You are three months post surgery and have for the most part returned to your normal routine. The fear you experienced heading into your procedure is a distant memory. Your post-surgical consults indicate everything has healed up well and you can move forward with your life. And then something occurs during your daily ritual that raises your anxiety about whether or not you are as healed up as you think you are. You pick up heavy box. You move furniture. A grandchild you haven’t seen in a year runs to greet you and you swoop her up. You feel that all too familiar pressure, discomfort, pain. And you panic. Have you done something to wreck your POP repair? I’m guessing nearly every woman who’s had POP surgery knows what I’m talking about...

From time to time we talk about post surgical maintenance, as valuable to your health as brushing your teeth between dental appointments. Fitness routines, pelvic floor muscle strengthening devices, posture, and behavior modification all play a role in maintaining your POP repair long term. There are after all five types of POP, we not only concerned about organs repaired going south again, we also don’t want any new surprises. But what about pessaries? Can they be used for maintenance post surgery?

To refresh, a  pessary is one of those terms women are seldom familiar with prior to being diagnosed with pelvic organ prolapse (POP), much like the condition itself. While pessaries aren’t new to POP treatment (they are one of the oldest medical devices documented, on record since 27BC), they have gone through multiple modifications over the course of thousands of years.

Hippocrates felt half a pomegranate did the trick for internal support (fruit in the vagina….don’t get me started….), Diocles “improved” on Hippocrates device by soaking it in vinegar (now we’re talking fruit salad) and Aurelius Cornelius Celsus wrote about them in De Medicina, a first century encyclopedia. A bronze cone shaped pessary with a perforated circular plate at its widest end was located in Pompeii. It is believed a band was attached to the openings and tied around the body to keep the device in place. Trotula, wife of Joannes Platearious, the first documented female gynecologist, developed a ball pessary made of strips of linen in approximately 1050AD. IN 1559, Caspar Stromayr of Germany recommended a sponge rolled in a tight ball, dipped in wax, and covered in oil or butter. Stone, cork, and wax have also been used over the years. I’ve heard of women inserting mud, rocks, even pieces of flip-flop in developing zones where they have little access to healthcare. While some aspects of pessary use have come a long way, we still have a long way to go regarding awareness, understanding, use, and access.

Pessaries are absolutely a low risk, cost effective tool for pelvic organ prolapse treatment. There are numerous types of pessaries; they come in both support and space filling styles and in a multitude of sizes. Most women are able to remove, clean, and reinsert  the most commonly used support pessaries. 

 Pessaries are of value to women with pelvic organ prolapse who:

  • · Don’t want to have POP surgery;
  • Can’t have surgery for medical reasons;
  • Are waiting to have surgery because of insurance, employment, or parenting concerns;
  • Want more children prior to considering surgery.

So what’s the rest of the story; what are we overlooking? Let’s consider for a moment women who’ve already had POP surgery. The failure rate of POP surgery when mesh is not used is about 30-35% and typically occurs in one to five years after the procedure. Would pessary use post surgical heal curve cut down rate of failure? Even if mesh is used, will other types of POP occur? Patients are often told a pessary is no longer necessary after surgical repair. I scoured multiple research study sources and found nothing. I asked several POP practitioners, but no one was aware of a study of this nature. The truth is we simply don’t know. Lifestyle has a significant impact to the female pelvic cavity and is absolutely a POP causal concern; I think there is value in thinking outside the box with post surgical pessary use. I must confess, I felt compelled to experiment a bit.

My seven year transvaginal mesh surgery anniversary is one month away. The POP repair included cystocele, rectocele, and enterocele; the entero was quite large. Mesh was used for the bladder and rectum but not for enterocele, which was discovered during surgery. I remember asking my urogynecologist if I should use a pessary after I was past the surgical heal curve, I was excited to return to my exercise regimen. (For the record, my urogynecologist is fantastic.) She said it was not necessary. Symptoms occurring now have me wondering if my enterocele has came back. Warning flags indicate something is going on inside and in an attempt to decide whether or not I should approach my specialist for an evaluation, I opted to experiment with a new over the counter product, Impressa, a disposable pessary.

This disposable pessary was designed to address stress urinary incontinence, but I felt it might work for my personal experiment and was thrilled how well it did. Can this disposable pessary have value for women navigating symptoms of grades 1 and 2 POP? The device inserts easily like a tampon but expands once inside to create support, yet still easily pulls out. (Clearly if you can’t keep a tampon in, you may have difficulty with this product as well, although tampons do not open like an umbrella as this product does.) I noticed immediate relief of pressure. I experienced a change in stool consistency. I didn’t need to run to the bathroom so often.  I had no discomfort on the days it was inserted. My symptoms improved until I removed it, and then they returned. This experiment absolutely made me recognize it was time to secure an appointment with my urogynecologist to check for enterocele return.

So what is the value of pessary use for women post surgery? Are pessaries safe to use after mesh surgery? Pessaries are known to erode vaginal tissues (pressure sores) if not properly monitored by a healthcare practitioner. Vaginal atrophy (dry vaginal tissue) is also a concern when estrogen levels drop and are not replaced with hormone meds. Pessary erosion would be an increased risk for women with these concerns and all women should be periodically checked for erosions, whether they've had mesh surgery or not.  I do believe a disposable pessary can serve as a valuable self assessment tool if women suspect POP has returned. If a disposable pessary removes post surgical POP symptoms, and you can wear it comfortably, you may want to consider discussing it with your practitioner.  Women who have had mesh removed because of complications will absolutely need something to provide support once they are healed.  Clearly we need to generate research regarding safety for use in women post mesh surgery, but in the meantime I’ll test the waters and as always, share my experiences with our community.

Like most layers of POP protocol, we have much to discover, explore, and study as we continue to move the POP treatment needle forward. Stay tuned.