larger space associated with advanced prolapse and levator atrophy. The donut pessary is available in diameter sizes similar to the Gellhorn, ranging from 1 to 3 inch sizes in one-quarter inch increments. Most women needing a donut pessary can be treated with the 2.5, 2.75, and 3 inch sizes. The author will occasionally use the donut pessary in women with POP in whom Gellhorn pessaries have failed.

The donut pessary is inserted by holding it vertically (figure 4) and then rotating it to a horizontal position during placement. A Kelly clamp may be required for pessary removal.

•Cube pessary – The cube pessary has six concave sides, as in letter H in the first picture (picture 3), which allow the cube to hold the vaginal walls with suction, thereby preventing prolapse (figure 5). The cube is also available with holes (picture 5), which have been theorized to reduce the risk of erosion. Although the cube is highly effective in correcting prolapse, both types must be removed every one to two nights, cleaned, and not reinserted until the next morning to prevent vaginal injury. Patients who are unable to remove it every one to two nights are advised to use a different type of pessary. In the author's experience, the risk of a neglected cube pessary is higher compared with other pessaries because even short-term use is associated with vaginal erosions, and rectovaginal fistula has been reported [69]. In addition, this pessary is associated with a malodorous discharge. However, with management as described above, these issues are minimal, and can be used with good success, as noted above [30].

Many clinicians find this pessary is an option for motivated and compliant patients whose symptoms have not been adequately resolved with ring or Gellhorn pessaries. The cube pessary is inserted by squeezing the flexible rubber sides together and then placing the device at the vaginal apex. It is available in sizes 0 to 7 with diameters ranging from 1.00 to 2.25 inches. Again, a string may be attached to aid in removal.

●Less commonly used

•Inflatable pessary (Inflatoball) – The Inflatoball pessary was designed to facilitate removal and insertion by the patient, as in letter M in the picture (picture 3). It has an air-filled ball and a stem with a port; a bulb is attached to the port to inflate or deflate the pessary, which makes the device less bulky during insertion and removal. However, the stem protrudes from the vagina and may cause unacceptable discomfort. Additionally, the pessary is made of latex, not silicone, so it cannot be used in women with latex allergy or sensitivity. The author no longer uses this pessary as patients are too often bothered by the protruding stem.

The Inflatoball is placed in a similar manner as the donut pessary. The bulb is then attached, a ball-bearing within the stem is moved to a lateral projection on the side of the stem, the pessary is inflated, the ball-bearing is moved back into position to keep the pessary inflated, and the bulb is removed (figure 6). The Inflatoball pessary is available in diameter sizes of 2 to 2.75 inches in one-quarter inch increments.

•Spherical pessary – Although no longer in production, the spherical pessary (commercial name Colpexin Sphere) was designed to make removal and insertion easier, improve comfort (because of its smaller size and spherical shape), and allow the patient to perform concomitant pelvic floor muscle exercises (figure 7). It is made of polycarbonate with an attached braided nylon string for ease of removal.

Incontinence pessaries — A few pessaries are designed specifically to treat SUI (table 1). When fitted properly, an incontinence pessary compresses the urethra against the upper posterior portion of the symphysis pubis, causing an increase in urethral resistance that prevents leakage associated with sudden increases in abdominal pressure (ie, cough, Valsalva, or exercise). The author typically uses a ring pessary or an incontinence ring pessary (with or without support) for women with SUI as these are commonly available, reasonably easy for patients to insert and remove, and relatively inexpensive. Whereas pessaries for POP are typically used all day, every day, pessaries for SUI can be used as needed (for example, during exercise). Additionally, some women are able to use a tampon as a pessary to treat SUI symptoms.

●Commonly used

•Incontinence ring and dish – The incontinence ring pessary, as in letter L in the picture (picture 3), has a knob that is placed beneath the urethra to increase urethral pressure to treat stress incontinence (figure 8). The incontinence dish is more rigid and shaped like a dish and generally has minimal added benefit. Some patients with large anterior prolapse may experience better tissue reduction with the dish compared with the ring, but this is anecdotal. The author prefers to fit all women with SUI with a ring pessary, with or without a support diaphragm, with or without an incontinence knob. The author starts with a ring without a knob because sometimes the knob is too big and uncomfortable. If the ring pessary alone does not control symptoms, then the ring with incontinence knob is tried. The author will try an incontinence dish pessary in patients whose symptoms do not adequately improve with the ring pessaries.

•Impressa incontinence device – The Impressa incontinence pessary is an over-the-counter, disposable, tampon-like device made from medical-grade silicone. It comes in three different sizes, is self-inserted into the vagina, and supports the urethra to prevent stress incontinence [70]. An initial sizing kit can be purchased over-the-counter to determine which size best reduces symptoms. The patient can then purchase supports in the correct size for continued use. Advantages of this device include that it does not require fitting by a clinician and can be purchased in a local drug store or online.

●Less commonly used

•Bell-shaped incontinence pessary – The bell-shaped incontinence pessary (commercial name Uresta) has a handle at its base for easy removal and insertion and has a narrow, rounded tip that allows easy insertion into the vaginal introitus. When properly positioned, the wide base supports the urethra. It is made of a medical-grade rubber that has been extensively tested for biocompatibility and safety and is available in sizes 3, 4, and 5 (small, medium, and large). It is available for purchase online from the manufacturer.

•Cylindrical intravaginal device – The cylindrical intravaginal device (commercial name Contiform) is shaped like a large, hollow tampon and is made of Santoprene, a nonallergenic thermoplastic rubber. The device sits behind the pubic bone and supports the urethra during episodes of increased intra-abdominal pressure. Its tampon-like shape was partly designed to facilitate self-insertion/removal by patients. This pessary can be ordered only in or from Australia or New Zealand [71].

Custom-designed pessaries — Some authors have described using material extrusion-based additive manufacturing, also known as 3D-printing, to custom design pessaries. This novel concept could prove valuable for women with difficult-to-treat SUI and POP [72-74].

Pessary materials — Most support and commonly used space-filling pessaries are made of silicone, which is inert. However, some latex pessaries exist. Clinicians should check the package materials to confirm the contents. Patients with latex allergy can safely use silicone pessaries.

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".)

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 5^th to 6^th 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 10^th to 12^th 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)")

●Beyond the Basics topics (see "Patient education: Urinary incontinence in women (Beyond the Basics)" and "Patient education: Urinary incontinence treatments for women (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Candidates and contraindications – A pessary trial can be offered to most women with prolapse or urinary incontinence, regardless of patient characteristics. Exceptions are women with exposed foreign body (eg, vaginal mesh), active pelvic infection, inability to remove the pessary (if sexually active), and those who cannot be compliant with follow-up. (See 'General principles' above.)

●Alternate treatment options – Alternate treatment options to pessary use include pelvic floor muscle training and surgical correction. Pessaries can be used alone or in combination with other therapies. (See 'Compared with other treatments' above.)

●Initial assessment – For patients who desire a pessary trial, the initial assessment includes taking a history to understand the patient's most bothersome symptoms, concerns, and activity limitations as well as a physical examination to understand the pelvic anatomy and exclude pathology. (See 'Patient evaluation' above.)

●Type of pessaries – Pessaries can be classified into two general categories: support and space-filling (table 1 and picture 3). Support pessaries are used to treat all stages of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) whereas space-filling pessaries are mostly used for severe POP. (See 'Support versus space-filling pessaries' above.)

The most commonly used pessaries are the ring, with (F) or without a support (G), and the Gellhorn (J, K) as seen in the image (picture 3). (See 'Empiric trial of ring or Gellhorn pessary' above.)

●Initial pessary selection – For individuals who desire a pessary for POP, SUI, or both:

•For those whose vaginal introitus measures 1 to 2 fingerbreadths or who have stage I to II prolapse, we suggest a ring pessary rather than a Gellhorn or other pessary types (Grade 2C). As 70 percent of patients can be fit with a ring pessary, the author typically begins with this device because they are comfortable and easily removed and inserted by the patient, and sexual intercourse is possible with the ring pessary left in place.  (See 'For POP or SUI' above and 'Empiric trial of ring or Gellhorn pessary' above.)

•For those whose vaginal introitus is 3 to 4 fingerbreadths or who have stage III to IV prolapse, we suggest a Gellhorn pessary rather than a ring or other pessary types (Grade 2C). (See 'For POP or SUI' above and 'Empiric trial of ring or Gellhorn pessary' above.)

The above recommendations are based on the author’s clinical experience and the limited available evidence suggesting ring and Gellhorn pessaries have similar outcomes. Initial treatment with other pessary types also appears reasonable, but supporting data are scarce.

●Repeat pessary selection – For women in whom the first pessary choice does not work, the selection of the next pessary is guided by the reasons for initial failure. Next steps can include a different size of the same device or a different type of device, including pessaries specific for SUI. (See 'If initial pessary is not successful' above.)

●Symptom resolution and continued use – Pessary use improves approximately 80 percent of prolapse symptoms (bulge, pressure, splinting), 50 percent of urinary symptoms (stress and urgency incontinence and voiding difficulty), and 40 percent of bowel symptoms (anal incontinence, anal urgency, and obstructive symptoms). In addition, approximately 50 percent of patients report increased sexual frequency and satisfaction. (See 'Symptom resolution' above.)

Short-term (two to six months) satisfaction and continued use is approximately 80 percent, and medium-term (one to two years) satisfaction and continued use is approximately 60 percent. (See 'Satisfaction and continued use' above.)

●Preoperative uses of pessaries – Pessaries have been used in women with POP to diagnose occult SUI and to predict postoperative cure of urinary retention after prolapse surgery. (See 'For prediction of surgical outcome' above.)