Gayle Hulme, Rama Swami, Leah Milne
Women’s pelvic health physiotherapists have many strategies, exercises, and innovations to help patients solve their pelvic health problems. One such option we now have as physiotherapists in Canada is to fit patients with an internal support device called a pessary. This article intends to give the reader a brief overview of what a pessary is, if a patient is a good candidate to try one, and what a pelvic health physiotherapist can do to augment the use of a pessary.
Pessaries are not a new thing, but they sure have come a long way from the bronzed objects they used in Roman times.
A pessary is a device placed into the vagina to support the prolapsing vaginal walls or to provide urinary continence. Most are made of medical grade silicone while a few of the larger pessaries may have surgical steel underneath the silicone to provide maximal support1.
There are a variety of pessary shapes and sizes and selection on which one a woman might require is dependent on her symptoms and clinical findings.
Many women experience symptoms such as a bulging discomfort in the vagina or the embarrassing problem of leaking urine with activity. Pelvic health physiotherapists are considered the first line of treatment for these concerns where retraining the responsiveness of the muscles of the pelvic floor are critical in the overall support of the vagina and urethra. Sometimes, the retraining of the neuromuscular control of the pelvic floor is not enough, or the daily physical demands that the woman experiences requires more immediate support while the muscles are rehabilitating. This is where a pessary becomes a suitable option.
A pessary offers support of to the vaginal walls which in turn supports the organs that might be falling downwards towards the vagina. Common prolapses are the bladder (cystocele), uterus (uterine prolapse), and rectum (rectocele). This type of pessary is called “prolapse pessary”. The incidence of pelvic organ prolapse (POP) ranges from 38 – 76% of the population.1
Often women have more than one organ prolapse and careful examination will determine which type pessary she would need. The purpose of wearing a pessary to support pelvic organ prolapse is to decrease or eliminate symptoms of heaviness, bulging sensation, or reduce the tissues protruding out the vagina. Successful fitting has been seen as high as 71 – 90% in reduction of these symptoms.2 In women successfully fitted with a pessary, 40‒60% will continue use for more than 6‒12 months.3 It has been suggested that using the pessary can perhaps even play a role in preventing the prolapse from getting worse.
A pessary can also support the urethra from inside the vagina and is used to control unwanted urine leakage, particularly during activity. This kind of urine leakage is called stress urinary incontinence (SUI) and these pessaries are not usually as rigid as the ones used to support pelvis organ prolapse but they do have a support “knob” which places the right amount of pressure and lift at the urethra to stop it from opening unexpectedly under pressure. A good fit will still allow urine to pass during voiding. Initial successful fitting ranges between 60 – 92%.4 These pessaries are often called “incontinence pessaries”.
If a woman has both prolapse and incontinence or experiences urine leakage when she is fit with a pessary, she would be best to be fit with a different pessary which supports the vaginal walls as well as the urethra. These pessaries often have properties that combine the two types above (the prolapse and incontinence pessary) such that it may have an inside diaphragm as well as the knob support to lift and slightly constrict the urethra.
Sometimes a pessary is desired by a woman as a non-invasive alternative to surgery to help manage symptoms of pelvic organ prolapse and/or urine incontinence. For some women, surgery is not an option due to their health status or for their own personal reasons. For others, a pessary is a good interim option while they wait to have surgery as it can take several months to have a surgical consult and surgery date. As well, a pessary can give medical professionals insight as to what possible implications might arise once the pelvic organs are lifted and supported.
Unmasking of incontinence, as described above, is when a prolapse is lifted by the pessary but the lack of urethra support is revealed when a woman experiences urine leakage. This information gained from fitting various styles of pessaries helps identify what structural problems may co-exist and assists the medical team in determining the appropriate course of action.
Pessaries can be used in pregnancy to help with pelvic organ prolapse. A gynecologist or more specialized medical centre would be the team to help fit a pessary in this case. Pelvic health physiotherapists are most suited to fit women who have POP and SUI who are not currently pregnant.
A pessary is a relatively safe device that a woman can learn to insert and remove on her own. Some problems that might arise are: vaginal tissue erosions, foul odour, bleeding, and bacterial or yeast infections. It is very important that the woman learns how to insert and remove the pessary on her own, how to clean it, and when to seek medical advice if she finds she is bleeding or has a foul odour. Typically, regular removal, good cleaning procedures, and the use of a moisturizer (Replens) or vaginal estrogen (prescribed by her doctor) are all that are needed to ensure that the pessary can be safely worn.
It is extremely important that a woman knows how to care for her pessary and that she is fit with the correct style and size for her needs. Pelvic Health Physiotherapists who have obtained the required training are well positioned to offer pessary fitting and care to their patients. Fitting the appropriate patient with a pessary in addition to providing them with the best opportunity to rehabilitate their pelvic floor muscle tone, strength, and endurance allow us to deliver a comprehensive treatment plan. We teach women about their bodies and how to move effectively with respect to their pelvic floor as well as give them exercises and strategies to improve and enhance their quality of life. These skills give pelvic health physiotherapists the unique vantage point to successfully treat and manage pelvic organ prolapse and urinary incontinence with pessaries and beyond.
Lakeview Physiotherapy & Acupuncture now provides pessary fitting services. Contact us to book your appointment.
1 Michel Bureau, MD; Kevin V. Carlson, MD: Pelvic organ prolapse: A primer for urologists. Can Urol Assoc J 2017;11(6Suppl2):S125-30. http://dx.doi.org/10.5489/cuaj.4634
2, 4 Technical Update on Pessary Use, SOGC No. 294, July 2013, Magali Robert, MD, Calgary AB Jane A. Schulz, MD, Edmonton AB Marie-Andrée Harvey, MD, Kingston ON
3 Bradley C. Pessaries and devices: Non-surgical treatment of pelvic organ prolapse and stress urinary incontinence. In: Cardozo L, Staskin D, editors. Textbook of Female Urology and Urogynecology Third Edition. Colchester: Informa Healthcare; 2010; 458.