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Continence Pessary

Continence (incontinence) pessaries are intravaginal devices specifically designed to manage stress urinary incontinence (SUI) — and selectively mixed incontinence — by mechanically supporting the bladder neck and adding urethral resistance. They sit between behavioral therapy and surgery in the SUI treatment algorithm, are appropriate for patients who prefer or require nonsurgical management, and can serve as a bridge to surgery, during pregnancy / postpartum, or for situational SUI.[1][2][5]

For the broader SUI ladder, see Female Stress Incontinence Database. For physical therapy, see Pelvic Floor PT. For office-based bulking, see Urethral Bulking Agents.

Mechanism​

Continence pessaries differ from prolapse pessaries in that they include a knob or protrusion positioned directly under the urethra. The knob compresses the urethra against the pubic symphysis, increasing urethral resistance and preventing involuntary leakage during increases in intra-abdominal pressure (cough, sneeze, exercise).[1][3] Standard prolapse pessaries (ring, Gellhorn) support the vaginal vault but do not specifically target urethral compression.

Indications​

  • Stress urinary incontinence — primary indication, including situational SUI (exercise-related).[4]
  • Mixed urinary incontinence — may improve symptoms; evidence more limited.[5]
  • Patients who prefer to avoid or delay surgery, have surgical contraindications, or wish to try conservative management first.[1][5]
  • Bridge therapy during pregnancy / postpartum or while awaiting surgery.

Device Types​

  • Provider-fitted continence pessaries — ring with knob, dish with knob, and similar configurations; require professional fitting.[1][6]
  • Over-the-counter / commercial:
    • Poise Impressa — single-use, tampon-like, disposable; OTC; self-fitted from a sizing kit (sizes 1–3); 8 h wear time.[1]
    • Uresta — reusable medical-grade plastic device (lasts up to 12 mo); telehealth-fitted without in-person exam.[1]
  • Emerging — 3D-printed custom pessaries and hormone-releasing pessaries.[7]

Fitting and Follow-Up​

Fitting is empiric — trial-and-error to identify the correct size and shape; a ring pessary is generally a good first choice.[8]

Fitting checkpoints:

  • A finger should sweep between the pessary and vaginal walls.[8]
  • Patient stands, walks, performs Valsalva, and voids successfully with the device in place before discharge.[8]
  • Reported fitting success 41–96.6% depending on population.[9]
  • Predictors of unsuccessful fitting — prior pelvic surgery, prior hysterectomy, short vaginal length, wide genital hiatus, posterior compartment prolapse.[9]

Follow-up:

  • Manufacturers recommend every 4–6 wk; evidence supports safe management with visits every 3 mo in the first year, then every 6 mo.[8]
  • Patients who self-manage (remove and reinsert) require less frequent follow-up.
  • Consider vaginal estrogen in patients with vaginal atrophy.[8][10]

Efficacy​

SourceFinding
Richter 2010 multicenter RCT[1][4]33% of pessary-only users had no bothersome incontinence at 3 mo vs 49% PFMT (p = 0.006); no significant difference at 12 mo (~ 50% satisfaction in both arms)
Lipp 2014 Cochrane[11]46% met ≥ 75% reduction in weekly incontinence episodes at 3 mo
Todhunter-Brown 2022 Cochrane overview[2]High-certainty: PFMT > pessary alone on some measures; pessary + PFMT > pessary alone; combination not clearly superior to PFMT alone
Long-term continuation[6]~ 50% of successfully fitted women continue at 1–2 yr

ACOG (PB 155) rates the evidence as Level B — pessaries may improve SUI / mixed-incontinence symptoms, but objective effectiveness data are limited.[5]

Complications​

Generally minimal and manageable:[6]

  • Vaginal discharge / odor — most common.[8]
  • Vaginal erosion / irritation — ~ 10–29% of long-term users; managed with temporary removal + topical estrogen.[8][12]
  • Paradoxical worsening of incontinence — ~ 8.6%.[10]
  • Discomfort during intercourse.[12]
  • Rare serious (almost always neglected pessary in elderly): vesicovaginal / rectovaginal fistula, fecal impaction, hydronephrosis, urosepsis, pessary impaction.[8][9]

If erosion develops — remove the pessary, apply vaginal estrogen until healing, then refit with a smaller or different shape. Non-healing erosions warrant biopsy.[8]

Place in the SUI Treatment Algorithm​

Per ACOG and contemporary review:[1][5]

  1. First-line — pelvic floor muscle training (PFMT) ± behavioral / lifestyle modification (weight loss BMI ≥ 25, fluid / caffeine).
  2. Second-line — continence pessary (or urethral bulking) when conservative measures fail or for situational use.
  3. Third-line — surgical intervention (midurethral sling, autologous fascial PVS, Burch colposuspension, or office-based bulking) when conservative options are insufficient.

Surgery — particularly the midurethral sling — remains the most effective definitive option for SUI.[1]

Summary​

The continence pessary is a low-risk, reversible, second-line option in the female SUI ladder, with ~ 33–46% short-term symptom-control benefit, ~ 50% long-term continuation, and primarily nuisance-level complications. PFMT outperforms pessary alone, and pessary + PFMT > pessary alone, but the combination is not clearly superior to PFMT alone. The role is greatest as a bridge to surgery or for patients who prefer or require non-surgical management.[1][2][4][5]

References​

1. Wu JM. Stress incontinence in women. N Engl J Med. 2021;384(25):2428-2436. doi:10.1056/NEJMcp1914037.

2. Todhunter-Brown A, Hazelton C, Campbell P, et al. Conservative interventions for treating urinary incontinence in women: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2022;9:CD012337. doi:10.1002/14651858.CD012337.pub2.

3. Thomas LH, Coupe J, Cross LD, Tan AL, Watkins CL. Interventions for treating urinary incontinence after stroke in adults. Cochrane Database Syst Rev. 2019;2:CD004462. doi:10.1002/14651858.CD004462.pub4.

4. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary incontinence in women: a review. JAMA. 2017;318(16):1592-1604. doi:10.1001/jama.2017.12137.

5. ACOG Practice Bulletin No. 155: urinary incontinence in women. Obstet Gynecol. 2015;126(5):e66-e81. doi:10.1097/AOG.0000000000001148.

6. Rogers RG. Urinary stress incontinence in women. N Engl J Med. 2008;358(10):1029-1036. doi:10.1056/NEJMcp0707023.

7. Sethi N, Yadav GS. Updates in pessary care for pelvic organ prolapse: a narrative review. J Clin Med. 2025;14(8):2737. doi:10.3390/jcm14082737.

8. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet. 2007;369(9566):1027-1038. doi:10.1016/S0140-6736(07)60462-0.

9. Rantell A, Abdool Z, Fullerton ME, et al. International Urogynecology Consultation Chapter 3 Committee 1 - pessary management. Int Urogynecol J. 2025;36(3):533-550. doi:10.1007/s00192-024-06020-x.

10. Gold RS, Baruch Y, Amir H, Gordon D, Groutz A. A tailored flexible vaginal pessary treatment for pelvic organ prolapse in older women. J Am Geriatr Soc. 2021;69(9):2518-2523. doi:10.1111/jgs.17223.

11. Lipp A, Shaw C, Glavind K. Mechanical devices for urinary incontinence in women. Cochrane Database Syst Rev. 2014;(12):CD001756. doi:10.1002/14651858.CD001756.pub6.

12. Bugge C, Adams EJ, Gopinath D, et al. Pessaries (mechanical devices) for managing pelvic organ prolapse in women. Cochrane Database Syst Rev. 2020;11:CD004010. doi:10.1002/14651858.CD004010.pub4.