Pessary Fitting

Referrals

If you are a health professional and would like to refer a client for a pessary fitting, please complete this form (PDF, DOC) and return it to us by fax at 613-907-1352.

If you are a new client who has been referred for a pessary fitting by your pelvic health physiotherapist, please have your physiotherapist complete the pdf form above and return it to us by fax.

Pessary Fitting for Pelvic Organ Prolapse and Incontinence

Ref: UK Clinical Guideline for best practice in the use of vaginal pessaries for pelvic organ prolapse, March 2021

What is pelvic organ prolapse? 

Pelvic organ prolapse is defined as the symptomatic descent of one or more of: the anterior vaginal
wall, the posterior vaginal wall, the cervix or uterus, or the apex of the vagina (vault or cuff scar
after hysterectomy). The vagina can be considered as having anterior, posterior and apical
compartments.

What are common symptoms of pelvic organ prolapse?  

Common prolapse symptoms include:
• vaginal heaviness and bulge;
• bladder and bowel difficulties that may include urgency, frequency, leakage and
incomplete emptying; and
• discomfort that may be felt vaginally, abdominally or during sexual activity and may include
low back pain
• possible associated bladder, bowel and sexual symptoms discomfort that may be felt vaginally, abdominally or during sexual activity and may include low back pain

20–40% of all women will experience prolapse symptoms that may be bothersome and affect their quality of life.

 

How is pelvic organ prolapse identified? 

Pelvic organ prolapse is measured by an internal vaginal exam consisting of coughing and bearing down. Prolapse is staged according to the extent of downwards displacement (descent) of the most-affected vaginal compartment.


Treatment options for pelvic organ prolapse 

Treatment for pelvic organ prolapse should start with non-surgical (conservative) management
options that may include: pelvic floor muscle training; lifestyle advice; a vaginal pessary to support the prolapse; and if indicated, vaginal (topical) oestrogen for post-menopausal women. Surgical treatment may also be offered with the aim of restoring the vaginal anatomy. If the prolapse
symptoms are not very bothersome, a woman may choose neither management option, and
instead, wait to see if her symptoms worsen or improve. The treatment goals should be discussed
to determine the management plan.

What is a pessary?

A pessary is a soft, flexible device that is placed in the vagina to help support the bladder, vagina, uterus and/or rectum in the case of pelvic organ prolapse. Pessaries offer a non-surgical way to reduce pelvic organ prolapse symptoms, to improve bowel and bladder emptying, to prevent a prolapse from getting worse, to delay or prevent surgery, to reduce incontinence, and to facilitate improved activity tolerance.  

Vaginal pessaries are used a first-line treatment for prolapse. They are used intravaginally to try to restore the prolapsed organs to their normal position and relieve symptoms. They are usually made of silicone and are available in a range of types and sizes. The ring pessary is the most commonly used. The addition of a knob may help with symptoms of stress urinary incontinence (SUI).  Non ring-shaped pessaries such as the Gellhorn, or cube, may offer support for different stages and compartments of prolapse. Choice and fit of pessary are based on clinician experience, availability, whether the woman wants to be sexually active, and which type of pessary is retained and comfortable. The fitting process is “trial and error”, and several different sizes and types may need to be tried before the woman is comfortable during all activities and able to pass urine with the pessary in place.

Pessary Indications 

A pessary may be offered to a woman:
• for short- or long-term management of bothersome symptoms of pelvic organ prolapse if
she has a preference for or is willing to agree to a trial of pessary use, there are no
contraindications (see below), and she understands that regular attendance for follow-up
is required unless self-management is chosen and available;
• who has not completed her family and needs an interim solution for symptomatic prolapse
until surgery, if indicated, can be considered at a later date; or
• to assess the effect of reducing a prolapse on bladder and bowel function prior to
considering surgical management.

Pessary Contraindications

A pessary should not be considered in the following situations:
• The woman is neither able to comply with regular follow-up, nor self-manage the pessary.
• There is active vaginal or pelvic infection, inflammation, unexplained bleeding, or ongoing
vaginal or cervical cancer
• There has been previous radiotherapy affecting the vaginal tissues
• The vaginal tissue is severely atrophic and has not responded to pre-pessary oestrogen
treatment
• The vaginal space is too narrow or too short to fit a pessary
• There is identifiable synthetic vaginal mesh erosion

Caution required

A pessary may be an option, but additional caution is required in the following situations:
• poor vaginal health requiring vaginal oestrogen therapy prior to a pessary fitting;
• a synthetic mesh has been placed in the vagina during previous surgery; and/or
• pre-existing vaginal pain (e.g. pudendal neuralgia).

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The pessary fitting process

The pessary fitting process includes:

  1. a pre-fitting assessment
  2. a pessary fitting appointment
  3. a pessary follow-up assessment
  4. ongoing follow-up appointments

Pre-fitting assessment

The pre-fitting assessment includes a thorough history-taking of current symptoms, and medical and pelvic health history.

A vaginal exam is required to assess:

  • the quality of the skin and vaginal tissues*
  • the type and degree of prolapse
  • functional movements which provoke symptoms
  • pelvic floor muscle strength in gravity positions
  • whether there are any factors that might delay the pessary fitting such perineal scar tissue, pelvic floor muscle hypertonus and tissue sensitization

*Some women may benefit from a 1–3 month course of local vaginal estrogen to help make the lining of the vagina thicker and healthier. Non-estrogen vaginal moisturizers can also be very beneficial to relieve symptoms of vaginal dryness and to improve the comfort of the pessary.

The key findings of the assessment are summarized in a pessary authorization form and faxed to the physician or specialist. The pessary fitting consent and pessary care forms are reviewed. Once the pessary authorization form is signed and returned to us by fax we can proceed with booking the pessary fitting appointment.

Pessary fitting appointment

The pessary fitting appointment includes:

  • a vaginal assessment to note any baseline tenderness of the vaginal walls and a speculum exam
  • trial and error of a number of different pessaries until the best fit is found
  • instruction in inserting and removing the pessary
  • a review of pessary care and medical follow-up

Pessary follow-up assessment

The pessary follow-up assessment is a brief 15-minute appointment carried out 1-2 weeks after wearing the pessary daily. The vaginal walls are palpated for any signs of tenderness and a repeat speculum exam is done. Pessary care is reviewed and any questions or concerns are discussed.

Pessary follow-up appointments

Follow-up appointments with a physician, your fitting physiotherapist or another designated health care professional, such as a nurse care practitioner, are recommended at 1, 3, 6 and 12 months following the pessary follow-up assessment. From that point onwards, it is recommended that you have a medical assessment once per year to have the tissues assessed. 

Pessary benefits

The benefits of a pessary may include:

  • Improved pelvic organ support
  • Improved comfort and function and quality of life
  • Improved bladder and/or bowel emptying
  • Improved pelvic floor muscle function
  • Reduced urinary incontinence
  • Preventing or avoiding surgery

Pessary fit

Your pessary is a good fit for you if:

  • you are not aware of it when wearing it
  • it feels supportive
  • you can empty your bladder and bowels fully
  • it is easy to remove every night and re-insert in the morning
  • it reduces or clears your symptoms of prolapse and/or incontinence
  • it enables you to be more active and feel more comfortable
  • it helps to prevent or avoid surgery

Please call us at 613-291-2956 or email our receptionist with any pessary questions.

We would be happy to discuss your questions with a complimentary phone consultation.

To learn more about prolapse and pessaries: