What Is A Pessary?

Nicole Coffey is our resident pelvic health guru and expert on all things related. Read as Nicole answers a Q& A about what exactly a pessary is and who could benefit from one.

What is a pessary? I get this question a lot.

A pessary is an internal vaginal support device typically made of medical grade silicone. They are generally used by women who experience bothersome symptoms from prolapse (when one or more of the abdominal organs including the bladder, uterus or rectum descend and decrease the space within the vaginal canal - find more information in my earlier blogs Part 1: What is Prolapse? and Part 2: I Have A Prolapse! Now What?). This can lead to symptoms such as vaginal heaviness, pressure, a sensation that something is “up there”, or noticing tissue protruding from your body. There might also be bladder and bowel symptoms such as incomplete emptying. Pessaries can also be used to treat urinary stress incontinence, which is accidental urine leakage with activities such as coughing, sneezing, jumping, running, and so on. The pessary acts like an internal shelf to hold the organs up, keeping them away from the entrance of the vagina.

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Typical Pelvic Floor Anatomy

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Uterine Prolapse

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Inserted Pessary

For some people, surgery is an option. For people who do not want to have surgery or who are not surgical candidates, a pessary can be a fantastic option for treatment. (For the record, pelvic floor exercises are also awesome and can help as well, but we are talking about pessaries today).  

So what holds people back? Pessaries can be intimidating. But have no fear, I am here to show you that they aren’t so bad after all!

Take a look at the most common questions I get about pessaries:

1.       Do they hurt?

No! The best thing about a pessary is when it is inserted you can’t feel the pessary and you can’t feel your prolapse! This is why they are so magical. Some women who have a history of vaginal pain (such as pain with intercourse and tampon use) might have discomfort while inserting and removing the pessary. Other women report an initial discomfort when inserting and removing the pessary until they get the hang of it but the majority of users report no pain.  If you do feel pain when inserting and removing the pessary and you are post-menopausal you might benefit from vaginal estrogen cream (this is an excellent conversation to have with your doctor).

2.       Are they hard to get in and out?

Not really. Some styles are trickier than others and require a little bit of skill, but with a little bit of practice you will be a pro at managing your pessary.

3.       When do I wear it?

This is mostly up to you. Some women only wear their pessaries during high intensity exercise. Some women insert it every morning and remove it every night. Others wear theirs for 3-5 days at a time. If a gynaecologist fits you with a pessary there is an option to wear it for longer periods (up to 3 months at a time), but this again is a conversation to have with your specialist.

4.       Can I have intercourse when I am wearing my pessary?

Usually no. There are some types (ring pessaries) that would allow for penetrative vaginal intercourse, but the majority of pessaries need to be removed for intercourse.

5.       How soon after having my baby can I be fit with a pessary?

I personally do not fit people with pessaries before 12 weeks post-partum because your body is still healing and changing. I also do not fit people who are currently pregnant. Again, if you see a gynaecologist they will be able to work with you in these situations as needed.

6.       I don’t have prolapse but I leak urine, can I still use a pessary?

If you leak urine due to stress incontinence (coughing, running, jumping, etc.), a pessary absolutely can help. It will probably just be a slightly different type and you likely will only have to wear it at times that you leak such as while at the gym. A pessary will not help with urge incontinence (leaking due to a very sudden and strong urge to pee).

7.       How do I know what size and type I need?

This one is unfortunately a little tricky. Fitting a pessary is a combination of experience, art, and some trial and error. During your appointment I discuss with you which type of pessary I think would be best for you to try first and why. Then we proceed to try a few different sizes and shapes as needed until the perfect one is found. Sometimes this happens right away and sometimes it takes a few tries. It might take more than one appointment but it is worth it in the end to have a pessary that fits properly.

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If you have any further questions about pessaries or would like to book a pessary fitting, book online, send us an email at clinic@ladnervillagephysio.com or give us a call at (778) 630-8800.

Prolapse Part 2: I Have a Prolapse! Now What?

OK, so you have prolapse. What do you do about it?

Treatment for prolapse depends on a few different factors including (but not limited to):

• Which structure(s) is/are prolapsed? (Anterior wall, posterior wall, uterus?)

• What is the extent (grade) of the prolapse?  (I covered the grading in my previous blog, but for a brief refresher Grade 1 = mild, Grade 2= moderate, grade 3 = large).

• How much is it bothering you? (Depending on the type of prolapse some things you might notice include sensations of vaginal heaviness or pressure, incomplete bladder emptying or trouble initiating a bowel movement).

A pelvic floor physiotherapist can help guide you as to which exercises and precautions are most appropriate for you and your specific situation.  

The three primary treatment options for vaginal prolapse are:

Pessaries

1. Pelvic Floor Exercises. Pelvic floor exercises are fantastic because they are easy to do, inexpensive, non-invasive, and fairly effective. I often say that running with prolapse might feel a bit like running without a bra on (not my favourite feeling in the world). But with a little strength and skill your pelvic floor musculature can become the sports bra. It can be strong and work to support the prolapse throughout the day, maybe even provide a little bit of lift. While pelvic floor exercises are useful and helpful, they are not a quick fix, nor are they magical. They are often more than enough for women with only minor bother symptoms or mild/moderate prolapse, but they cannot turn a prolapse that is protruding outside of your body (grade 3) into a “barely there” grade 1.

2. A Pessary. If pelvic floor muscles are the sports bra then a pessary is a sports bra with underwire! If you have never heard of a pessary you aren’t alone. Essentially, they are silicone vaginal support inserts (maybe like an ankle brace, only for your vagina) that work to lift and support the prolapse. I get that this sounds intimidating, but here is the thing…. When a pessary is inserted (and fits correctly) you can’t feel the pessary and you can’t feel the prolapse! You read that right. It essentially takes your prolapse bother symptoms away (whatever they might be, such as feelings of vaginal heaviness, pressure, etc). Pessaries come in many shapes and sizes and have different wearing patterns. Some women only wear a pessary while exercising. Others insert it every day and take it out every night. Some people wear the pessary for several days at a time. There is some upkeep involved such as cleaning the pessary and follow up visits to ensure the pessary fits correctly. They are a successful long-term management tool as an alternative to surgery.

3. Surgery. This is the only “true fix” that is not just supporting from below but actually “re-stringing” from above. It is also obviously the most invasive procedure. Each gynecologist and surgeon will have their own protocols so I suggest having an in-depth conversation with your specialist if you are considering the surgical route. Surgical recovery times and potential complications such as re-occurrence rates are all important questions to ask.

One big consideration, no matter which treatment route you choose, are steps you can take to help prevent further progression of the prolapse. These can include avoiding chronic constipation, minimizing high impact activity, being mindful of correct lifting techniques to name. Or maybe you have no sensations of vaginal heaviness but do experience symptoms such as incomplete bladder emptying or trouble initiating a bowel movement. These could also be a sign of prolapse.

If you have any questions about prolapse or would like to book an assessment please feel free to email us at clinic@ladnervillagephysio.com or phone the clinic at 778-630-8800.

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Wondering where to find Part 1? Right here - Part 1: What is Prolapse?

Prolapse Part 1: What is Prolapse?

Whenever I am doing an initial intake interview with a client who has come in with concerns about their pelvic floor I ask about prolapse. The most common answer I get when asking if people have any concerns about prolapse is simply “what the heck is prolapse?” Well, let me tell you.

You have various organs within your abdominal cavity, the lowest of which include your bladder, your uterus and your rectum. They are all strapped into place and held in the correct position with connective tissue, like a marionette being held upright by strings. But sometimes those strings get over-stretched (like during childbirth). So instead of having nice upright puppets you now have puppets with extra long strings, which means you now have droopy puppets. These “droopy” organs then begin to collapse downwards.

It’s like your vagina is a tent (yes, like a camping tent), and then a big old bear (aka one of your organs such as your bladder) comes and sits on the edge of your tent. The bear is not physically inside your tent, but he’s leaning on it and squishing it, and making the space inside your tent smaller. This can lead to a “bagginess” or “sagging” within the vaginal canal which is also known as prolapse!

Women who have a prolapse (that they are aware of) generally describe sensations of vaginal heaviness, pressure, of something being inside of their vagina (like a tampon or a “bubble”), or a general feeling of their “insides falling out.” This can occur all day every day or occasionally. Often activities such as coughing, sneezing, carrying something heavy, or being on your feet all day can increase awareness and sensations of the prolapse. That being said, many women have a prolapse and have no sensation of it at all. This applies to small, moderate, and large prolapses. Some women have tissue protruding outside of their vagina for the majority of the day but if you asked them to stand clothes-free and hands-free they would have no awareness that their anatomy was different or changed.  

The name of the prolapse will depend on the structure causing the issue. I have listed a few of the more common terms below:

• Anterocele/cystocele/anterior vaginal wall prolapse: these are all generally names used for when the bladder is the offender. When the bladder decides to droop, it collapses into the empty space of your vaginal canal. This can sometimes lead to symptoms such as incomplete bladder emptying.

• A rectocele is also known as a posterior vaginal wall prolapse. This is when the back wall of your vagina (the wall between your vagina and rectum) is pushed forward due to external pressure from the rectum. Please note that a rectocele is not the same as a rectal prolapse. This is when tissue is loose inside the rectum resulting in excess tissue bulging out of the anus. A rectocele can cause, among other things, difficulty initiating a bowel movement.

• A uterine prolapse is pretty straight forward. If your uterus is dropping it’s more like the tent is collapsing from above. It can sometimes “drag” the front and back walls of the vagina down with it and seems to be the most noticeable type of prolapse.

You can usually tell which structure has prolapsed with a brief self exam. If you put your finger inside of your vagina and it feels squishy in the front, it’s a cystocele. Squishy in the back is a rectocele. If the extra tissue feels firm like the end of your nose you are feeling your cervix and it means that your uterus is the structure that has dropped.

The grade of a prolapse will depend on how much “droop” there is. If the bagginess is happening in the upper half of the vaginal canal it’s a grade 1. If the bagginess is in the lower half of the vaginal canal it’s a grade 2. If there is tissue protruding out the entrance of the vagina the prolapse is a grade 3.

Treatment options for prolapse vary and the right option for you will depend on a few things such as A)which structure is prolapsed? B) how big is the prolapse? And C) how much does it bother you?

I will discuss treatment options for prolapse in my next blog, but if you have any specific questions or would like a consultation please feel free to contact the clinic or book an appointment and I would be more than happy to help you out!

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If you’re looking for the second half of this blog, check out Part 2 - I Have A Prolapse! Now What?