Prolapse Pessaries
Vaginal pessaries are first-line nonsurgical treatment for pelvic organ prolapse (POP), recommended by ACOG, AAFP, NICE, and the International Urogynecological Association (IUGA) as an alternative to surgery for all women with symptomatic POP.[1][2][3] Up to 92% of women can be successfully fitted, and vaginal bulge and pressure symptoms resolve in over 90% of those with successful placement.[1][4]
This page is the canonical 04g Prolapse Repair entry for prolapse-reducing pessaries. For the pessary used to treat stress urinary incontinence specifically (the knob-style continence pessary that compresses the urethra against the pubic symphysis), see the dedicated Continence Pessary page.
Types of Pessaries
Pessaries are broadly categorized into two groups:[5][6]
| Group | Devices | Typical role |
|---|---|---|
| Support pessaries | Ring, ring with support, Shaatz, Smith-Hodge with support | First-line attempt; ring is the workhorse |
| Space-filling pessaries | Gellhorn, donut, cube, Marland with support | Advanced prolapse or when support pessaries fail to retain |
All modern pessaries are made of silicone or plastic and come in multiple sizes.[6]
Fitting and Selection
A stepwise approach is commonly used: a ring pessary is inserted first, followed by a Gellhorn if the ring does not stay in place.[1] Ring pessaries are more successful with stage II (100%) and stage III (71%) prolapse, while stage IV prolapse more frequently requires Gellhorn pessaries (64%).[1] Fitting considerations include the nature and extent of prolapse, vaginal size, cognitive status, manual dexterity, and sexual activity level. The clinician should be able to sweep a finger between the pessary and the vaginal walls to confirm proper fit.[6]
Predictors of unsuccessful fitting include previous POP surgery, previous hysterectomy, short vaginal length, wide genital hiatus, and posterior compartment involvement.[4]
Efficacy
A meta-analysis of 627 patients demonstrated significant improvement in validated quality-of-life scores after pessary use, including PFDI-20 (mean change −46.1), PFIQ-7 (mean change −36.0), and POPIQ-7 (mean change −16.3).[7] Pessary combined with pelvic floor muscle training (PFMT) probably improves prolapse symptoms and quality of life more than PFMT alone (NNT = 3 at 12 months).[2][5] Anatomic improvement has also been demonstrated, with reductions in POP-Q measurements across all vaginal compartments.[8]
Beyond bulge symptoms, pessaries improve:[4]
| Symptom | Improvement rate |
|---|---|
| Obstructive voiding | 40–97% |
| Urinary urgency | 38% |
| Urgency incontinence | 29–77% |
| Stress incontinence | 9–45% |
Pessary vs. Surgery
A landmark RCT (van der Vaart et al., JAMA 2022) compared pessary therapy to surgery in 439 women with symptomatic POP at 24 months:[9]
- Subjective improvement: 76.3% (pessary) vs. 81.5% (surgery)
- The difference of −6.1% did not meet the prespecified noninferiority margin of −10% — noninferiority of pessary to surgery was not established
- Both groups showed similar improvements in PFDI-20 and PFIQ-7 total scores
Notably, 24–49% of women discontinue pessary therapy within 12–24 months due to discomfort, pain, or excessive discharge.[9] In the per-protocol analysis, only 74 of 173 women randomized to pessary were still using it at 24 months.
Follow-Up and Management
Per ACOG:[1]
| Patient profile | Follow-up cadence |
|---|---|
| Self-manages (removes / reinserts independently) | Annual follow-up |
| Unable to self-manage | Every 3–4 months for removal, vaginal inspection, cleaning |
All patients should be counseled on self-management when possible, as it enhances autonomy and reduces clinic visits.[10] Vaginal estrogen is commonly recommended (though evidence is limited) to reduce irritation and erosion.[1][11]
Complications
Most complications are minor and manageable:[1][4][5]
- Vaginal discharge — most common side effect (up to 40% of users)
- Vaginal erosion / ulceration — 2–9%; managed by removing the pessary for 2–4 weeks ± topical estrogen
- De novo stress urinary incontinence — ~8.6%[11]
- Vaginal bleeding — may occur, especially with erosion
- Discomfort or pain — common reason for discontinuation
Neglected pessary syndrome.
Rare but serious complications — vesicovaginal or rectovaginal fistula, bowel obstruction, pessary impaction, and vaginal cancer — occur almost exclusively in older women with neglected pessary maintenance.[1][4] Caregivers of patients with cognitive impairment must be made aware of the need for regular pessary changes.
Special Populations
| Population | Consideration |
|---|---|
| Pregnancy | ACOG recommends considering a pessary for symptomatic POP in women who wish to become pregnant[1] |
| Older / frail | Particularly valuable in poor surgical candidates; tailored protocol in women ≥ 65 yr — only 3.6% eventually required surgery[11] |
| Dementia | Caregivers must be counseled on regular pessary changes to prevent neglected-pessary complications[1] |
Emerging Innovations
Recent developments include 3D-printed custom pessaries, self-removable designs, and hormone-releasing pessaries, all aimed at improving comfort, adherence, and reducing complications.[12]
See Also
- Pelvic Organ Prolapse (clinical condition)
- Apical Prolapse
- Principles of Prolapse Repair
- Continence Pessary (for SUI)
- Pelvic Floor Physical Therapy
- Vaginal & Topical Estrogen
Videos
References
1. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. "Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214." Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519
2. Qiu J, Jiang D. "Pessaries for Managing Pelvic Organ Prolapse in Women." Am Fam Physician. 2021;103(11):660-661. PMID 34060790
3. Sung VW, Jeppson P, Madsen A. "Nonoperative Management of Pelvic Organ Prolapse." Obstet Gynecol. 2023;141(4):724-736. doi:10.1097/AOG.0000000000005121
4. 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
5. 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
6. Jelovsek JE, Maher C, Barber MD. "Pelvic Organ Prolapse." Lancet. 2007;369(9566):1027-38. doi:10.1016/S0140-6736(07)60462-0
7. Sansone S, Sze C, Eidelberg A, et al. "Role of Pessaries in the Treatment of Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis." Obstet Gynecol. 2022;140(4):613-622. doi:10.1097/AOG.0000000000004931
8. Mendes LC, Bezerra LRPS, Bilhar APM, et al. "Symptomatic and Anatomic Improvement of Pelvic Organ Prolapse in Vaginal Pessary Users." Int Urogynecol J. 2021;32(4):1023-1029. doi:10.1007/s00192-020-04540-w
9. van der Vaart LR, Vollebregt A, Milani AL, et al. "Effect of Pessary vs Surgery on Patient-Reported Improvement in Patients With Symptomatic Pelvic Organ Prolapse: A Randomized Clinical Trial." JAMA. 2022;328(23):2312-2323. doi:10.1001/jama.2022.22385
10. Hagen S, Kearney R, Goodman K, et al. "Clinical Effectiveness of Vaginal Pessary Self-Management vs Clinic-Based Care for Pelvic Organ Prolapse (TOPSY): A Randomised Controlled Superiority Trial." EClinicalMedicine. 2023;66:102326. doi:10.1016/j.eclinm.2023.102326
11. 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
12. 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