Great Pessary Workshop

Last week I attended a long awaited workshop in Adelaide on fitting pessaries for pelvic organ prolapse. Under the combined efforts of the University of South Australia, the International Centre for Allied Health Excellence and the Australian Continence Foundation, this is the first Australian evidenced based workshop on pessaries.

Dr Patricia Neuman and Dr Chris Barry ran the day with expert teachers for practical sessions of measuring and fitting pessaries. Before the supervised practical sessions with live models there were sessions on

Development of the pessary guidelines

An overview female pelvic organ prolapse – anatomy, aetiology, anthropology

Subjective and objective measures of pelvic organ prolapse

Management options for POP, the effect of pessaries on symptom relief and morphology

Indications/contraindications for pessary use and patient selection

Factors predicting successful fitting  and continuation of pessary use.

Side effects, complications

Follow up of pessary users, including long-term monitoring, teaching self-care

Theory of pessary fitting

Video: how to fit a pessary

As 50% of childbearing women have pelvic organ prolapse (POP), it’s important to provide a potential alternative to surgery for these women. POP is associated with vaginal birth, pregnancy, heavy lifting, weak collagen, chronic coughing, constipation and increasing age. It’s more common in women who tear the levator ani muscle attachment during birth, after a hysterectomy or surgery for POP.

Pessaries have been around for centuries and the modern ones are commonly made of silicone, which is inert and hypoallergenic and lasts well with repeated cleaning. As more women are choosing a pessary trial before or instead of surgery, it’s crucial to have experienced fitters who follow guidelines for suitable candidates, accurate measurement, and fitting and follow up.

Pessaries are offered as first line management for women

  • With symptomatic POP
  • Waiting for surgery, unsuitable for surgery or failed surgery
  • Who are pregnant, postpartum or wishing to have more children
  • With manual dexterity and able to do self management
  • Willing to attend regular follow up sessions

Women who are unsuitable for a pessary include those with

  • Active vaginal infection
  • Pelvic inflammatory disease
  • Undiagnosed vaginal bleeding
  • Not willing to attend follow up sessions

The likelihood of a successful fitting is reduced with

  • Prior hysterectomy or POP surgery
  • Wide vaginal opening
  • Short vaginal length
  • Severe posterior vaginal wall prolapse
  • Prior stress incontinence

Support for the pessary is provided by the perineum and from the levator muscle plate. Women with a deficient perineum (damaged during childbirth), open vagina, avulsed or weak levators are less likely to retain a pessary.

The good news is that research shows pessaries can slow the progression of a prolapse and improve the prolapse severity. Other researchers have noted a reduction in the genital hiatus size after 2 weeks to 3 months following fitting.

If you know women with symptomatic POP, tell them about pessaries as a non - surgical option for the treatment of pelvic organ prolapse. Women’s health physiotherapists also teach lifestyle interventions, aim to reduce rises of internal abdominal pressure, advise on strengthening pelvic floor muscles and pelvic friendly exercise.