Pessaries are being increasingly utilised as a component of the biopsychosocial non-surgical management of Pelvic Organ Prolapse (POP), in addition to pelvic floor muscle training, lifestyle changes and topical oestrogen. It is vital that these treatments are provided effectively and safely following evidence based and competency assessed standards. 

Once the domain of gynaecologists and some GPs, pessaries are being increasingly provided by pelvic health physiotherapists.

This article, written in conjunction with Specialist Pelvic Health Physiotherapist Dr Patricia Neumann explores recommendations, treatment options and competency standards for the use of pessaries as part of POP management.

Why Consider A Pessary For POP?

Pessaries are particularly helpful for those not wanting to pursue surgery, have not finished their childbearing, are unfit for surgery, or want to be able to participate in higher levels of exercise. Pessaries have been shown to be suitable and safe in both older and younger populations¹. 

There is level 1 evidence that supports pessary self-management, reducing the risk of complications and the need for specialist visits without compromising quality of life^2,3. This facilitates increased engagement in sport and exercise and if required an increased ability to care for family and participate in heavy physical work. 

A recent study⁴ found that physiotherapists in private practice are seeing younger women (<40) and providing them with the option of a pessary. This is helping to reduce POP symptoms and encouraging women to re-engage with physical activity which in turn leads to improved management of other health conditions such as mental health and bone mineral density. 

A Competency Framework For Physiotherapists Fitting Pessaries

In 2018, the Australian Commission on Safety and Quality in Healthcare (ACSQHC)⁵ published treatment options of POP, which included the fitting of a vaginal pessary.  They stated that a physiotherapist with a “special interest” in the pelvic floor can provide these treatments - but is a special interest enough?

There is Level 1 evidence for pelvic floor muscle training (PFMT) as first line therapy to improve both the symptoms and anatomical stage of POP⁶ when delivered by a physiotherapist who has had specific post-graduate training in managing pelvic floor dysfunction. 

The physiotherapist should be able to manage bladder, bowel, sexual and pain issues and provide trauma-informed care6, which requires much more than an ‘interest’ but rather further professional development, training and qualifications.

What You Should Expect From A Physiotherapist Competent In Pessary Management

• Clear understanding of indications for pessary fitting, contra-indications and precautions.
• Collaboration with the patient’s GP or gynaecologist, to address the medical issues which include⁸:
  • Confirming the diagnosis of prolapse and excluding a pelvic mass.
  • Prescribing topical oestrogen as indicated for vaginal atrophy.
  • Providing medical follow-up for complications e.g bleeding, signs of infection etc. 
  • Providing annual medical review, discussing goals and surgical options.
• Advanced skills in assessing the pelvic floor muscles, connective tissue support and prolapse for stage and compartment.
• Knowledge regarding pessary choices including different types, not just ring pessaries, as these are likely to fail with a levator avulsion. In this case, space-occupying pessaries may be indicated (Cube and Gellhorn)².
• Skills in fitting and removing the different types of pessaries, teaching self-management.
• Knowledge of possible complications, when to escalate care and best practice infection control.
• Data management and protocols ensuring regular follow-up and contingency plans for urgent problems.  
• Interprofessional collaboration and governance.

A Call To Action