Pelvic organ prolapse & pessary fitting- A Women's health physio service

In this blog post our Women's Health physiotherapist Tracey Matthews answers the most common questions.

What is Pelvic Organ Prolapse?

Pelvic Organ Prolapse is when one of more of the pelvic organs, such as the uterus, bladder or rectum loses its ligamentous support and it drops down into the vagina. Ligament laxity can be caused by a number of things such as, childbirth, aging and pelvic surgery. Changes such as repeated force like a chronic cough or constant straining due to constipation can gradually worsen this laxity over years, not just one or two bouts of coughing or constipation but, continuous difficulty in going to the toilet which is also why toilet positioning and bowel health is very important.

What is a Pessary and why are they used?

Pessaries are used in the management of pelvic organ prolapse. Some women wear them all the time and some women just need a little extra support when doing sport, imagine it like using a sports bra. Pessaries come in lots of different shapes and sizes as do vaginas and are there to help relief from pelvic organ prolapse symptoms. Pessary fitting is a trial and error process, it may take a couple of fittings to find the right fit for you. It can be very helpful for many women, however it is does not help all women with prolapse and other solutions to manage your prolapse may work for you.

Pessaries are another management tool along with strengthening and conditioning of the pelvic floor muscles. A good pelvic floor muscle function is still very important as your pessary can fall down/out.

What are the symptoms of pelvic organ prolapse?

Prolapse can present as:

Backache or lower abdominal ache
The sensation of a bulge inside the vagina or a visible bulge, 'something coming down', feeling of heaviness. Some women describe it as a sensation of a heavy tampon falling out.
Bladder: urinary leakage, incomplete emptying, urgency, waking at night to empty your bladder, weak or prolonged stream, position chagne to start or complete voiding
Bowel-difficulty emptying your bowel, incomplete emptying, urgency, faecal incontinence
Sexual-painful sex, obstructed intercourse, avoidance of intercourse

What happens during an appointment?

The appointment can be between 1-1.5hours long and will include:

A short briefing on symptoms and current management. A discussion around your medical history should’ve already taken place.
Discuss indications and contraindications of pessary use.
An alignment assessment – including movement such as walking, lifting, carrying.
Breathing assessment - how the ribs, diaphragm, stomach move in conjunction with one another
Abdominal separation assessment.
An internal examination to assess pelvic floor strength, co-ordination and timing.
Measurement of the prolapse - helpful when choosing the appropriate pessary but gives a baseline measurement to compare with in the future. This may involve patient to be side lying and use of half a speculum.
Discuss which pessary would be suitable and the fitting shall commence.
The patient shall then get changed have a walk around the room go outside and walk down the road, sometimes run if the pessary is for sporting use.
A standing assessment is carried out to see where the pessary is sitting in a functional position.
If the pessary is in a good position and comfortable, patients are shown how to self-manage their pessary – how to insert and remove.
If the pessary is not sitting in a satisfactory position then your physio will trial a different size and in some cases a different type.

Our Physio team recommend coming back to clinic 2 weeks later for a follow up to discuss how things are doing, check the pessary and answer any questions. Pelvic floor programme’s will be adjusted and progressed if needed. Follow up appointments are usually booked at 3, 6 and 12 months.

How do I clean a pessary?

All pessaries the clinic purchase are made of medical silicone and do not allow bacteria to grow on them however, if dried with a towel or tissue, small fibres can stay on the pessary leading to a possible infection when inserted.

It is recommended to clean a pessary with warm water and leave to air dry, so in an open Tupperware tub. Sterilise your pessary each month by boiling it for 3-5mins in a pan of boiling water.

Are there any side effects?

Most of the potential side effects of using a pessary are low risk however, it is important to be aware of them and how to remove the pessary safely if required:

More vaginal discharge than normal
Vaginal discharge that has developed an odour
Vaginal irritation
Women who are post-menopausal may need to use oestrogen cream
If bad vaginal odour, lots of discharge or blood occurs, please remove the pessary immediately and contact the clinic.
If you can’t get hold of our physio or the clinic then please contact a GP.
Pessaries should not be felt generally. If a pessary is uncomfortable or there is difficulty urinating or passing a bowel movement, please remove the pessary and contact a women's health physio.

Will the pessary fall out?

Many women worry that the pessary can get lost but the vagina is a closed tube. However, the pessary can fall when straining on the toilet or in a bend or squat position to lift something heavy. This could mean that the pessary is too small or that intra-abdominal pressure needs managing when lifting. If a pessary falls in the toilet, try to retrieve it as it can be sterilised and reused. New pessaries can be purchased if preferable.

Can a pessary be used during a period?

Yes. Pessaries can be used during a period although, most women prefer not to. If using one of the suction pessaries such as a cup or cube, it would need to be removed daily as blood can collect in the pessary. It is not possible to use a tampon with the cube pessary.

Is it possible to have sex with the pessary in?

With a ring pessary it is possible to have intercourse although most patients prefer to remove the pessary before intercourse.

Is it possible to use birth control coil (IUD) with the pessary?

If an IUD is already fitted, it is still possible to use a pessary however, we suggest that your GP cuts the wires a little shorter so that they do not interfere with insertion and removal of the pessary.

Can a pessary be used during pregnancy?

The only pessary that is safe to use during pregnancy is the ring. All other pessaries have some form of suction and are therefore contraindicated during pregnancy.

What do I need to bring to the appointment?

If you participate in any active training or sport, then please bring a pair of trainers to the session as your physio may carry out relevant testing to your activity.

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