Prolapse Pessaries
Vaginal pessaries are a nonsurgical option for symptomatic pelvic organ prolapse (POP), alone or with pelvic floor muscle training (PFMT). They are discussed alongside observation, PFMT and surgery according to symptoms and patient goals. NICE considers at least 16 weeks of supervised PFMT a first option for symptomatic stage 1–2 POP, not a mandatory pessary trial before surgery.[1][3][4][13] The IUC review found reported fitting success ranging from about 41% to 97%, depending on the definition and follow-up interval; initial fitting, continued use and symptom improvement are different outcomes.[4]
For the pessary used to treat stress urinary incontinence specifically (the knob-style continence pessary that compresses the urethra against the pubic symphysis), see the dedicated Continence Pessary page.
Types of Pessaries
Pessaries are broadly categorized into two groups:[5][6]
| Group | Devices | Typical role |
|---|---|---|
| Support pessaries | Ring, ring with support, Shaatz, Smith-Hodge with support | Ring is widely used; fitting choice varies.[4] |
| Space-filling pessaries | Gellhorn, donut, cube | Advanced prolapse or when a support pessary does not stay in place.[4][22] |
Marland with support is a support design; one FDA-cleared Gynethotics model is indicated for stage I–II prolapse and SUI.[18]
Pessaries are commonly made of silicone, polyvinyl chloride, polythene or latex; available sizes and materials vary by model.[5][6]
Fitting and Selection
Fitting often starts with a ring pessary. For patients wishing to have penetrative intercourse, a ring may remain in place, whereas Gellhorn, donut, and cube pessaries are generally removed first.[4] A Gellhorn or other space-filling design is considered when a support pessary does not stay in place. No single type or prolapse stage guarantees fitting success, and more than one fitting may be needed.[4][13] The 2026 UK guideline advises deferring fitting for unexplained bleeding or active vaginal or pelvic infection or inflammation, and against fitting if neither self-management nor regular clinic follow-up is feasible, or with ongoing vaginal or cervical cancer, severe atrophy unresponsive to pre-pessary estrogen, or identifiable synthetic mesh erosion.[22] Fitting considerations include the nature and extent of prolapse, vaginal size, cognitive status, manual dexterity, and sexual activity level. After insertion, confirm comfort and ability to void before departure, offer review at 4–6 weeks, and teach daily removal for cube pessaries.[22] A properly fitted pessary allows a finger to be swept between the pessary and the vaginal walls.[6]
Predictors of unsuccessful fitting include previous POP surgery, previous hysterectomy, short vaginal length, wide genital hiatus, and posterior compartment involvement.[4]
Efficacy
A meta-analysis of eight studies (627 patients, pre-treatment versus post-treatment scores, mostly about 3 months of follow-up) reported improvement in validated quality-of-life scores after pessary use: PFDI-20 (mean change −46.1), PFIQ-7 (mean change −36.0) and POPIQ-7 (mean change −16.3).[7] In the Cochrane review, one trial (260 women) found that a pessary combined with pelvic floor muscle training (PFMT) probably improves prolapse symptoms and prolapse-specific quality of life at 12 months more than PFMT alone (moderate-certainty evidence; NNT = 3 for symptom improvement in the AFP summary).[2][5] The same review is uncertain whether a pessary differs from PFMT alone or from no treatment, and pessaries may carry more adverse events than PFMT.[5] In a prospective cohort of 50 women, POP-Q measurements fell in all measured compartments (Ba, Bp and C) after at least 4 months of ring use, assessed 72 hours after removal.[8]
In the PESSRI randomized crossover trial, 134 women (median POP-Q stage III) were enrolled to use a ring with support and a Gellhorn pessary for 3 months each; 3-month data were available for 94 ring and 99 Gellhorn periods. Both pessaries produced statistically and clinically significant improvement in most PFDI and many PFIQ scales, with no clinically significant difference between them in relief of protrusion or voiding symptoms.[16]
The IUC review reports improvement in other symptoms after successful fitting:[4]
| Symptom | Improvement rate |
|---|---|
| Obstructive voiding | 40–97% |
| Urinary urgency | 38% |
| Urgency incontinence | 29–77% |
| Stress incontinence | 9–45% |
Pessary vs. Surgery
A randomized trial (van der Vaart et al., JAMA 2022) assigned 440 women with symptomatic POP; one was excluded after randomization. Its 24-month comparison tested an initial pessary strategy after successful fitting:[9]
- Subjective improvement at 24 months among primary-outcome respondents: 132/173 (76.3%) assigned to pessary versus 132/162 (81.5%) assigned to surgery[9]
- The estimated risk difference was −6.1% (one-sided 95% CI lower bound −12.7%); because the bound crossed the prespecified −10% margin, noninferiority was not established[9]
- In the randomized groups, changes in PFDI-20 and PFIQ-7 did not differ significantly, but improvement on the PGI-S favored surgery (134/157 [85.4%] versus 121/162 [74.7%]); in the selected per-protocol sample, PFDI-20 improvement also favored surgery (mean change −42.2 versus −30.4).[9]
118 of 218 participants assigned to pessary crossed over to surgery during follow-up, and only 74 of 173 pessary-arm primary-outcome respondents were still using one at 24 months. Crossover and continued-use denominators differ; the trial separately reported pessary discontinuation in 123/204 women with 24-month treatment-status data. All 218 women assigned to pessary therapy started treatment, so the 204 denominator is an observed subset.[9]
Follow-Up and Management
Follow-up is individualized by pessary type, ability to self-manage and risk of complications.[4][13] NICE advises removal at least every 6 months and a six-month pessary-clinic appointment for those at risk because they cannot manage their own care; the IUC review describes a range of practice intervals.[4][13]
| Patient profile | Follow-up cadence |
|---|---|
| Self-manages (removes / reinserts independently) | Agree a review and symptom-triggered contact plan. The 2026 UK guideline advises daily removal for cube pessaries.[22] For other devices, follow model-specific instructions and ensure removal at least every 6 months under NICE guidance, with an individualized inspection schedule. Annual clinical review is one reported practice, not a universal ACOG requirement.[4][13] |
| Unable to self-manage | Arrange clinic-based removal and vaginal inspection; NICE specifies a six-month appointment for those at risk, with shorter intervals when device type, symptoms or tissue findings warrant it. |
Self-management training is offered when feasible; willingness and ability vary, and additional support may help some patients.[19] In TOPSY, prolapse-specific quality-of-life scores did not differ significantly between self-management and clinic care at 18 months; the mean percentage of applicable complication types reported per participant was 16.7% (142 self-management respondents) versus 22.0% (152 clinic-care respondents), respectively.[10] The trial excluded shelf, Gellhorn and cube pessaries, and many clinic-care participants also removed their devices themselves.[10] At four years, 186/340 participants responded; neither the quality-of-life difference nor the difference in the mean percentage of applicable complication types reported by each responder over the preceding 6 months (17.9% for self-management versus 22.0% for clinic-based care in the results table) reached statistical significance.[20] Vaginal estrogen is an option for genitourinary symptoms associated with menopause. In a 2025 placebo-controlled trial limited to successfully fitted ring-with-support users, conjugated estrogen did not improve the composite of continued pessary use and a PGI-I response of much better or very much better at 12 months in the modified intention-to-treat population (181/208 versus 176/203); continuation alone was also similar (186/208 versus 182/203).[14] Exploratory secondary analyses suggested less discharge, erosion or ulceration, and bleeding.[13][14]
Complications
Most complications are minor and manageable:[1][4][5]
- Vaginal discharge. The IUC review lists discharge or bacterial vaginitis among the most commonly reported side effects (13–28% across studies).[4]
- Vaginal erosion or ulceration. In the 12-month ring-with-support trial, this occurred in 4/208 (1.9%) assigned vaginal estrogen and 14/203 (6.9%) assigned placebo.[14] A pessary holiday of several weeks, sometimes with topical estrogen, is described in case series for erosion or ulceration; the IUC review found no supporting treatment trials.[4]
- Urinary retention or obstructed defecation. Pessary pressure can impair emptying; assess new symptoms and review fit.[22]
- Stress urinary incontinence after insertion. This developed in 12 of 140 (8.6%) older women in one tailored-protocol cohort.[11]
- Vaginal bleeding. Bleeding may occur with erosion, but unexplained or persistent bleeding warrants examination; ulceration that does not heal may require biopsy.[22]
- Discomfort or pain. These are common reasons for discontinuation. In a double-blind randomized placebo-controlled trial of 54 postmenopausal women (mean age 77.8 years) undergoing office pessary removal and reinsertion, lidocaine-prilocaine cream applied intravaginally and on the perineum 5 minutes beforehand reduced pain at removal versus placebo (adjusted mean difference −2.05 cm on a visual analog scale, 95% CI −3.69 to −0.41; p = 0.015). This single trial supports topical anesthetic as an option for a patient who finds office removal painful; it does not address pain at insertion or fitting.[15]
Neglected pessary syndrome.
Serious reported complications include vesicovaginal or rectovaginal fistula, bowel obstruction, pessary impaction, and vaginal cancer; earlier case series chiefly involved older women with neglected maintenance.[4] In a 2025 systematic review of 76 reported pessary-associated fistulae (34 urogenital, 42 rectovaginal), 50% were associated with neglected care.[21] Caregivers of patients with cognitive impairment need to know that the pessary requires regular changes.
Special Populations
| Population | Consideration |
|---|---|
| Planning pregnancy | ACOG recommends considering a pessary for symptomatic POP in women who wish to become pregnant in the future[1] |
| Older / frail | Used in poor surgical candidates. In a single-center cohort of 140 women aged ≥65 yr managed with a tailored protocol, 5 (3.6%) eventually had prolapse surgery[11] |
| Dementia | Caregivers are counseled on regular pessary changes to prevent neglected-pessary complications[1] |
Emerging Innovations
Recent developments include 3D-printed custom pessaries, self-removable designs and hormone-releasing pessaries, which are intended to improve comfort and adherence and to reduce complications.[12]
In a 7-center, open-label equivalence study of an investigational collapsible pessary, current ring or Gellhorn users with stage 2 or greater prolapse served as their own controls. Of 62 women fitted, 48 (62% of 78 enrolled) completed 3 months. Change in PFDI-20 was equivalent to that with the participants' usual pessaries in the intention-to-treat analysis, prolapse support was similar, and visual analog pain scores were lower with insertion (mean difference 9.9 mm) and removal (11.2 mm); no serious pessary-related adverse events were reported.[17]
See Also
- Pelvic Organ Prolapse (clinical condition)
- Apical Prolapse
- Principles of Prolapse Repair
- Continence Pessary (for SUI)
- Pelvic Floor Physical Therapy
- Vaginal & Topical Estrogen
Podcasts
Videos
References
1. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. "Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214." Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519
2. Qiu J, Jiang D. "Pessaries for Managing Pelvic Organ Prolapse in Women." Am Fam Physician. 2021;103(11):660-661. PMID 34060789
3. Sung VW, Jeppson P, Madsen A. "Nonoperative Management of Pelvic Organ Prolapse." Obstet Gynecol. 2023;141(4):724-736. doi:10.1097/AOG.0000000000005121
4. 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
5. 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
6. Jelovsek JE, Maher C, Barber MD. "Pelvic Organ Prolapse." Lancet. 2007;369(9566):1027-38. doi:10.1016/S0140-6736(07)60462-0
7. Sansone S, Sze C, Eidelberg A, et al. "Role of Pessaries in the Treatment of Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis." Obstet Gynecol. 2022;140(4):613-622. doi:10.1097/AOG.0000000000004931
8. Mendes LC, Bezerra LRPS, Bilhar APM, et al. "Symptomatic and Anatomic Improvement of Pelvic Organ Prolapse in Vaginal Pessary Users." Int Urogynecol J. 2021;32(4):1023-1029. doi:10.1007/s00192-020-04540-w
9. van der Vaart LR, Vollebregt A, Milani AL, et al. "Effect of Pessary vs Surgery on Patient-Reported Improvement in Patients With Symptomatic Pelvic Organ Prolapse: A Randomized Clinical Trial." JAMA. 2022;328(23):2312-2323. doi:10.1001/jama.2022.22385
10. Hagen S, Kearney R, Goodman K, et al. "Clinical Effectiveness of Vaginal Pessary Self-Management vs Clinic-Based Care for Pelvic Organ Prolapse (TOPSY): A Randomised Controlled Superiority Trial." EClinicalMedicine. 2023;66:102326. doi:10.1016/j.eclinm.2023.102326
11. 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
12. 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
13. NICE. Urinary incontinence and pelvic organ prolapse in women: management. NG123. Current recommendations on POP options, pessaries and follow-up. Accessed 20 September 2026.
14. Zhou Y, Yin R, Zhang Y, et al. Effects of intravaginal conjugated oestrogen on pessary continuation for pelvic organ prolapse: multicentre, randomised, double blind, placebo controlled trial. BMJ. 2025;389:e084418. doi:10.1136/bmj-2025-084418
15. Taege SK, Adams W, Mueller ER, Brubaker L, Fitzgerald CM, Brincat C. Anesthetic cream use during office pessary removal and replacement: a randomized controlled trial. Obstet Gynecol. 2017;130(1):190-197. doi:10.1097/AOG.0000000000002098
16. Cundiff GW, Amundsen CL, Bent AE, Coates KW, Schaffer JI, Strohbehn K, 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(4):405.e1-405.e8. doi:10.1016/j.ajog.2007.02.018
17. Strohbehn K, Wadensweiler PM, Richter HE, Grimes CL, Rardin CR, Rosenblatt PL, et al. Effectiveness and safety of a novel, collapsible pessary for management of pelvic organ prolapse. Am J Obstet Gynecol. 2024;231(2):271.e1-271.e10. doi:10.1016/j.ajog.2024.05.009
18. U.S. Food and Drug Administration. "Gynethotics Pessary: Indications for Use (K231786)." 2024. FDA 510(k)
19. Dwyer L, Dowding D, Kearney R. "What is known from the existing literature about self-management of pessaries for pelvic organ prolapse? A scoping review." BMJ Open. 2022;12(7):e060223. doi:10.1136/bmjopen-2021-060223
20. Bugge C, Kearney R, Best C, et al. "Four year clinical and cost effectiveness of vaginal pessary self-management versus clinic-based care for pelvic organ prolapse (TOPSY): long term follow-up of a randomised controlled superiority trial." BJOG. 2025;132(12):1762-1771. doi:10.1111/1471-0528.18333
21. Curtis TJ, Chant C, Quek S, Giarenis I, Gray TG. "Fistulae Secondary to Vaginal Pessary Use for Pelvic Organ Prolapse: A Systematic Review." Int Urogynecol J. 2025;36(3):491-521. doi:10.1007/s00192-024-06035-4
22. Brown C, Rantell A, Anders K, et al. "UK Clinical Guideline for Best Practice in the Use of Vaginal Pessaries for Pelvic Organ Prolapse." Neurourol Urodyn. 2026;45(6):1113-1151. doi:10.1002/nau.70306