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Continence Pessary

Continence (incontinence) pessaries are intravaginal devices designed to manage stress urinary incontinence (SUI) and, selectively, mixed incontinence by mechanically supporting the bladder neck and adding urethral resistance. AUA/SUFU 2023 states that clinicians may offer a continence pessary or vaginal insert to patients with SUI or stress-predominant mixed incontinence .[13] Pessaries suit patients who prefer or require nonsurgical management, and they can serve as a bridge to surgery, during pregnancy or postpartum, or for situational SUI.[1][2][5]

For the broader SUI ladder, see Female Stress Incontinence Database. For physical therapy, see Pelvic Floor PT. For office-based bulking, see Urethral Bulking Agents.

Mechanism​

Provider-fitted continence rings and dishes use a knob beneath the urethra.[7] Self-fitted inserts use different support shapes.[16][18] The knob compresses the urethra against the pubic symphysis, increasing urethral resistance and limiting leakage during increases in intra-abdominal pressure (cough, sneeze, exercise).[1][6] Standard prolapse pessaries (ring, Gellhorn) support the vaginal vault but do not specifically target urethral compression.

Indications​

  • Stress urinary incontinence. Primary indication, including situational SUI (exercise-related).[4]
  • Stress-predominant mixed urinary incontinence. Symptoms may improve, but evidence is more limited.[5] AUA/SUFU includes these patients among candidates for a continence pessary or vaginal insert .[13] Poise Impressa specifically excluded mixed incontinence.[15]
  • Patients who prefer to avoid or delay surgery, have surgical contraindications, or wish to try conservative management first.[1][5]
  • Bridge therapy while awaiting surgery or postpartum after device-specific eligibility is checked.[16][17] Uresta advises against it, and Impressa excludes pregnancy and the first 3 months postpartum.[16][17]

Device Types​

  • Provider-fitted continence pessaries. Ring with knob, dish with knob, and similar configurations; require professional fitting.[1][6]
  • Over-the-counter / commercial:
    • Poise Impressa. Wu describes a single-use, tampon-like vaginal insert sold over the counter.[1] The manufacturer has discontinued it; its instructions described a sizes 1–3 sizing kit, limit wear to 12 hours in 24 hours and exclude mixed incontinence, pregnancy and use within 3 months postpartum, among other restrictions.[15]
    • Uresta. Reusable medical-grade plastic device (manufacturer recommends replacement at least once a year); self-fitted at home from a starter kit, without an in-person exam (manufacturer information).[1][16]

Fitting and Follow-Up​

Before provider fitting, screen for precautions described in prolapse-pessary care: active vaginal infection, vaginal ulceration or mesh erosion, latex allergy for latex-containing devices, and ability to return for follow-up.[7] Fitting is empiric. Trial and error identifies the correct size and shape, and a ring pessary is generally a good first choice for prolapse.[8] NICE advises counseling before fitting a prolapse pessary that more than one fitting may be needed.[14] The fitting-success and follow-up data below come largely from prolapse-pessary studies and are extrapolated to continence pessaries.

Fitting checkpoints:

  • A finger should sweep between the pessary and vaginal walls.[8]
  • For a provider-fitted pessary, the patient stands, walks, performs Valsalva and voids with the device in place before leaving.[8] For a self-fitted insert, instruct the patient to confirm comfortable voiding at home; if emptying is difficult, remove it and reassess size or fit.[16]
  • In prolapse-pessary series, reported fitting success ranged from 41% to 96.6% across populations and definitions of success, from fitting-day comfort and intent to continue to use for at least 3 months.[9]
  • Predictors of failed fitting in the cited prolapse series included prior prolapse surgery, prior hysterectomy, short vaginal length, wide genital hiatus and posterior compartment involvement.[9] In a continence-pessary study without advanced prolapse, 235/255 women (92%) with a recorded final fit outcome were fitted successfully; hysterectomy and genital-hiatus measures did not predict failure, while mean vaginal length was shorter in those with failure (8.8 vs 9.6 cm).[19]

Follow-up:

  • For prolapse pessaries, NICE advises removal at least once every 6 months and a pessary-clinic visit every 6 months for women at risk of complications.[14] A cohort of 140 older women with prolapse was managed safely with a mean visit interval of 3.3 months.[10]
  • For prolapse pessaries, AUGS guidance summarized by Sethi and Yadav advises a fit review within 4 weeks, followed by clinic-based review every 1–6 months or review every 6–12 months for self-managers. Individualize these intervals when applying them to provider-fitted continence pessaries, and arrange earlier assessment if problems occur.[7]
  • Before fitting a prolapse pessary, consider vaginal estrogen for genitourinary symptoms and signs associated with menopause (NICE NG123).[14]

Efficacy​

SourceFinding
Richter 2010 ATLAS multicenter RCT (446 women randomized; 445 analyzed; pessary vs behavioral therapy vs combined)[3]At 3 mo, 33% of the pessary group vs 49% of the behavioral group reported no bothersome stress-incontinence symptoms (P = 0.006), and 46% of the pessary group (69/149) had at least a 75% reduction in incontinence episodes. By 12 mo, between-group differences were no longer statistically significant; pessary-group satisfaction was 50% (63% at 3 mo). At 3 mo, 39/149 (26%) in the pessary arm, 22/146 (15%) in the behavioral arm and 18/150 (12%) in the combined arm had withdrawn; 12 pessary-arm withdrawals were for inadequate fit. Combination therapy was not superior to behavioral therapy alone
Lipp 2014 Cochrane[11]Eight trials (787 women) of mechanical devices; evidence was inconclusive for device vs no treatment, and the review concluded that the place of mechanical devices remains in question
Todhunter-Brown 2022 Cochrane overview[2]Moderate or high certainty that a continence pessary plus PFMT was more beneficial than a pessary alone for cure or improvement
Lovatsis 2017 Uresta placebo-controlled RCT (18 per arm)[20]During a single-visit pad test, at least 50% pad-weight reduction occurred in 12/18 (66.7%) with Uresta vs 4/18 (22.2%) with a vaginal-ring placebo (P = 0.01); long-term efficacy was not tested
Lange 2024 postpartum cube-pessary RCT (52 women)[21]At 12 weeks, patient-reported at least somewhat improved urinary incontinence symptoms was 14/18 (77.8%) with pessary vs 7/17 (41.2%) with standard care and 4/17 (23.5%) with PFMT
Escobar 2026 Yōni.Fit sham-controlled RCT (58 randomized; 56 completed treatment)[22]After one blinded treatment week, the full-text Results report at least 50% reduction in mean 12-hour pad weight in 51.6% vs 25.9% (P < 0.05). During two weeks of fitting and treatment, adverse events occurred in 17/31 (54.8%) vs 8/27 (29.6%), mostly mild; long-term efficacy remains untested

ACOG PB 155 lists pessaries among nonsurgical options for stress and mixed incontinence.[5]

Complications​

Complications are generally minor. Most data come from prolapse-pessary studies.[6] A Cochrane review of prolapse pessaries found that adverse events (increased vaginal discharge, increased urinary incontinence, or erosion or irritation of the vaginal walls) may be more frequent than with PFMT, based on one study of 97 women (low-certainty evidence).[12]

  • Vaginal discharge or odor. Most common.[8]
  • Vaginal erosion or irritation. In the 140-woman prolapse cohort, 11 (7.9%) needed temporary removal for 2-4 weeks because of significant discharge or superficial erosion.[10] Management is temporary removal and topical estrogen.[8]
  • New SUI during prolapse-pessary use. In a cohort of 140 older women treated for pelvic organ prolapse, 12 (8.6%) developed stress urinary incontinence after prolapse-pessary insertion.[10]
  • Discomfort during intercourse. For prolapse pessaries, NICE advises discussing the effect of pessary type on intercourse.[14]
  • Serious complications reported mainly in prolapse-pessary care, especially with neglected devices, include vesicovaginal or rectovaginal fistula, fecal impaction, hydronephrosis, urosepsis and pessary impaction. A prolapse-pessary review estimates fistula prevalence at <1% overall and up to 3% with Gellhorn use or neglected care.[7][8][9]

For erythema or superficial abrasion, reassess fit and consider reinsertion; vaginal estrogen may help when atrophy is present. For worsening erosion or ulceration, remove the pessary for about 4–6 weeks and reassess healing before reinsertion, with a different size or shape if needed. Biopsy persistent lesions.[7][8]

Place in the SUI Treatment Algorithm​

AUA/SUFU 2023 directs clinicians to counsel patients about observation, PFMT with or without biofeedback, other nonsurgical options such as a continence pessary, and surgery, and its text states that patients should be offered all viable options before a decision .[13] The AUA/SUFU 2023 guideline lists observation, PFMT, other nonsurgical options and surgery for counseling, without requiring patients to progress through a numbered sequence .[13] PFMT may be combined with behavioral or lifestyle measures such as weight loss when BMI ≥25 and fluid or caffeine changes.[1][5] Current EAU guidance strongly recommends at least 3 months of supervised intensive PFMT as first-line treatment for women with SUI or MUI.[24] For the index female SUI patient, CUA 2024 recommends supervised intensive PFMT for 3 months (Strong, high-quality evidence) and offering a pessary or vaginal device to suitable candidates (Weak, moderate-quality evidence).[23] A continence pessary may suit situational use or a preference to defer surgery. NICE NG123 advises against routine intravaginal-device use for urinary incontinence except occasional leakage prevention, while the later NG210 permits a trial after other nonsurgical options have been unsuccessful.[14][25] Surgical options include a midurethral sling, autologous fascial pubovaginal sling, Burch colposuspension and urethral bulking.[13]

Surgery, particularly the midurethral sling, remains the most effective definitive option for SUI.[1]

Summary​

The continence pessary is a reversible nonsurgical option for female SUI with mainly minor complications. In the ATLAS trial, 46% (69/149) of women assigned to the pessary arm had at least a 75% reduction in weekly incontinence episodes at 3 months, behavioral therapy gave more women no bothersome symptoms at 3 months, and the difference was gone by 12 months.[3] Pessary plus PFMT was more beneficial than a pessary alone, but the combination was not superior to behavioral therapy alone. The role is greatest as a bridge to surgery or for patients who prefer or require non-surgical management.[2][3]

References​

1. Wu JM. Stress incontinence in women. N Engl J Med. 2021;384(25):2428-2436. doi:10.1056/NEJMcp1914037.

2. Todhunter-Brown A, Hazelton C, Campbell P, et al. Conservative interventions for treating urinary incontinence in women: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2022;9:CD012337. doi:10.1002/14651858.CD012337.pub2.

3. Richter HE, Burgio KL, Brubaker L, et al. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol. 2010;115(3):609-617. doi:10.1097/AOG.0b013e3181d055d4.

4. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary incontinence in women: a review. JAMA. 2017;318(16):1592-1604. doi:10.1001/jama.2017.12137.

5. ACOG Practice Bulletin No. 155: urinary incontinence in women. Obstet Gynecol. 2015;126(5):e66-e81. doi:10.1097/AOG.0000000000001148.

6. Rogers RG. Urinary stress incontinence in women. N Engl J Med. 2008;358(10):1029-1036. doi:10.1056/NEJMcp0707023.

7. Sethi N, Yadav GS. Updates in pessary care for pelvic organ prolapse: a narrative review. J Clin Med. 2025;14(8):2737. doi:10.3390/jcm14082737.

8. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet. 2007;369(9566):1027-1038. doi:10.1016/S0140-6736(07)60462-0.

9. Rantell A, Abdool Z, Fullerton ME, et al. International Urogynecology Consultation Chapter 3 Committee 1 - pessary management. Int Urogynecol J. 2025;36(3):533-550. doi:10.1007/s00192-024-06020-x.

10. Gold RS, Baruch Y, Amir H, Gordon D, Groutz A. A tailored flexible vaginal pessary treatment for pelvic organ prolapse in older women. J Am Geriatr Soc. 2021;69(9):2518-2523. doi:10.1111/jgs.17223.

11. Lipp A, Shaw C, Glavind K. Mechanical devices for urinary incontinence in women. Cochrane Database Syst Rev. 2014;(12):CD001756. doi:10.1002/14651858.CD001756.pub6.

12. Bugge C, Adams EJ, Gopinath D, et al. Pessaries (mechanical devices) for managing pelvic organ prolapse in women. Cochrane Database Syst Rev. 2020;11:CD004010. doi:10.1002/14651858.CD004010.pub4.

13. Kobashi KC, Vasavada S, Bloschichak A, et al. Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2023). J Urol. 2023;209(6):1091-1098. doi:10.1097/JU.0000000000003435.

14. National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: management (NG123), recommendations 1.7.8 and 1.7.9 (pessary treatment for prolapse). Recommendations.

15. Poise. "Impressa frequently asked questions." Manufacturer product information and instructions for use (accessed October 2026). Product FAQ.

16. Uresta. "Frequently asked questions." Manufacturer product information (accessed October 2026). Uresta FAQ.

17. Poise. "Impressa frequently asked questions." Manufacturer product information and instructions for use (accessed October 2026). Product FAQ.

18. Poise. "Impressa frequently asked questions." Manufacturer description of insert mechanism (accessed October 2026). Product FAQ.

19. Nager CW, Richter HE, Nygaard I, et al. "Incontinence pessaries: size, POPQ measures, and successful fitting." Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(9):1023-1028. doi:10.1007/s00192-009-0866-1.

20. Lovatsis D, Best C, Diamond P. "Short-term Uresta efficacy (SURE) study: a randomized controlled trial of the Uresta continence device." Int Urogynecol J. 2017;28(1):147-150. doi:10.1007/s00192-016-3090-9.

21. Lange S, Lange R, Tabibi E, Hitschold T, Müller VI, Naumann G. "Comparison of Vaginal Pessaries to Standard Care or Pelvic Floor Muscle Training for Treating Postpartum Urinary Incontinence: a Pragmatic Randomized Controlled Trial." Geburtshilfe Frauenheilkd. 2024;84(3):246-255. doi:10.1055/a-2243-3784.

22. Escobar C, Sokol ER, Rosenblum N, Milikien D, Echols K. "A Randomized Controlled Trial of a Novel Device for Stress Incontinence." Urogynecology (Phila). 2026;32(2):105-115. doi:10.1097/SPV.0000000000001676.

23. Carlson K, Andrews M, Bascom A, et al. "2024 Canadian Urological Association guideline: Female stress urinary incontinence." Can Urol Assoc J. 2024;18(4):83-102. doi:10.5489/cuaj.8751.

24. European Association of Urology. EAU Guidelines on Non-neurogenic Female LUTS: Disease Management (accessed October 2026). Guideline.

25. National Institute for Health and Care Excellence. Pelvic floor dysfunction: prevention and non-surgical management (NG210), recommendation 1.6.21. 2021. Recommendations.