If it’s a phrase I’m really sick of hearing, it’s the one that many of my patients have had said to them by too many health professionals (and some of them are doctors):
“There’s no point in having a pessary, pessaries are just for old ladies”.
Today’s blog is to refute that argument because it just isn’t true.
A pessary is a silicone or plastic device designed to help support prolapsing pelvic organs. The first pessaries date back prior to the days of Hippocrates and their use has been documented in early Egyptian papyruses. Throughout the centuries many unusual remedies have been used such as honey, hot oil, wine, fumes, succussion, leg binding and even pomegranates. In the middle ages, linen and cotton wool soaked in many different potions were used. As new materials were discovered, pessaries evolved and began to resemble those used today. Cork and brass were soon replaced with rubber and of course now medical grade silicone. (1)
Demonstration of Hippocratic succussion (From Appolonius
Funnily enough, this is what many women feel like they want to do, to reduce their prolapse.
Pessaries are for any woman:
- Whose anatomy (post vaginal delivery) can hold the pessary in a comfortable position, where the woman does not feel it and it effectively reduces her prolapse.
- Who can be taught to self-manage the pessary (is cognitively sound; has a good memory; has the dexterity and finger strength to manage; can reach her vagina and feels comfortable inserting her fingers into her vagina to enable her, of course, to insert the pessary).
- Who is able to have local oestrogen if she is post-menopausal (or if she is breast-feeding for that matter).
- Of any age if they answer any of the previous statements.
Health professionals should not make blanket negative statements about pessaries without examining the patient and checking out the above criteria. It’s uninformed and obstructing a woman from trying a potentially, really successful, conservative option. Pessaries are amazing and life-changing………when they work. And there are many, many patients for whom they work if they get an opportunity to try them.
There is now good evidence that screening for prolapse symptoms early, and in primary care, such as by the GP, there can be 40% symptom resolution with conservative measures and watchful waiting. (2) Now many blogs ago, I came up with an idea that the GP’s could be integral to early discovery of prolapse at the PAP smear. Using the acronym PIPES, when a woman is having her PAP smear, this could remind the GP of important things to screen for.
A simple checklist for GPs to check at every PAP smear
¤ P stands for prolapse – Vaginal, rectal.
¤ I stands for incontinence – Urinary, faecal, gas.
¤ P stands for pain – Pelvic, abdominal, sexual.
¤ E stands for exercises- pelvic floor exercises; general physical exercise for bone density, weight management, stress and general ‘feel good’ management- (release of endorphins) -‘if you don’t move it you’ll lose it!’; ‘pelvic floor safe’ exercises.
¤ S stands for sex – pain, dryness, low libido, anxiety about the look, anxiety about doing damage, relationship issues.
There has been plenty of evidence about the value of pelvic floor muscle training (PFMT) as a part of the treatment package for managing prolapse (including correct defaecation position, the knack (bracing), and other lifestyle advice) and a recent meta-analysis demonstrated women who received PFMT showed a greater subjective improvement in prolapse symptoms and an objective improvement in POP severity. (3)
Below are a couple of pessary stories. Women have written them in their own words. They have chosen their alias – but I have not changed anything. Please be aware these stories are to bring the value of pessaries into focus; and specialists such as Urogynaecologists and Gynaecologists and many Women’s and Men’s Pelvic Health Physiotherapists who are trained to fit pessaries, are able to assess if you are able to use a pessary in the short-term, medium term or longer term.
Ring Pessary: A Mother Journey
Amanda, 34. Mother of 2 boys
About 10 days after my second unassisted, uncomplicated vaginal birth, I became aware of a heavy feeling inside my vagina. As someone who is well read and informed about the risks of prolapse, I had been extremely diligent between the birth of my two sons, seeing a specialist physiotherapist regularly to restrengthen my pelvic floor and then manage my second pregnancy as well as possible. I was therefore extremely surprised and quite devastated to suddenly feel the heaviness inside my vagina.
The feeling deeply troubled me and affected not only my physical ability to go about my day but also affected my sense of self and my confidence. I felt like my feet had been swept out from under me and that I was somehow not fully able to cope with the demands of caring for a vibrant toddler and a new born. I became increasing depressed and felt like I couldn’t cope.
I went to see Sue who diagnosed a Grade 1 uterine Prolapse with levator avulsion. Her solution, as well as continuing with my program of pelvic floor exercises, was a ring pessary which she fitted. I have not looked back. It gave me my life and my confidence back. I can’t describe what a difference it makes. It is easy to self manage and takes little time or effort.
Instead of being a constant strain and stress on my conscience, my prolapse has become something to be managed, but more as a part of my overall health. It’s a part of the background now, no longer the major strain that it was on my sense of self and my ability to function. I have my feet back under me again and I feel like along with my exercises, that the pessary will be a lifelong aid to maintaining my pelvic floor health. I am so glad to have avoided the risks and trauma of surgery and I genuinely encourage other women of all ages to give it a try before resorting to more drastic measures. Good luck!
What a beautiful, encouraging story. Thank you Amanda for sharing your journey.
Prolapse is devastating if women have not realised just how common a prolapse diagnosis is.
50% of women over the age of 50 who have had a vaginal delivery will have some degree of prolapse….YES SHOUTY LETTERS TIME AGAIN…….50% OF WOMEN OVER THE AGE OF 50 WHO HAVE HAD A VAGINAL DELIVERY WILL HAVE A VAGINAL PROLAPSE.
If I think about what has transformed many women’s lives- of all the things that a Pelvic Health physiotherapist does – I think fitting a pessary, when it works, is one of those amazing miracles. When a woman has a prolapse and can feel it all the time and then by simply inserting a pessary, she no longer feels the prolapse, no longer feels the drag, no longer feels the heaviness, can exercise with more confidence and isn’t constantly thinking about her prolapse every second of the day – well they are very happy patients.
Below is another story – Heather’s story – short, succinct and to the point!
I am 54 years of age and have had a bladder prolapse for a while now. I hated the bulging uncomfortable feeling. It was something I was always aware of and could never forget about my condition. After having been fitted with a pessary for over six months now, it has made a huge difference. It is very comfortable, I don’t even know it is in place. It has never fallen out and I can do my usual safe exercises . I don’t think about the pessary much, except when it is time to remove for cleaning which is once a week. The only other thing I have to remember is to use Ovestin cream twice a week. It has made a difference to my well-being, I am so glad I gave it a go.
Thank you Heather.
Don’t get me wrong. There are quite a few patients where we can’t make the pessary work, but if we try all types of pessaries and we can’t make it work, at least the patient feels they have given every conservative option a shot. Below is a case study about Sandra. I am writing her story to demonstrate how important ‘failing the fitting of a pessary’ can be!
Sandra had a significant vault prolapse. Her vault (she had a hysterectomy 10 years previously) was 5 cms out of her vagina. Her prolapse was obstructing her voiding, leaving her with sizeable residuals, so during the day when standing, she was hardly voiding more than 100 mls and when she lay down and reduced her prolapse, her volumes were much bigger. But she could never empty completely.
Sandra was adamant she didn’t want surgery when she presented to me.
She had quite good levator muscles on both sides and I felt there was a fair chance the pessary may work. But with pessaries, it is trial and error. We have fitting kits, which we sterilise and this enables the patient to be fitted and then cough, squat, jump, and then go for a long walk if all of those other challenges had not dislodged the pessary. So Sandra did this and she felt wonderful- the pessary reduced the prolapse and the heaviness was gone and she even voided and emptied with a minimal residual. But she went home and the next morning, when she passed a bowel motion, unfortunately the pessary dislodged. Despite using the correct technique for defaecation and many repeat attempts to use devices such as the Femmeze and hand support it just wouldn’t stay in with passing her motion.
Eventually, Sandra found this too much and having felt the relief from not having the prolapse dragging down, she then decided she would go ahead with the surgery. This is a wonderful exercise in exhausting every option, so the patient feels, of course, surgery is the next, correct option. With significant failure rates in the literature for gynaecological repair surgery (up to 30% for repair surgery; up to 80% if the patient has a bilateral levator avulsion), it is important the patient feels all conservative options have been tried.
And finally another story from Sally:
I had my last child 26 years ago. I had three 9lb babies, all very intelligent babies (with big heads). After my last baby I became aware that there was an unusual feeling (like a tampon was dislodged) that would come and go. I started to read and learn about pelvic floor dysfunction and became aware that I had developed a prolapse. I was religious with my pelvic floor exercises and the ‘knack’ and by using a tampon for heavy lifting or playing sport I managed to keep things at bay until last year.
I had turned 60 and started to feel a different feeling, a heaviness that I didn’t like. So I got fitted with a pessary and it IS like magic. I was told the most critical thing is to remove and wash the pessary weekly – and I had to sign a form promising I would do that! As if I’m not going to remember to remove the pessary every seven (7) days?!? Well very quickly I realised it is so comfortable, and I am so unaware that I have it in, that it is very easy to forget and lose track of time – those 7 days literally zoom by and are occasionally missed. My thoughts at the moment are that me and my pessary are going to be good friends for many years to come.
Thank you to all my patients who have contributed to this blog and all the others below.
And to all my patients who I have asked to write a story about their pessary journey, do not feel I do not need them anymore now I have posted this blog.
Every story is relevant to someone and if your story helps them understand and make an enquiry about this pessary option with their medical practitioner – and the more stories, then that is fantastic. So keep writing them and sending them – because each of them is a good learning opportunity.
(1) Shah SM, Sultan AH, Thakar R. The history and evolution of pessaries for pelvic organ prolapse. Int Urogynecol J (2006) 17: 170–175 DOI 10.1007/s00192-005-1313-6