The Pessary and Pelvic Organ Prolapse (POP)

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.