What happens in a pessary fitting appointment?

I spend every working day in my urogynecology world.  It is all so routine for me- diagnostic testing, pelvic exams, history taking, sling surgeries.  Sometimes I forget how foreign this world is to most women.  Many women have questions about the details of what really happens during an office visit or a procedure.  These visits are often anxiety-producing because you aren’t quite certain about what will happen.  Knowing the nitty gritty details can help ease the anxiety around an office visit.  One of the common questions that I have gotten recently is, “What happens in a pessary fitting appointment.”  So, let’s break a pessary fitting appointment down.

What is a pessary?

A pessary is a medical device that fits in the vagina to correct an ongoing issue.  In general, women take care of their own pessaries and can remove them and place them.  There are three types of pelvic pessaries:

1. Pessaries to correct pelvic organ prolapse
2. Pessaries to correct stress urinary incontinence
3. Pessaries to correct fecal incontinence

Each type’s shapes are different, and there are more than 15 different shapes and sizes. I’m going to focus on incontinence pessaries in this posting.

Incontinence pessaries

Incontinence pessaries are designed to support the urethra and stop leaking during activities like exercise, laughing, coughing, and sneezing (stress urinary incontinence). Many women will notice an improvement in stress urinary incontinence when they are wearing a tampon or a menstrual cup.  In some women, these devices are functioning like a pessary, although often not quite as well.

Incontinence pessaries are both available over the counter (the impressa  https://www.poise.com/en-us/products/impressa/introduction and the revive (https://userevive.com/)) and through a physician (see Cooper Surgical https://www.coopersurgical.com/detail/milex-flexible-incontinence-ring-pessary/, Bioteque https://bioteque.com/product/rk2-252-ring-pessary-w-knob) and the uresta (https://uresta.com/) uresta (.  The impressa is single-use and is made from a fabric-like material.  The revive is made from silicone and can be used 31 times.  The incontinence pessaries from a physician are made from medical grade silicon, are reusable, and last for one year or longer.

Prescription Needed

The uresta requires a prescription in the US (although not in Canada).  They’re working on making it available over the counter but aren’t quite there yet.  A uresta is unique in that it doesn’t require an office fitting.  You get three sizes and try them out on your own.  One of these three sizes works for most women.  The other prescription-based incontinence pessaries all require a fitting.  If you want more information  check out this post (https://thewomensbladderdoctor.com/pessaryforsui/)

Just a quick note about all of these pessaries.  They’ve never been compared.  So, I can’t tell you which one works the best.  Efficacy rates are likely different for different women as a pessary’s anatomy and resulting fit can be very different.  And one shape might be more comfortable than another.  Marketing suggests they significantly improve leaking in 75-85% of women, while research tells us that about one-third of women are totally dry when wearing a pessary.  In general, I like the idea of reusable pessaries because they are cheaper and decrease waste.  But I understand if you want to try one on your own first.

What happens during your fitting?

There are a few things that we need to do during a pessary fitting.

• We need to find one that is comfortable for you
• We need to make sure that it doesn’t slip
• We need to make sure you can place it and remove it.

Sometimes this is a quick appointment, and sometimes it is not.  We may have to try several different pessaries to find the right one.  Think of it like shoe shopping.  You may have to try several styles, even different sizes until you find the most comfortable shoe.  We can always break it into multiple appointments if this is too much for you.  When I am looking for a perfect pair of shoes, it may take me a few trips to the store.  Doing this over several appointments is always an option.

It would help if you were comfortable.

I always have a good idea of the size pessary I need based on a pelvic exam.  I usually start with an incontinence ring.  I lubricate the pessary and place it in the vagina and make sure it is comfortable.  I will go up or down a size or two depending on how It feels.  Again, it may take several pessary placements to ensure the fit is comfortable for you.

Ensuring the pessary doesn’t slip.

Once I know the fit is good, I need you to try to make it slip since they move based on your activity. And if it is going to slip, I want to know this while you are in the office.  Then we can refit the pessary.  At this point, I want you to move around, jump, squat- whatever activities you routinely do that might dislodge it.  I usually step out of the room at this point, figuring that no one wants an audience while they try to knock it out.

If the fit is good, then I have you try to use the bathroom.  This squatting position is one that will often dislodge a pessary.  I always put a hat in the toilet to catch the pessary.  This way, no one has to go fishing for it.

If it slips, I may try a different size.  There are also incontinence pessaries that are a little bulkier, like a ring with a knob or an incontinence dish.  These bulkier versions are also worth a try.  This is where the process becomes trial and error, and we are looking for the one that works best for you.

Learning to place and remove a pessary

At this point, we go back to the exam room, and I teach to remove and place it.  There really isn’t a graceful way to remove it.  You just hook it with a finger and pull it out.  If you have trouble, remember that gravity is your friend.  The pessary will always sit lower when you are standing than when you are in another position.  To place it, you fold the pessary in half and insert it in the vagina.  I usually let you do this on your own (since I don’t think anyone wants an audience here either).  But I can always help if needed.

Final thoughts

At the end of the appointment, I will give you some information on cleaning the pessary and maintaining it.  And that is it.  This appointment may take quite some time, but it is worth it to get the right pessary, just like it is worth it to get the right pair of running shoes.  You may also go home and realize that the pessary slips when you are in the middle of some part of your daily routine.  That means you need a second fitting.

Pessaries may seem like old-fashioned technology and something only your grandma would use.  I think they need to be rebranded.  For so many of us, they should be considered part of your routine exercise equipment, just like a cup is for baseball.  A pessary works better than tying your shirt around your waist or wearing black tights, or peeing before exercise. You should consider it.  And if you decide it is not for you, you can always move on to another option.

Wu NEJM 2021