Gynaecology - Vaginal pessaries for treatment of prolapse

Using a pessary for vaginal prolapse

This leaflet explains what vaginal prolapse is, the benefits and the risks of having a pessary for treatment of vaginal prolapse and the alternatives to pessaries.

We have answered the most common questions asked by women regarding prolapse and pessaries. However, we do understand that every woman’s situation is different and individual to them and advice from an appropriate healthcare professional is always preferable. If you do have any specific questions, it is important to speak to your own doctor, nurse specialist or physiotherapist for further help.

What is a vaginal prolapse?

Vaginal prolapse is a common condition where the walls of the vagina and sometimes the uterus (womb), or vaginal roof (Vault) (if you have had a hysterectomy) bulge downwards towards the entrance of the vagina.

A vaginal prolapse is also known as a pelvic organ prolapse.
 
Fig.1 Female external anatomy – No prolapse visible at vaginal entrance

Fig.2 Female external anatomy – Prolapse visible at vaginal entrance

What are the symptoms of a vaginal prolapse?

You could have one or more of these symptoms:

• A feeling of something coming down, a dragging sensation or a bulge in the vagina
• Difficulty emptying your bladder or bowel
• Discomfort/pain during sexual intercourse
• Discomfort or aching in the pelvis and low backache

What increases the risk of vaginal prolapse?

Pelvic floor muscles help prevent vaginal prolapse. Some women have weaker pelvic floor muscles, putting them at risk of prolapse. This can be aggravated by other factors such as:

• Pregnancy and childbirth
• Getting older
• Being overweight
• Persistent coughing
• Constipation
• Heavy lifting
• Smoking

Fig.3 Female pelvic floor muscles (courtesy of RCOG website)

What can be done to help improve your symptoms?

The following are sometimes referred to as 'conservative' or 'non-surgical' approaches.

• Lifestyle changes can reduce symptoms. Losing weight, treating constipation, reducing heavy lifting and stopping smoking all reduce the pressure on your pelvic floor muscles
• Using a vaginal pessary to support the prolapse alongside doing pelvic floor exercises
• Pelvic floor muscle exercises help to strengthen the pelvic floor muscles and will help improve support and reduce symptoms. They tend to be more effective when supervised by a qualified pelvic floor physiotherapist over at least a few sessions. You can be referred to them through your GP or if seen in gynaecology outpatient clinic through a doctor or a nurse
• Information about pelvic floor muscle exercises: https:// thepogp.co.uk/patients/pelvic_health_advice/ pelvic_floor_muscles.aspx
• Audio pelvic floor muscle exercise guide: https:// www.youtube.com/watch?v=92KUPKi-ii4&feature=emb_logo
• NHS squeezy app - available on app store

In some cases, surgery may be recommended. Surgery is offered when non-surgical treatments fail to control your symptoms.

What is a vaginal pessary?

A vaginal pessary is a device, made of plastic or silicone, which is inserted into the vagina to hold a prolapsed uterus or vaginal wall in place. It will also support your bowel and bladder. There are different types of pessaries and the healthcare professional (nurse or doctor) who assesses your prolapse will discuss the type best suited to you. It sometimes takes more than one visit to get the right size, fit and type for you.

Fig.4 Ring pessary (courtesy of RCOG website)

This is the most common type of pessary. They are made of polythene or PVC (polyvinyl chloride) and available in a number of sizes (50mm-120mm). The size is their diameter in mms.

Fig.5 Shelf/ Gelhorn pessary (courtesy of RCOG website)

Some patients will not be able to retain a ring pessary and for these a shelf or a Gellhorn pessary can be used. Neither of these should be used in sexually active patients or patients having periods.

What are the benefits of a vaginal pessary?

Once fitted correctly a vaginal pessary may help to reduce your symptoms and make you feel more comfortable. You will be able to continue with your everyday activities including exercising, working and caring for your family.

Fig.6 Inside view of female anatomy – with pessary sitting in place in the vagina

PLEASE NOTE: This diagram is an illustration of how the pessary supports the vaginal walls and is not 'the correct position'. The exact position that the pessary rests in will be very personal to you and may be much lower.

Once fitted, the pessary is normally removed and replaced no earlier than every 3 - 6 months, dependent on the type of pessary you are using. This can be done either at a hospital outpatient clinic by nurse or doctor or at your GP practice by a nurse. Some patients choose to do this themselves at home i.e. “self-manage” their pessary.

What are the risks of a vaginal pessary?

• You may notice you have more vaginal discharge than normal. If the discharge is offensive inform your pessary fitting clinician or your GP
• Occasionally bladder or bowel function could be affected
• You may have vaginal irritation. If you feel sore, and have been through the menopause, you may benefit from using vaginal oestrogen
• Long-term use of a vaginal pessary may cause grazing or ulcers (sores) inside the vagina and/or infection. To reduce the risk of this happening you may also be prescribed vaginal oestrogen.

Vaginal oestrogen can be used either as a cream or in the form of a pellet (also called a pessary) which is inserted into the vagina.
The hormone is absorbed by the vaginal tissue and works locally. This means that unlike other hormone replacement therapy (HRT) the amount absorbed into the blood stream and travelling round the body (systemic absorption) is very small.

Frequently Asked Questions

Who will fit my pessary?

A qualified health care professional with experience in managing pessaries.

Can I ask for a female practitioner?

Yes, you can, although there may not be a female practitioner available in every clinic so you may want to make this request in advance of your appointment. You should be offered a chaperone and you may also choose to have someone with you such as a partner or friend.

Will I get a choice of device, or see what my pessary looks like before it is fitted?

Not all pessaries work for all women and all types of prolapse. After you have been assessed, you would be shown which device is most likely to be appropriate for you. Sometimes it can take more than one fitting to find the device and size that works best for you. Throughout the process your doctor or nurse specialist will work with you to make sure that you get the best possible results.

How is a pessary fitted?

You will have your pessary fitted by one of our doctors or specialist nurses in the gynaecology clinic. You will have a vaginal examination to assess which pessary would be most appropriate for you.

The pessary will then be placed into your vagina and moved into place to sit just behind the pubic bone. This may cause some discomfort, but it should not be painful.

After the fitting you will be asked to walk around and pass urine. This is to ensure the pessary does not fall out and that you can pass urine without problems.
 
Once you feel that the pessary is comfortable and is not causing any problems you can go home with contact numbers in case of any issues. We will also give you a follow up appointment in about 4 months initially, then if all is well 6 monthly to have it replaced.

Will I feel it in place?

No, ideally you should not feel it once it is in place and have a good fit. However, the pessary can move within the vagina, a bit like a tampon, so you may be aware of it at times, but it should not be uncomfortable. The person fitting your pessary will be able to show you what to do if it does become uncomfortable. You will be given a contact telephone number in case you have any problems when you get home.

Will it fall out when I exercise?

A pessary should not fall out if correctly fitted. There is an element of trial and error when fitting pessaries for the first time, so a pessary could fall out while you are trying different ones. Once you have a well-fitting and comfortable pessary, it will not come out during exercise, but it can still move.

Should I give up my exercise activities?

No. You should be able to continue exercise with a pessary. Many women find they can be more active once they have a correctly fitted device in place.

I have been doing pelvic floor exercises. Should I continue with them?

Yes. It is important to continue with your pelvic floor exercises.

Can I use a tampon?

Yes. You can use a tampon if you have a ring type pessary as long as it feels comfortable.

Will it fall out when I strain to open my bowels?

If it is fitted well, this should not happen. However, supporting the area between the anus and the vagina when opening your bowels gives confidence to push, without pushing the pessary out. Wrap toilet paper or a sanitary pad around your hand and press and support the area just in front of the anus and around the opening of the vagina. Avoid getting constipated.

Will I be prone to more vaginal infections?

You may occasionally get a vaginal infection which can be treated with a local antibiotic vaginal cream or by removing the pessary and leaving it out for a while. Oral antibiotic tablets will be given if required.

An infection is less likely if the pessary is changed regularly and the vaginal tissues are kept healthy by using vaginal oestrogen which may be prescribed.

Will it affect my sex life?

It is possible to have penetrative vaginal sex with some pessaries such as a ring or Shaatz pessary, but others would have to be removed first and replaced. You will be able to discuss with your healthcare professional options of which pessary might best suit you, along with any concerns you may also have about contraception.

How difficult is it to remove and put back in?

Some pessaries can be self-managed. The clinician who fitted your device will assess suitability and discuss this with you and will teach you how to remove it and reinsert it while you are with them in clinic. It is not usually difficult to remove a pessary or replace one once you have been shown how and have practiced.

Can I self-manage my pessary?

Yes. You may be offered self-management of your pessary by your healthcare professional if suitable. You can manage your pessary yourself once you have been shown how to, have practiced and are confident to do so.

Do I need to use lubricants?

You may find it more comfortable to use a vaginal lubricant when inserting a pessary, especially a new one, but you do not have to.

Can I expect my prolapse condition to go back to normal after a while or is this it for the rest of my life?

Using a vaginal pessary controls the symptoms of a prolapse by supporting it. The pessary will not ‘heal’ or ‘cure’ the prolapse. Sometimes when the pessary is removed, there may be a temporary improvement, but this is not likely to last over time.

Is this currently the preferred treatment for prolapse?

It is a non-surgical option for managing vaginal prolapse, but each woman is different and treatment choice varies with each individual. You can change your mind about your treatment at any time.

My pessary is not controlling my symptoms. What are my options?

Surgery may be considered. Surgery for prolapse may include hysterectomy if the uterus has prolapsed. However, with some surgical procedures women do not need to have a hysterectomy. Removing the uterus itself does not always cure the prolapse and may make other types of prolapses more common.

Can I buy a pessary from my local chemist myself to experiment myself?

It is possible to buy online but it is not advisable without having been assessed by a trained professional who can make sure you have the correct and most suitable pessary. There are a large variety of pessaries on the market and an appropriately trained healthcare professional will be able to help you find one that is likely to help you and your specific prolapse and symptoms. If you buy one online, it would be advisable to ask a healthcare professional to check it is suitable for you before you use it.

Pessaries can also be used as a diagnostic trial on occasion, to see if your symptoms improve when the prolapse is elevated. If they don't, then this would indicate not to operate. Your doctor will discuss this with you as needed.

What happens if I am self-managing my pessary and it gets stuck?

Don’t panic! It is much easier to remove a pessary if you are relaxed and in the right frame of mind.

Contact the clinic where the pessary was fitted, your GP or go to the nearest A&E.

Who do I contact with any queries or concerns?

Please phone our Urogynaecology nurse specialists or consultants secretaries

Nurse Specialist - 0161 206 -1681
Secretaries - 0161 206 5258/5259 (Monday - Friday 8am - 5pm)
Gynaecology Reception - 0161 206 5224

References

RCOG Pelvic Organ Prolapse online package
RCOG “ your pelvic floor” patient information leaflet
UK Clinical Guideline for best practice in the use of vaginal pessaries for pelvic organ prolapse – Dec 2020