INTRODUCTION

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are common conditions, with prevalence rates of 25 to 65 and 20 to 55 percent, respectively [1-6]. Surgical repair is one approach to treatment: approximately 200,000 women undergo surgery for POP and 135,000 women undergo surgery for SUI annually in the United States [7,8], and approximately 11 percent of women undergo surgery for POP or SUI by age 80; 30 percent of these women will have repeat surgery because of persistent or recurrent symptoms [9]. (See "An overview of the epidemiology, risk factors, clinical manifestations, and management of pelvic organ prolapse in women" and "Treatment of urinary incontinence".)

Vaginal pessaries are an alternative treatment option for women with these conditions.

INDICATIONS

A pessary trial can be offered to all women with pelvic organ prolapse (POP) or stress urinary incontinence (SUI), regardless of patient characteristics. Clinical settings where pessary use should be considered include:

• Patient preference for nonsurgical treatment.
• Presence of severe medical comorbidities that make the patient a poor surgical candidate.
• Need to delay surgery for several weeks or months.
• Recurrent POP or SUI and patient preference for avoidance of repeat surgery. However, prior prolapse surgery and prior hysterectomy are risk factors for failure to fit a pessary (see 'Risk factors for an inability to fit a pessary' below).
• Vaginal ulcerations caused by severe POP. Reduction of POP through use of a pessary and application of vaginal estrogen cream both promote healing of the ulcers within three to six weeks, which is useful prior to surgical repair.
• Current pregnancy, to manage POP and cervical insufficiency.
• Desire for future childbearing. The benefit of surgical repair of POP may be nullified by subsequent pregnancy and childbirth.

PATIENT ACCEPTANCE

Patient acceptance of pessaries varies from 42 to 100 percent [10-13], and is related to appropriate counseling and encouragement from the provider. Patients who decline a pessary trial are more likely to be nulliparous [11], younger [12,13], or have severe prolapse and incontinence [12]. This was illustrated in two studies of treatment choices among women with pelvic organ prolapse (POP) that found older women were more likely than younger women to choose a pessary, whereas women with prior prolapse surgery, more severe prolapse, and more severe symptoms related to bowel emptying, sexual function, and quality of life were more likely to choose surgical treatment [13,14].