Pessary Clinic

Non-surgical support for pelvic organ prolapse

Pelvic organ prolapse can cause a feeling of heaviness, pressure or a vaginal bulge and may affect bladder, bowel or everyday physical activity.

A vaginal pessary is a removable support device placed inside the vagina to help support the pelvic organs and reduce prolapse symptoms. It provides a non-surgical option that can be used either temporarily or as part of longer-term prolapse management.

A pessary clinic provides assessment, fitting, review and ongoing support to help determine whether a pessary is suitable and comfortable for you.

What is a vaginal pessary?

A vaginal pessary is a small device, commonly made from silicone or plastic, that sits inside the vagina and provides additional support to the pelvic organs.

Pessaries are available in different shapes and sizes.

A correctly fitted pessary should provide useful support without causing significant discomfort or interfering unnecessarily with normal everyday activities.

Finding the most suitable size or type can sometimes require more than one fitting.

What is pelvic organ prolapse?

Pelvic organ prolapse occurs when the muscles and supporting tissues in the pelvis are no longer providing enough support and one or more pelvic organs move downwards towards the vagina.

This may involve:

• The bladder
• The uterus
• The bowel
• The top of the vagina following hysterectomy

The type and degree of prolapse vary between individuals.

Not everyone with prolapse requires treatment. Management is usually based on how much the symptoms affect everyday life.

Symptoms a pessary may help with

A pessary may be considered if prolapse is causing symptoms such as:

• A feeling of heaviness in the pelvis
• A dragging sensation
• A feeling of pressure in the vagina
• A visible or noticeable vaginal bulge
• Symptoms that become worse after standing for longer periods
• Discomfort during physical activity
• Difficulty remaining active because of prolapse symptoms
• Some bladder or bowel difficulties associated with prolapse

Prolapse can affect people differently, so the aim is to determine whether supporting the prolapse improves the symptoms that are important to you.

Who may consider a pessary?

A pessary may be suitable if you:

• Want to manage prolapse without surgery
• Prefer to delay or avoid surgery
• Are waiting for prolapse surgery
• Are not currently suitable for surgery
• Want additional support during everyday activities
• Experience prolapse symptoms during exercise
• Want to explore conservative management before considering other options

A pessary can also be used alongside pelvic floor rehabilitation where appropriate.

Using a pessary does not mean that surgery will necessarily be required later.

For some people, pessary management provides satisfactory long-term symptom control.

What happens during your first appointment?

Your first appointment begins with a discussion about your symptoms and how they affect everyday life.

The clinician may ask about:

• Pelvic pressure or heaviness
• A vaginal bulge
• Bladder symptoms
• Bowel symptoms
• Pelvic discomfort
• Previous pregnancies and childbirth
• Previous pelvic surgery
• Hysterectomy where relevant
• Menopause
• Sexual activity where relevant to pessary choice
• Current exercise
• Work and daily activities
• Previous prolapse treatment
• Previous pessary use
• Your goals and preferences

This information helps establish whether a pessary may be an appropriate option.

Pelvic examination

A vaginal examination is normally required before fitting a pessary so that the prolapse and vaginal tissues can be assessed and an appropriate pessary size or type considered.

The assessment should be explained before it begins and carried out only with your consent.

You can ask questions, request a chaperone and ask for the examination to stop at any point.

The aim is to understand the support required and choose a pessary that is likely to be both comfortable and effective.

Choosing the right pessary

Pessaries are available in different designs and sizes.

The most appropriate option depends on factors such as:

• The type of prolapse
• Degree of prolapse
• Vaginal shape and size
• Previous surgery
• Comfort
• Bladder and bowel symptoms
• Lifestyle
• Sexual activity
• Whether you would like to remove and replace the pessary yourself

Ring pessaries are commonly used, but other designs may be appropriate depending on the individual situation.

The clinic will consider these factors rather than using the same pessary for everyone.

Pessary fitting

During fitting, the selected pessary is gently inserted into the vagina and positioned to support the prolapse.

You may then be asked to perform movements such as:

• Standing
• Walking
• Coughing
• Squatting
• Bending
• Moving around the room

This helps determine whether the pessary remains comfortably in position during normal movement.

You may also be asked whether you:

• Feel pressure or discomfort
• Can feel the pessary excessively
• Feel that the prolapse is better supported
• Have difficulty passing urine
• Feel that the pessary may fall out

The pessary should provide support without creating significant discomfort.

Finding the correct size

The first pessary tried is not always the correct one.

A pessary that is too small may:

• Move excessively
• Fall out
• Provide inadequate support

A pessary that is too large may:

• Cause pressure
• Feel uncomfortable
• Make bladder or bowel function more difficult

It can therefore take more than one attempt to find the most appropriate fit.

This is a normal part of pessary management rather than a sign that pessary treatment will not work.

What should a correctly fitted pessary feel like?

Once fitted appropriately, you should generally not be constantly aware of the pessary.

You should usually be able to:

• Walk comfortably
• Sit
• Stand
• Bend
• Complete normal household activities
• Use the toilet

The aim is for the pessary to reduce prolapse symptoms without creating a new physical problem.

If you experience ongoing discomfort, the pessary may need to be reviewed.

What happens after fitting?

After your pessary has been fitted, you will receive information about what to expect and when review is required.

You may be advised about:

• Normal activity
• Pelvic floor exercises
• Cleaning or pessary care where relevant
• Sexual activity
• Vaginal discharge
• Symptoms that require review
• Your next follow-up appointment

Follow-up is an important part of pessary care because the vaginal tissues and the fit of the pessary need to be checked regularly.

Pessary review appointments

A pessary should not normally be fitted and then forgotten.

Regular review allows the clinician to assess:

• Whether your symptoms have improved
• Whether the pessary remains comfortable
• Whether it stays in position
• Vaginal tissue health
• Bleeding or discharge
• Bladder or bowel symptoms
• Whether the pessary still fits appropriately
• Whether a different size or type may be useful

The timing of review depends on the pessary, your symptoms and whether you manage it yourself.

For pessaries managed by a healthcare professional, regular removal, cleaning and reinsertion or replacement is generally required.

Self-management of a pessary

Some people can learn to remove, clean and replace their own pessary.

Whether this is appropriate depends on:

• The pessary type
• Hand strength and dexterity
• Mobility
• Confidence
• Comfort with self-management
• Individual preference

If self-management is suitable, you can be shown how to remove and reinsert the pessary safely.

There is no requirement to manage the pessary yourself if you would prefer regular clinic reviews.

Pessary care

Pessary care depends on the device being used and whether it is self-managed.

You will receive individual instructions about:

• Removal where appropriate
• Cleaning
• Reinsertion
• Follow-up
• When the pessary needs reviewing or replacing

Avoid following generic online cleaning instructions if they differ from the advice provided for your particular pessary.

Pelvic floor rehabilitation alongside pessary use

A pessary provides physical support to the prolapse, but pelvic floor rehabilitation may still be useful.

Treatment may include:

• Pelvic floor muscle training
• Breathing and pressure management
• Strengthening
• Bladder or bowel advice
• Return-to-exercise guidance
• Lifting strategies

Pelvic floor muscle training can be used alongside pessary treatment as part of conservative prolapse management.

The two approaches do different things and may complement each other.

Exercise with a pessary

Many people want to remain active while managing prolapse.

A pessary may provide additional support during activities that normally increase symptoms.

Depending on your individual situation, this may include:

• Walking
• Gym exercise
• Strength training
• Exercise classes
• Running
• Household activity
• Work involving physical movement

Exercise should still be adjusted according to symptoms.

If you continue to experience heaviness, pressure, pain or difficulty keeping the pessary in position, the fit or activity programme may need reviewing.

Returning to running

Some people mainly notice prolapse symptoms during higher-impact activities such as running.

Where appropriate, pessary support can form one part of a wider return-to-running programme.

Rehabilitation may also consider:

• Pelvic floor strength
• Hip and leg strength
• Impact tolerance
• Running volume
• Breathing
• Pressure management

The aim is to help you remain active rather than automatically avoiding impact exercise permanently.

Lifting with prolapse

Lifting increases pressure through the abdomen and pelvis.

This does not mean that everyone with prolapse needs to avoid lifting.

Where appropriate, treatment may involve:

• Pelvic floor coordination
• Breathing
• Strength
• Lifting technique
• Gradual progression of load
• Pessary support

The approach depends on your symptoms and the physical demands of work or everyday life.

Pessary use after childbirth

Prolapse symptoms can sometimes develop following pregnancy and childbirth.

A pessary may be considered as part of conservative management where appropriate.

Treatment may also include pelvic floor rehabilitation to address:

• Pelvic floor weakness
• Bladder symptoms
• Pressure management
• General strength
• Return to exercise

Management should take account of recovery after childbirth, future pregnancy plans and individual symptoms.

Pessary use around menopause

Pelvic organ prolapse becomes more common with age and after menopause.

Changes in vaginal tissues may sometimes affect comfort with pessary use.

Where clinically appropriate, vaginal oestrogen may be discussed with your GP, gynaecologist or another prescribing clinician.

This is considered individually according to symptoms, medical history and suitability.

Bladder symptoms and pessary use

Prolapse can sometimes affect bladder function.

Symptoms may include:

• Urgency
• Frequent urination
• Leakage
• Difficulty starting urination
• A feeling that the bladder has not completely emptied

Some bladder symptoms may improve when the prolapse is supported, while others may remain or occasionally become more noticeable.

Bladder function is therefore considered during fitting and follow-up.

If you develop significant difficulty passing urine after fitting, the pessary should be reviewed.

Bowel symptoms

Prolapse can also be associated with bowel symptoms such as:

• Difficulty emptying
• Constipation
• A feeling of incomplete emptying
• The need to strain

Pessary support may help some symptoms depending on the type of prolapse.

Bowel habits and pelvic floor function may also need to be addressed as part of wider treatment.

Persistent or changing bowel symptoms should receive appropriate medical assessment where required.

Sexual activity with a pessary

Whether sexual intercourse is possible with a pessary in place depends on the type of pessary being used.

Some pessaries can remain in place during vaginal intercourse, while others may need to be removed.

If sexual activity is important to you, mention this during your assessment so it can be considered when selecting the most appropriate pessary.

Vaginal discharge

Some change in vaginal discharge may occur while using a pessary.

However, new or significant changes should be discussed at review, particularly if there is:

• An unpleasant smell
• Irritation
• Pain
• Bleeding
• A significant change from your usual discharge

These symptoms may indicate that the pessary or vaginal tissues need assessment.

Vaginal bleeding

Bleeding while using a pessary should not simply be ignored.

Possible causes include irritation or pressure from the pessary, but bleeding can also have causes unrelated to pessary use.

You should contact an appropriate healthcare professional if you experience unexpected vaginal bleeding.

This is particularly important for new bleeding after menopause.

What if the pessary falls out?

A pessary can occasionally move or fall out, particularly during bowel movements, coughing, heavy activity or if the fit is not suitable.

If this happens repeatedly, the pessary may need to be:

• Repositioned
• Resized
• Changed to another type

Do not assume that pessary treatment is unsuitable simply because the first device does not remain in position.

Finding the correct fit can take more than one attempt.

What if the pessary feels uncomfortable?

A pessary should not cause persistent pain.

Arrange a review if you experience:

• Ongoing pressure
• Pelvic pain
• Vaginal pain
• Difficulty sitting
• New bladder difficulties
• New bowel difficulties
• Repeated slipping
• Difficulty walking comfortably

A different size or type may be required.

Possible problems with pessary use

Most pessaries can be used without significant problems when appropriately fitted and reviewed, but possible issues include:

• Increased vaginal discharge
• Bleeding
• Irritation
• Infection
• Pressure areas or ulceration
• Discomfort
• The pessary falling out
• Difficulty removing the pessary
• Changes in bladder or bowel symptoms

Regular follow-up helps identify and manage problems early.

When should the pessary be reviewed sooner?

Do not wait until your routine appointment if you develop:

• Significant pain
• Persistent vaginal bleeding
• Foul-smelling or unusual discharge
• Difficulty passing urine
• New difficulty emptying the bowel
• Repeated pessary displacement
• A pessary that falls out frequently
• Significant vaginal irritation
• Difficulty removing a self-managed pessary
• A noticeable change in prolapse symptoms

An earlier review can determine whether the pessary needs adjusting, temporarily removing or changing.

When further medical assessment may be needed

Not every pelvic symptom is caused by prolapse or the pessary.

Further medical assessment may be appropriate if you experience:

• Unexplained vaginal bleeding
• New bleeding after menopause
• Blood in the urine
• Repeated urinary infections
• Significant pelvic pain
• Difficulty passing urine
• Significant changes in bowel function
• Unexplained weight loss
• New or rapidly worsening pelvic symptoms

If symptoms are severe or significantly different from your normal prolapse symptoms, seek appropriate medical advice.

Pessary or surgery?

A pessary and prolapse surgery are different management options.

A pessary:

• Does not require an operation
• Can usually be removed
• Can be reviewed or changed
• May be used temporarily or longer term
• Requires ongoing care and follow-up

Surgery aims to repair or improve support to the pelvic organs but involves an operation and its associated recovery and risks.

Some people prefer pessary management, while others eventually choose surgery.

The right option depends on your symptoms, health, preferences and how prolapse affects your everyday life.

Pessary treatment does not need to be permanent

Choosing a pessary does not mean you have committed to using one permanently.

Your management can be reviewed if:

• Symptoms change
• The pessary becomes uncomfortable
• You wish to try another treatment
• You want to consider surgery
• Your activity or lifestyle changes

Likewise, someone who initially uses a pessary temporarily may later decide that it works well enough to continue.

Treatment based on your goals

Pessary management should focus on the symptoms and activities that matter to you.

Your goals may include:

• Reducing pelvic heaviness
• Feeling less aware of a vaginal bulge
• Walking more comfortably
• Exercising
• Running
• Returning to the gym
• Managing work
• Standing for longer periods
• Avoiding or delaying surgery
• Feeling more comfortable during everyday activities

The pessary and wider pelvic health programme can be reviewed according to these goals.

How long can a pessary be used?

Pessaries can be used for different lengths of time depending on individual circumstances.

Some people use a pessary temporarily.

Others choose it as a longer-term way of managing prolapse.

Long-term use requires appropriate follow-up, with removal, cleaning and review at intervals based on the type of pessary and the way it is being managed. RCOG advises regular removal and review because pessaries can occasionally cause discharge, bleeding, infection or vaginal ulceration.