PessaryEdit

Pessary is a medical device designed to be placed in the vagina to support pelvic organs. It is most commonly used to treat pelvic organ prolapse, a condition in which parts of the pelvic contents sag or descend due to weakness in the pelvic floor. By providing structural support, pessaries can relieve symptoms such as pressure, bulging, and urinary issues, enabling many patients to avoid or delay surgical repair. In addition to prolapse, pessaries are sometimes used to manage urinary incontinence or to support the cervix in certain pregnancy-related scenarios. For more on the anatomy involved, see pelvic floor and pelvic organ prolapse.

Pessaries come in a range of shapes and sizes, and fitting is typically performed by a clinician who specializes in gynecology or urogynecology. After fitting, many patients can manage routine care themselves, though regular follow-up is important to monitor for irritation, infection, or changes in symptoms. The pessary can be temporary or long-term, depending on the individual’s health, her preferences, and the advice of her healthcare team. See also vagina for anatomical context and urinary incontinence for related conditions.

Medical uses

Prolapse of pelvic organs (such as the bladder, uterus, or uterus-cervix complex) that causes symptoms but is not immediately dangerous. Pessary use is a well-established first-line or interim management strategy in many patients, particularly older individuals or those who are not ideal candidates for surgery. See pelvic organ prolapse for details on the condition and treatment options.
Some forms of urinary incontinence where vaginal support influences bladder function. In certain cases, pessaries can reduce leakage by improving urethral support.
Cervical support during pregnancy in specific high-risk situations, where a cervical pessary may be considered to reduce the risk of preterm birth. See cervical pessary for related discussion.

Types of pessaries

Ring pessaries: The most common type, shaped like a ring that sits around the cervix and provides circumferential support. See ring pessary for more.
Gellhorn pessaries: A more rigid design with a stem that can provide deeper support in certain prolapse patterns.
Cube pessaries: Small, three-dimensional shapes that fill vaginal space and press outward to support pelvic organs.
Donut pessaries and shelf pessaries: Other configurations chosen based on anatomy and symptom pattern.
Cervical pessaries: Designed specifically to support the cervix in pregnancy and to reduce uterine descent in selected cases; see cervical pessary for more information.

Fitting and management

Fitting is individualized: a clinician assesses vaginal anatomy, the type and severity of prolapse, and the patient’s lifestyle and preferences. The goal is to choose a pessary that stays in place comfortably while providing effective support.
Insertion and removal: Pessaries are typically placed by a clinician, but many patients are taught how to remove, clean, and reinsert their device at home. Regular follow-up is advised to check for irritation, discharge, or infection.
Care and maintenance: Hygiene is important. Some pessaries can be cleaned with mild soap and water, while others require alternative care according to the device type and physician instructions. If symptoms worsen, or if there is unusual discharge, odor, or bleeding, medical advice should be sought promptly.
Duration of use: Some patients use pessaries long-term, while others may have a trial period or use them as a bridge to surgical repair if desired. The decision depends on medical factors and personal choice.

Advantages and limitations

Advantages: Non-surgical, reversible, and often cost-effective for many patients. Pessaries can provide rapid symptom relief and preserve pelvic organ function, with the option to pursue surgical repair later if needed.
Limitations: Not a cure for underlying pelvic floor weakness; symptoms may persist if the device shifts, becomes uncomfortable, or if hygiene is not maintained. Some patients experience irritation, vaginal discharge, ulcers, or pressure from the device, requiring adjustment or removal. Regular follow-ups are essential to minimize complications and ensure continued effectiveness.

Safety and complications

Common issues: Vaginal irritation, discharge, odor, or discomfort. These can often be addressed by adjusting the type or size of pessary, or by improved cleaning and fit.
Less common problems: Ulceration of the vaginal wall, erosion into adjacent tissues, or infection if the device is not properly cared for or if there is an underlying infection.
When to seek care: New or worsening symptoms, fever, heavy bleeding, or severe pain should prompt a clinical evaluation. See vaginal infection and pelvic inflammatory disease for broader considerations of vaginal and pelvic infections.

Controversies and debates

Role in treatment pathways: Pessaries are widely accepted as a conservative option that can delay or prevent surgery. Critics sometimes argue that reliance on devices may delay definitive repair in cases where underlying pelvic floor weakness would benefit from earlier surgical intervention; supporters emphasize patient autonomy and individualized care, enabling choices aligned with patient health status and preferences.
Evidence base and guidelines: Research supports pessaries as effective for many patients with prolapse, though findings can vary by prolapse type, symptom profile, and follow-up duration. Ongoing trials and meta-analyses continue to refine which patients benefit most and how best to optimize fitting and maintenance.
Access and training: Availability depends on access to trained clinicians and follow-up care. In some settings, limited access to specialists can constrain the use of pessaries, leading to greater reliance on surgical repair. Proponents of broad access argue that conservative management can reduce overall healthcare costs and patient risk, while opponents point to the need for consistent training and patient education to prevent complications.
Patient autonomy and non-surgical care: Advocates stress that patients should have the full range of options, including long-term conservative management, with informed consent and transparent discussion of risks and benefits. Critics who prioritize rapid resolution of symptoms may favor earlier surgical intervention. In practice, many patients benefit from a mixed approach tailored to their goals, health status, and life circumstances.