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Management Pathway: Management of Pelvic Organ Prolapse with Pessaries

This management tool is a guide to assist general practitioners, continence nurse advisors and continence & women’s health
physiotherapists in primary care to prescribe and fit pessaries for women with pelvic organ prolapse.

Assessment & Pessary Management of Women with POP in Primary Care

Pessaries are a conservative management option for all women with POP [L: III-3, IV, Opinion]

 Exclude abdominal/pelvic pathology Refer to GP or gynaecologist for

abdo/pelvic exam [L:Opinion]

Stage I & II POP [L:*]  Objective: POP stage or POPQ Stage III & IV POP [L:*]
 Subjective: Validated questionnaires

Insert pessary as per guideline

 Preference for conservative management
and refer to specialist [L:*]
Assess suitability for pessary  Willingness for self-management
[L: I, III-1, III-2, Opinion]  Willingness to attend regular follow up
 Intact cognition Referral to GP or gynaecologist
 Adequate physical mobility & dexterity for topical oestrogen if indicated
 Need for topical oestrogen Refer to oncologist if past
history of breast cancer [L:*]
 Active vaginal infection
Assess contraindications
[L: III-3, IV, Opinion]
 Undiagnosed vaginal bleeding Specialist review required if on
 When follow-up is not assured Warfarin or with mesh implants
 Thorough patient education about position of
pessary, opportunity to see & touch
Prior to fitting  Full information about risks, benefits, need for
[L: Opinion] long-term follow up
 Informed consent

 There are no factors absolutely predicting

type/size. Fitting is based on trial & error &
experience. Several trials may be needed to fit
a pessary successfully.
Selection of pessary type  Stage I & II POP – try ring first
[L: III-2, III-3, Opinion]  Stage III & IV POP – try ring then Gellhorn
 Trial of other types e.g. cube, donut if these fail

Assess vaginal dimensions:

 width of upper vagina
 length from posterior fornix to pubic symphysis
Selection of pessary size
 visually compare with available pessaries for
[L: Opinion] size
Manufacturer’s instructions or
institution policy will dictate
 Wash new pessary in soap and water whether pessaries can be
 Apply water-based gel to leading edge of sterilized and re-used [L:*]
Fitting procedure pessary
Re-fitting: a new pessary should
[L: Opinion]  Separate labia, asking woman to relax her pelvic
be fitted when it cannot be
floor muscles
 Slide pessary into position in upper vagina
cleaned satisfactorily [L:*]
A pessary fits if:
Assess for correct fit  There is no discomfort or pain
 It is retained in supine with cough/Valsalva
[L: III-2, III-3, IV, Opinion]
 It is retained in standing, walking, bending,
squatting & with cough/Valsalva
 There is no occult stress urinary incontinence

Mandatory review to avoid risks & complications:

 Review in 1-2 weeks PVR>100mls to trigger specialist
Follow up
 Assess for Risks & Complications and for review [L:*]
[L:I, III-3, Opinion]
symptoms of obstructed voiding or defaecation.
If present, assess PVR with US or refer for US
Risks & Complications [L: 1]
Common complications:
 mild vaginal discharge
If for self-care: If not for self-care:  constipation
Teach removal/re-insertion, to be 4-6 monthly follow up for  erosion
done weekly and left out removal/washing of pessary and  vaginal bleeding
overnight. Provide speculum exam by appropriately
 denovo or worsening
handout/instructions. Review at 4 trained Health Care Provider.
urinary incontinence
months, then annually by GP or Annual review by GP /
More serious & less common
gynaecologist for speculum exam gynaecologist.
[L: III-2, III-3, Opinion] [L: I, III-3, Opinion] complications:
 severe vaginal discharge
associated with infection
e.g. bacterial vaginosis
Patients should be alerted to seek help immediately in the event of any
symptoms [L: *]  urological complications
 cervical incarceration
 septicaemia
 impacted/embedded
 Mild side-effects e.g. 1. mild erosion, vaginal pessaries, causing fistulae
discharge and 2. constipation managed by 1.  vaginal or cervical cancer
leaving pessary out/use of topical oestrogen
and 2. dietary advice
Assessment of side effects
 Patients should be monitored for serious
[L: III-2]
GP review of mild complications
 Severe, foul-smelling vaginal discharge – take
[L: III-2]
swab or refer for swab
Specialist review of severe
complications / side effects
[L: *]

 Record type & size of pessary and any side-

effects or complications in patient’s medical
records and in practice/department database
Recording & Communication to facilitate follow-up
[L: *]  Communication with other appropriate Health
Care Providers

Key: Where recommendations are evidence based, they appear with

Assessment tools: Appropriate Patient
the level of evidence according to NHMRC levels of evidence (Merlin
Reported Outcome Measures are provided in
2009). Where recommendations are based on the consensus of the
Appendix A of the full Pessary Guidelines
Expert Working Party, they appear with the symbol *.

Information in this pathway is based on the Guidelines for the Use of Support Pessaries in the Management of Pelvic Organ Prolapse. 18.7.2012
The full guidelines can be obtained at http://w3.unisa.edu.au/cahe/Resources/GuidelinesiCAHE/iCAHEGuidelines.asp or www.continence.org.au.