Vaginal Support Pessaries: Indications for Use and Fitting ... - SUNA

SERIES 

Vaginal Support Pessaries: 

Indications for Use and Fitting 

Strategies 

SPECIAL SERIES ON PESSARIES 

Shanna Atnip and Katharine O’Dell 

Pelvic floor disorders are 

common in women, and 

as the population ages, 

these disorders may be 

seen more frequently by health 

care providers (Nygaard et al., 

2008). When pelvic symptoms 

are associated with loss of structural 

support of the pelvic organs 

and vagina, vaginal support pessaries 

offer an important option 

for relief (American College of 

Obstetricians & Gynecologists 

[ACOG], 2007). 

Historically, vaginal pessaries 

have been used to manage pelvic 

floor relaxation and were made 

from a variety of materials, 

including fruit, metal, porcelain, 

© 2012 Society of Urologic Nurses and Associates 

Atnip, S., & O’Dell, K. (2012). Vaginal support pessaries: Indications for use and 

fitting strategies. Urologic Nursing, 32(3), 114-125. 

Flexible silicone vaginal support pessaries offer a low-risk, effective option for 

treatment of symptoms of pelvic organ prolapse. This first article in a three-part 

series summarizes clinical recommendations and current evidence related to 

pessary indications, choice, and fitting. 

Key Words: 

Pelvic organ prolapse, pessary, indications, fitting. 

Objectives: 

1. List the symptoms of pelvic organ prolapse that may be successfully treated 

with a vaginal support pessary. 

2. Discuss the various types of pessaries and their uses to treat pelvic organ 

prolapse. 

3. Outline the pessary selection process and steps to pessary fitting. 

Shanna Atnip, MSN, WHNP-BC, is a Nurse 

Practitioner, the Division of Urogynecology 

and Reconstructive Pelvic Surgery, 

Parkland Health & Hospital System, and the 

University of Texas Southwestern Medical 

Center, Dallas TX. 

Katharine O’Dell, PhD, CNM, WHNP-BC, 

is an Assistant Professor of OB/GYN, the 

Division of Pelvic Medicine and Recon - 

structive Surgery, UMass Memorial Medical 

Center, Worcester, MA. 

rubber, and acrylic (Shah, Sultan, 

& Thakar, 2006). Modern pessaries 

are made from silicone, acrylic, 

latex, or rubber. Flexible, medicalgrade 

silicone pessaries are the 

primary subject of this article and 

series because they offer many 

advantages over other materials. 

For example, flexible, medicalgrade 

pessaries are pliable, longlasting, 

non-absorbent (related to 

odor and secretions), biologically 

inert, non-allergenic, non-carcinogenic, 

and washable, and can generally 

be sterilized using an autoclave, 

boiling water, or a cold sterilization 

product (Cooper Surgical, 

2008; Personalmed, 2012). 

Support pessaries are experiencing 

a renaissance and are currently 

recommended as a first-line, 

low-risk treatment option for a variety 

of prolapse-related symptoms 

(ACOG, 2007; Clemons, Aquilar, 

Sokol, Jackson, & Myers, 2004). 

However, to provide satisfactory 

Note: Objectives and CNE Evaluation Form 

appear on page 125. 

Statement of Disclosure: The authors 

reported no actual or potential conflict of 

interest in relation to this continuing nursing 

education activity. 

This learning activity was partially funded 

by an unrestricted educational grant from 

CooperSurgical, Inc. 

Urologic Nursing Editorial Board Statements of Disclosure 

In accordance with ANCC-COA governing rules Urologic Nursing Editorial Board statements 

of disclosure are published with each CNE offering. The statements of disclosure for 

this offering are published below. 

Susanne A. Quallich, ANP-BC, NP-C, CUNP, disclosed that she is on the Consultants’ 

Bureau for Coloplast. 

All other Urologic Nursing Editorial Board members reported no actual or potential 

conflict of interest in relation to this continuing nursing education activity. 

114 UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3

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care, health care providers must 

effectively evaluate pelvic symptoms 

and related health attitudes; 

assess vaginal size, shape, and 

support; select a comfortable and 

effective pessary; and provide 

health education and appropriate 

follow up. This article addresses 

basic information essential to prescribing 

pessaries to women, 

including an overview of current 

patterns of clinical use, a review 

of existing evidence, and suggestions 

for ongoing research. 

Pessary Indications 

Pessaries are a low-risk option 

for treatment of pelvic floor disorders 

with few absolute contraindications. 

Typically, pro viders are 

advised to use caution if pessary 

candidates have an active vaginal 

infection, persisting vaginal erosion 

or ulceration, or severe vaginal 

atrophy (Weber & Richter, 

2005). In addition, non-compliance 

with follow up can be problematic 

because it may result in 

late recognition of complications; 

therefore, providers are advised to 

weigh risks, family support, and 

alternative options carefully 

before providing pessaries to 

women with dementia or other 

conditions that may lead to irregular 

follow up or pessary neglect 

(Weber & Richter, 2005). Common 

indications for the use of support 

pessaries include relief of symptoms, 

avoidance of surgery, diagnosis 

and surgical outcome prediction, 

and prevention (see 

Table 1). 

Table 1. 

Pessary Indications 

Relief of prolapse symptoms 

Convenience in scheduling surgery 

Surgical avoidance 

Diagnostic tool, as in identifying occult stress incontinence 

Prediction tool to clarify likely surgical outcomes 

Prevention of future increasing prolapse and related morbidity 

Symptom Improvement 

Symptoms of pelvic organ 

prolapse (POP) may include 

pelvic pressure, vaginal bulge, 

irritative voiding symptoms, urinary 

incontinence (UI), fecal 

incontinence, dyspareunia, constipation, 

and difficulty emptying 

both the bladder and bowels. 

Many trials have reported significant 

improvement of common 

symptoms, including urinary ur - 

gency and frequency, and urgency 

UI; vaginal bulge; pelvic and 

abdominal heaviness and pressure; 

incomplete or difficult 

bowel emptying; flatal incontinence; 

and fecal urgency and 

incontinence (Barber, Walters, 

Cundiff, & the PESSRI Trial 

Group, 2006; Clemons, Aguilar, 

Tillinghast, Jackson, & Myers, 

2004a; Fernando, Thakar, Sultan, 

Shah, & Jones, 2006; Komesu et 

al., 2007, 2008). Improved bladder 

emptying subsequent to reduction 

of POP and urethral obstruction 

may prevent many causes of 

ongoing morbidity or mortality, 

including recurrent urinary tract 

infection, acute urinary retention, 

and renal injury (Micha et al., 

2008). Both stress and mixed 

UI were improved with pessary 

use in approximately 50% of 

women in two separate trials 

(Donnelly, Powell-Morgan, Olsen, 

& Nygaard, 2004; Richter et al., 

2010). Additionally, overall body 

image improves in many successful 

pessary users (Patel, Mellen, 

O’Sullivan, & LaSala, 2010). 

Other areas of symptomrelief 

related to pessary use have 

been less well studied. For example, 

women with a vaginal bulge 

can develop epithelial ulceration 

due to dryness and friction on 

clothing. The risk of infection 

and hemorrhage can be effectively 

treated in a plan of careful follow 

up and pessary use to 

enhance healing. 

In addition to symptom 

improvement, use of support 

pessaries can help women meet 

their health improvement goals. 

In one study, women who 

achieved their own pre-determined 

treatment goals (improved 

bladder control, increased comfort 

with physical activity, de - 

creased prolapse symptoms) 

were more likely to be satisfied 

and continue pessary use as compared 

with women who did not 

meet their treatment goals 

(Komesu et al., 2008). Helping 

patients set realistic goals for 

treatment outcomes based on 

current evidence will help 

women meet their treatment 

goals and encourage continued 

pessary use. 

While a majority of women 

may note symptom relief with 

pessary use, some women cannot 

be successfully fitted, and others 

may experience burdensome 

new symptoms during a pessary 

trial. New symptoms can include 

de novo problems with bowel 

and bladder emptying, discomfort, 

pressure, or pain; increases 

in vaginal discharge or odor, or 

new onset stress UI due to 

unkinking of an otherwise inadequately 

supported urethra 

(Bump, Fantl, & Hurt, 1988). In 

one study, the most common risk 

factors for dissatisfaction related 

to pessary use included de novo 

stress incontinence, a pre-existing 

strong desire for surgical 

repair, and more advanced prolapse 

(where the leading edge of 

the prolapse is halfway beyond 

the hymen or more) (Clemons, 

Aguilar, Tillinghast et al., 2004b). 

Potential distress may be re - 

duced if women considering pessary 

use are aware of common 

uses, benefits, and potential risks 

prior to their initial pessary fitting. 


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Surgical Avoidance or 

Scheduling Convenience 

Conservative management 

with a pessary, either on a temporary 

or long-term basis, may be 

the optimum choice for many 

women for a variety of reasons. 

Although evidence is sparse, 

clinical examples of indications 

include fear of surgery or anesthesia, 

significant co-morbidities 

that preclude surgery, or prior 

failed surgery with resultant 

higher risk of poor surgical outcome. 

Temporary use of a support 

pessary may improve comfort 

for women delaying surgery 

due to career or family priorities, 

or for women who have been 

advised to defer vaginal reconstruction 

until child bearing is 

completed. 

Diagnostic Assessment 

And Prediction of Surgical 

Outcomes 

A pessary trial can provide 

an opportunity to explore likely 

symptom improvement or the 

potential for onset of new 

adverse effects, and help women 

develop realistic expectations 

during pre-operative treatment 

planning. In a classic study, 

researchers used a trial with a 

lever pessary to successfully 

predict surgical cure of stress 

incontinence via retropubic urethropexy. 

In this trial, 24 of 26 

women with stress UI became 

continent with a supine stress 

test after pessary insertion, and 

all patients remained continent 

after a retropubic urethropexy 

was performed (Bhatia & 

Bergman, 1985). In another 

study, de novo stress incontinence, 

which can occur when an 

otherwise deficient urethra is 

straightened during repair of the 

prolapsed anterior compartment, 

was shown to be a major 

reason for post-treatment dissatisfaction 

(Clemons, Aguilar, 

Tillinghast et al., 2004a). 

Post-surgical expectations 

have also been explored with 

women reporting two common 

symptoms often attributed to 

POP – lower abdominal pressure 

and low back pain (Heit, 

Culligan, Rosenquist, & Shott, 

2002). In that study, participantrated 

symptom severity using 

visual analog scales, (n = 152) 

was compared with objective 

prolapse determination and 

demonstrated no significant 

association. Therefore, because 

prolapse may not be the cause of 

some symptoms, a pessary trial 

can play a role in clarifying 

treatment expectations during 

pre-operative decision-making. 

Pessaries have also been 

useful in predicting successful 

outcomes in cases of pre-operative 

elevated post-void residual 

(PVR) due to urethral obstruction. 

A retrospective chart 

review of women with pre-operative 

PVR greater than 100 cc (n 

= 24) found that pessary use normalized 

PVR in 75% (n = 19) of 

the women, with only one 

woman subsequently experiencing 

elevated PVR three months 

post-operatively. A trial pessary 

reduction was found to be a reliable 

tool in predicting improvement 

in urinary retention 

(Lazarou, Scotti, Mikhail, Zhou, 

& Powers, 2004). 

Prevention of Progressive 

Prolapse 

Emerging evidence also suggests 

a potential preventive role 

for pessaries. Handa and Jones 

(2002) observed a significant 

improvement in stage of POP in 

19 women following one year of 

successful pessary use, suggesting 

a therapeutic effect associated 

with the use of a supportive 

pessary. In addition, in an observational 

cohort study of women 

using pessaries for three months 

(n = 90), measurement of the genital 

hiatus decreased, leading the 

authors to postulate that pessary 

use allows recovery of the levator 

ani muscles (Jones et al., 2008). 

In another small case series (n = 

6), prolapse regressed to normal 

after a median duration of pessary 

use of 27.5 months and 

remained resolved for a median 

of 42.0 months of follow up 

(Matsubara & Ohki, 2010). 

Whether this observed prolapse 

improvement is due to temporary 

physiologic tissue response to 

reduced strain and/or has potential 

long-term preventive ramifications 

is currently unclear. 

Pessary Selection 

Modern silicone pessaries 

come in a variety of shapes and 

sizes; therefore, selection is primarily 

determined by the 

lifestyle of the potential wearer, 

as well as findings on physical 

examination. Both providers and 

patients are likely to benefit if 

pessary success could be predicted 

because counseling would be 

improved, time would be saved, 

and needless discomfort would 

be eliminated; however, predictive 

parameters for pessary 

choice and fitting success have 

proven difficult to quantify 

(Cundiff et al., 2007). For that 

reason, expert opinion from clinical 

observation continues to 

inform both patient and pessary 

selection and is included here for 

the potential benefit of novice 

providers. 

Patient-Specific Factors 

Several recent studies concluded 

that the majority of 

women can be successfully fitted 

with a pessary, with POP-reduction 

success rates ranging from 

63% to 86% (Clemons, Aguilar, 

Tillinghast et al., 2004b; Hanson, 

Schulz, Flood, Cooley, & Tam, 

2006; Maito, Quam, Craig, 

Danner, & Rogers, 2006; Mutone, 

Terry, Hale, & Benson, 2005; 

Nyguyen & Jones, 2005; Wu, 

Farrell, Baskett, & Flowerdew, 

1997). However, specific factors 

that might predict successful fitting 

have not been consistently 

identified. Some studies have 

suggested that patient satisfaction 

is higher in women who are 

older, have had no prior pelvic 

surgery (including hysterectomy), 

have higher parity or less 

severe prolapse, and have no UI 


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(Maito et al., 2006; Nyguyen & 

Jones, 2005; Wu et al., 1997). 

Hanson et al. (2006) assessed the 

importance of estrogen therapy 

to successful pessary fitting, 

reporting that women using vaginal 

estrogen, with or without systemic 

hormone replacement therapy 

(HRT), had higher fitting success 

compared to both systemiconly 

and non-HRT users. Maito 

et al. (2006) reported presence of 

mild posterior compartment prolapse 

as a positive predictor of 

fitting success, and history of a 

prior prolapse procedure or hysterectomy 

as negative predictors. 

Clemons, Aguilar, Tillinghast et 

al. (2004b) also found a shortened 

vaginal length (≤ 6 cm) and 

wide genital hiatus (4 fingerbreadths) 

to be predictive of 

unsuccessful pessary fitting. 

Other researchers have reported 

no significant predictive value 

regarding age, weight, vaginal 

length, size of genital hiatus, 

compartment of prolapse, stage 

of prolapse, or hormone use 

(Maito et al., 2006; Mutone et al., 

2005; Nyguyen & Jones, 2005; 

Wu et al., 1997). Because of this 

lack of consistent predictors, a 

pessary trial may be appropriate 

for any woman seeking treatment 

for prolapse-related symptoms 

(ACOG, 2007; Clemons, Aguilar, 

Sokol et al., 2004). 

Factors related to patient 

preference, lifestyle, and ability 

may guide pessary choice. For 

example, some pessaries may be 

easier to self-remove and selfinsert. 

This may affect choice 

related to patient comfort with 

self-touch, interest in performing 

self-care, and desire to have vaginal 

intercourse. Clinical experience 

suggests that arthritis, 

mobility impairment, and obesity 

may limit successful self-care, 

even in very motivated women. 

Women who are not doing selfcare 

will need to wear their pessary 

continuously between the 

periodic office visits for removal 

and cleaning. 

With the appropriate pessary, 

a sexually active woman has a few 

options. The pessary can be re - 

moved for intercourse either by 

the woman or her partner. If she 

prefers leaving the pessary in 

place, some styles (for example, 

Ring pessaries) are more likely to 

be comfortable for both partners 

during intercourse. However, 

there is little research to assess this 

specifically, and clinical reports 

from individual couples vary 

greatly. Overall, sexual function 

has been shown to improve with 

pessary use, including frequency 

and satisfaction (Fernando et al., 

2006), desire, orgasm, and lubrication 

(Kuhn, Bapst, Stadlmayr, Vits, 

& Mueller, 2009). Additionally, 

one study found sexually active 

women were more likely to continue 

pessary use compared to 

women who were not sexually 

active (Brincat, Kenton, Fitzgerald, 

& Brubaker, 2004). Overall, pessary 

use may be acceptable to 

many sexually active women. 

Pessary-Related Factors 

Many pessary styles and 

sizes are available, and new 

styles continue to be designed. 

Figure 1 displays a variety of current 

pessaries. While successfully 

fitted pessaries offer a high 

Figure 1. 

Pessary Shapes 

Note: The large variety of pessary shapes can be categorized as pessaries that 

require significant introital support (top row), pessaries that are relatively selfsupporting 

(seond row), and pessaries with an incontinence support (third row). 

likelihood of symptom and quality-of-life 

improvement for most 

users, no specific shape of pessary 

is best for all women. In one 

crossover study comparing two 

different pessaries (Ring and 

Gellhorn), both shapes were 

effective for the majority of 

women and significantly im - 

proved urinary, bowel, and prolapse 

symptoms (n = 134, mean 

age 61 years, median prolapse 

Stage 3 – descent halfway 

beyond the hymen, satisfaction 

rates – Ring 80%, Gellhorn 76%) 

(Cundiff et al., 2007). 

Because no quantitative mea - 

sures have been identified to 

direct pessary choice and fitting, 

providers must continue to rely 

on manufacturer guidelines, 

expert opinion, product availability, 

clinical judgment, and 

provider or patient preferences 

when choosing initial pessary 

shape and style. 

One way to conceptualize 

support pessary options is to categorize 

them by their functional 

design. Using that paradigm, 

flexible silicone pessaries fall 

into three categories: those that 

need some support from the 

woman’s own introital integrity 



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to stay in place (basic support pessaries), pessaries 

with concavities that make them relatively selfretaining 

(self-retaining pessaries), and pessaries 

with additional urethral support designed to 

improve stress incontinence (incontinence pessaries). 

Use of these classifications to guide initial 

choice is summarized in Table 2. 

In the authors’ experience, pessaries retained by 

introital integrity can be folded or deflated to ease 

insertion through the introitus. Examples include 

the Ring (see Figure 2), Donut (see Figure 3), and 

Inflatable Donut (see Figure 4), and the Shaatz and 

lever pessaries (not pictured separately). Those that 

have a relatively slim profile and fit along the length 

of the vaginal shaft, such as the Ring pessary, are 

most likely to be comfortable when left in place during 

vaginal intercourse. Others, such as Donut pessaries, 

which are sometimes referred to as space-filling 

pessaries because they occupy more of the vaginal 

width, may preclude intercourse when in situ. 

Pessaries designed to easily fold or deflate may also 

be most amenable to self-insertion and removal. 

In contrast, self-retaining pessaries are generally 

concave in shape. The vaginal walls conform to 

these areas, allowing the pessaries to stay in place in 

women with minimal or no introital strength. These 

include the Gellhorn (see Figure 5) and Cube pessaries 

(see Figure 6). These are traditionally considered 

more likely to support advanced POP but may 

also increase the risk of mechanical injury to the 

vaginal epithelium. They may also be more difficult 

for both the patient and provider to remove and reinsert. 

Incont inence pessaries include a knob that fits 

behind the pubic symphysis, supporting the urethra 

during times of increased abdominal pressure to 

diminish stress incontinence (see Figure 7). 

Although the topic is not well studied, when a 

pessary is worn over time (longer than 24 hours), 

Figure 2. 

Ring and Ring with Support Membrane 

Note: Note the hinge bends at the notch in the left pessary 

and at the finger-sized holes of the right pessary. This pessary 

is folded at the hinge for insertion and removal. 

Figure 3. 

Donut Pessary 

Note: Some clinicians aid insertion and removal by carefully 

deflating the Donut using a needle and syringe, inserting it, and 

then re-inflating the pessary once it is in place and viceversa. 

Table 2. 

Sample Simple Pessary Selection Guide Based 

on a Woman’s Planned Coital Activity 

and Introital Integrity 

Sexual Activity 

Planned 

Introital Integrity 

Present 

Ring* 

Oval 

Lever Pessary* 

Inflatable Donut 

Introital Laxity 

Present 

Cube 

Acoital Donut Gellhorn 

Cube 

Note: If stress incontinence increases or continues with pessary 

use, an incontinence pessary can be used,* but coitally 

active women will need to be able to do self-care. 

*Pessaries that have a stress urinary incontinence support 

option. 

Figure 4. 

Inflatable Donut Pessary 


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Figure 5. 

Gellhorn Short and Long-Stem Pessaries 

Figure 6. 

Cube Pessaries 

Figure 7. 

Incontinence Pessaries 

Note: Examples include, top row: 

Incontinence Dish (with and without 

support); middle row: Marland (with 

and without support); bottom row left: 

Ring with support membrane and 

incontinence knob; bottom right: 

Incontinence Ring. 

presence of drainage holes should 

allow continuous drainage of normal 

vaginal epithelial shedding 

and discharge. Retained discharge 

may act as a medium for bacterial 

overgrowth, increasing infection 

risk, and/or odor. For this reason, 

pessary styles with optional 

drainage holes (such as Cube pessaries) 

are typically preferred 

whenever possible. 

Providers often prefer to use a 

limited selection of available pessaries. 

For example, in a survey of 

urogynecologists, the majority 

reported using Ring pessaries for 

anterior and apical defects, spacefilling 

pessaries (such as a Donut) 

for women who have introital 

integrity and posterior defects, and 

self-retaining pessaries (such as the 

Gellhorn) for severe prolapse 

(Cundiff, Weidner, Visco, Bump, & 

Addison, 2000). General gynecologists 

reportedly also used Ring pessaries 

most frequently, deeming 

them easiest to use, with Gellhorn 

pessaries used most commonly for 

advanced prolapse (Pott-Grinstein 

& Newcomer, 2001). The latter 

respondents rated Donut pessaries 

the least easy to wear and Gellhorn 

pessaries most difficult to remove. 

Generally, providers’ choice of 

styles of pessary to stock and fit 

appears to be based on the individual’s 

training, experience, and 

product availability. 

Pessary size selection is also 

currently guided by experience 

because no specific vaginal measures 

have predicted successful fit. 

In one study, Pelvic Organ 

Prolapse Quantification (POP-Q), 

parameters were tested as a potential 

objective predictor but were 

not found to predict pessary size; 

however, women with a shorter 

total vaginal length were less likely 

to be successfully fitted (Nager 

et al., 2009). Thus, pessary fitting 

remains an art, with some reliance 

on trial and error. 

Pessary Fitting 

Because there has been little 

success in identifying objective 

evidence to improve pessary 

choice, new providers must rely 

on expert opinion and mentorship. 

Pessary manufacturers provide 

recommendations to help the 

novice match pessary styles with 

patient findings (Bioteque of 

America, 2011). Successful fitting 

also depends on clinician experience 

and training. Few nursing or 

medical programs spend time 

teaching pessary use (Pott- 

Grinstein & Newcomer, 2001). 

However, with a sound general 

background of women’s health 

care, even in the absence of optimal 

mentorship, clinicians can 

educate themselves to become 

competent and safe providers of 

this low-risk intervention. 

The goal of fitting is to find a 

pessary that improves the target 

pelvic floor symptoms, is comfortable 

for the patient, is retained 

during activity and toileting, and 

does not obstruct voiding or defecation, 

or cause vaginal irritation. 

Suggestions for improving fitting 

outcomes are listed in Table 3. 



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Table 3. 

Pessary Selection and Fitting Tips 

Assess for and treat causes of vaginal tenderness prior to fitting (infection, lesions, 

or tension myalgia). 

Familiarize the woman with the pessary before fitting (let her see, feel, and fold it; use 

visual aids, such as pelvic models or charts, to show how it will stay in her vagina). 

Fitting will be more comfortable if the woman has an empty bladder and bowel; 

however, to test for stress incontinence, fitting with the bladder full will facilitate 

assessment. If the bowel is full and cannot be emptied voluntarily, an enema onsite 

or rescheduling the appointment may be most helpful. 

Autoclavable fitting kits are available, but keeping a small stock of silicone pessaries 

in commonly used sizes and shapes may offer a more true-to-life fitting experience. 

Fitting comfort may be improved for women who are very apprehensive or sensitive 

by the use of lidocaine gel applied to the introitus 5 minutes before fitting. If genital 

tissue is very atrophic or non-elastic, several weeks of topical estrogen therapy prior 

to fitting may be optimal. 

Refitting may be necessary after weight loss or weight gain, any period of temporary 

removal, or during long-term use if atrophic tissue change continues (increased 

stenosis or decreased support). 

During post-fitting pessary testing, placement of a urine receptacle (“Hat”) in the 

commode will ease retrieval if the pessary is expelled. Otherwise, instruct the woman 

not to flush the pessary into the plumbing system. 

A pessary that is comfortable and retained except during bowel movements may be 

a success if the woman chooses to either remove the pessary for defecation or 

support it digitally during evacuation. 

If the pessary is easily expelled, try a larger size or different style. If the pessary is 

uncomfortable or the patient feels pressure, try a smaller size or different style. 

Successfully sized, the pessary should be comfortable; women often say, “I can’t 

even tell it’s there!” 

Make sure a system is in place to identify missed pessary follow-up visits to avoid 

potential problems related to pessary neglect. 

Figure 8. 

Illustration of Digital Measurement of the Vagina, a Potential Aid to 

Initial Pessary Choice 

Notes: Line A: The vaginal length from posterior symphysis to apex or posterior 

fornix can be useful for sizing Ring and Donut pessaries, or the length of a Gellhorn 

neck. Line B: The vaginal width at the apex can be useful when considering the 

diameter of the Gellhorn dish. Line C: The diameter of the introitus and vaginal shaft 

can help in making an initial Cube choice. 

Although definitive measurements 

have not been identified to 

aid size and style choice, experienced 

providers typically note 

several digital measurements and 

assess pelvic muscle tone and 

support during pelvic examination 

(see Figure 8). These determinations 

can help the provider 

develop a mental image of the 

vaginal size, shape, and support. 

The initial pessary attempt can 

then be made using the pessary 

that fits this visual image. Table 4 

lists suggested steps in pessary fitting 

based on clinical experience 

and expert opinion. 

The average number of pessaries 

tried during a successful 

pessary fitting is two to three, typically 

at a single session; however, 

up to two follow-up fitting sessions 

have been reported prior to 

successful fitting (Jones et al., 

2008; Komesu et al., 2007; Maito 

et al., 2006; Robert & Mainprize, 

2002; Wu et al., 1997). Women 

unable to retain a pessary at an 

initial fitting are less likely to be 

successful at subsequent fittings 

(Maito et al., 2006), but persistence 

may pay off. Clemons, 

Aguilar, Tillinghast et al. (2004b) 

found 22 of 49 women who could 

not be fit at the first visit were successfully 

fit on the second visit. In 

that study, a Gellhorn pessary was 

more likely to require refitting 

than a Ring, suggesting Ring pessaries 

are easier for providers to 

size correctly. For women who prefer 

pessary treatment but have difficulty 

retaining any single pessary, 

occasional use of double pessaries, 

including a Donut with Gellhorn 

or double Ring, has been reported 

(Myers, LaSala, & Murphy, 1998; 

Singh & Reid, 2002). 

Prior to fitting, women should 

be informed that the risk of a pessary 

trial is minimal, while the 

potential symptom-relief can be 

great. It may be helpful to be optimistic, 

normalizing the fitting situation, 

while informing the woman 

prior to fitting that an appropriate 

pessary may not be identified. 

Clinicians also need to remember 

that successful fitting after three or 


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four attempts is less likely. To aid 

understanding of current pessary 

choices, the following sections 

look more specifically at commonly 

used pessary options. 

Table 4. 

Steps to Pessary Fitting 

1. Review treatment goals and expectations. 

2. Ask the woman to empty her bladder and bowels. 

3. Ask the woman to assume Semi-Fowler position, a position that is generally 

comfortable and offers her a view of the fitting if desired. 

4. Gently replace any vault eversion or procidentia prior to sizing. 

5. After amply applying water-based lubricant to the vaginal introitus, digitally 

assess vaginal size, shape, and support, and for any relative contraindications 

to the fitting (pain with palpation, vaginal infection or lesions, full rectum). 

6. Select the appropriate stocked pessary or fitting kit model, and clean it with 

soap, rinsing well with water. 

7. Apply additional water-based lubricant to the leading edge of the pessary if 

needed. 

8. Insert the pessary, applying pressure gently toward the posterior vaginal wall 

and/or obliquely (at 11:00 and 5:00 positions related to the introitus) in the 

largest diameter, avoiding pressure on the sensitive urethra. 

9. To check initial fit, ask the woman to Valsalva and cough (in lithotomy and 

standing postions) – the correct pessary should be comfortable and may 

advance toward the introitus with pressure and recede with relaxation, but it 

should not pass through the introitus. The examiner should be able to gently 

rock the pessary in place, demonstrating that it is not pressing too tightly on the 

vaginal walls. 

10. Ask the woman to stand, move about the examination room, and simulate 

activities she would normally do (walking, bending to pick up objects on the 

floor, changing from standing to sitting) and report any discomfort. 

11. Ask the woman to sit on the toilet, void, and Valsalva gently, simulating 

defecation. For actual defecation, it may be helpful for her to support the 

pessary digitally. 

12. If the fitting is successful to this point, review expectations and schedule a 

return visit. If the pessary is expelled or uncomfortable, start the fitting process 

again. 

13. Whether or not the fitting is successful, document any shape and size of 

pessary used to avoid repeat attempts at subsequent visits. 

Insertion and Removal of 

Specific Pessaries for Women 

With Introital Support 

Ring with and without support 

membrane. The Ring pessary 

and Ring with support membrane 

(see Figure 2) are common 

first-line choices for most types 

of POP. They typically include a 

rigid, hinged nylon ring that fits 

into the length of the vagina, providing 

support for the anterior, 

posterior, and apical walls. The 

optional support membrane may 

add additional support if anterior 

or posterior compartment prolapse 

are present (such as cystocele 

or rectocele). The position of 

the hinge is marked either by 

notches in a Ring or finger-sized 

holes in the Ring with support 

membrane. To retain this type of 

pessary, the introitus and/or 

pelvic floor must provide enough 

support to contain the pessary. 

Ring pessaries tend to be easiest 

for both clinicians and 

patients to use. Many women are 

able to remove and replace a Ring 

pessary without difficulty. Even 

when a Ring pessary is in place, 

coitus may be comfortable for 

both partners. Ring pessaries with 

or without support are also available 

with a urethral support knob 

for the treatment of stress UI. 

To fit a Ring pessary, the vagina 

is measured digitally or with a 

vaginal measuring instrument to 

assess the depth, obtaining a general 

idea of the shape and size of 

the intra-vaginal space (see Figure 

8). To insert the pessary, lubrication 

of the vagina or a hinged edge 

of the pessary and not the gloved 

exam fingers will facilitate a grip 

on the folded pessary. The pessary 

is folded in half at the hinge and 

inserted through the introital 

opening, while applying gentle 

downward posterior or perineal 

pressure to avoid the sensitive 

urethral area. Once inside the 

vagina, the pessary will open 

spontaneously. This pessary follows 

the length of the vagina, 

from loosely behind the symphysis 

to the vaginal apex or posterior 

fornix. A Ring pessary can be 

rotated 90 degrees while in-place, 

which may help prevent spontaneous 

expulsion by placing the 

hinge transversely to the introitus. 

A well-fit Ring pessary will stay 

in place without applying undue 

pressure on the sidewalls, apex, 

or introitus, and will not be 

noticeable by the patient. If the 

woman describes discomfort from 

the pessary fitting too near the 

introitus during movement, it is 

either too large or there is insufficient 

introital support to hold the 

pessary in place. Removal and 

digital re-sizing may suggest 

whether a larger or smaller pessary 

may work better. If two or 

three tries are not effective, a selfretaining 

pessary, such as a 

Gellhorn or Cube, may be a better 

option. 

To remove a Ring pessary, 

lubricate the introitus, put an 

examining finger through the finger-size 

hole or at a hinge notch, 

rotate the pessary to bring the 

hinge anteriorally to the introi- 



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tus, and gently pull downward, 

diagonally, and out. The vaginal 

walls will help to fold the pessary 

as it exits. Atrophic or 

scarred tissue may fissure at the 

posterior fornix with removal. 

Increased lubrication, moisturization, 

or estrogenation may 

ease future use. The most common 

sizes of Ring pessary are 2 

through 5 (whole numbers). 

Donut and Inflatable-Donut 

pessaries. If a Ring pessary is not 

successful, but there is some 

introital support, a Donut or 

Inflatable-Donut pessary may be an 

option (see Figures 3 and 4). Donut 

pessaries are essentially thicker 

Rings and may fill a vagina 

enlarged by loss of elasticity more 

completely; however, these pessaries 

are in more complete contact 

with the vaginal epithelium, which 

may increase the risk of mechanical 

tissue injury or discharge production 

and retention. Some 

women may be able to remove and 

replace traditional Donut pessaries 

themselves, but comfortable vaginal 

intercourse is unlikely. Infla - 

table Donut pessaries, which are a 

silicone variation of an older latex 

inflatable pessary called the Inflatoball, 

have a stem and valve for 

inflation and deflation like a balloon, 

and are designed to be inserted 

and removed at frequent intervals 

(within 48 hours). Manu - 

facturer instructions should be 

reviewed before attempting to autoclave 

Donut pessaries because of 

their air-filled core. 

During fitting, digital examination 

is used to assess both the 

depth and width of the vagina. 

Introital stretching and discomfort 

is more likely with a traditional 

Donut, and with either type, adequate 

lubrication is essential. 

With firm digital pressure, a traditional 

Donut pessary may be compressed 

somewhat to slip through 

the introitus more comfortably. 

Additionally, some Donut pessaries 

can be deflated using a needle 

and syringe to remove air. 

After pessary insertion, it can then 

be re-inflated by carefully inserting 

the needle into the Donut and 

injecting air with the syringe. All 

Donut pessaries are typically fit 

either like a Ring pessary – along 

the length of the vagina – or may 

stay in place if fitted snugly into 

the circumference of the vaginal 

apex with appropriate intrinsic 

support. 

To remove a traditional Donut 

pessary, the introitus is lubricated, 

and with the examination finger 

in the Donut center, the pessary is 

pulled gently downward at a diagonal 

angle. Some Donut pessaries 

can be carefully deflated in situ 

using a needle and syringe to ease 

removal, and the Inflatable Donut 

pessary should also be deflated 

prior to removal. 

Other support pessaries re - 

quire introital integrity, with indications 

based on clinical experience. 

They include the Oval 

(which may be useful with a narrow 

vaginal width); the Hodge and 

Smith Lever pessary (which may 

be more comfortable in women 

with a narrow vaginal introitus); 

the Gehrung Arch (which may be 

effective in women who have an 

isolated anterior or posterior wall 

prolapse), and the Shaatz (which is 

a disc, similar to the Ring, but may 

offer firmer support). Fitting for 

these pessaries is very similar to fitting 

of the Ring pessary. Manu - 

facturers typically include fitting 

instructions with each pessary. If 

these types of pessaries cannot be 

retained, a self-retaining pessary 

may be appropriate. 

Insertion and Removal 

Of Self-Retaining Pessaries 

Gellhorn. The flexible Gellhorn 

pessary is an option in women who 

cannot retain Ring or similar pessaries 

due to introital laxity (see 

Figure 5). The shape of the 

Gellhorn pessary allows the lateral 

vaginal walls to in-fold under 

the top dish, while the concave 

dish itself may create a suctionlike 

action against the proximal 

vagina, facilitating pessary retention. 

The stem of the Gellhorn follows 

the shaft of the vagina, maintaining 

correct alignment. The 

option of two different stem 

lengths (short and long) allows 

optimal fitting even in women 

with a shortened vagina, such as 

post-hysterectomy wo men. 

Although the ability of the 

Gellhorn to be somewhat selfretaining 

can be a considerable 

advantage, it also makes this pessary 

more difficult for clinicians 

and patients to remove. In addition, 

the Gellhorn pessary may be 

more likely to cause mechanical 

trauma to the vaginal tissue. As 

with other pessaries, Gellhorn fitting 

involves measurement of the 

vagina, in this case, assessing both 

the diameter of the introitus and 

the apex to approximate the correct 

size of the dish and of the 

vaginal length to determine 

whether a long or short neck is 

appropriate (see Figure 8). 

To insert the flexible Gellhorn, 

the stem can be bent down to the 

dish and the dish folded, with the 

edge of the dish inserted first. The 

pessary is then corkscrewed gently 

down toward the perineum to 

avoid the urethra, then upward to 

bring the dish perpendicular to 

the vaginal vault. The pessary can 

then be pushed gently upward 

using the index finger on the knob 

at the end of the neck, placing the 

dish into the vaginal apex. The 

woman can then bear down as an 

initial assessment of the likelihood 

of retention. If two to three 

adjustments in the size of the pessary 

do not work, a Cube pessary 

may be an option. 

Removal of a flexible Gellhorn 

is generally achieved by lubricating 

the introitus, pulling the knob 

at the end of the pessary neck gently 

downward (toward the introitus) 

and laterally (toward a thigh), 

and using the index finger to hook 

and bend down the edge of the 

dish. When the knob cannot be 

easily grasped, a carefully placed 

tenaculum or ring forceps may be 

helpful to assist removal. Gellhorn 

pessaries are sized in quarter-inch 

intervals by the dish diameter, 

with common sizes generally ranging 

from 1.75 to 3 inches. 

Cube. The Cube pessary can 

also be considered self-retaining 


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(see Figure 6). Compared to a 

Gellhorn pessary, a smaller size 

can be used; however, Cube use 

may also result in mechanical tissue 

injury. Cube pessaries are 

held in place because the concavities 

in the six sides allow vaginal 

tissue to conform to the pessary 

shape. Because large amounts of 

epithelium are in contact with the 

pessary, drainage holes are important 

to allow desquamated cells 

and vaginal discharge to drain. 

The Cube is designed for self-care, 

but like the Gellhorn, some 

women and providers find it difficult 

to remove due to the suction. 

Softness and compressibility of 

the silicone used vary by manufacturer. 

Softer Cubes can be easier 

to insert, but firmer devices 

may be more likely to be retained, 

and choice is typically based on 

provider experience. The Cube 

pessary can be placed at different 

depths in the vagina, which may 

offer an advantage when a woman 

has an isolated or site-specific 

prolapse. 

Size is estimated by digitally 

measuring the diameter of the 

vaginal shaft and vault. To insert, 

lubricate the pessary and introitus, 

compress the pessary, part the 

introitus gently, and insert the pessary 

to the depth that best corrects 

the bulge and is most comfortable 

for the patient. Com monly used 

sizes range from 1 to 4. 

To remove, lubricate the in - 

troitus, apply gentle traction on 

the pessary cord to stabilize and 

bring the device toward the introitus, 

and then insert the tip of the 

index finger up above the Cube to 

release it and pull it gently out of 

the vagina. Pulling too hard on the 

cord alone will break the cord. If 

removal is difficult, a tenaculum, 

ring forceps, pessary remover or 

crochet hook, or dental tape tied 

through several holes can be used 

to facilitate bringing the Cube to 

the introitus. 

Incontinence Pessary Options 

Incontinence pessaries help 

stabilize the urethra and the urethral 

vesicle junction to prevent 

leakage during times of increased 

abdominal pressure. Options 

include the Incontinence Ring or 

Dish, which are similar to regular 

Ring pessaries but offer less vaginal 

support; and standard Ring, 

Arch (Gehrung), or Lever (Smith- 

Hodge) pessaries with an optional 

incontinence support knob. Most 

of these pessaries are fitted similarly 

to a standard Ring pessary. 

While some women use incontinence 

pessaries only during exercise, 

others use them continuously. 

Generally, the incontinence 

knob pessaries are fitted more 

snugly behind the symphysis, 

beneath the urethra. A pessary 

that is too loose will not decrease 

stress UI and may rotate in the 

vagina. Too much pressure may 

cause discomfort, epithelial in - 

jury, and urinary retention. If the 

woman plans to use the pessary 

only intermittently or during 

exercise, it may be fitted more 

snugly to retain urine. Although 

pessaries are typically fitted with 

an empty bladder, fitting an 

incontinence pessary in a woman 

with a full bladder may facilitate 

testing of both stress UI treatment 

during exercise and voiding adequacy. 

Suggestions for Future Research 

Although the evidence base 

for pessary use has been building 

in recent years, much of practice 

continues to be based predominantly 

on expert-opinion. Prac - 

ticing providers may fill some of 

these gaps through their own 

observations and inventiveness, 

as well as in formal clinical trials 

in their own practice. Nurses 

involved in pessary care may be 

interested in studying ways to 

improve patient satisfaction and 

experience. Questions may in - 

clude looking at changes in sexual 

function; testing appropriate 

pre-trial, goal-setting models; 

comparing methods of providing 

information about pessary op tions 

for individuals and lay groups; 

and evaluating symptom relief 

when pessaries are used in conjunction 

with other modalities, 

such as anticholinergic medications 

or urethral bulking agents. 

Expert opinion regarding indications 

for specific pessary types 

should be tested in additional 

crossover or head-to-head clinical 

pessary trials. Cost analyses related 

to different aspects of pessary 

use are needed. For example, 

comparison of costs of pessary use 

over time versus surgery, and 

analysis of potential savings from 

morbidity prevention may be useful 

both to inform individuals 

making treatment choices and 

public policy related to reimbursement. 

Conclusion 

Support pessaries are an 

important option for treatment of 

many pelvic floor symptoms. 

Currently, providers new to the 

field continue to learn pessary 

indications, selection, and fitting 

strategies from a relatively small 

evidence base, and occasionally, 

from conflicting expert opinion. 

This article has summarized basic 

concepts related to initiating pessary 

use. Other articles in this 

series will discuss pessary follow 

up and business strategies. 

References 

American College of Obstetricians and 

Gynecologists (ACOG). (2007). Pelvic 

organ prolapse. ACOG Practice 

Bulletin No. 85. 110, 717-729. 

Barber, M.D., Walters, M.D., Cundiff, G.W., & 

the PESSRI Trial Group. (2006). 

Responsiveness of the Pelvic Floor 

Distress Inventory (PFDI) and Pelvic 

Floor Impact Questionnaire (PFIQ) in 

women undergoing vaginal surgery 

and pessary treatment for pelvic organ 

prolapse. American Journal of 

Obstetrics & Gynecology, 194(5), 1492- 

1498. doi:10.1016/j.ajog.2006.01.076 

Bhatia, N.N., & Bergman, A. (1985). Pessary 

test in women with urinary incontinence. 

Obstetrics & Gynecology, 65(2), 

220-226. 

Bioteque of America. (2011). Pessary products. 

Retrieved from http://www. 

bioteque.com/downloads/index 

Brincat, C., Kenton, K., Fitzgerald, M.P., & 

Brubaker, L. (2004). Sexual activity predicts 

continued pessary use. American 

Journal of Obstetrics & Gynecology, 

191, 198-200. doi:10.1016/j.ajog.2004. 

03.083 



SERIES 


Bump, R.C., Fantl, J.A., & Hurt, W.G. (1988). 

The mechanism of urinary continence 

in women with severe uterovaginal 

prolapse: Results of barrier studies. 


295. 

Clemons, J.L., Aguilar, V.C., Sokol, E.R., 

Jackson, N.D., & Myers, D.L. (2004). 

Patient characteristics that are associated 

with continued pessary use versus surgery 

after 1 year. American Journal of 

Obstetrics & Gynecology, 191(1), 159-164. 

doi:10.1016/j.ajog.2004.04.048 

Clemons, J.L., Aguilar, V.C., Tillinghast, T.A., 

Jackson, N.D., & Myers, D.L. (2004a). 

Patient satisfaction and changes in prolapse 

and urinary symptoms in women 

who were successfully fitted with a pessary 

for pelvic organ prolapse. American 


190(4) 1025-1029. doi:10.1016/j.ajog. 

2003.10.711 

Clemons, J.L., Aguilar, V.C., Tillinghast, T.A., 

Jackson, N.D., & Myers, D.L. (2004b). 

Risk factors associated with an unsuccessful 

pessary fitting trial in women 

with pelvic organ prolapse. American 


190(2), 345-350. doi:10.1016/j.ajog. 

2003.08.034 

CooperSurgical. (2008). Silicone (latex-free) 

pessary fitting instructions for the 

healthcare professional [Milex pessary 

device instructional insert]. Trumbull, 

CT: Author. 

Cundiff, G.W., Weidner, A.C., Visco, A.G., 

Bump, R.C., & Addison, W.A. (2000). A 

survey of pessary use by members of the 

American Urogynecologic Society. 


Cundiff, G.W., Amundsen, C.L., Bent, A.E., 

Coates, K.W., Schaffer, J.I,. Strohbehn, 

K., & Handa, V.L. (2007). The PESSRI 

Study: Symptom relief outcomes of a 

randomized crossover trial of the Ring 

and Gellhorn pessaries. American 


196(4), 405.e1-405.e8. doi:10.1016/j. 

ajog.2007.02.018 

Donnelly, M.J., Powell-Morgan, S., Olsen, 

A.L., & Nygaard, I.E. (2004). Vaginal pessaries 

for the management of stress and 

mixed urinary incontinence. 

International Urogynecology Journal, 

15, 302-307. doi:10.1007/s00192-004- 

1163-7 

Fernando, R.J., Thakar, R., Sultan, A.H., Shah, 

S.M., & Jones, P.W. (2006). Effect of vaginal 

pessaries on symptoms associated 

with pelvic organ prolapse. Obstetrics & 

Gynecology 108(1), 93-99. 

Handa, V.L., & Jones, M. (2002). Do pessaries 

prevent the progression of pelvic organ 

prolapse? International Urogynecology 

Journal, 13, 349-352. 

Hanson, L.M., Schulz, J.A., Flood, C.G., 

Cooley, B., & Tam, F. (2006). Vaginal pessaries 

in managing women with pelvic 

organ prolapse and urinary incontinence: 

Patient characteristics and factors 

contributing to success. Inter national 

Urogynecology Journal, 17, 155-159. 

doi:10.1007/s00192-005-1362-x 

Heit, M., Culligan, P., Rosenquist, C., & 

Shott, S. (2002). Is pelvic organ prolapse 

a cause of pelvic or low back 

pain? Obstetrics & Gynecology, 9(1), 

23-28. 

Jones, K., Yang, L., Lowder, J.L., Meyn, L., 

Ellison, R., Zycynski, H.M., … Lee, T.l. 

(2008). Effect of pessary use on genital 

hiatus measurements in women with 

pelvic organ prolapse. Obstetrics & 

Gynecology, 112(3), 630-636. 

Komesu, Y.M., Rogers, R.G., Rode, M.A., 

Craig, E.C., Gallegos, K.A., Montoya, 

A.R., & Swartz, C.D. (2007). Pelvic 

floor symptom changes in pessary 

users. American Journal of Obstetrics 

& Gynecology, 197, 620.e1-620.e6. 

doi:10.1016/j.ajog.2007.08.013 

Komesu, Y.M., Rogers, R.G., Rode, M.A., 

Craig, E.C., Schrader, R.M., Gallegos, 

K.A., & Villareal, B. (2008). Patientselected 

goal attainment for pessary 

wearers: What is the clinical relevancy? 

American Journal of Obstetrics & 

Gynecology, 198, 577.e1-577.e5. 

doi:10.1016/j.ajog.2007.12.033 

Kuhn, A., Bapst, D., Stadlmayr, W., Vits, K., 

& Mueller, M.D. (2009). Sexual and 

organ function in patients with symptomatic 

prolapse: Are pessaries helpful? 

Fertility & Sterility, 91(5), 1914- 

1918. doi:10.1016/j.fertnstert.2008.02. 

142. 

Lazarou, G., Scotti, R.J., Mikhail, M.S., 

Zhou, H.S., & Powers, K. (2004). 

Pessary reduction and postoperative 

cure of retention in women with anterior 

vaginal wall prolapse. Inter - 

national Urogynecology Journal, 15, 

175-178. doi:10.1007/s00192-00411 

38-8 

Maito, J.M., Quam, Z.A., Craig, E., Danner, 

K.A., & Rogers, R.G. (2006). Predictors 

of successful pessary fitting and continued 

use in a nurse-midwifery pessary 

clinic. Journal of Midwifery & 

Women’s Health, 51(2), 78-84. doi: 

10.1016/j.jmwh.2005.09.003 

Matsubara, S., & Ohki, Y. (2010). Can a Ring 

pessary have a lasting effect to reverse 

uterine prolapse even after its 

removal? Journal of Obstetric & 

Gynaecologic Research, 36(2), 459- 

461. doi:10.1111/j.1447-0756.2009. 

01162.x 

Micha, J.P., Rettenmaier, M.A., Clark, M., 

Hu, J.C., Chang, M., Brown, J.V., & 

Goldstein, B.H. (2008). Successful 

management of acute renal failure with 

a vaginal pessary: A case report. 

Gynecologic Surgery, 5, 49-51. 

doi:10.1007/s10397-007-0305-6 

Mutone, M.F., Terry, C., Hale, D.S., & 

Benson, J.T. (2005). Factors which 

influence the short-term success of 

pessary management of pelvic organ 

prolapse. American Journal of 


doi:10.1016/j.ajog.2004.12.012 

Myers, D.L., LaSala, C.A., & Murphy, J.A. 

(1998). Double pessary use in grade 4 

uterine and vaginal prolapse. 


1020. 

Nager, C.W., Richter, H.E., Nygaard, I., 

Paraiso, M.F., Wu, J.M., Kenton, K., … 

Spino, C., for the Pelvic Floor 

Disorders Network. (2009). POP-Q 

measures do not predict incontinence 

pessary size. International Uro - 

gynecology Journal, 20, 1023-1028. 

doi:10.1007/s00192-009-0866-1 

Nygaard, I., Barber, M.D., Burgio, K.L., 

Kenton, K., Meikle, S., Schaffer, J., … 

Brody, D.J., for the Pelvic Floor 

Disorders Network. (2008). Prevalence 

of symptomatic pelvic floor disorders 

in US women. Journal of the American 

Medical Association 300(11), 1311- 

1316. 

Nyguyen, J.N., & Jones, C.R. (2005). Pessary 

treatment of pelvic relaxation: Factors 

affecting successful fitting and continued 

use. Journal of Wound Ostomy 

and Continence Nursing, 32(4), 255- 

261. 

Patel, M., Mellen, C., O’Sullivan, D.M., & 

LaSala, C.A. (2010). Impact of pessary 

use on prolapse symptoms, quality of 

life, and body image. American 


202(5), 499e14. doi:10.1016/j.ajog. 

2010.01.019 

Personalmed. (2012). Management with 

Eva Care ® flexible silicone pessaries. 

Retrieved from http://www.personal 

med.com/pessaries.php 

Pott-Grinstein, E., & Newcomer, J.R. (2001). 

Gynecologists’ patterns of prescribing 

pessaries. Journal of Reproductive 

Medicine, 46(3), 205-208. 

Richter, H.E., Burgio, K.L., Brubaker, L., 

Nygaard, I.E., Ye, W., Weidner, A., … 

Spino, C. (2010). Continence pessary 

compared with behavioral therapy or 

combined therapy for stress incontinence: 

A randomized controlled trial. 


617. doi:10.1097/AOG.0b013e318 

1d055d4 

Robert, M., & Mainprize, T.C. (2002). Longterm 

assessment of the incontinence 

Ring pessary for the treatment of stress 

incontinence. International Uro gyne - 

cology Journal, 13, 326-329. 

Shah, S.M., Sultan, A.H., & Thakar, R. 

(2006). The history and evolution of 

pessaries for pelvic organ prolapse. 

International Urogynecology Journal, 

17, 170-175. doi:10.1007/s00192-005- 

1313-6 

Singh, K., & Reid, W.M.N. (2002). Non-surgical 

treatment of uterovaginal prolapse 

using double vaginal rings. BJOG: An 

International Journal of Obstetrics and 

Gynaecology, 108(1), 112-113. doi:10. 

1111/j.1471-0528.2001.00011.x 

Weber, A.M., & Richter, H.E. (2005). Pelvic 

organ prolapse. Obstetrics & Gyne - 

cology, 106(3), 615-634. 

Wu, V., Farrell, S.A., Baskett, T.F., & 

Flowerdew, G. (1997). A simplified 

protocol for pessary management. 


994.

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