Vaginal Pessaries Alongside Physiotherapy: The Option Beside It

A vaginal pessary is a device fitted inside the vagina by a clinician to support prolapsing tissue, and because it is conservative treatment it belongs beside pelvic floor muscle training rather than after training has failed. That sequencing point is the reason this page exists. Women are routinely told that a pessary is what happens next if the exercises do not work, and the guideline does not say that. NICE says to offer surgery for pelvic organ prolapse to women whose symptoms have not improved with or who have declined non-surgical treatment¹, and a pessary is non-surgical treatment.

My own prolapse experience is second hand and I am going to say so rather than borrow it. A woman at my running club was fitted with one, and when I next saw my physiotherapist I asked about it, half expecting to be told that it was the thing you were given when physiotherapy had run out of road. She said two things I did not expect. The first was that she did not fit them and would refer to a clinic that did. The second was that her patients who used one usually carried on with their programme, because the two were doing different jobs. I had assumed a ladder. It was not a ladder. For the treatment this site is mainly about, start at pelvic floor physiotherapy.

What a pessary is

A support device, made in various shapes and sizes, placed inside the vagina to hold prolapsing tissue in a better position. It works mechanically and it works while it is in place. That is the whole of the mechanism, and it is worth stating plainly because it explains everything else on this page.

The population it is aimed at is larger and vaguer than most people realise, which is itself a reason for careful individual assessment. Prolapse defined by symptoms has a prevalence of about 3% to 6% of women, and up to 50% when it is defined by what is found on vaginal examination². NICE records the same divergence in UK primary care, where 8.4% of women reported a vaginal bulge or lump while prolapse is present on examination in up to 50%¹. Those are answers to two different questions, and the difference between them is the subject of prolapse symptoms versus prolapse stage.

Why it sits beside physiotherapy rather than after it

Because both are conservative treatment, and the guideline draws its line between conservative and surgical rather than between one conservative option and another.

NICE NG123 says to consider a programme of supervised pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic POP-Q stage 1 or stage 2 prolapse, and to advise women to continue training afterwards if the programme is beneficial¹. NG210 expresses the same duration as at least 4 months, for symptomatic prolapse that does not extend more than 1 cm beyond the hymen on straining³. Its own rationale explains that both derive from the same evidence, because 16 weeks and 3 months were the most common points at which trials measured their results, so this is one duration described twice rather than two different prescriptions.

Now read the surgical recommendation next to those. It is framed around non-surgical treatment, not around muscle training specifically¹. A pessary falls inside that category. Being fitted with one is therefore not an admission that physiotherapy failed, and declining one is not a failure to try everything either, because the same recommendation treats a declined option as a legitimate route to the next conversation.

What this page does not contain

No pessary numbers, of any kind. This site’s fact file holds no fitting success rate, no continuation rate at six months or a year, no complication rate, and no trial comparing pessaries against pelvic floor muscle training or against surgery. So there are none here, and I am not going to import one from a source I have not checked, because the whole point of this site is that a confident figure with no denominator behind it is how people end up making decisions on somebody’s guess.

It is worth seeing what a checked figure looks like, for contrast. The POPPY trial randomised 447 women with newly diagnosed symptomatic stage I, II or III prolapse across 25 centres in three countries, 225 to individualised pelvic floor muscle training and 222 to a control group given a prolapse lifestyle advice leaflet and no muscle training, and reported a mean reduction of 3.77 points on the 0 to 28 Pelvic Organ Prolapse Symptom Score against 2.09 in controls, an adjusted difference of 1.52 with a 95% confidence interval of 0.46 to 2.59, with 295 of the 447 women, 66%, still in the trial at 12 months⁴. That is the standard of evidence this site quotes at. Nothing of that kind about pessaries has been checked into it.

The older Cochrane review of conservative management of prolapse, from 2011, reported that pooled data from two trials indicated pelvic floor muscle training increases the chance of an improvement in prolapse stage by 17% compared with no training⁵. It predates POPPY and PREVPROL, which is why this site leads with POPPY rather than with it, and it does not answer the pessary question either.

Who fits one, and why it is not a self-service item

A clinician, working from an examination of you specifically. This site carries no fitting instruction, no sizing information, no insertion or removal guidance and no cleaning protocol, and that is a deliberate line rather than an oversight: that instruction belongs in a room with somebody who has examined you and can check what they have fitted.

The reason is anatomical variety rather than caution for its own sake. In the Pelvic Organ Support Study, 1,004 women aged 18 to 83 attending routine outpatient gynaecology appointments had a POP-Q distribution of 24% stage 0, 38% stage 1, 35% stage 2 and 2% stage 3, so 76% had stage 1 or above⁶. That is a clinic population rather than a population estimate, and it makes the point: prolapse is not one shape. The International Urogynecological Association publishes patient information across this subject for people who want to read further before an appointment⁷.

Some women are also offered treatments that are prescribed rather than fitted. This site carries no medication content beyond naming that it is a conversation for a clinician, and that includes anything topical.

How it differs from surgery

In reversibility and in commitment, and those two differences do most of the work in the decision.

A pessary can be removed. An operation cannot be undone, and prolapse surgery is common enough for that asymmetry to matter: NICE records that one in 10 women will need at least 1 surgical procedure, with a re-operation rate as high as 19%¹. A treatment that can be tried and reversed occupies a genuinely different place in a decision from one that cannot.

The ordering of the pathway is emphatic rather than polite for reasons that are recent. The Independent Medicines and Medical Devices Safety Review, chaired by Baroness Cumberlege and published in July 2020, stated that conservative measures must be offered to women before surgery, and added the concern that specialist pelvic floor physiotherapy cannot match the demand⁸. The same review heard from women who had mesh surgery for relatively minor stress urinary incontinence without ever having been offered conservative treatment first. What that changed is set out in mesh and what changed after the inquiries, and what a fair trial of conservative treatment looks like before the surgical conversation is in when physiotherapy is not enough.

What you are still doing the exercises for

Because a pessary supports and does not train. It holds tissue while it is in, and it makes no claim on the muscle around it, which is why a programme usually runs alongside rather than stopping.

The training has its own modest, measured effect on symptoms independent of any device: a mean reduction of 3.77 points on the 0 to 28 symptom score against 2.09 in women given a leaflet and no muscle training, an adjusted difference of 1.52⁴. That is good evidence of direction and modest evidence of magnitude, and NICE’s advice to continue training after a beneficial programme is not conditional on what else you are using¹. How a dose is actually built and progressed is in pelvic floor exercise programmes explained, and the movement itself, which is the part most often done wrong, is in how to do a pelvic floor contraction correctly.

One caution belongs here as it does on every strengthening page on this site. Strengthening is not universally the right treatment: for an overactive or hypertonic pelvic floor the muscle is failing to switch off rather than failing to switch on, and conventional strengthening can make symptoms worse. If a programme is making things worse, see hypertonic pelvic floor and downtraining and ask to be reassessed rather than doing more repetitions.

Review, follow-up and when something is wrong

Whatever is fitted, somebody should be checking it and checking you. NICE requires at least 1 review to assess progress during a supervised programme and 1 review at the end of it³, and a device handed over with no arranged follow-up is the situation to query rather than accept.

Separately from any of that, a prolapse that has become painful, that looks discoloured or ulcerated, or that cannot be pushed back inside needs a clinician the same day, and so does a prolapse accompanied by an inability to pass urine at all. That list and the rest of it is in red flags and when to stop and get checked. For what conservative treatment achieves for prolapse overall, and what it does not, see pelvic organ prolapse.