Prolapse and Pessary management

Prolapse of the uterus (womb) and/or walls of the vagina (with the bladder or bowel sitting behind them) is a common condition affecting up to 50% of women. It is commonly referred to as ‘pelvic organ prolapse (POP)’ or just a ‘prolapse’. Prolapse is associated with symptoms of heaviness/bulging/dragging or functional changes such as difficulties with bladder or bowel emptying, discomfort with intercourse or leakage.

Prolapses usually occur due to weakness of the supporting structures of the vagina, this can occur during childbirth, or because of chronic heavy lifting or straining, or as part of the ageing process. The prolapse/s are named based on the location in your vagina that is affected ie. ‘Posterior vaginal wall prolapse’. Depending on how far the prolapse/s move downwards in the vagina, they are given different grades or stages, however your symptoms of the prolapse may not correlate with these stages. The good news is that the majority of prolapses can be treated and you can live a normal, healthy, functional life. There are a variety of treatment options for prolapses including conservative treatment (pelvic health physiotherapy and lifestyle changes), pessary or surgery.

What is a pessary?

A pessary is a removable silicone medical device that acts like a support system within your vagina – it helps hold up your pelvic organs within your vagina. By providing this support to your vagina, your prolapse symptoms can be reduced or eliminated completely. There are different types of pessaries, in different sizes and shapes and, as every woman has a uniquely shaped vagina, what works for one woman may not work for another. That is why we must individually fit them for you, and it might take a bit of trial and error over a few treatments to get it right for you. Some women leave the pessary in place all the time while others only put the pessary in place when they are doing the activities that cause their symptoms, such as during sports or gardening. It’s up to you how you want to use the pessary.

Who is suitable for using a pessary?

You are not suitable for pessary fitting if you have pelvic inflammatory disease, active infections in the vagina or pelvic area, allergies to silicone, vaginal or cervical cancer, previous radiotherapy in the pelvic region, undiagnosed vaginal bleeding, or are unable to comply with the self-care requirements of using pessaries. If you have vaginal tissue that is very dry and thin (this is called ‘atrophic’) due to menopause or while breastfeeding, then it is advisable to discuss possible oestrogen cream with your GP or medical specialist for at least two weeks prior to your pessary fitting appointment.

If you have had surgical mesh inserted with previous pelvic surgery, your gynaecologist will need to determine if you are suitable for pessary fitting and they will coordinate your pessary management. Some women can wear a pessary safely during pregnancy. However, this needs to be confirmed and managed by your lead maternity care provider or obstetrician

A requirement for having a pessary fitted is a medical screening appointment with your GP or specialist. This is to make sure your cervical screening is up to date (if appropriate), and that you have had pelvic health check up with your medical doctor within 6 months of your pessary fitting appointment to ensure you have no pathologies or diseases in the area. This requirement is for your safety.

You also must be able to commit to ongoing appointments for the duration of your pessary use. These appointments are usually every 3 – 12 months depending on your pessary type and personal situation.

What does it cost?

Your initial pessary fitting appointment normally takes around 45 minutes and costs $250 which includes your appointment fee, own new pessary, and a replacement one if needed. For further follow up appointments to check your progress, the cost is a standard follow up fee. If we need to order a new pessary at any point (ie. 4 years’ time), we will confirm the price of the pessary with you prior to ordering it for you.

Please note these prices are effective from 1 November 2024 and may change.

What are the complications and risks with pessaries?

We have listed the known complications of pessaries below for you. They are ranked from the most common to extremely rare.

Bothersome vaginal discharge ± offensive odour

It is common to develop a small increase in your vaginal discharge. However, your risk of developing a vaginal infection is slightly higher with a pessary inserted. If your discharge becomes discoloured, copious, or has an unpleasant odour, contact your therapist for assessment.
We may need to then send you to your GP for a medical review.

Discomfort

You should not feel the pessary or experience any discomfort after the first 12 – 24 hours of insertion.
Some women experience a cramping sensation in the lower abdomen on first insertion. If you feel ongoing discomfort or the pessary moving around, please contact your therapist.

Pessary expulsion

The pessary may fall out of your vagina during certain activities. If this occurs frequently, please contact your therapist as we may need to re-size or change the type of pessary you are using.

Vaginal tissue changes

These can occur due to pressure of the pessary on the vaginal walls, causing abrasions or ulcerations. Symptoms usually are vaginal bleeding, odour, increased vaginal discharge, or pain.
The risk of this occurring is reduced if you have been using oestrogen cream as prescribed by your medical doctor (if indicated).
If any of these symptoms occur, remove the pessary, and contact your therapist for an appointment.
If changes have occurred to the tissues, you will not be able to use the pessary until the tissues have healed, normally in 4 – 6 weeks.

Difficult removal of the pessary

This can occur due a simple access issue (i.e., difficulty reaching it) or due to missing regular follow up appointments with your therapist. If you are self-managing your pessary and you are having issues removing it, please contact your therapist for an appointment to assist you.

Bleeding

It is important to realise that post-menopausal or inter-menstrual bleeding is not normal. If this occurs, remove the pessary, and contact your health professional as soon as possible. Alongside this, make an appointment with your medical doctor for an internal assessment.

Pain

You should not experience any pain after the first 12 – 24 hours of first insertion when some women experience a cramping sensation in the lower abdomen. If you feel ongoing pain, please remove the pessary, and contact your therapist.

Bladder and bowel changes

If you have increased or new urinary leakage or urgency, frequency changes or difficulties emptying your bowel you need to remove your pessary. Contact your therapist for a review.

Vaginal infections

If your vaginal secretions change to bothersome, develop a foul odour, or change colour from clear to green/yellow/bubbly/white, please remove the pessary and contact your therapist for a review. We may need to refer you onwards to your medical doctor for vaginal swabs.

Neglected pessary, septicaemia, fistula, and death

These are rare complications that occur if the pessary is neglected for long periods of time, i.e., the patient does not return to their therapist or medical doctor for regular reviews of their pessary and vaginal tissues.
It is vitally important that you keep attending for follow up appointments to allow us to check the pessary and your vaginal health to avoid these complications.

Contact Information

If at any stage you have concerns regarding your pessary or you develop any symptoms that concern you, please get in touch.

Adapted from original document created by Dr Melissa Davidson, 2024.