What a pessary does
A pessary is a removable silicone or plastic device placed in the vagina to hold the pelvic organs up. It does not repair anything. While it is in place, it takes over the job that your ligaments and pelvic floor are no longer doing well. When it is taken out, the prolapse is still there.
Pessaries come in many shapes and sizes. ACOG notes that choice depends on your symptoms and the type of prolapse, and that many women feel relief as soon as a well-fitted pessary is in. NICE adds that more than one fitting may be needed before the right one is found.
The same kind of device is used whether the bladder, the rectum or the uterus is the part that has dropped. What differs is how well a given pessary holds a given type of prolapse, which is something a fitting shows.
When a pessary is usually considered
NICE recommends that every woman with symptomatic prolapse be offered a discussion of all options, including no treatment, non-surgical treatment and surgery. The factors it lists are your preferences, the site of the prolapse, lifestyle, other health conditions, age, whether you want more children and any previous pelvic surgery.
Within that discussion, NICE says to consider a pessary for any woman with symptomatic prolapse, on its own or together with supervised pelvic floor training. ACOG describes a pessary as often the first non-surgical option tried. Neither body limits pessaries to older women or to people who cannot have surgery.
In practice a pessary tends to come up first when you want relief now and time to think, when you plan to have children and want to put off surgery until your family is complete, when another health condition makes anesthesia a concern, or when you simply prefer not to have an operation. It is also a way to test whether lifting the organs relieves the symptoms that bother you most.
Living with a pessary
A pessary needs ongoing care. NICE lists the things you should be told before starting: that more than one fitting may be needed, how different pessary types affect sex, and the possible complications, which include vaginal discharge, bleeding, difficulty removing the device and the pessary falling out.
NICE also says the pessary should be removed at least once every six months to prevent serious complications, and that women at risk of problems, for example because a physical or cognitive condition makes self-care hard, should be offered a pessary clinic appointment every six months. Some women learn to remove, clean and reinsert their own pessary. Others rely on a clinic to do it.
NICE recommends considering vaginal estrogen before pessary treatment for women with menopause-related vaginal symptoms. If you travel often or live far from a clinic that fits pessaries, the follow-up schedule is a practical point to weigh. Leaving a pessary in for long periods is what NICE's six-month rule is meant to prevent.
When surgery is usually considered
NICE's position is plain: offer surgery to women whose symptoms have not improved with non-surgical treatment, or who have declined it. You do not have to fail a pessary to be a candidate. Declining one is a valid choice, and so is trying one and finding it does not suit you.
ACOG frames the decision around the severity of your symptoms, then your age, your childbearing plans and your general health. It notes that prolapse can return after surgery, and that the risk is higher for women under 60, for women who are overweight, and for more advanced prolapse before the first operation. Surgery at a young age may therefore mean further treatment later.
Both bodies make the same point about expectations. ACOG says surgery may relieve some symptoms but not all, and that new problems such as pain with sex, pelvic pain or urinary leakage can appear afterwards. NICE asks surgeons to discuss changes in urinary, bowel and sexual function and the chance of recurrence before you decide. If this is not covered at your consultation, ask for it.
What surgery changes and what it asks of you
The difference between the two paths is what they do to your anatomy. A pessary supports from inside the vagina and changes nothing when it is out. Reconstructive surgery, the common type, tries to move the organs back toward their original position and rebuild support so that they stay there without a device. ACOG describes this as the goal; it does not describe it as a certainty.
In exchange, surgery asks for anesthesia, an incision, a recovery period and some risk of complications, and it carries the chance that the prolapse comes back. NICE asks that you be told how procedures differ in anesthesia type, hospital stay, incisions and recovery, and that for uterine prolapse the options discussed with you include both removing the uterus and keeping it. How surgery is done without mesh, and how a ligament-based repair differs from a standard native-tissue repair, are covered in the cystocele mesh guide and the uterine prolapse options guide, so they are not repeated here.
There is also a second type of surgery, called obliterative, which narrows or closes the vagina to support the organs. ACOG describes it as an option for women who do not plan to have vaginal sex in the future, because vaginal sex is not possible after this procedure. Knowing the term lets you ask which type is being proposed.
Pessary first, surgery later
Trying a pessary does not close the door on surgery. NICE lists continued non-surgical management as one of the options to be discussed even when a woman is considering an operation, and it expects that many women will move from one path to the other over time.
A pessary trial can also give you information. If lifting the organs with a device relieves the bulge, pressure or bladder emptying problems that bother you, you learn that support is what you are missing, and that is what reconstructive surgery sets out to restore. If the pessary gives little relief, tell your surgeon. It may be a sign that some of your symptoms have another cause, and that is a point to raise rather than a conclusion to draw on your own.
Practically, if you are already using a pessary and plan to travel for surgery, ask the operating team when they want it removed before the examination and the operation, and ask whether the tissue needs time to recover from any irritation first. Bring the pessary type and size with you.
Questions to bring to either appointment
Before you decide, write down which symptom bothers you most: the bulge, pressure, trouble emptying the bladder or bowel, or discomfort during sex. Then ask the doctor fitting the pessary, and the surgeon, how their option addresses that specific symptom. The honest answer is sometimes that it addresses one and not another.
For a pessary, ask who will do the six-monthly checks, whether you can learn to manage it yourself, what to do if it falls out or causes bleeding, and how it affects sex. For surgery, ask which type is proposed, whether the uterus would be kept, what is done about the chance of recurrence, what the recovery period looks like, and which urinary, bowel or sexual changes are possible afterwards.
For both, ask how far the prolapse has come down on the one to four scale the NHS describes, and whether the plan would change if you want another pregnancy. NICE advises a written decision aid for prolapse surgery. If you are given one, read it before the next appointment.
Where Podo fits
Consultations are available in English. Before treatment, the clinic uses vaginal endoscopy imaging to examine the vaginal wall, and vaginal laxity is measured numerically rather than judged by hand. A numerical measure of support is useful whichever path you are weighing.
The surgical approach used at the clinic for cystocele, rectocele and uterine prolapse is pelvic ligament suspension, which uses the patient's own ligaments and sutures without synthetic mesh. The procedure pages for each type of prolapse describe it. Pessaries are not fitted or managed at the clinic, and a pessary trial is not required before surgery. Vaginal estrogen is prescribed when appropriate.
Results and recovery vary from person to person. This page is general information and is not a diagnosis; a consultation is needed to decide whether a procedure suits you.
Questions
Is a pessary just for women who cannot have surgery?
No. NICE recommends considering a pessary for any woman with symptomatic prolapse, and ACOG describes it as often the first non-surgical option tried. It is a choice in its own right.
Do I have to try a pessary before I can have surgery?
Not at Podo, where a pessary trial is not required before surgery. NICE guidance also says to offer surgery to women whose symptoms have not improved with non-surgical treatment or who have declined it. Your insurer may have its own requirements, so ask.
Does Podo fit or manage pessaries?
No. Pessaries are not fitted or managed at the clinic. If you already use one, bring its type and size to your consultation.
Can a pessary make the prolapse worse or cause damage?
A pessary that is left in too long can cause serious complications, which is why NICE says it must be removed at least every six months. With regular removal and checks, discharge, minor bleeding and expulsion are the usual problems.
Is prolapse surgery effective?
ACOG says surgery may relieve some symptoms but not all, and that prolapse can return, with higher risk under age 60, with excess weight and with more advanced prolapse. Ask your surgeon how recurrence is addressed in the operation proposed.
Is the pessary decision different for bladder, uterine or rectal prolapse?
The guidance is the same for all three. What changes is how well a particular pessary holds a particular prolapse, which a fitting shows, and which operation would be proposed if you choose surgery.
Sources
About the reviewer
Dr. Mo Hyung-jin, MD, PhD, board-certified OB-GYN specialist, is the medical director of Podo Women's Clinic. He developed the pelvic ligament suspension technique used at the clinic for stress urinary incontinence and pelvic organ prolapse. Profile