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.

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!