What Is a Pessary? Types, Fitting, and Care

A pessary is a removable device inserted into the vagina to support pelvic organs that have shifted out of position, most commonly due to pelvic organ prolapse. Pessaries have been used in some form for thousands of years, and modern versions made of medical-grade silicone remain one of the first-line treatments for prolapse and certain types of urinary incontinence. Despite being safe, inexpensive, and effective for most women who try them, pessaries are surprisingly under-discussed, and many people encounter the term for the first time only when a clinician suggests one.

What a Pessary Actually Does

Pelvic organ prolapse happens when the muscles and connective tissues of the pelvic floor weaken, allowing the bladder, uterus, or rectum to drop downward and press against or bulge into the vaginal wall. A pessary sits inside the vagina and mechanically props those organs back into a more normal position. This relieves the sensation of heaviness, bulging, or pressure that many women with prolapse describe, and it can also reduce associated urinary symptoms like leaking or difficulty emptying the bladder.

Computational modeling has shown how this works at a tissue level. After a pessary is placed, the displacement of the bladder neck and uterine cervix decreases, the stress on pelvic ligaments drops, and bladder pressure stabilizes. Different pessary shapes achieve this in different ways, which is why clinicians choose among several designs depending on the individual anatomy and severity of prolapse.¹

Types and How They Are Chosen

Pessaries come in two broad categories. Supporting types, like the ring pessary, work by propping up the vaginal walls and are typically the first choice for mild to moderate prolapse. Space-occupying types, like the Gellhorn pessary, fill more of the vaginal canal and are reserved for more advanced prolapse where a simple ring would not stay in place.² Within those categories there are dozens of specific shapes and sizes. Ring pessaries with a supportive membrane, for instance, can handle stage III or IV prolapse despite being classified as a “supporting” type.

Modeling work suggests the Gellhorn pessary is better at limiting organ displacement and reducing ligament stress, but it tends to create higher localized pressure against vaginal tissue. The ring pessary distributes its contact pressure more evenly and produces a more stable urinary flow environment.³ In practice, this trade-off means Gellhorn and similar space-occupying designs are associated with higher rates of vaginal erosion than ring-type pessaries.⁴

Fitting and Who It Works For

Getting the right pessary requires a trial-and-error fitting process. A clinician selects a size and type, inserts it, and checks whether it stays in place during activities like standing, walking, and bearing down. Most women can be successfully fitted. One prospective study found an initial success rate of about 88%.⁵

The main predictors of a failed fitting are anatomical. A shorter vaginal length is the most consistent risk factor. One study found that women whose total vaginal length measured less than about 7 centimeters had a much higher rate of unsuccessful fitting.⁶ A wide vaginal opening also makes retention harder.⁷ Prior hysterectomy roughly quadruples the odds of fitting failure, likely because the surgery changes the vaginal vault’s shape and support. More advanced prolapse also reduces fitting success.⁸ Higher body mass index has been identified as an additional independent predictor, though its influence is smaller than vaginal length.⁹

If the first pessary does not stay in place or feels uncomfortable, a clinician will try a different size or shape. When multiple attempts fail, surgery becomes the more likely path forward. But for most women, a workable fit can be achieved within a few tries.

Pessary Versus Surgery

The question most women want answered is whether a pessary works as well as an operation. The honest answer is that surgery tends to produce somewhat greater improvement in prolapse-specific symptoms, but the gap is smaller than many people assume, and pessaries cost far less.

A large randomized trial published in JAMA found that at two years, about 76% of women in the pessary group reported subjective improvement compared with about 82% in the surgery group. That difference was not large enough for the pessary to meet the formal statistical test for being “just as good” as surgery, but both groups clearly improved substantially from where they started.¹⁰ A smaller prospective study comparing the same women before and after each treatment found that patients rated their improvement as greater after surgery, particularly for prolapse-specific distress scores.¹¹

On the other hand, a study looking at quality-of-life measures at six months found that the absolute changes in vaginal symptom scores were nearly identical between pessary users and surgical patients.¹² The picture that emerges is nuanced: surgery edges out pessaries on some outcome measures, particularly over longer timeframes, while pessaries hold their own on quality-of-life scores in the shorter term.

Where pessaries clearly win is cost. An economic analysis alongside a randomized trial found that healthcare costs were roughly €1,800 lower for pessary therapy compared to surgery, and the probability that pessary therapy was the more cost-effective option was essentially 100% at standard willingness-to-pay thresholds.¹³ A separate cost-effectiveness model estimated that starting with a pessary and transitioning to surgery only if needed achieved about 10.4 quality-adjusted months at roughly $10,000 per patient, while going straight to surgery achieved 11.4 quality-adjusted months at $15,000.¹⁴ For most women, starting with a pessary and reserving surgery for when it is genuinely needed is the financially sensible approach.

Complications and Side Effects

Pessaries are generally safe, but they are a foreign body sitting in moist tissue, so some degree of side effects is common. The most frequent issues are vaginal discharge, vaginal bleeding, and tissue erosion.¹⁵ One clinic-based study found that over the course of a year, the overall adverse event rate was about 84%, though most of those events were minor irritations rather than anything requiring treatment changes.¹⁶ That sounds alarming, but context matters: the category is broad, and the most serious issues are rare.

Several factors raise or lower the risk of vaginal tissue problems. Longer time since menopause, more advanced prolapse, and higher education level (possibly a proxy for better symptom reporting) all increase the odds. Protective factors include having had vaginal deliveries, being sexually active, and using topical estrogen continuously for at least a year.¹⁷ The finding about sexual activity likely reflects the fact that women who are having sex tend to remove and reinsert their pessary regularly, which allows tissue inspection and recovery.

Serious complications, while documented, are overwhelmingly linked to neglected pessaries that go months or years without removal or checkup. A systematic review of case reports found the most common rare complications were fistulas between the vagina and bladder or rectum, pessary impaction in the vaginal wall, and in extreme cases, bowel herniation through vaginal tissue.¹⁸ These outcomes are essentially preventable with routine follow-up care.¹⁹

The Role of Topical Estrogen

Clinicians often prescribe vaginal estrogen cream alongside a pessary, particularly for postmenopausal women whose vaginal tissue has thinned. The logic is that healthier, better-lubricated tissue should tolerate a foreign body with fewer problems. The evidence, though, is more mixed than many clinicians realize.

A systematic review and meta-analysis found that topical estrogen did not significantly reduce vaginal ulceration or erosion rates among pessary users. It did, however, appear to lower the rate of bacterial vaginosis.²⁰ A separate study found no protection against erosions or vaginal bleeding, but it did find that estrogen users were significantly less likely to experience bothersome discharge and much less likely to discontinue pessary use entirely.²¹ So the benefit of estrogen may be less about preventing tissue damage and more about improving the overall experience enough that women stick with the treatment longer. Given that long-term continuous estrogen use was independently protective against vaginal tissue adverse events in a separate analysis, there may also be a duration-dependent effect that shorter studies miss.²²

Managing Your Own Pessary

Traditionally, women visit a clinic every few months to have a nurse or doctor remove the pessary, clean it, inspect the vaginal tissue, and reinsert it. But a growing body of evidence supports teaching women to handle this themselves. A large randomized trial called TOPSY compared self-management against clinic-based care over 18 months. Women in the self-management group reported fewer pessary-related complications, with about a 4-percentage-point lower complication rate. They were also more likely to intend to continue using their pessary and found the process of changing it more convenient. Tissue problems like ulceration and granulation were less common in the self-management group as well.²³

A meta-analysis of available studies confirmed that continuation rates were not statistically different between self-care and clinic-based management, meaning women who learned to do it themselves were just as likely to keep using the pessary over time.²⁴ Self-management also offers practical advantages: fewer clinic visits, more autonomy over timing, and the ability to remove the pessary for activities like sex or exercise whenever you want.

Removal frequency appears to affect vaginal health. Research on the vaginal microenvironment found that women who removed their pessary less often than once a week were more likely to develop a predominance of anaerobic bacteria at three months.²⁵ Pessary wearers in general are more likely to experience vaginal discharge and microscopic signs of inflammation, and these changes develop within the first two weeks of use. The actual bacterial species found in the vagina do not differ dramatically between women with and without bothersome discharge, suggesting that the inflammation is a mechanical tissue response rather than an infection.²⁶

Pessaries and Sexual Activity

Many women worry that a pessary will interfere with their sex life. The evidence is reassuring, if slightly complicated. Among women who remained sexually active during pessary use, overall sexual function scores did not change meaningfully over the first three months. The one exception was a small but statistically significant drop in the score related to partner-related concerns.²⁷

In practice, about 70% of sexually active pessary users remove the device before intercourse. The most common reasons are that the partner can feel it during sex and that it is uncomfortable during intercourse.²⁸ Whether a woman removes the pessary for sex or leaves it in does not appear to affect her sexual function scores, so this is largely a matter of personal comfort and preference. In longer-term data on women using cube pessaries with self-management, roughly three-quarters described their sexual well-being as better or much better than before treatment, and over 90% said removing the device before sex was not disruptive.²⁹ The improvement in sexual well-being makes sense because untreated prolapse itself often makes sex uncomfortable or unappealing, so resolving the prolapse symptoms tends to help even if the pessary itself introduces a minor logistical step.

Cervical Pessaries for Preterm Birth Prevention

There is a completely different application of the word “pessary” that confuses many people who search the term: the cervical pessary used during pregnancy to try to prevent preterm birth. This is a silicone ring placed around the cervix in women whose cervix has been found to be unusually short on ultrasound, a known risk factor for early delivery. The theory is that the ring changes the angle of the cervical canal and redistributes the weight of the growing uterus, potentially delaying labor.

The evidence here is genuinely conflicted, which is unusual in medicine for a device this simple. An early Spanish trial found a dramatic reduction in spontaneous delivery before 34 weeks, with only 6% of women in the pessary group delivering that early compared to 27% in the control group.³⁰ But subsequent larger trials failed to confirm this benefit. A trial published in the New England Journal of Medicine found no significant difference in preterm delivery rates between the pessary and control groups.³¹ The TOPS trial, published in JAMA, was even more definitive: preterm birth or fetal death occurred in about 46% of both the pessary and usual-care groups, yielding a relative risk of essentially 1.0.³²

The likely explanation for the discrepancy is that the early positive trial was open-label and relatively small, while the larger trials had more robust designs. As of now, cervical pessaries for preterm birth prevention are not supported by the weight of the evidence, though some researchers continue to explore whether specific subgroups of pregnant women might benefit.

The Stigma Problem

One of the least-discussed barriers to pessary use is social. Pelvic organ prolapse itself carries stigma, and inserting a device into the vagina adds another layer of discomfort for many women. Qualitative research has found that the subject is widely recognized as taboo, with some women feeling unable to discuss their pessary use even with close family members.³³ In some cultural contexts, barriers extend further: a study of Tanzanian women using pessaries for stress urinary incontinence identified shame, husband’s disapproval, limited access to care, and lack of knowledge among both patients and healthcare workers as major obstacles.³⁴

This matters because pessaries work only if women are willing to use them consistently. When a woman feels she cannot tell anyone about her treatment, cannot ask for help with insertion, or fears judgment from a partner, she is more likely to abandon the device. Clinicians who normalize the conversation and involve partners or caregivers early tend to see better long-term adherence. For women with cognitive impairment or dementia, the situation adds another layer of complexity. Pessary removal and reinsertion can be distressing for a woman who does not understand what is happening, and caregivers must weigh the benefits of symptom relief against the distress of maintenance visits.³⁵

3D-Printed and Custom Pessaries

Standard pessaries come in fixed shapes and sizes, which means fitting is inherently a compromise. A size 4 ring might be slightly too small while a size 5 is slightly too large, and for women with unusual anatomy, no standard shape works well. This is where 3D printing is starting to make an entrance. Pilot studies have used transvaginal ultrasound measurements to design pessaries tailored to an individual woman’s pelvic dimensions.³⁶

In one early study, women who switched from a standard pessary to a patient-specific 3D-printed version reported improved prolapse symptoms and higher satisfaction. Every patient reported either improvement or no change in comfort, ease of use, and the feeling of support the pessary provided.³⁷ Other researchers have explored using 3D printing to create pessaries with complex internal structures, such as urethral pessaries that combine mechanical support with drug delivery.³⁸

These are still pilot-stage technologies, and the studies involve small numbers of patients. But the concept is promising. A pessary that is literally molded to your anatomy should, in theory, fit better, stay in place more reliably, and cause less tissue irritation. If the manufacturing costs come down and the regulatory pathways clear, custom-printed pessaries could address the fitting failures that currently push some women toward surgery they might otherwise avoid. Pessaries made from cork and brass gave way to rubber and then silicone over the centuries.³⁹ Personalized 3D printing may be the next step in that long evolution.