Pessary

The most common use for pessaries is to treat pelvic organ prolapse. A pelvic organ prolapse can occur when the muscles and tissues surrounding the bladder, uterus, vagina, small bowel, and rectum stop working properly to hold the organs in place and the organs begin to drop outside the body. The most common cause of such prolapse is childbirth, usually multiple births. Obesity, long-term respiratory problems, constipation, pelvic organ cancers, and hysterectomies can all be causes for pelvic organ prolapses as well.[7] Some signs and symptoms include feeling pressure in the pelvic area, lower back pain, painful intercourse, urinary incontinence, a feeling that something is out of place, constipation, or bleeding from the vagina.[7] Pessaries are manual devices that are inserted into the vagina to help support and reposition descended pelvic organs, which helps to prevent the worsening of prolapse, helps with symptom relief, and can delay or prevent the need for surgery.[3][5] Further, pessaries can be used for surgery preparation as a way to maintain prolapse without progression.[3] This is especially useful when a surgery may need to be delayed.[3]

Stress urinary incontinence is leakage of urine that is caused by sudden pressure on the bladder. It occurs during activities that increase the amount of pressure on the bladder such as coughing, sneezing, laughing, and exercising.[8] The pressure causes opening of the sphincter muscles which usually help prevent urine leakage. Stress urinary incontinence is a common medical problem especially in women as about 1 in 3 women are affected by this condition at some point in their lives.[8] Pessaries are considered a safe non-surgical treatment option for stress urinary incontinence as it can control the urine leakage by pushing the urethra closed. Pessaries can be removed any time.[8][9]

Some additional uses for pessaries are for an incarcerated uterus, prevention of preterm birth and an incompetent cervix.[3][10] In early pregnancy the uterus can be displaced, which can lead to pain and rectal and urinary complications.[3] A pessary can be used to treat this condition and support the uterus.[3] Preterm birth is when babies are born prematurely, which puts the baby at increased risk for complications and even death. Currently, the use of pessaries to help prevent preterm birth is an ongoing area of research.[10] The use of pessaries for an incompetent cervix is not commonly practiced today, but they have been used in the past.[3] Specifically, an incompetent cervix is when the cervix begins to open up prematurely.[11] This can lead to a preterm birth or even a miscarriage. Pessaries can be used to correctly position the cervix, increasing the success of pregnancy.[3]

A therapeutic pessary is a medical device similar to the outer ring of a diaphragm. Therapeutic pessaries are used to support the uterus, vagina, bladder, or rectum.[12] Pessaries are most commonly used for pelvic organ prolapse and considered a good treatment option for women who need or desire non-surgical management or future pregnancy.[12] It is used to treat prolapse of uterine, vaginal wall (vaginal vault), bladder (cystocele), rectum (rectocele), or small bowel (enterocele). It is also used to treat stress urinary incontinence.[13]

There are different types of pessaries but most of them are made out of silicone—a harmless and durable material.[14] Pessaries are mainly categorized into two types, supporting pessaries and space-occupying pessaries.[5] Support pessaries function by supporting the prolapse and space-occupying pessaries by filling the vaginal space.[3] There are also lever type pessaries.[15]

Ring with support pessaries are the supporting type.[5] These are often used as a first-line treatment and used for earlier stage prolapse since individuals can easily insert and remove them on their own without a doctor's help. These can be easily folded in half for insertion.[12][14]

Gellhorn pessaries are considered a type of supporting and space-occupying pessary.[5] These resemble the shape of a mushroom and are used for more advanced pelvic organ prolapse.[5][14] These are less preferred than ring with support pessary due to difficulty with self-removal and insertion.[14]

Marland pessaries are another type of supporting pessary.[12] These are used to treat pelvic organ prolapse as well as stress urinary incontinence.[12] These pessaries have a ring at their base and a wedge-shaped ridge on one side.[14] Although these pessaries are less likely to fall out than standard ring with support pessaries, individuals find it difficult to insert or remove them on their own.[14]

Donut pessaries are considered space-occupying pessaries.[5] These are used for more advanced pelvic organ prolapse including cystocele or rectocele as well as a second or third-degree uterine prolapse.[12] Due to its shape and size, it is one of the hardest ones to insert and remove.[14]

Cube pessaries are space-occupying pessaries in the shape of a cube that are available in 7 sizes. The pessary is inserted into the vagina and kept in place by the suction of its 6 surfaces to the vaginal wall. Cube pessaries must be removed before sexual intercourse and replaced daily.[5] Cube pessaries are generally used as a last resort only if the individuals cannot retain any other pessaries.[3] This is due to undesirable side effects such as vaginal discharge and erosion of the vaginal wall.[3][5] In order to remove the cube pessary, the suction must be broken by grasping the device.[3]

Gehrung pessaries are space-occupying pessaries that are similar to the Gellhorn pessaries.[3] They are silicone devices that are placed into the vagina and used for second or third degree (more severe) uterine prolapse. These contain metal and should be removed prior to any MRI, ultrasound or X-rays. They can also be used to help with stress urinary incontinence such as urine leaks during exercising or coughing. These types of pessaries need to be fitted by a health care professional to ensure proper size. Once placed it should not move when standing, sitting, or squatting. It should be cleaned with mild soap and warm water every day or two.[16]

Hodge pessaries are a type of lever pessary. Although these can be used for mild cystocele and stress urinary incontinence, they are not commonly used. Smith, and Risser pessaries are other types of lever pessaries and they differ in shape.[14][15]

Treating vaginal yeast infections is one of the most common uses of pharmaceutical pessaries. They are also known as vaginal suppositories, which are inserted into the vagina and are designed to dissolve at body temperature. They usually contain a single use antifungal agent such as clotrimazole. Oral antifungal agents are also available.[17]

Pessaries can also be used in a similar way to help induce labor for women who have overdue expected delivery dates or who experience premature rupture of membranes. Prostaglandins are usually the medication used in these kinds of pessaries in order to relax the cervix and promote contractions.[18]

According to Pliny the Elder, pessaries were used as birth control in ancient times.[19]

Occlusive pessaries are most commonly used for contraception. Also known as a contraceptive cap, they work similar to a diaphragm as a barrier form of contraception. They are inserted into the vagina and block sperm from entering the uterus through the cervix. The cap must be used in conjunction with a spermicide in order to be effective in preventing pregnancy. When used correctly the cap is thought to be 92–96% effective. These caps are reusable but come in different sizes. It is recommended for anyone attempting this form of contraception to be fitted for the correct size by a trained health care professional.[20]

The stem pessary, a type of occlusive pessary, was an early form of the cervical cap. Shaped like a dome, it covered the cervix, and a central rod or "stem" entered the uterus through the external orifice of the uterus, also known as the cervical canal or the os, to hold it in place.[21]

Lubricating pessaries, designed to improve vaginal dryness during sexual intercourse, consist of a solid block of lubricating gel which slowly melts when inserted into the vagina. These have the advantage over conventional sexual lubricants in that they may be inserted well before intercourse to improve spontaneity. They are commonly used by female sex workers to maintain a level of lubrication within the vagina.