Pelvic health rehabilitation has grown tremendously over the decades, expanding from a publicly viewed mentality of “just Kegels” to a comprehensive, whole-body, and whole-life approach. As rehabilitation providers, we now treat the complex interplay of muscles, fascia, organs, and the nervous system that influences bladder, bowel, and sexual health. But one area that is still underrepresented in many rehabilitation settings is pessary care.;

Pessary fitting has historically been performed by gynecologists and urogynecologists, but in more recent years, especially since the APTA released a position statement in favor of pelvic health physical therapists being able to fit pessaries in 2022, pessary care has entered the rehab scope of practice. Adding pessary fitting, management, and follow-up into a pelvic rehab practice can provide immense benefits for patients, providers, and the healthcare system at large.

Pelvic organ prolapse (POP) is incredibly common, affecting nearly half of people who have given birth. As pelvic health providers, we are not surprised to hear many patients are left with only two extremes: surgery or “wait and see.” We know that pelvic floor therapy can help POP, with things like lifestyle changes, bowel/bladder habit changes, support garments, pressure management, and exercise, but what about our patients who need more?

Pessaries provide a non-surgical, reversible, and evidence-based option that can dramatically improve symptoms of prolapse and stress incontinence. Pelvic rehab providers have been happy to provide traditional therapy options, but now we’re able to offer the additional option of pessary care if we have the right training and permissions from our licensing and state boards. Pelvic health rehabilitation providers already assess pelvic floor function, educate patients on anatomy, and provide individualized exercise programs. Integrating pessary fitting for appropriate patients is a natural progression or addition of this care.

Most of our patients are seeking pelvic therapy because they want to get back to the activities that matter. They come in with goals like running after their kids, practicing yoga without leakage, enjoying intimacy, or simply walking without pressure or heaviness. A pessary can act like a structural support “orthotic” for the pelvic floor, allowing therapy exercises to be more effective, reducing discomfort, and helping patients meet their functional goals faster. The amazing part about pessaries is that they can be used as short-term solutions, like for a run, or an all-day solution, like with a patient who stands for a 12-hour shift.

Why don’t pelvic rehabilitation providers just wait and refer to the “experts” for pessary fittings? Appointments with urogynecologists or surgeons can require long wait times, travel to urban centers, or may not even exist in rural areas. There is a possibility of higher expenses if a person goes to a larger facility and has a high deductible. In other countries (like Australia, Canada, France, and Germany, to name a few), rehab providers are the primary pessary fitters! And even in the US, there are many therapists who have been fitting pessaries for years, usually under the training and guidance of gynecologists or urogynecologists.

When rehabilitation providers offer pessary care, this expands access to conservative treatment for all patients, but especially those with less access to pessary care due to financial, scheduling, or access issues. For patients who feel dismissed in or apprehensive of traditional medical settings, the supportive, education-focused, trauma-informed environment of pelvic rehab can also reduce anxiety and improve outcomes.

Patients often see their pelvic rehab providers weekly, developing strong trust and rapport. This relationship may make a patient more open to learning about pessaries, asking questions, and following up regularly for fit checks and care. Integrating pessary education and management strengthens that continuum of care, reducing the drop-off that can occur when patients are bounced between multiple providers. Be mindful that fitting pessaries is an art and comes with a need to have a medical provider looped into the patient’s plan of care. Medical providers can help manage any potential skin issues, discharge issues, or infection. There will also be times when a rehabilitation provider does not have the skill set to meet the needs of a patient, and the patient needs to be referred to a more skilled or advanced provider.

For therapists, adding pessary care is not just about tools; it is also an opportunity for professional growth. Pessary fitting requires advanced clinical reasoning, commitment to whole-patient solutions, and adaptability to evolving best practices. From a business standpoint, it allows a clinic to differentiate itself, attract new referrals, and provide a comprehensive service that keeps patients within its continuum of care longer.

Current research shows that pessaries are safe, cost-effective, and highly acceptable to patients. Professional organizations (such as the APTA Academy of Pelvic Health and AOTA) recognize the need for interdisciplinary, conservative options in managing POP and incontinence. By adopting pessary care, rehab providers position themselves at the forefront of evidence-based pelvic health practice.

Ultimately, pelvic rehab is about giving patients the knowledge and tools to take ownership of their health. Implementing pessary care provides one more option, whether used as a long-term solution, a bridge to surgery, or a way to stay active and comfortable during postpartum recovery, high-impact activity, or menopause.

Adding pessary fitting to our skill set is not about replacing what we already do as pelvic rehab providers. Fitting pessaries can enhance our provider toolkit, help us collaborate with other providers, and meet patients where they are. When used alongside education, exercise, and behavioral strategies, pessaries can be life-changing. By implementing pessary care, pelvic rehab providers honor the true spirit of our profession: addressing the whole person, restoring function, and empowering patients with choices beyond the “surgery or nothing” dichotomy.

Take the Next Step: Learn Pessary Care in Practice
If you’re ready to expand your clinical toolkit and bring the benefits of pessary care to your patients, join us for Pessaries and Pelvic Rehab: Introduction to Pessary Fitting, Care, and Management.

This two-day, in-person continuing education course is designed for experienced pelvic rehab providers who want to integrate pessary fitting into their practice. With a blend of pre-course lectures and hands-on lab instruction, you’ll gain the advanced assessment skills, fitting techniques, and clinical reasoning tools to confidently and safely implement pessary care.

Upcoming Course Dates & Locations:

• Chicago, IL | November 8–9, 2025
• Tacoma, WA | January 31–February 1, 2026
• Houston, TX | September 12-13, 2026

This course features pre-course anatomy and POP modules, lab-based POP and vaginal dimension assessments, supervised pessary fitting practice, and a pessary fitting kit included with registration. Give your patients more options, strengthen your scope of care, and be part of the growing movement to integrate pessary care into pelvic rehabilitation.

AUTHOR BIO:
Mora Pluchino, PT, DPT, PRPC

Mora Pluchino, PT, DPT, PRPC (she/her) is a graduate of Stockton University with a BS in Biology (2007) and a Doctorate of Physical Therapy (2009). She has experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. She began treating Pelvic Health patients in 2016 and now has experience treating women, men, and children with a variety of Pelvic Health dysfunction. There is not much she has not treated since beginning this journey, and she is always happy to further her education to better help her patients meet their goals.

She strives to help all of her patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at the present time. In 2020, she opened her own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. She has been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. She has also been a TA with Herman & Wallace since 2020 and has over 150 hours of lab instruction experience. Mora has also authored and instructs several courses for the Institute.

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are common conditions affecting people with a vagina across the lifespan, often leading to significant impairments in quality of life. Conservative management is increasingly prioritized, particularly among those who are not surgical candidates, wish to delay surgery, or are managing symptoms during pregnancy or postpartum recovery. Pessaries, intravaginal devices used to support the pelvic organs or compress the urethra, represent a cornerstone of conservative pelvic health management. Their safe, relatively non-invasive nature and growing evidence base make them essential tools in a clinician’s pelvic health toolkit. Pessaries are considered relatively safe for many patient populations and are well tolerated when a proper fit is achieved (Rogers 2017). Well fit pessaries are expected to allow people with POP to participate in a full range of physical activities and exercise comfortably (O’Dell 2012).

This essay explores the current evidence on pessary use, including types, indications, contraindications, patient selection, fitting considerations, and integration with pelvic therapy. Emphasis is placed on empowering pelvic health providers to incorporate pessaries confidently and collaboratively in clinical practice.

Clinical Indications
Pessaries can be used for a range of pelvic health conditions, including:

• Pelvic organ prolapse (POP), this includes management of symptomatic cystocele, rectocele, uterine prolapse, or vault prolapse.
• Stress urinary incontinence (SUI): Especially in cases where the patient is participating in pelvic therapy and making gains in pelvic floor function but continues to have symptoms during lifting or during high-impact activities.
• Pregnancy-related prolapse or urinary symptoms: Providing support during gestation. This is prescribed by a birth provider including an MD, NP, or CNM.
• Postpartum recovery: For temporary support during tissue remodeling.

Types of Pessaries and Their Functions
Pessaries are broadly categorized into supportive and space-filling devices. The selection of type depends on the specific condition being treated, the degree of prolapse, and the patient’s anatomy and functional goals.

1. Support Pessaries

These include the ring pessary (with or without support) and are generally used for mild to moderate prolapse or stress urinary incontinence. Ring with support is frequently used in patients with a widened introitus some apical loss of support (either the cervix or the cuff in the event of hysterectomy). Ring without support can be a good choice for patients with mild to moderate cystocele and/or rectocele with generally good pelvic floor muscle tone.

2. Space-Filling Pessaries

Designed for more advanced prolapse or when support pessaries fail, these include Gellhorn, Donut, and Cube pessaries. The Gellhorn is often used in cases of more severe prolapse (stage III or IV prolapse). For stress urinary incontinence, the incontinence dish or ring with knob can elevate the urethra and reduce leakage under load of the knob.

Contraindications and Cautions
Although pessaries are safe, contraindications and red flags must be observed. They include:

• Active vaginal infections (e.g., candidiasis or bacterial vaginosis) should be treated prior to fitting.
• Severe vaginal atrophy may increase the risk of erosion and should be managed with topical estrogen before long-term use.
• Noncompliance with prior use and cleaning, or cognitive impairment may limit self-care ability unless caregivers are trained.
• Allergy to pessary material (e.g., latex, silicone), though rare, must be considered.

Fitting Process: A Collaborative and Individualized Approach
Proper fitting is essential for comfort, function, and adherence. The process typically includes a pelvic exam to assess prolapse stage, vaginal length, introital laxity, and tissue integrity. Additionally, trial and error during fitting with a range of pessary sizes and types is common. The right pessary should sit comfortably behind the pubic symphysis and under the cervix or vaginal vault without protruding or causing discomfort.

Functional testing during the fitting process is helpful to ensure comfort and optimal use for the patient. To do this, ask the patient to stand, bear down, cough, and walk around the office to ensure stability and effectiveness.

Patient education: On insertion, removal, cleaning, and signs of complications.
Follow-up after a pessary is fit is usually done after 1–2 weeks, then at 3-month intervals depending on patient autonomy and tissue health. Patients should also be instructed in managing complications and problem solving. Most pessary complications are minor and manageable, including:

• Increased vaginal discharge
• Odor or irritation
• Light bleeding or spotting, especially in estrogen-deficient tissues
• Expulsion or shifting of the pessary
• Urinary retention (rare, more common with space-filling devices)

Management strategies:

• Encourage regular removal and cleaning (daily to weekly for self-managing patients; every 1–3 months for clinician-managed).
• Use vaginal estrogen for tissue health in postmenopausal patients.
• Resize or switch device types if discomfort or expulsion occurs.
• Refer for evaluation to a physician or nurse practitioner if persistent bleeding, pain, or infection is noted.

Patient Empowerment and Adherence
Patient-centered education improves long-term success with a pessary. Education that pessaries are not permanent and can be removed at any time often alleviates anxiety that they may be feeling. Additionally, pessaries do not stretch or weaken the vagina; in fact, they often support pelvic rehabilitation efforts in conjunction with pelvic health therapy. Additionally, self-care is safe and achievable with practice and symptom relief can be immediate, as the patient works on restoring mobility, confidence, and function. Offering video tutorials, printed guides, and in-person instruction increases adherence and reduces fear or confusion.

Conclusion
Pessaries are a powerful, evidence-based tool for managing pelvic organ prolapse and stress urinary incontinence. When thoughtfully integrated into a multidisciplinary pelvic health plan, they provide a non-invasive, low-risk option that empowers patients while supporting tissue healing and function. Pelvic health providers play a crucial role in identifying appropriate candidates, facilitating fittings, and supporting ongoing care, especially when combined with targeted physical therapy. Understanding the nuances of pessary selection, education, and monitoring will continue to elevate care standards and improve outcomes in this essential area of women’s health.

References:

1. O’Dell K, Atnip S. (2012). Pessary Care: Follow Up and Management of Complications. Urologic Nursing.32 (3), 126-145. 
2. Rogers, R. G., & Fashokun, T. B. (2017). Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations, and management. Waltham, MA: Wolters Kluwer.

AUTHOR BIO
Dr. Amanda Olson

Dr. Amanda Olson is a pelvic health physical therapist, entrepreneur, author, and global educator with a passion for empowering men and women and advancing conversations around pelvic health. She has dedicated her career to breaking stigmas around pelvic health, supporting patients with conditions including cancer, incontinence, pelvic pain, cancer, pelvic organ prolapse, endometriosis, and MRKH, and developing innovative solutions to improve quality of life.

Dr. Olson is the president of Intimate Rose, a successful pelvic health device company that includes tools for managing pelvic pain, holds multiple patents, and has authored six peer-reviewed journal articles as well as the book Restoring the Pelvic Floor for Women. She is also the recipient of the Elizabeth Nobel Award, the highest honor bestowed in the field of pelvic health. She has collaborated with clinics worldwide, transforming lives through her tools, teaching, and consulting. As an advocate for patients with sensitive issues, and medical innovation, Dr. Olson is committed to bridging the gap in pelvic and women’s healthcare and bringing education to underserved patient populations.

A pessary is a device that is placed in the vaginal canal to support the pelvic organs. They can be worn only during an activity that typically provokes symptoms, such as running, or used almost continuously with periodic cleaning. People looking to avoid or delay pelvic organ prolapse surgery, such as those planning to give birth, may especially benefit from pessary use. Many transgender and nonbinary people with a front canal also find pessary use helpful for reducing POP symptoms.

Pessaries have additional benefits beyond improving prolapse symptoms. For example, some pessaries are designed to mitigate urinary incontinence by applying pressure to the urethra (1). A 2024 study even indicated that they may improve sexual wellness in people with pelvic organ prolapse (2). One case study series suggests that intersex people who have undergone vaginoplasty or neovaginoplasty may also benefit from pessary use for maintaining the patency of the canal (5).

Traditionally in the United States, pessaries have been placed by medical professionals rather than rehabilitation professionals (although some PTs at the Veterans Affairs were involved in fitting pessaries under the guidance of urogynecologists). In 2021, the American Physical Therapy Association’s Academy of Pelvic Health convened a Pessary Task Force to look at the feasibility of physical therapists fitting and managing pessaries. In 2022, the Academy of Pelvic Health released its position statement to include pessary fitting and management in the scope of practice of pelvic health physical therapists in the United States and its five territories. By the end of 2022, the Academy of Pelvic Health hosted its first pessary fitting course. Several more courses have been offered since then. Physical therapists specialize in showing clients how to tend to and support their bodies. Active participation in pessary fitting and management is a way to help the nearly 40% of people with vaginal canals who are expected to develop pelvic organ prolapse. 

If you would like to learn more, Herman & Wallace now has a pessary course! Pessaries and Pelvic Rehab is a two-day in-person course designed for pelvic therapists interested in adding pessary fitting to their clinical practice and have completed Pelvic Function Level 1 and Level 2B. Pessaries and Pelvic Rehab is scheduled for Chicago, IL on November 8-9, 2025. We look forward to seeing you there!

Note: HW does not currently know of any occupational therapists fitting pessaries in the United States, but they hope that this becomes a part of OT scope in the future.

References

1. Shah SM, Sultan AH, Thakar R. The history and evolution of pessaries for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(2):170-175.
2. Jin C, Yan H, Shang Y, et al. Real-world clinical effectiveness of nonsurgical treatments for female with POP-Q stage II cystocele: a retrospective analysis of therapeutic efficacy. Transl Androl Urol. 2024;13(4):483-492.
3. Petter Rodrigues M, Bérubé MÈ, Charette M, McLean L. Conservative interventions for female exercise-induced urinary incontinence: a systematic review. BJU Int. Published online July 23, 2024.
4. Nemeth Z, Vida P, Markovic P, Gubas P, Kovacs K, Farkas B. Long-term self-management of vaginal cube pessaries can improve sexual life in patients with pelvic organ prolapse, results from a secondary analysis. Int Urogynecol J. Published online August 5, 2024.
5. Mensah V, Christianson MS, Yates M, Tobler K, Kolp LA. Novel use of a pessary to maintain vaginal patency following vaginoplasty or neovaginoplasty for mullerian anomalies or agenesis. Fertility and Sterility. 2013;99(3):S37.
6. Wang B, Chen Y, Zhu X, et al. Global burden and trends of pelvic organ prolapse associated with aging women: An observational trend study from 1990 to 2019. Front Public Health. 2022;10:975829.

Pessaries and Pelvic Rehab includes 6 hours of pre-course video lectures that cover relevant pelvic anatomy, types of prolapse, indications and contraindications for prolapse, and medical-legal considerations for pessary fitting. The in-person portion will include labs on advanced POP assessment and assessment of vaginal dimensions, as well as provide participants the opportunity to fit various pessary types under the supervision of an instructor.

This two-day in-person course is targeted to pelvic therapists who are interested in adding pessary fitting to their clinical practice and have completed Pelvic Function Level 1 and Level 2B.

Attendees will:

• -Identify Which Patients to Refer to medical providers for pessary assessment and fitting
  -Learn Indications and Contraindications for pessary fitting
  -Assess Perineal and Vaginal Dimensions to determine pessary choices and fitting
  -Perform a Pessary Fitting for 4 types of pessaries including ring, dish, donut, and cube
  -Screen for Complications of pessary fitting and use
  -Create Plans of Care that consider lifespan issues, the role of hormones, and other pelvic functions including, but not limited to, bowel, bladder, and sexual health.

Pessaries and Pelvic Rehab is perfect for practitioners eager to add pessary fitting to their clinical practice. Look for this course to be scheduled for 2025!

The Herman & Wallace course catalog does not include a pessary-focused course at the time of posting. Pelvic Organ Prolapse is discussed in Pelvic Function Level 1 and more in-depth in Pelvic Function Level 2B.

A pessary is a device that is placed in the vaginal canal to support the pelvic organs. They have been used by humans for millennia to treat pelvic organ prolapse (POP), being crafted of various materials from pomegranate to cork¹. Most modern-day pessaries are made of silicone, although some medical pessaries are even engineered to release estrogen. Recent research suggests that combining pessary use with pelvic floor muscle training for treating POP may be even more effective than pelvic floor muscle training alone².

A pessary can be worn only during an activity that typically provokes symptoms, such as running, or used almost continuously with periodic cleaning. People looking to avoid or delay pelvic organ prolapse surgery, such as those planning to give birth, may especially benefit from pessary use. Many transgender and nonbinary people with a front canal also find pessary use helpful for reducing POP symptoms.

Pessaries have additional benefits beyond improving prolapse symptoms. For example, some pessaries are designed to mitigate urinary incontinence by applying pressure to the urethra¹. A 2024 study even indicated that they may improve sexual wellness in people with pelvic organ prolapse². One case study series suggests that intersex people who have undergone vaginoplasty or neovaginoplasty may also benefit from pessary use for maintaining the patency of the canal⁵.

Traditionally in the United States, pessaries have been placed by medical professionals rather than rehabilitation professionals (although some PTs at the Veteran Affairs were involved in fitting pessaries under the guidance of urogynecologists). In 2021, the American Physical Therapy Association’s Academy of Pelvic Health convened a Pessary Task Force to look at the feasibility of physical therapists fitting and managing pessaries. In 2022, the Academy of Pelvic Health released its position statement to include pessary fitting and management in the scope of practice of pelvic health physical therapists in the United States and its five territories. By the end of 2022, the Academy of Pelvic Health hosted its first pessary fitting course. Several more courses have been offered since then.

If you are looking to include pessary fitting and management in your clinical toolkit, first check with your state physical therapy board to ensure that it is permitted where you practice. If your state does allow pessary fitting, select a class that ideally includes both didactic and lab-based coursework. Be aware that most will require a pelvic health fundamentals class with internal examination as a prerequisite. Once you have passed your pessary class, it will be important to maintain solid connections with advanced clinicians (i.e., trusted urogynecologists and gynecologists) who you can coordinate with on more complex cases, such as those that present with vaginal dermatoses or genitourinary syndrome of menopause.

Physical therapists specialize in showing clients how to tend and support their bodies. Active participation in pessary fitting and management is a way to help the nearly 40% of people with vaginal canals who are expected to develop pelvic organ prolapse⁷.

Note: The author does not currently know of any occupational therapists fitting pessaries in the United States, but they hope that this becomes a part of OT scope in the future.

References

1. Shah SM, Sultan AH, Thakar R. The history and evolution of pessaries for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(2):170-175.
2. Jin C, Yan H, Shang Y, et al. Real-world clinical effectiveness of nonsurgical treatments for female with POP-Q stage II cystocele: a retrospective analysis of therapeutic efficacy. Transl Androl Urol. 2024;13(4):483-492.
3. Petter Rodrigues M, Bérubé MÈ, Charette M, McLean L. Conservative interventions for female exercise-induced urinary incontinence: a systematic review. BJU Int. Published online July 23, 2024.
4. Nemeth Z, Vida P, Markovic P, Gubas P, Kovacs K, Farkas B. Long-term self-management of vaginal cube pessaries can improve sexual life in patients with pelvic organ prolapse, results from a secondary analysis. Int Urogynecol J. Published online August 5, 2024.
5. Mensah V, Christianson MS, Yates M, Tobler K, Kolp LA. Novel use of a pessary to maintain vaginal patency following vaginoplasty or neovaginoplasty for mullerian anomalies or agenesis. Fertility and Sterility. 2013;99(3):S37.
6. Wang B, Chen Y, Zhu X, et al. Global burden and trends of pelvic organ prolapse associated with aging women: An observational trend study from 1990 to 2019. Front Public Health. 2022;10:975829.

AUTHOR BIO
Ken McGee, PT, DPT

Ken McGee, PT, DPT, (they/he) is a queer transmasculine pelvic health physical therapist based in Seattle. Their mission is to bring greater awareness to the pelvic health needs of the LGBTQIA2S community. They enjoy mentoring other rehabilitation professionals to better care for people of all genders.

Ken received their Doctor of Physical Therapy from the University of Washington in 2014 and their board certification as a Women’s Health Clinic Specialist (WCS) in 2018. Ken has lectured nationally and internationally on birth tears. Their practice, B3 Physical Therapy and Wellness, centers on transgender and perinatal rehabilitation. Ken also provides peer bodyfeeding support and doula care.