The clinician should use a dry glove to better grasp the pessary and water-soluble lubricants as needed. The size of the pessary is estimated after a digital examination and use of ring forceps to reduce the prolapse or bladder neck. Once the approximate size is determined, the appropriate type is selected based on the patient’s needs and activity level. When fitted, the patient is asked to stand, perform Valsalva, and cough to ensure the pessary is retained. The pessary should be assessed to ensure it is providing the desired support and leakage control. The patient should be able to void with the pessary in place before leaving the office. Proper size is ensured by the ability to sweep the index finger between the pessary and the vaginal wall. The patient should feel comfortable with the pessary in place.
Insertion of the pessary is eased by using a water-soluble lubricant for insertion, folding or collapsing the pessary to reduce its size, and when it is inside the vagina, pushing it high to an area behind the symphysis pubis and inserting the device more posteriorly to avoid the urethra. Instructing the patient how to insert and remove the pessary may be done with the patient in a standing or supine position, depending on her dexterity (49).
Ring pessaries, with or without support, are the most commonly used type. They are the easiest to fold, insert, and remove. Gellhorn and cube pessaries are typically more difficult to insert and remove by the patient. They are held in place by significant space occupation and suction and offer strong support. The suction of the cube pessary needs to be broken, facilitating removal. Cube pessaries should be removed daily; Gelhorns can stay in longer (up to 6–8 weeks). Donut pessaries, which are very popular, are considered a space-fitting pessary for large vaginal vault prolapse, complete procidentia with decreased perineal support, and good introital integrity.
The patient should be questioned about a latex allergy and instructed to remove and clean the device every 2 to 3 days. Continence pessaries, rings, and dishes with support typically also are easy to fold, insert, and remove (50).
After the initial fitting, the patient should return in 1 to 2 weeks and then at 4 to 6 weeks, depending on her independence with the pessary, her proficiency in placement and removal, and her cognitive and motor abilities (44). After this initial follow-up, follow-up should continue at 6-to 12-month intervals at the discretion of the provider and depending on the patient’s ability to insert and remove the pessary effectively. If the patient needs to return to the provider for removal and cleaning of the pessary, 4-to 12-week intervals are more appropriate.
On follow-up visits, proper placement of the pessary and support of the prolapse as well as continence efficacy should be ensured. Because pessaries are fitted through a process of trial and error, it is not uncommon to change the size or type at least once after the initial fitting. The pessary’s integrity should be checked, and the tissues should be evaluated for irritation, pressure sores, ulceration, and lubrication (44).