Pessaries offer a safe, nonsurgical option for the treatment of urinary incontinence and pelvic organ prolapse. The concept of pessaries for the treatment of prolapse is not a new one. The pessary dates back thousands of years, prior to the days of Hippocrates, and innumerable varieties have been available over the last 200 years. One of the earliest “pessaries” used was placement of half a pomegranate in the vagina, as described by a Greek physician called Polybus.¹ Other methods described include a linen tampon soaked with astringent vinegar or a piece of beef as advocated by Soranus, another Greek physician. It was only in the 16th century that a device was made specifically to be used as a pessary, as opposed to using naturally occurring objects.

Since the 20th century, considerable refinements have been made of existing pessaries. At present, pessaries are generally made from inert plastic or silicone and can be used in patients allergic to latex.² Although it is not possible to establish a global perspective of the full extent of pessary use, a survey of the members of the American Urogynecologic Society showed that 75% of surgeon members used pessaries as first-line therapy for pelvic organ prolapse. No clear consensus emerged regarding the type of pessary used or their indications for use by these surgeons.³ In the United Kingdom, a recent postal survey demonstrated that 87% of consultants (physicians) use vaginal pessaries for management of POP.⁴

Clinicians primarily opt for vaginal pessaries as a treatment option for those with comorbid medical conditions, those who still wish to bear children, as interim relief prior to surgery, and for those who prefer nonsurgical treatment.⁵ However, a recent study has shown that when pessaries are offered to patients with symptomatic pelvic organ prolapse,⁶ nearly two-thirds of women choose a pessary rather than surgery as initial management. Furthermore, a case–control study comparing women who chose pessaries with those who underwent surgery one year after their respective treatment found no difference in prolapse symptoms, bladder, bowel, or sexual function between groups.⁷ Although traditionally thought of as treatment only for women deemed unfit for surgery or infirm, pessaries should be considered a viable treatment option for the majority of women in the initial management of pelvic organ prolapse and stress incontinence.

Pelvic Organ Prolapse

Pelvic organ prolapse is the most common indication for pessary use.^3,8 The aim of treatment in the management of POP is to decrease the frequency and severity of prolapse symptoms and to avert or delay the need for surgery.⁹ Pessary use may prevent worsening of the prolapse as demonstrated in a small retrospective review of patients using pessaries for the treatment of POP.¹⁰ Pessary use success rates, defined as continued pessary use of women who were successfully fitted, range from 56% to 89% at two to three months^11-13 and 56% to 68% at 6 to 12 months after insertion.^7,14 Long-term continuation rates have not been determined, although many women continue to use a pessary for life.

Urinary Incontinence

Pessaries can also be used to treat urinary incontinence. A randomized controlled trial compared tampon use and pessary with no device among incontinent women during exercise and found that both the pessary and tampon resulted in less incontinence as measured by a pad test than women who did not have an intervention.¹⁵ Up to 59% of women using incontinence pessaries continue using them approximately a year after insertion.¹⁶ Farrell et al.¹⁷ recently designed an easy-to-insert, self-positioning incontinence pessary, with 76% of women continuing use at one year. In a prospective cohort study of 68 women, Robert and Mainprize¹⁸ found that only 16% continued pessary use at one year with a trend of improved continuation rates in younger patients (41 years vs 52 years) and in those without previous surgery, suggesting this to be a viable alternative option in this group of patients.

Pessaries may also be used as a diagnostic tool to unmask occult stress urinary incontinence to evaluate if a concomitant anti-incontinence procedure is necessary at the time of prolapse surgery. The Colpopexy and Urinary Reduction Efforts (CARE) randomized surgical trial investigated whether stress leakage during urodynamic testing with prolapse reduction predicted postoperative SUI.¹⁹ Preoperatively, only 3.7% subjects demonstrated urodynamic stress urinary incontinence without prolapse reduction and 6% after prolapse reduction with pessary. Women who demonstrated preoperative stress incontinence during prolapse reduction were more likely to report postoperative stress incontinence, regardless of concomitant colposuspension. A recent study, using the ring pessary to unmask occult urinary incontinence at the time of video cystourethrography, showed that the pessary test has poor sensitivity (67%) but high specificity (93%) in predicting postoperative stress urinary incontinence following prolapse repair. The positive predictive value of the pessary for postoperative incontinence was low (40%) but had excellent negative predictive value (98%).²⁰

Other Uses of Vaginal Pessaries

Vaginal Wind

Although vaginal wind is a distressing and embarrassing condition, its prevalence is underestimated and it is a difficult condition to treat successfully. The mechanism is poorly understood. Vaginal wind may be due to the opening of the potential space of the vagina while a woman is at rest, resulting in air trapping in the vagina as the introitus closes with movement. With activity, the air is expelled through a narrowed or closed introitus. Insertion of a pessary^21,22 prevents closure of the vagina and introitus thereby preventing trapping and subsequent expulsion of the air.

Neonatal Prolapse

Pessaries have been used successfully as a temporary measure to correct neonatal prolapse, mainly seen in association with neural tube defects such as spina bifida.²³ Small doughnut-shaped pessaries constructed from 1 to 2 cm Penrose drains have been used effectively. As neonatal prolapse is usually temporary, mechanical repositioning of the prolapse with the pessary is all that is necessary to correct the condition.

Prolapse in Pregnancy

Pessaries have been used successfully as temporary measures for treatment of prolapse or urinary incontinence during pregnancy to afford symptom relief until delivery.

Pessaries for Pelvic Organ Prolapse

Vaginal pessaries can be broadly divided into two types: support and space-filling pessaries (Table 19-1). As there is no evidence to support the use of a specific type of pessary, choice is based on experience and trial and error. It is generally accepted that the ring pessary should be the first pessary tried because of ease of insertion and removal, and, if this fails, other pessaries can be used. Clemons et al.²⁴ found that the ring pessary is successful in grades II and III prolapse on the Baden Walker scale, but for higher grades, a Gellhorn pessary was more effective. By contrast, a randomized crossover trial of the ring versus the Gellhorn pessary did not demonstrate any difference in effectiveness between the two types of pessaries.²⁵ Support pessaries are generally easier to insert, allow sexual intercourse, and are associated with less discharge or vaginal irritation than space-occupying pessaries.

Support Pessaries

Support pessaries lie along the vaginal axis, with the posterior component sitting in the posterior fornix and the anterior component coming to rest just under the symphysis pubis. In this way the pessary provides a supportive shelf for the descending pelvic organs.²⁶

Ring

The simple ring pessary (Figure 19-1) is the most commonly used pessary⁸ probably because of the ease with which it can be used for both the patient and health care provider. Folding the pessary reduces its size and allows for easy introduction through the vaginal introitus. Its shape prevents collection of vaginal discharge and women can continue to engage in vaginal intercourse with the pessary in situ. The ring pessary with support (Figure 19-2), which is a closed, perforated ring pessary, is useful in cases of procidentia as the uterus cannot prolapse through the closed ring. Women can also remain sexually active with sexual intercourse with this pessary.

Gehrung

The Gehrung (Figure 19-3) is an arch-shaped pessary with arms that can be manually molded to fit the prolapse. The pessary should be positioned with the convexity of the curved bars toward the vaginal wall depending on whether the prolapse is anterior or posterior.

Space-filling Pessaries

Gellhorn

The Gellhorn pessary (Figure 19-4A) is useful in higher grades of prolapse. The base is circular with a concave surface on the bottom and a convex surface on top, to which is attached a stem of varying lengths ending in a knob. The circular base has regular holes and the stem has a central hollow column to allow drainage of secretions. The concave surface is positioned against the vaginal cuff or the cervix and the stem lies along the axis of the vagina with the knob inside the introitus. Short-stemmed variations are available for women with shorter vaginal lengths. The Gellhorn is not compatible with sexual intercourse.

Shaatz

This is essentially a Gellhorn pessary without a stem (Figure 19-4B) and can be folded, although not as easily as the ring pessary. Removal of the Shaatz pessary is more difficult than removal of the simple ring pessaries as it has a suction effect similar to the base of the Gellhorn but does not possess a stem that can facilitate removal. This pessary is ideal for a woman who wishes to use the Gellhorn pessary but does not wish to handle it and is interested in preserving the possibility of intercourse.²⁶

Donut

The donut pessary (Figure 19-4C) is effective for the treatment for more severe stages of prolapse, especially if the perineal support is lax. Although the pessary is soft, it is difficult to alter its shape to facilitate insertion and removal. Intercourse is not possible with this type of pessary.

Cube

The cube pessary (Figure 19-4D) is highly effective for higher stages of prolapse. It retains its position in the vagina by suction of its 6 concave surfaces on the vaginal wall. Daily removal and replacement is necessary as the suction can lead to severe erosions of the vaginal walls. The suction is broken by feeling along the string attached to the cube prior to removal of the pessary. A model with perforations is available to facilitate drainage of vaginal secretions.

Inflatoball Pessary

The shape of this pessary is similar to a donut pessary (Figure 19-4E). The advantage of this pessary is that it can be deflated to facilitate insertion, and then reinflated through the inflation tubing that can be tucked in the vagina. These pessaries are often chosen for self-adjustment and specific for intermittent use according to the patient’s circumstances. It needs to be removed and replaced every one to two days. The major disadvantage is that it is made of rubber and therefore cannot be used in patients with latex allergies.

Pessaries Used for Incontinence of Urine

Incontinence Ring

The incontinence ring (Figure 19-5A) consists of a ring with a knob, which must be positioned in the midline of the vagina under the urethra to provide mechanical support. As it is very flexible, it is easy to insert but does not typically provide enough support in presence of an anterior vaginal wall prolapse. The incontinence ring can be left in place during sexual intercourse.