Pessary therapy - types of pessaries and their uses

Pessary therapy is a treatment method for certain gynecological conditions that involves placing a pessary, a special device, into the patient's vagina. It is often used in cases of pelvic organ prolapse or urinary incontinence, particularly in postmenopausal women.

Pessary therapy involves selecting the appropriate type and size of pessary, which should be performed by a specialist in urogynecology. Pessary therapy is a safe method, but it also requires patients to be careful and know how to use it. Pessary therapy allows for the avoidance of surgery in many cases.

  

What are pessaries?

Pessaries are specially designed, usually silicone, vaginal inserts used for conditions such as pelvic organ prolapse or prolapse, or urinary incontinence in women. They are also used in pregnant women with a shortening cervix. They are made of medical-grade silicone, which is safe for the body.

   

What is pelvic organ prolapse?

Pelvic floor pessary therapy is a non-surgical treatment for pelvic organ prolapse, utilizing various types of pessaries to support the pelvic organs and alleviate symptoms.

Pelvic organ prolapse is a condition in which the pelvic floor muscles weaken, leading to displacement and abnormal positioning of pelvic organs, such as the bladder, uterus, or rectum. It is a common condition, particularly in women, and can lead to various problems, such as urinary incontinence and lower abdominal pain.

Pelvic organ prolapse, prolapse, and urinary incontinence are serious issues that impact the quality of life of many women. Urogynecological problems affect 15 to 30% of women over the age of 50 who experience pelvic organ prolapse.

In developing countries, surgical treatment for pelvic organ prolapse (POP) or urinary incontinence (UI) is approximately 11%. 6–11% of women who undergo surgery for urogynecological conditions require reoperation. In the US, over 226,000 women undergo surgery for pelvic organ prolapse (POP) annually, with treatment costs exceeding $1 trillion.

Pelvic organ prolapse can be treated both conservatively and surgically. Conservative treatment includes:

• lifestyle changes,
• maintaining an appropriate BMI,
• pharmacological therapy,
• pelvic floor muscle exercises,
• pessaries and vaginal tampons.

Surgical treatment, on the other hand, involves surgical reconstruction of the pelvic floor. Surgical treatment should always be preceded by conservative treatment. Surgery should be used in patients for whom conservative treatment is ineffective. In their study, Kapoor et al. indicate that nearly two-thirds of women with urogynecological problems choose a vaginal pessary as their first-line treatment.

Pessary therapy does not require surgical intervention (if sufficient), providing a safe and effective treatment option for women with pelvic floor dysfunction who prefer or need alternatives to surgery.

Furthermore, pessaries are used in daily practice by over 86% of gynecologists and 98% of urogynecologists.

  

Applications of Pessary Therapy - When is a Pessary Used?

Pessaries are used for various conditions and illnesses, including:

• Pelvic Organ Prolapse: Pessaries can be used as a non-surgical treatment for uterine, vaginal, bladder, or rectal prolapse to reduce the discomfort associated with prolapse and restore normal anatomy and function of the genitals.
• Urinary Incontinence: Pessaries can be used to improve bladder control and reduce the symptoms of urinary incontinence.
• Atrophic Vaginitis: Pessaries, along with vaginal estrogen, can help treat the symptoms of atrophic vaginitis, such as dryness, burning, and pain during intercourse.
• Prolonged Urination: Pessaries can be used to aid bladder emptying in patients with neurological disorders such as multiple sclerosis or other POP patients who experience prolonged urination.
• Postoperative treatment: Pessaries can be used temporarily after pelvic surgery to provide support and tissue protection for rapid healing.
• Before elective pelvic floor surgery, they are used in conjunction with vaginal estrogen therapy to improve tissue circulation.
• To loosen vaginal adhesions and stenoses, e.g., after previous urogynecological surgery in patients experiencing pain related to adhesions.

 

Gynecological Pessaries - Types of Pessaries

There are several types of pessaries, each with a different shape. These include cube pessaries, ring pessaries with or without central support, disc pessaries, and bud pessaries. Vaginal support tampons also exist in cube or cylindrical shapes. They are used to treat varying degrees of uterine and vaginal prolapse, including those with urinary incontinence. They are also effective for urinary incontinence. They are also used to treat urinary incontinence after childbirth. The key is a properly fitted pessary – both the type and size.

Cube Pessary

A cube pessary, also known as a cubic pessary, is a specific type of pessary used primarily to treat advanced pelvic organ prolapse and pronounced uterine prolapse. It is a cube-shaped device made of a flexible material, usually silicone, and is characterized by numerous protrusions and perforations that help hold the pessary in place by creating a suction effect. The perforations in a cube pessary not only allow for better ventilation and drainage of secretions but also minimize the risk of irritation and infection.

A cube pessary requires precise fitting and regular medical monitoring, and improper use can lead to complications such as irritation, infection, and even perforation of the vaginal wall. A cube pessary can be inserted at home. It is recommended that the patient remove it at night.

Cube-shaped pessaries are held in place by creating a vacuum effect, or suction. This type of pessary is stable, even though the pelvic floor muscles are not strong enough to support other pessaries. A cube pessary does not interfere with an active lifestyle. It should be removed before intercourse.

They are available in sizes 0 to 7. Use above size 5 should only be in exceptional circumstances. Sizes 2 and 3 are most commonly chosen (according to the authors of the studies cited). These pessaries are worn only during the day and removed at night or before intercourse.

Some women may need to replace the pessary with a smaller or larger size after some time of use.

 

Ring Pessary

A ring pessary is often used to treat mild to moderate cases of pelvic organ prolapse, such as a prolapsed uterus or bladder. It is also effective for mild urinary incontinence, especially stress-related incontinence. Due to its simple design and ease of insertion, the ring pessary is a popular choice for women seeking non-surgical treatments for these conditions.

Plate Pessary

When the use of a cube pessary is not possible, other pessaries are used, such as a perforated plate pessary. This is a closed version of the ring pessary. It is used in cases of mild pelvic organ prolapse (descendancy of the anterior vaginal wall or cervix) with or without mild symptoms of stress urinary incontinence.

The basis for the proper functioning of this pessary is well-functioning pelvic floor muscles. This pessary is more effective than ring pessaries because the cervix does not prolapse through its closed ring. The disadvantage is that the closed structure makes intercourse difficult.

 

Fungiform Pessary

The fungiform pessary, with its characteristic mushroom-like shape, is particularly useful in the treatment of moderate to severe cases of pelvic organ prolapse, including uterine prolapse. Its unique design allows for effective support of the pelvic organs, providing support where it is most needed.

This pessary is especially recommended for women for whom other types of pessaries, such as ring pessaries, have proven insufficient. However, it is important to remember that its insertion and monitoring require more professional attention, and regular follow-up visits are crucial to ensure the safety and effectiveness of the treatment.

Urethral Pessary (Flanged)

The urethral pessary is particularly effective in treating mild to moderate pelvic organ prolapse, such as uterine or bladder prolapse. It is also beneficial in cases of mild to moderate urinary incontinence, especially when associated with physical exertion. Furthermore, the flange pessary is used in situations where surgery is contraindicated or when the patient prefers non-invasive treatment methods. It requires regular monitoring and possible replacement by a physician, allowing for monitoring the effectiveness of the treatment and preventing potential complications.

Obstetric Pessary

An obstetric pessary is a specially designed device used in pregnant women with cervical incompetence, a condition in which the cervix shortens and opens prematurely, increasing the risk of premature labor. It is usually a flexible silicone ring or disc that is placed inside the vagina to support the cervix and prevent premature dilation.

Obstetric pessaries are often used as an alternative to more invasive procedures, such as cerclage, the surgical closure of the cervix. Its use is particularly recommended for women in the second trimester of pregnancy when the diagnosis indicates a shortened cervix. The use of an obstetric pessary requires regular monitoring by a physician, and its effectiveness and safety have been confirmed in numerous clinical studies.

Who selects a pessary and how is it inserted?

The shape and size of the pessary are individually selected by a gynecologist or urogynecological physiotherapist (or urogynecological physiotherapist) to suit the patient's needs. The gynecologist or physiotherapist inserts the pessary for the first time, and then the patient performs this procedure independently at home (in the case of the cube and ring types). The patient also receives instructions on how to remove, clean, and care for the pessary.

It is inserted into the vagina to support the pelvic organs, thus preventing pelvic organ prolapse or prolapse, or urine leakage. Correct insertion should be tested by coughing, pushing, and moving. After the test, the pessary's position should be rechecked.

   

Alternatives to pessaries? Contrelle and Contam Tampons

In addition to pessaries, you can also use supportive vaginal tampons in the shape of a cube, a cylinder, or the unique shape of the Contrelle tampon. They are used to treat vaginal and uterine prolapse of varying degrees, possibly with accompanying symptoms of urinary incontinence. They are also used for difficulty urinating.

For stress urinary incontinence, which manifests itself during things like sneezing, coughing, or exercise, Contrelle is an extremely effective solution. Furthermore, if the correct size is chosen, it is completely imperceptible to the body, even during physical activity, which cannot be said for other products.

 

Side Effects of Wearing a Pessary

Wearing a pessary may cause side effects and adverse reactions, such as discomfort, mucosal irritation, genital tract infections, and an increased risk of abrasions. In some cases, intolerance to the material from which the pessary is made may also occur.

In rare cases, pressure sores and ulcers may occur. This usually occurs as a result of the patient not following the recommended care and follow-up visits.

It is important to regularly monitor your health and consult your doctor if you experience any concerning symptoms, such as pain, itching, unpleasant odor, or abnormal discharge. Your specialist can recommend appropriate care for the pessary and instructions for wearing it to minimize the risk of side effects.

Women wearing a pessary should also be aware that good hygiene and regular check-ups are crucial to maintaining health and comfort.

   

When not to use a pessary?

• short vagina (< 6 cm),
• wide vaginal opening (> 4 fingers),
• posterior vaginal wall prolapse,
• previous vaginal surgery, or coexisting stress urinary incontinence.

Pessary use during the day is best tolerated and safe, along with proper hygiene and care. With long-term use of permanent pessaries without proper medical supervision, isolated cases of cervical incarceration, fistulas, and pessary erosion into the intestine or bladder occur.

Such situations do not occur with cube pessaries that are removed at night. The biggest problem is improper use of the pessary by patients, which manifests itself through a lack of regular vaginal removal and hygiene. This can result in increased infection rates and vaginal erosion, requiring subsequent medical intervention.

   

Advantages of pessary therapy:

• Effectiveness - immediate elimination of urinary incontinence
• A pessary can effectively replace surgery
• Safety of use
• Non-invasive - The patient does not need to undergo surgery or hospitalization
• The pessary is initially inserted by a gynecologist or urogynecological physiotherapist,
• Then the pessary is inserted at home (cube/ring)
• Reversible - The pessary can be easily removed
• All decisions regarding pessary use should be made by a physician based on the patient's individual needs.

 

Disadvantages of pessary therapy:

• Several visits to a doctor or physical therapist are required to select/change a pessary.
• Requires follow-up visits.
• Missing follow-up visits can lead to infections and inflammation.
• In the case of cube and ring pessaries, they are removed at night and reinserted in the morning after thorough washing.
• The inserted pessary is palpable.

 

Pessary therapy and expected results

Studies show remission of almost all symptoms associated with pelvic organ prolapse while using a pessary.

Approximately 70% of women using a pessary experience relief from symptoms. Handa et al. demonstrated in their study that pessaries can improve the degree of pelvic organ prolapse (POP) after just one year of use, suggesting a therapeutic role for them.

Pessaries have been used in urogynecology for centuries, and are currently experiencing a renaissance. Combined with vaginal estrogens, they expand therapeutic options and improve treatment outcomes. Estrogen deficiency can lead to weakening of the ligaments and muscles supporting the pelvic floor organs by disrupting the synthesis and breakdown of collagen. Studies have confirmed the significant impact of vaginal estrogens in the treatment of lower urinary tract infections. The use of estrogens in the treatment of stress urinary incontinence is unclear. Estrogens restore normal blood flow to the urethra by increasing the number of periurethral vessels, which increases urethral resistance and may aid urinary continence. Estrogens can reduce the frequency and amplitude of detrusor muscle contractions, increase the bladder sensitivity threshold, and cause detrusor muscle relaxation, which is important in women with symptoms of overactive bladder.

The best results will be achieved with combined therapy—the use of vaginal estrogens along with pessary therapy.

References:

1. Lamers BH, Broekman BM, Milani AL. Pessary treatment for pelvic organ prolapse and health-related quality of life: a review. Int Urogynecol J. 2011 Jun;22(6):637-44. doi: 10.1007/s00192-011-1390-7. Epub 2011 Apr 7. PMID: 21472447; PMCID: PMC3097351.