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Pessary and Pelvic Floor Fittings

Pessary and Pelvic Floor Fittings

A pessary fitting is an in-office clinical procedure where a Rose Physical Therapist determines the appropriate style and size of a vaginal pessary—a flexible silicone device designed to support pelvic organs or stabilize the urethra. It is a common, non-surgical treatment for pelvic organ prolapse (POP) and stress urinary incontinence (SUI).

Because vaginal anatomy, prolapse stage, and pelvic tone vary widely, pessary selection relies on individualized trial and error. Our goal at Rose Physical Therapy is to find the smallest device that holds the prolapse or prevents leakage without causing discomfort, urinary retention, or tissue erosion.

1. Pre-Fitting Assessment

Before inserting any device, the clinician performs a comprehensive pelvic exam:

  • Assessing anatomy: The provider measures vaginal length, width, and introitus diameter, and evaluates the stage of prolapse (cystocele, rectocele, or uterine prolapse).

  • Evaluating tissue health: Postmenopausal vaginal atrophy or thin, friable tissue increases the risk of ulceration. Providers often prescribe local vaginal estrogen cream for a few weeks prior to fitting to strengthen the vaginal epithelium.

  • Reviewing dexterity: The provider will ask whether the patient intends to manage the pessary independently (removing and cleaning it at home) or return to the clinic for periodic maintenance.

2. Selecting the Type and Size

Pessaries fall into two broad categories:

  • Support pessaries (e.g., Ring, Ring with Support, Shaatz): These are flexible, flat, and circular. They are typically the first-line choice because they are easy to insert, fold, and remove independently, and patients can often remain sexually active without removing them (depending on the specific shape).

  • Space-occupying pessaries (e.g., Gellhorn, Cube, Donut): These are larger and bulkier, used when the pelvic floor hiatus is too wide to retain a standard ring pessary or for severe (Stage III–IV) prolapse. Devices like the Gellhorn or Cube create suction or fill the vault; they are more difficult to self-remove and often require professional removal and cleaning.

Clinicians use dedicated, sterilizable "fitting sets" to test sizes. Typically, they start with a mid-sized ring (such as a size 3 or 4) and adjust up or down based on fit.

3. The Fitting Process and "Stress Testing"

Once folded and lubricated, the trial pessary is gently inserted into the posterior fornix behind the pubic symphysis, similar to placing a diaphragm.

Once placed, the clinician evaluates fit through several functional checks:

  1. Digital check: The clinician sweeps a finger around the rim. There should be a small space (about one fingertip width) between the device and the vaginal wall to prevent pressure necrosis.

  2. Movement test: The patient is asked to stand, walk around the clinic, cough, and bear down (Valsalva maneuver). The device should neither slip out nor cause a sensation of fullness or pain.

  3. Voiding trial: The patient is asked to urinate before leaving the clinic. A pessary that presses too firmly against the urethra can cause acute urinary retention or difficulty emptying the bladder.

If the device falls out, twists, causes discomfort, or impedes urination, it is removed and a different size or shape is tested. Your physical therapist will work together with you to find the best solution.