A pessary is a medical device inserted into the vagina, most commonly used to support pelvic organs that have descended, a condition known as pelvic organ prolapse. The device provides structure to the weakened pelvic floor muscles and connective tissues, holding the bladder, uterus, or rectum in their proper positions. Due to the close anatomical relationship between the vagina and the rectum, a pessary can be a direct or contributing factor to constipation.
The Physical Relationship Between Pessaries and Bowel Function
The vagina and the rectum are separated by only a thin layer of tissue, meaning that devices placed in the vagina can directly influence bowel function. A pessary, particularly one used to support a rectocele (where the rectum bulges into the vagina), sits directly adjacent to the large intestine. The presence of the pessary can therefore exert physical pressure on the front wall of the rectum.
This pressure can narrow the space available for stool to pass, creating a mechanical obstruction. When the rectum fills with feces, the tissue naturally expands, pushing toward the pessary. If the pessary is too large or positioned incorrectly, it can resist this expansion, making it difficult to fully empty their bowels. Patients often report a feeling of incomplete evacuation, which is a common symptom of this defecatory dysfunction.
The mechanical blockage caused by the device can be subtle, only appearing when the stool is firm or when the rectum is significantly full. This interference with the natural process of defecation is the primary way a pessary contributes to new-onset or worsened constipation. Preventing the free passage of stool can lead to straining, which is discouraged as it may cause the pessary to shift or even fall out.
Factors That Increase Constipation Risk
The likelihood and severity of constipation while using a pessary are influenced by several variables. The specific type of pessary can play a role, as space-filling devices like the Gellhorn or cube pessaries occupy a greater volume within the vaginal vault compared to a simple ring pessary. A larger device size increases the chance of mechanical pressure on the rectum.
Improper fitting is a major factor contributing to bowel issues. The goal of fitting is to use the largest size that is comfortable and stays in place without interfering with bladder or bowel function. If the device is selected incorrectly and is too large, it will press excessively on the rectal wall, making defecation difficult.
Pre-existing conditions and lifestyle habits increase the risk for constipation in pessary users. Factors that can aggravate symptoms include:
- Chronic constipation or other pre-existing bowel conditions.
- Taking certain medications, such as iron supplements or opioid pain relievers.
- Inadequate fluid intake.
- A low-fiber diet, which results in harder, bulkier stool.
Managing Constipation While Using a Pessary
Managing constipation involves proactive lifestyle adjustments and medical interventions, all aimed at ensuring soft, easily passable stool. Increasing the intake of dietary fiber is important, as is ensuring adequate fluid consumption. Fiber adds bulk to the stool, and water helps keep that bulk soft and mobile, reducing the effort needed for a bowel movement.
Establishing regular bowel habits is another key element of management. It is important not to ignore the urge to defecate, and to avoid excessive straining, which can displace the pessary. If diet and fluid adjustments are insufficient, over-the-counter options can be used under the guidance of a healthcare provider. Bulk-forming laxatives or stool softeners are often effective first-line treatments.
If constipation is severe, chronic, or accompanied by significant pain, it is essential to contact the prescribing physician. Persistent difficulty may signal that the pessary itself is the problem and requires adjustment. The provider may need to refit the device, perhaps selecting a smaller size or a different style to alleviate the pressure on the rectum. In rare cases, a severe complication like fecal impaction can occur if the pessary is left in place without proper management, necessitating immediate medical attention.