Consult the medical resource doctors trust

UpToDate is one of the most respected medical information resources in the world, used by over 360,000 doctors and thousands of patients to find answers to medical questions.

  • Content written by a faculty of over 4,000 physicians from leading medical institutions
  • Unbiased: free of advertising or pharmaceutical funding
  • Evidence-based treatment recommendations
  • Continuously updated to incorporate new medical findings

Vaginal pessary treatment of prolapse and incontinence

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 clinical manifestations, diagnosis, and classification of pelvic organ prolapse" 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 POP or 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 [10-12], 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], or have severe prolapse and incontinence [12]. This was illustrated in a study of treatment choices among women with POP that found older women were more likely than younger women to choose a pessary, whereas women with prior prolapse surgery and more severe prolapse were more likely to choose surgical treatment [13].
To continue reading this article you need to subscribe.

Read the rest of this article and others like it

The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use (click here) ©2010 UpToDate, Inc.
References Top
  1. Swift, S, Woodman, P, O'Boyle, A, et al. Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol 2005; 192:795.
  2. Nygaard, I, Bradley, C, Brandt, D. Pelvic organ prolapse in older women: prevalence and risk factors. Obstet Gynecol 2004; 104:489.
  3. Samuelsson, EC, Victor, FT, Tibblin, G, Svardsudd, KF. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol 1999; 180:299.
  4. Grodstein, F, Fretts, R, Lifford, K, et al. Association of age, race, and obstetric history with urinary symptoms among women in the Nurses' Health Study. Am J Obstet Gynecol 2003; 189:428.
  5. Melville, JL, Katon, W, Delaney, K, Newton, K. Urinary incontinence in US women: a population-based study. Arch Intern Med 2005; 165:537.
  6. Thom, DH, van den, Eeden SK, Ragins, AI, et al. Differences in prevalence of urinary incontinence by race/ethnicity. J Urol 2006; 175:259.
  7. Boyles, SH, Weber, AM, Meyn, L. Procedures for pelvic organ prolapse in the United States, 1979-1997. Am J Obstet Gynecol 2003; 188:108.
  8. Waetjen, LE, Subak, LL, Shen, H, et al. Stress urinary incontinence surgery in the United States. Obstet Gynecol 2003; 101:671.
  9. Olsen, AL, Smith, VJ, Bergstrom, JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997; 89:501.
  10. Clemons, JL, Aguilar, VC, Tillinghast, TA, et al. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol 2004; 190:345.
  11. Donnelly, MJ, Powell-Morgan, S, Olsen, AL, Nygaard, IE. Vaginal pessaries for the management of stress and mixed urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15:302.
  12. Powers, K, Lazarou, G, Wang, A, et al. Pessary use in advanced pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:160.
  13. Heit, M, Rosenquist, C, Culligan, P, et al. Predicting treatment choice for patients with pelvic organ prolapse. Obstet Gynecol 2003; 101:1279.
  14. Pott-Grinstein, E, Newcomer, JR. Gynecologists' patterns of prescribing pessaries. J Reprod Med 2001; 46:205.
  15. Cundiff, GW, Weidner, AC, Visco, AG, et al. A survey of pessary use by members of the American urogynecologic society. Obstet Gynecol 2000; 95:931.
  16. Cundiff, GW, Amundsen, CL, Bent, AE, et al. The PESSRI study: symptom relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries. Am J Obstet Gynecol 2007; 196:405.
  17. Myers, DL, LaSala, CA, Murphy, JA. Double pessary use in grade 4 uterine and vaginal prolapse. Obstet Gynecol 1998; 91:1019.
  18. Singh, K, Reid, WM. Non-surgical treatment of uterovaginal prolapse using double vaginal rings. BJOG 2001; 108:112.
  19. Allen, WA, Leek, H, Izurieta, A, Moore, KH. Update: the "Contiform" intravaginal device in four sizes for the treatment of stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:757.
  20. Ziv, E, Stanton, SL, Abarbanel, J. Efficacy and safety of a novel disposable intravaginal device for treating stress urinary incontinence. Am J Obstet Gynecol 2008; 198:594.
  21. Bump, RC, Mattiasson, A, Bo, K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175:10.
  22. Hanson, LA, Schulz, JA, Flood, CG, et al. Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient characteristics and factors contributing to success. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:155.
  23. Wu, V, Farrell, SA, Baskett, TF, Flowerdew, G. A simplified protocol for pessary management. Obstet Gynecol 1997; 90:990.
  24. Nguyen, JN, Jones, CR. Pessary treatment of pelvic relaxation: factors affecting successful fitting and continued use. J Wound Ostomy Continence Nurs 2005; 32:255.
  25. Alnaif, B, Drutz, HP. Bacterial vaginosis increases in pessary users. Int Urogynecol J Pelvic Floor Dysfunct 2000; 11:219.
  26. Moore, KH, Foote, A, Burton, G, King, J. An open study of the bladder neck support prosthesis in genuine stress incontinence. Br J Obstet Gynaecol 1999; 106:42.
  27. Farrell, SA, Baydock, S, Amir, B, Fanning, C. Effectiveness of a new self-positioning pessary for the management of urinary incontinence in women. Am J Obstet Gynecol 2007; 196:474.
  28. Robert, M, Mainprize, TC. Long-term assessment of the incontinence ring pessary for the treatment of stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2002; 13:326.
  29. Fernando, RJ, Thakar, R, Sultan, AH, et al. Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse. Obstet Gynecol 2006; 108:93.
  30. Lukban, JC, Aguirre, OA, Davila, GW, Sand, PK. Safety and effectiveness of Colpexin Sphere in the treatment of pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:449.
  31. Mutone, MF, Terry, C, Hale, DS, Benson, JT. Factors which influence the short-term success of pessary management of pelvic organ prolapse. Am J Obstet Gynecol 2005; 193:89.
  32. Maito, JM, Quam, ZA, Craig, E, et al. Predictors of successful pessary fitting and continued use in a nurse-midwifery pessary clinic. J Midwifery Womens Health 2006; 51:78.
  33. Brincat, C, Kenton, K, Pat Fitzgerald, M, Brubaker, L. Sexual activity predicts continued pessary use. Am J Obstet Gynecol 2004; 191:198.
  34. Handa, VL, Jones, M. Do pessaries prevent the progression of pelvic organ prolapse?. Int Urogynecol J Pelvic Floor Dysfunct 2002; 13:349.
  35. Sulak, PJ, Kuehl, TJ, Shull, BL. Vaginal pessaries and their use in pelvic relaxation. J Reprod Med 1993; 38:919.
  36. Farrell, SA, Singh, B, Aldakhil, L. Continence pessaries in the management of urinary incontinence in women. J Obstet Gynaecol Can 2004; 26:113.
  37. Mokrzycki, ML, Hatangadi, SB, Zaccardi, JE, Cox, S. Preexisting Stress Urinary Incontinence: A predictor of discontinuation with pessary management. J Low Genit Tract Dis 2001; 5:204.
  38. Clemons, JL, Aguilar, VC, Tillinghast, TA, et al. Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse. Am J Obstet Gynecol 2004; 190:1025.
  39. Clemons, JL, Aguilar, VC, Sokol, ER, et al. Patient characteristics that are associated with continued pessary use versus surgery after one year. Am J Obstet Gynecol 2004; 191:159.
  40. Barber, MD, Walters, MD, Cundiff, GW. Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery and pessary treatment for pelvic organ prolapse. Am J Obstet Gynecol 2006; 194:1492.
  41. Komesu, YM, Rogers, RG, Rode, MA, et al. Pelvic floor symptom changes in pessary users. Am J Obstet Gynecol 2007; 197:620.
  42. Jones, K, Yang, L, Lowder, JL, et al. Effect of pessary use on genital hiatus measurements in women with pelvic organ prolapse. Obstet Gynecol 2008; 112:630.
  43. Komesu, YM, Rogers, RG, Rode, MA, et al. Patient-selected goal attainment for pessary wearers: what is the clinical relevance?. Am J Obstet Gynecol 2008; 198:577.
  44. Nygaard, I. Prevention of exercise incontinence with mechanical devices. J Reprod Med 1995; 40:89.
  45. Abu-Sitta, MI, Kapur, G, Enhorning, G. Stress incontinence alleviated by an intravaginal device. Int Urogynecol J 1995; 6:95.
  46. Davila, GW, Neal, D, Horbach, N, et al. A bladder-neck support prosthesis for women with stress and mixed incontinence. Obstet Gynecol 1999; 93:938.
  47. Vierhout, ME, Lose, G. Preventive vaginal and intra-urethral devices in the treatment of female urinary stress incontinence. Curr Opin Obstet Gynecol 1997; 9:325.
  48. Noblett, KL, McKinney, A, Lane, FL. Effects of the incontinence dish pessary on urethral support and urodynamic parameters. Am J Obstet Gynecol 2008; 198:592.
  49. Bhatia, NN, Bergman, A, Gunning, JE. Urodynamic effects of a vaginal pessary in women with stress urinary incontinence. Am J Obstet Gynecol 1983; 147:876.
  50. Komesu, YM, Ketai, LH, Rogers, RG, et al. Restoration of continence by pessaries: magnetic resonance imaging assessment of mechanism of action. Am J Obstet Gynecol 2008; 198:563.
  51. Rosenzweig, BA. Severe genital prolapse and its relationship to detrusor instability. Int Urogynecol J 1995; 6:86.
  52. Bergman, A, Koonings, PP, Ballard, CA. Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse. Am J Obstet Gynecol 1988; 158:1171.
  53. Chaikin, DC, Groutz, A, Blaivas, JG. Predicting the need for anti-incontinence surgery in continent women undergoing repair of severe urogenital prolapse. J Urol 2000; 163:531.
  54. Hextall, A, Boos, K, Cardozo, L, et al. Videocystourethrography with a ring pessary in situ. A clinically useful preoperative investigation for continent women with urogenital prolapse?. Int Urogynecol J Pelvic Floor Dysfunct 1998; 9:205.
  55. Liang, CC, Chang, YL, Chang, SD, et al. Pessary test to predict postoperative urinary incontinence in women undergoing hysterectomy for prolapse. Obstet Gynecol 2004; 104:795.
  56. Reena, C, Kekre, AN, Kekre, N. Occult stress incontinence in women with pelvic organ prolapse. Int J Gynaecol Obstet 2007; 97:31.
  57. Brubaker, L, Cundiff, GW, Fine, P, et al, Pelvic Floor Disorders Network. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 2006; 354:1557.
  58. Lazarou, G, Scotti, RJ, Mikhail, MS, et al. Pessary reduction and postoperative cure of retention in women with anterior vaginal wall prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15:175.
  59. Romanzi, LJ, Chaikin, DC, Blaivas, JG. The effect of genital prolapse on voiding. J Urol 1999; 161:581.
  60. Goldstein, I, Wise, GJ, Tancer, ML. A vesicovaginal fistula and intravesical foreign body. A rare case of the neglected pessary. Am J Obstet Gynecol 1990; 163:589.
  61. Duncan, LE, Foltzer, M, O'Hearn, M. Unilateral hydronephrosis, pyelonephritis, and bacteremia caused by a neglected vaginal ring pessary. J Am Geriatr Soc 1997; 45:1413.
  62. Roberge, RJ, Keller, C, Garfinkel, M. Vaginal pessary-induced mechanical bowel obstruction. J Emerg Med 2001; 20:367.
  63. Hanavadi, S, Durham-Hall, A, Oke, T, Aston, N. Forgotten vaginal pessary eroding into rectum. Ann R Coll Surg Engl 2004; 86:W18.
  64. Arias, BE, Ridgeway, B, Barber, MD. Complications of neglected vaginal pessaries: case presentation and literature review. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:1173.
  65. Kaaki, B, Mahajan, ST. Vesicovaginal fistula resulting from a well-cared-for pessary. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:971.
  66. Jain, A, Majoko, F, Freites, O. How innocent is the vaginal pessary? Two cases of vaginal cancer associated with pessary use. J Obstet Gynaecol 2006; 26:829.
white circle LOG IN
white circle DEMO